Exhibit 10.21
TDH Doc. 7526032317* 01-02A
AMENDMENT NO. 1
TO THE
2000 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HEALTH AND HMO
This Amendment No. 1 is entered into between the Texas Department of Health
(TDH) and AMERICAID Texas, Inc., dba Americaid Community Care (HMO), to amend
the 2000 Contract for Services between the Texas Department of Health and HMO in
the Dallas 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 all clean claims paid or denied
within 30 days of receipt and 99% of all clean claims paid or
denied within 90 days of receipt. Failure to meet these
performance levels is a default under this contract and could
lead to damages or sanctions as outlined in Article 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.
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: TDH DOC. NO. 7526032317* 01-02A
/s/ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇
-------------------------------.
Office of General Counsel
\
AMENDMENT NO. 2
TO THE
2000 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. (HMO) in the Dallas Service Area, to amend the
2000 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 is 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/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
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▇▇▇▇▇▇▇ ▇. ▇▇▇▇ M.D. ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
Executive Deputy Commissioner of Health President and CEO
Approved as to Form:
Sda 8/20/01
Office of General Counsel
AMENDMENT NO. 3
TO THE
2000 CONTRACT FOR SERVICES
BETWEEN
HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 3 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 Dallas
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 2000 Contract for Services entered into between the Health and
Human Services Commission and AMERICAID Texas, Inc. in the Dallas
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. 3 hereby substitutes AMERIGROUP Texas, Inc. in the
place of AMERICAID Texas, Inc. in the 2000 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 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
6.6.9 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 DO in the State of Texas either as a primary care provider
or in the area of specialization under which they will provide
medical services under
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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 applicable
Practitioner licensing agency of the State of Texas who is enrolled in the
Provider 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 designation
Clinic (RHC) as a rural health clinic and is enrolled in the Texas Medicaid
Program.
Local Health A local health department established pursuant to Health and
Department Safety Code, Title 2, Local Public Health Reorganization Act
Section 121.031 ff.
Non-Hospital A provider of health care services which is licensed and
Facility Provider credentialed to provide services and is enrolled in the 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 Safety
Treatment 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 or
Counselor 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 change 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 FY2001 and
again after the end of FY2002. The first final report must
reflect expenses incurred through the 90lh day after the end
of FY2001 for FY2001 and again after the end of FY2002 for
FY2002. The first final report must be filed on or before the
120th day after the end of each state fiscal year. The second
final report must reflect data completed through the 334th day
after the end of each state fiscal year and must be filed on
or before the 365th day following the end of each state fiscal
year
12.5 PROVIDER NETWORK REPORTS
12.5.2 Provider Termination Report. HMO must submit a monthly report
which identifies any providers who cease to participate in
HMO's provider network, either voluntarily or involuntarily.
The report must be submitted to TDH in the format specified by
TDH. HMO will submit the report no later than thirty (30) days
after the end of the reporting month. The information must
include the
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provider's name, Medicaid number, the reason for the
provider's termination, and whether the termination was
voluntary or involuntary.
12.5.3 PCP Error Report. HMO must submit to the Enrollment Broker an
electronic file summarizing changes in PCP assignments. The
file must be submitted in a format specified by HHSC and can
be submitted as often as daily but must be submitted at least
weekly. When HMO receives a PCP assignment Error Report /File,
HMO must send corrections to HHSC or its designee within five
working days.
12.13 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.
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Risk Group Monthly Capitation Amounts
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TANF Adults $ 195.59
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TANF Children > 12 Months of Age $ 78.72
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Expansion Children > 12 Months of Age $ 77.18
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Newborns < or = 12 Months of Age $ 353.41
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TANF Children < or = 12 Months of Age $ 353.41
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Expansion Children < or = 12 Months of Age $ 353.41
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Federal Mandate Children $ 56.61
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CHIP Phase I $ 75.19
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Pregnant Women $ 226.93
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Disabled/Blind Administration $ 14.00
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Delivery Supplemental Payment: A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO as
provided below in the following amount: $3,076.23.
13.1.3 HHSC 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 its proposed capitation rates from HHSC
for the second year of this contract, HMO may terminate this
contract as provided in Article 18.1.6.
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, HHSC
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 77th 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 HHSC at
the end of the first quarter of the 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
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as measured by any positive amount on Line 7 of "Part 1:
Financial Summary, All Coverage Groups Combined" of the Final
Managed Care Financial Statistical Report set forth 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
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Net Income Before Taxes as
a Percentage of Revenues HMO Share State Share
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0% - 3% 100% 0%
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Over 3% - 7% 75% 25%
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Over 7% - 10% 50% 50%
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Over 10% - 15% 25% 75%
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Over 15% 0% 100%
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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.
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 HHSCp. 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 time 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 Repot is submitted to HHSC for the
specified tune 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
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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 percentage in order to be eligible for payment of
financial incentives. Performance objectives are subject to
change. TDH will consult with HMO prior to revising
performance objectives.
13.3.6 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, TDH 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 TDH 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.
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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%
---------------------------------------------------------------------
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 that are 65%
successfully accepted into C21
---------------------------------------------------------------------------
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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 SPY 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 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.
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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.
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 ail 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 contract year.
Retaining premium, recoupment, sanctions, or penalties that
are allowed under this contract or that result from HMO's
failure to
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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 contract year as set out
in Article ▇▇.▇.▇.▇:
18.2.3 If the contract is terminated by HMO for any reason other than
based on lower capitation rates for the second contract years
as set out in Article ▇▇.▇.▇.▇:
Article XIX TERM
19.1 The effective date of this contract is September 1, 2000. 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 and CEO
Approved as to Form:
/s/ [ILLEGIBLE]
----------------------------
Office of General Counsel
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14
AMENDMENT NO. 4
TO THE
2000 CONTRACT FOR SERVICES
BETWEEN
THE HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 4 is entered into between the Health and Human Services
Commission (HHSC) and AMERIGROUP Texas, Inc. (HMO) in the Dallas Service Area,
to amend the 2000 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:
1. 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.
15.2.6.1 If federal or state laws, rules, regulations, policies or
guidelines are adopted, promulgated, judicially interpreted or
changed, or if contracts
October 30, 2001
1 of 3
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).
2. APPENDIX C: Appendix C is deleted in its entirety and is replaced by a
new Appendix C which is Attachment No. 1 to this amendment. This
amendment provides for the deletion of "Dental Benefits for Adults"
services from the Dallas Service Area contract.
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/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
--------------------------- -----------------------------
▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
President and CEO
Approved as to Form:
/s/ [ILLEGIBLE]
------------------------------
Office of General Counsel
October 30, 2001
3 of 3
ATTACHMENT 1
PHYSICAL HEALTH VALUE-ADDED SERVICES
AMERIGROUP (DALLAS SERVICE AREA)
24 Hour Nurse Hotline Nurses available 24 hours a day, 7 days a week for assistance with medical issues.
Gifts for completing health education Gifts are given for completing all prenatal care include: baby gym, diaper bag with
classes and prenatal care baby gifts or baby layette. Gifts for completing prenatal classes include: onesy, baby
blanket, baby bibs and washcloths and a bag of baby play toys. More than one gift may be
received for each type of prenatal class that is attended (ie. Prenatal, childbirth,
parenting or breast feeding). Expectant mothers must complete a form to verify prenatal
care or attendance at classes.
Benefit Substitution When appropriate (and identified through proved and recognized medical standards
of care). Members are offered services not covered under the plan benefits in
order to avoid an inpatient hospital admission or remove barriers to access and
health care services. These services may include special transportation to
medical appointments, temporary phones in the home, and extra home health care.
Additional transportation For Members with chronic illnesses, AMERICAID offers transportation assistance
for medical appointments, as determined appropriate by HMO case manager, through
the provision of taxicab or bus coupons.
Health Promotion with Gifts Gifts are provided for members that complete THSteps visits including baby
bottles, growth charts and medicine spoons. Members are given a choice of one of
the gifts for each THSteps visit that is completed.
Quarterly Member Newsletter Quarterly newsletters promoting healthy lifestyles sent to all member
households. AmeriTips provides one page health information on such health-care
topics as alcohol abuse, asthma, ADD, breast feeding, depression, earaches and
fever.
1999 Contract
August ▇▇▇▇ ▇▇▇▇▇▇▇▇ C
1 of 2
ATTACHMENT 1
Membership to Boys/Girls club All services of the Boys and Girls Club are open to AMERICAID members.
Available to all AMERICAID members age 6-18. One membership per household.
1999 Contract
August ▇▇▇▇ ▇▇▇▇▇▇▇▇ C
2 of 2
AMENDMENT NO. 5
TO THE
2000 CONTRACT FOR SERVICES
BETWEEN
HEALTH AND HUMAN SERVICES COMMISSION AND HMO
This Amendment No. 5 is entered into between the Health and Human Services
Commission (HHSC) and AMERIGROUP Texas, Inc. (HMO), to amend the 2000 Contract
for Services between the Health and Human Services Commission and HMO in the
Dallas Service Area. The effective date of this amendment is January 1, 2002.
The Parties agree to amend the Contract as follows:
1. Article XIII is amended to read as follows:
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.2 HMO capitation rates listed below reflect program increases
appropriated by the 76th and 77th legislatures for physician services
(to include THSteps providers) and outpatient facility services. Rates
will be increased starting January 1, 2002, to reflect increases in
traditional fee-for-service payments for 1) Evaluation and Management
Level 3 services (procedure code 99213), and 2) high-volume providers.
The methodology for determining high-volume providers will be
distributed to HMO by HHSC ("High-volume Provider Methodology"). The
first rate increase will be effective January 1, 2002, and will
reflect increases for procedure code 99213. Rate increases for high
volume providers will be effective the first day of the month after
the "High-volume Provider Methodology" is released by HHSC. The
Methodology will state the amount of each increase (99213 and
high-volume provider). Final rates with all increases included are
shown in the table below.
13.1.2. HMO must submit reports to HHSC indicating the methodology used and
must certify that the funds provided to the HMO for the pass through
have been passed through to providers. HMO must use the reporting
format specified by HHSC and follow the reporting schedule indicated
on the HHSC deliverables matrix.
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13.1.2.2 Capitation Rates
Risk Group Monthly Capitation Amounts
TANF Adults $196.56
TANF Children > 12 Months of
Age $ 79.00
Expansion Children > 12 Months
of Age $ 77.72
Newborns ((less than or equal to)
12 Months of Age) $354.21
TANF Children (less than or equal to)
12 Months of Age $354.21
Expansion Children (less than or equal to)
12 Months of Age $354.21
Federal Mandate Children $ 56.75
CHIP Phase I $ 75.37
Pregnant Women $229.56
Disabled/Blind Administration $ 14.00
13.1.2.3 Delivery Supplemental Payment. A one-time per pregnancy supplemental
payment for each delivery shall be paid to HMO in the following
amount: $3,076.23. HMO will receive a DSP for each live or still
birth. The one-time payment is made regardless of whether there is a
single or multiple births at time of delivery. A delivery is the birth
of a liveborn infant, regardless of the duration of the pregnancy, or
a stillborn (fetal death) infant of 20 weeks or more gestation. A
delivery does not include a spontaneous or induced abortion,
regardless of the duration of the pregnancy.
13.1.2.4 For an HMO Member who is classified in the Pregnant Women, TANF
Adults, TANF Children >12 months, Expansion Children >12 months,
Federal Mandate Children, or CHIP risk group, HMO will be paid the
monthly capitation amount identified in Article 13.1.2 for each month
of classification, plus the DSP amount identified in Article 13.1.2.
13.1.2.5 HMO must submit a monthly DSP Report (report) that includes the data
elements specified by TDH. TDH will consult with contracted HMOs prior
to revising the report data elements and requirements. The reports
must be submitted to TDH in the format and time specified by TDH. The
report must include only unduplicated deliveries. The report must
include
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only deliveries for which HMO has made a payment for the delivery, to
either a hospital or other provider. No DSP will be made for
deliveries which are not reported by HMO to TDH within 210 days after
the date of delivery, or within 30 days from the date of discharge
from the hospital for the stay related to the delivery, whichever is
later.
13.1.2.6 HMO must maintain complete claims and adjudication disposition
documentation, including paid and denied amounts for each delivery.
HMO must submit the documentation to TDH within five (5) days from the
date of a TDH request for documents.
13.1.2.7 The DSP will be made by TDH to HMO within twenty (20) state working
days after receiving an accurate report from HMO.
13.1.2.8 All infants of age equal to or less than twelve months (Newborns) in
the TANF Children, Expansion Children, and Newborns risk groups will
be capitated at the Newborns classification capitation amount in
Article 13.1.2.
AGREED AND SIGNED by an authorized representative of the parties on
______________________________2001.
Health and Human Services Commission AMERIGROUP Texas, Inc.
By: By:
------------------------- --------------------------
▇▇▇ ▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
President and CEO
Approved as to Form:
---------------------------
Office of General Counsel
PPAC Rate Increase Amendment
12/12/01
AMENDMENT 6
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
DALLAS SERVICE DELIVERY AREA
AMENDMENT 6
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM IN THE DALLAS SDA
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 SECTION 1.4, RENEWAL REVIEWS.................................................... 1
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS.......................................................... 2
SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS.................. 3
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS RETENTION.......................... 3
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS REQUIREMENTS.................................. 3
SECTION 2.07 MODIFICATION OF SECTION 4.3, PERFORMANCE BOND................................................... 4
SECTION 2.08 MODIFICATION OF SECTION 4.6, AUDIT.............................................................. 4
SECTION 2.09 MODIFICATION OF SECTION 4.9, THIRD PARTY RECOVERY............................................... 4
SECTION 2.10 MODIFICATION OF SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS.................................... 4
SECTION 2.11 MODIFICATION TO SECTION 5.4, SAFEGUARDING INFORMATION........................................... 5
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED BUSINESSES (HUBS)....................... 5
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL................................................. 6
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY................................................ 6
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS.................... 7
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES................................................. 8
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS ........... 8
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS........................................ 9
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS.................................................... 9
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS............................................ 9
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM................................................ 9
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM.......................................... 9
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE....................................... 10
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA) COMPLIANCE........................................................................................ 10
SECTION 2.25 MODIFICATION OF SECTION 12.1., FINANCIAL REPORTS................................................ 10
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER COMPLAINTS............................. 11
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS................................................. 12
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH REPORT............................... 12
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT.................................... 12
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS.............................. 12
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS............................................... 13
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE.................................... 13
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES............................................................ 15
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS..................... 15
SECTION 2.35 MODIFICATION OF SECTION 14.3, NEWBORN ENROLLMENT................................................ 16
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES.......................................................... 16
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO.............................................. 16
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED....................... 16
SECTION 2.39 MODIFICATION OF SECTION 19.1, CONTRACT TERM..................................................... 17
SECTION 2.40 MODIFICATIONS TO CONTRACT APPENDICES............................................................ 17
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES........................................................ 17
HHSC CONTRACT ▇▇. ▇▇▇-▇▇-▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇
▇▇▇▇▇▇ OF ▇▇▇▇▇▇
AMENDMENT 6
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
DALLAS 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. ("HMO"),
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 HMO 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 Section 15.2
of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective September 1, 2002, and terminates on August 31,
2003, unless extended or terminated sooner in accordance with the Agreement.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
The Health Care Financing Administration (HCFA) has had a name change to
the Centers for Medicare and Medicaid Services (CMS). All references to HCFA in
the Agreement should be replaced with CMS.
SECTION 2.02 MODIFICATION OF SECTION 1.4, RENEWAL REVIEWS
Section 1.4 is replaced with the following language:
"Renewal Review. At its sole discretion, HHSC may choose to
conduct a renewal review of HMO's performance and compliance with
this contract as a condition for retention and renewal."
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SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS
(a)The following terms amend and modify the definitions set forth in
Article 2:
"CMS means the Centers for Medicare and Medicaid Services,
formerly known as the Health Care Financing Administration
(HCFA), which is the federal agency responsible for administering
Medicare and overseeing state administration of Medicaid.
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 woman, serious jeopardy to the
health of the fetus.
FAIR HEARING means the process adopted and implemented by
the Texas Health and Human Services Commission, 25 TAC Chapter 1,
in compliance with federal regulations and state rules relating
to Medicaid Fair Hearings.
HEDS means the HMO/EPO/Dental Services Division of the Texas
Health and Human Services Commission.
HHSC means the Texas Health and Human Services Commission or
its designees.
THIRD PARTY LIABILITY (TPL) means the legal responsibility
of another individual or entity to pay for all or part of the
services provided to Members under this contract (see 1 TAC,
Subchapter 354.2301 et seq., relating to Third Party Resources).
TP 40 means Type Program 40, which is a TDHS Medicaid
program eligibility type assigned to pregnant women under 185% of
the federal poverty level (FPL).
TP 45 means Type Program 45, which is a TDHS Medicaid
program eligibility code assigned to newborns (under 12 months)
who are born to mothers who are Medicaid eligible at the time of
the child's birth.
TexMedNet means Texas Medical Network, which is the State's
information system that processes claims and encounters.
TexMedNet's functions include, but are not limited to eligibility
verification, claims and encounters submissions, e-mail
communications, and electronic funds transfers."
(b) The term "HHSCS" is deleted and replaced with "TDHS" as defined in
Article 2 of the Contract.
(c) The term "THHSC" is deleted and replaced with "HHSC" as defined above.
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SECTION 2.04 MODIFICATION OF SECTION 3.4, PLAN MATERIALS AND DISTRIBUTION OF
PLAN MATERIALS
Section 3.4.3 is replaced with the following language:
"3.4.3 All plan materials regarding the STAR Program,
including Member education materials, must be submitted to HHSC
for approval prior to distribution. HHSC has fifteen (15) working
days to review the materials and recommend any suggestions or
required changes. If HHSC has not responded to HMO by the
fifteenth (15th) day, HMO may print and distribute these
materials. HHSC reserves the right to request HMO to modify plan
materials that are deemed approved and have been printed or
distributed. These modifications can be made at the next printing
unless substantial non-compliance exists. An exception to the
fifteen (15) working day timeframe may be requested in writing by
HMO, for written provider materials that require a quick
turn-around time (e.g., letters). These materials will generally
be reviewed by HHSC within five (5) working days. HHSC reserves
the right to require revisions to materials if inaccuracies are
discovered or if changes are required by changes in policy or
law. These changes can be made at the next printing unless
substantial non-compliance exists, as determined by HHSC.
SECTION 2.05 MODIFICATION OF SECTION 3.5, RECORDS REQUIREMENT AND RECORDS
RETENTION
Section 3.5.1 is replaced with the following language:
"3.5.1 HMO must keep all records required to be
created and retained under this Agreement in accordance with the
standards set forth herein. Records related to Members served in
the HMO's service area(s) must be made available in HMO's local
office when requested by HHSC.
Original records, except paper claims, must be kept in the
form they were created in the regular course of business for a
minimum of three (3) years following the expiration of the
contract period, including any extensions. Paper claims may be
digitally copied from the time of initial receipt, if the HMO: 1)
receives HHSC prior written approval; 2) certifies that an
unaltered copy of the original claim received can be produced
upon request; 3) the retention system is reliable and supported
by a retrieval system that allows reasonable accurate records.
HHSC may require the HMO to retain the records for an additional
period if an audit, litigation or administrative action involving
the records exists."
SECTION 2.06 MODIFICATION OF SECTION 3.7, HMO TELEPHONE ACCESS REQUIREMENTS
Section 3.7. is replaced with the following language:
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%;
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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 8.8) 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.
SECTION 2.07 MODIFICATION OF SECTION 4.3, PERFORMANCE BOND
Section 4.3 is replaced with the following language:
"4.3 HMO has furnished HHSC with a performance bond
in the form prescribed by HHSC and approved by TDI, naming HHSC
as Obligee, securing HMO's faithful performance of the terms and
conditions of this Agreement. The performance bond must be issued
in the amount of $100,000 for the Contract Period, plus an
additional 12 months after the expiration of the Contract Period.
If the Contract Period is renewed or extended pursuant to Article
15, the HMO must replace the performance bond with a separate
bond covering performance during the renewal or extension period,
plus an additional 12 months. The bond must be issued by a surety
licensed by TDI, and specify cash payment as the sole remedy. HMO
must deliver the bond to HHSC at the same time the signed HMO
contract, renewal or extension is delivered to HHSC."
SECTION 2.08 MODIFICATION OF SECTION 4.6, AUDIT
Section 4.6.2 is replaced with the following language:
"4.6.2 HHSC or its designee will conduct an audit of
HMO at least once every two years. HMO is responsible for paying
the costs of an audit conducted under this Article. The costs of
the audit paid by HMO are allowable costs under this Agreement."
SECTION 2.09 MODIFICATION OF SECTION 4.9, THIRD PARTY RECOVERY
Section 4.9.2 is replaced with the following language:
"4.9.2 Identification. HMO must develop and implement
systems and procedures to identify potential third parties who
may be liable for payment of all or part of the costs for
providing medical services to Members under this contract
Potential third parties must include any of the sources
identified in 42 C.F.R. 433.138, relating to identifying third
parties, except workers' compensation, uninsured and underinsured
motorist insurance, first and third party liability insurance and
tortfeasors. HMO must coordinate with HHSC to obtain information
from other state and federal agencies and HMO must cooperate with
HHSC in obtaining information from commercial third party
resources. HMO must require all providers to comply with the
provisions of 1 TAC Section 354.2301, et seq., relating to Third
Party Recovery in the Medicaid program."
SECTION 2.10 MODIFICATION OF SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS
Section 4.10.8 is replaced with the following language:
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"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 two or
three years, as applicable, from the date the rules promulgated
under HIPAA are adopted (see 45 CFR parts 160 through 164).
SECTION 2.11 MODIFICATION TO SECTION 5.4, SAFEGUARDING INFORMATION
Section 5.4. is replaced with the following language:
"5.4.1 The use and disclosure of all Member
information, records, and data (Member Information) collected or
provided to HMO by HHSC or another state agency is protected by
state and federal law and regulations, including, but not limited
to, the Health Insurance Portability and Accountability Act of
1996 (HIPAA), Public law 104-191, and 45 CFR parts 160 through
164. HMO agrees to ensure that any of its agents, including
subcontractors, to whom HMO discloses Member Information agrees
to the same restrictions and conditions that apply to HMO with
respect to Member Information.
SECTION 2.12 MODIFICATION OF SECTION 5.6, HISTORICALLY UNDERUTILIZED BUSINESSES
(HUBS)
Sections 5.6.1 through 5.6.3 are replaced with the following language:
"5.6.1 In accordance with Texas Government Code
Chapter 2161 and 1 TAC Section 111.11 et seq. and Section 392.100
state agencies are required to make a good faith effort to assist
Historically Underutilized Businesses (HUBs) in receiving
contract awards issued by the State. The goal of this program is
to promote full and equal business opportunity for all businesses
in contracting with the state. It is HHSC's intent that all
contractors make a good faith effort to subcontract with HUBs
during the performance of their contracts.
IMPORTANT NOTE: The Health and Human Services Commission has
concluded that HUB subcontracting opportunities may exist in
connection with this contract. See Appendix B to the Agreement
for the following instructions and form: "Grant/Contract
Applicants Client Services HUB Subcontracting Plan Instructions"
(C-IGA), and Determination of Good Faith Effort for Grant
Contracts (C-DGFE). If an approved HUB subcontracting plan is not
already on file with HHSC, THE HMO SHALL SUBMIT A COMPLETED
C-DGFE FORM ALONG WITH THE SIGNED CONTRACT OR RENEWAL.
If HMO responds, 'yes' to question two on Form C-DGFE, HMO
shall document good faith efforts to develop a HUB Subcontracting
Plan by completing and documenting the steps on form C-DGFE.
Additionally, quarterly reports on HUB subcontracting are
required according to the schedule on Form C-QSR. Quarterly
Report forms are included in Appendix B of this amendment.
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If HMO decides after the award to subcontract any part of
the contract, the HMO shall notify the contract manager prior to
entering into any subcontract. The HMO shall comply with the good
faith effort requirements relating to developing and submitting a
subcontracting plan.
5.6.2 HMO is required to submit HUB quarterly reports
to HHSC as required in Article 12.11.
5.6.3 HHSC will assist HMO in meeting the contracting
and reporting requirements of this Article."
SECTION 2.13 MODIFICATION OF SECTION 5.10, NOTICE AND APPEAL
Section 5.10 is replaced with the following:
"5.10 HMO must comply with the notice requirements
contained in 1 TAG Section 354.2211, and the maintaining benefits
and services contained in 1 TAC Section 354.2213, whenever HMO
intends to take an action affecting the Member benefits and
services under this contract. Also see the Member appeal
requirements contained in Article 8.6 of this Agreement."
SECTION 2.14 MODIFICATION OF SECTION 6.3, SPAN OF ELIGIBILITY
Section 6.3 and its subparts are replaced with the following language"
"6.3 The following outlines HMO's responsibilities
for payment of hospital and freestanding psychiatric facility
(facility) admissions:
6.3.1 The payor responsible for the hospital/facility
charges at the start of an inpatient stay remains responsible for
hospital/facility charges until the time of discharge, or until
such time that there is a loss of Medicaid eligibility.
6.3.2 HMO is responsible for professional charges
during every month for which the payor receives a full capitation
payment.
6.3.3 HMO is not responsible for any services after
effective date of loss of Medicaid eligibility
6.3.4 Plan Change. A Member cannot change from one
STAR health plan to another STAR health plan during an inpatient
hospital stay.
6.3.5 Hospital/Facility Transfer. Discharge from one
acute care hospital/facility and readmission to another acute
care hospital/facility within 24 hours for continued treatment is
not a discharge under this contract.
6.3.6 HMO insolvency or receivership. HMO is
responsible for payment of all services provided to a person who
was a Member on the date of insolvency or receivership to the
same extent they would otherwise be responsible under this
Article 6.3.
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6.3.7 For purposes of this Section 6.3, a Member
"loses Medicaid eligibility" when:
6.3.7.1 Medicaid eligibility is terminated and never
regained under one Medicaid Type Program with no subsequent
transfer of eligibility to another Medicaid Type Program; or
6.3.7.2 Medicaid eligibility is terminated and there is
a lapse of at least one month in regular Medicaid coverage.
The term "regular Medicaid coverage" refers to either
traditional fee-for-service Medicaid or Medicaid managed
care coverage; or
6.3.7.3 A client re-applies for Medicaid eligibility
and is certified for prior Medicaid coverage, as defined by
TDHS, for any month(s) prior to the month of application.
The term "prior Medicaid coverage" refers to Applicants who
are eligible for Medicaid coverage during the three-month
period before the month they apply for TANF or Medical
Programs. Prior Medicaid coverage may be continuous or there
may be interrupted periods of eligibility involving all or
some of the certified Members.
Administrative process limitations within the State's
application and recertification process do not constitute a "loss
of Medicaid eligibility".
SECTION 2.15 MODIFICATION OF SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK
PROVIDERS
Section 6.4.3 is replaced with the following language:
"6.4.3 HMO must pay a Member's existing out-of-network
providers for covered services until the Member's records,
clinical information and care can be transferred to a network
provider. Payment must be made within the time period required
for network providers. This Article does not extend the
obligation of HMO to reimburse the Member's existing
out-of-network providers for on-going care for more than 90 days
after Member enrolls in HMO or for more than nine months in the
case of a Member who at the time of enrollment in HMO has been
diagnosed with and receiving treatment for a terminal illness.
The obligation of HMO to reimburse the Member's existing
out-of-network provider for services provided to a pregnant
Member with 12 weeks or less remaining before the expected
delivery date extends through delivery of the child, immediate
postpartum care, and the follow-up checkup within the first six
weeks of delivery.
6.4.3.1 HMO will pay reasonable and customary rates for
all out-of-network provider claims with dates of service between
September 1, 2002 and November 30,2002. HMO must forward any
complaints submitted by out-of-network 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. Failure to comply with this provision
constitutes a default under Article XVI, Default and Remedies.
6.4.3.2 For all out-of-network provider claims with
dates of service on or after December 1, 2002, HMO must pay
providers a reasonable and
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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 providers submitted
after December 1, 2002 to HHSC, which will review all complaints.
If HHSC determines that payment is not consistent with the HMO's
approved methodology, the HMO must pay the provider a rate, using
the approved reasonable and customary methodology, as determined
by HHSC. Failure to comply with this provision constitutes a
default under Article XVI, Default and Remedies.
SECTION 2.16 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5.1 is replaced with the following language:
"6.5.1 HMO must pay for the professional, facility,
and ancillary services that are medically necessary to perform
the medical screening examination and stabilization of HMO Member
presenting as an emergency medical condition or an emergency
behavioral health condition to the hospital emergency department,
24 hours a day, 7 days a week, rendered by either HMO's
in-network or out-of-network providers. 6.5.1.1 For all
out-of-network providers, HMO will pay a reasonable and customary
amount for emergency services.
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
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.
6.5.1.2 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 submitted after
December 1, 2002 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 XVI, Default and
Remedies.
SECTION 2.17 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH CARE SERVICES -
SPECIFIC REQUIREMENTS
Section 6.6.8 is replaced with the following language:
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"6.6.8 When assessing Members for behavioral health
care services, HMO and network behavioral health providers must
use the DSM-IV multi-axial classification. HHSC may require use
of other assessment instrument/outcome measures in addition to
the DSM-IV. Providers must document DSM-IV and assessment/outcome
information in the Member's medical record."
SECTION 2.18 MODIFICATION TO SECTION 6.16, BLIND AND DISABLED MEMBERS
Section 6.16.1 is replaced with the following language:
"6.16.1 Blind and disabled Members' SSI status is
effective the date of State's eligibility system, SAVERR,
identifies the Member as Type Program 13 (TP13). On this
effective date, the Member becomes a voluntary STAR enrollee.
The State is responsible for updating the State's
eligibility system within 45 days of official notice of the
Members' federal SSI eligibility by the Social Security
Administration (SSA).
SECTION 2.19 MODIFICATION OF SECTION 8.4, MEMBER ID CARDS
Section 8.4.1 is replaced with the following language:
"8.4.1 A Medicaid Identification Form (Form 3087) is
issued monthly by the TDHS. The form includes the "STAR" Program
logo and the name and toll free number of the Member's health
plan. A Member may have a temporary Medicaid Identification (Form
1027-A), which will include a STAR indicator."
SECTION 2.20 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS
Section 10.1.3.6 is replaced with the following language:
"10.1.3.6 HMO is required to provide representation to
attend and participate in the HHSC Systems Workgroup as a part of
the Systems Scan Call."
SECTION 2.21 MODIFICATION OF SECTION 10.4, PROVIDER SUBSYSTEM
Subparts 7 and 8 of Section 10.4 are replaced with the following language:
"7. Support national provider number format (UPIN, NPIN,
CLIA, TPI, etc., as required by HHSC).
8. Provide Provider Network and Affiliation files 90 days
prior to implementation and updates monthly. Format will be
provided by HHSC to contracted entities."
SECTION 2.22 MODIFICATION OF SECTION 10.9, DATA INTERFACE SUBSYSTEM
Section 10.9.3 is replaced with the following language:
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"10.9.3 Provider Network and Affiliation Files. The HMO
will supply network provider data to the Enrollment Broker and
Claims Administrator. This data will consist of a Provider
Network File and a Provider Affiliation File. The HMO will submit
the Provider Network File to the Enrollment Broker and the
Provider Affiliation File to the Claims Administrator. Both files
shall accomplish the following objectives:
1. Provide identifying information for all managed care
providers (e.g. name, address, etc.).
2. Maintain history on provider enrollment/disenrollment.
3. Identify PCP capacity.
4. Identify any restrictions (e.g., age, sex, etc.)
5. Identify number and types of specialty providers
available to Members.
6. Provide other (Master Provider File) information
identified by HHSC."
SECTION 2.23 MODIFICATION OF SECTION 10.11, YEAR 2000 (Y2K) COMPLIANCE
Section 10.11 is deleted in its entirety.
SECTION 2.24 ADDITION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.
Section 10.12 is added as follows:
"10.12 Health Insurance Portability and Accountability
Act (HIPAA) Compliance. HMO's system must comply with applicable
certificate of coverage and data specification and reporting
requirements promulgated pursuant to the Health Insurance
Portability and Accountability Act (HIPPA) of 1996, P.L. 104-191
(August 21, 1996), as amended or modified.
SECTION 2.25 MODIFICATION OF SECTION 12.1., FINANCIAL REPORTS
Sections 12.1.4, 12.1.11, and 12.13 are replaced with the following
language, and Section 12.14 is added. Sections 12.1.2, 12.1.3, 12.1.7 and
12.1.10 are deleted in their entirety.
12.1.2 [Deleted]
12.3 [Deleted]
12.1.4 Final MCFS Reports. HMO must file two final
MCFS Reports for each of the following:
The initial two-year contract period (SFY 2000-2001),
The first one-year contract extension period (SFY
2002), and
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This second one-year contract extension period (SFY 2003).
The first final report must reflect expenses incurred during
each contract period and paid through the 90th day after the end
of the contract period. The first final report must be filed on
or before the 120th day after the end of each contract period.
The second final report must reflect expenses incurred during
each contract period and paid through the 334th day after the end
of the contract period. The second final report must be filed on
or before the 365th day after the end of each contract period.
12.1.7 [Deleted]
12.1.10 [Deleted]
12.1.11 IBNR Plan. HMO must furnish a written IBNR Plan
to manage incurred-but-not-reported (IBNR) expenses, and a
description of the method of insuring against insolvency,
including information on all existing or proposed insurance
policies. The Plan must include the methodology for estimating
IBNR. The plan and description must be submitted to HHSC no later
than 60 days after the effective date of this contract. Changes
to the IBNR plan and description must be submitted to HHSC no
later than 30 days before changes to the plan are implemented by
HMO.
12.1.13 Each report required under this Article must be
mailed to: Medicaid HMO Contract Deliverables Manager, HEDS
Division, Texas Health and Human Services Commission, ▇.▇. ▇▇▇
▇▇▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇ (Exception: The MCFS Report may
be submitted to HHSC via E-mail to ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇).
12.1.14 Bonus and/or Incentive Payment Plan. The HMO
must furnish a written Bonus and/or Incentive Payments Plan to
HHSC to determine whether such payments are allowable
administrative expenses in accordance with Appendix L, "Cost
Principles for Administrative Expenses, 11. Compensation for
Personnel Services, i. Bonuses and Incentive Payments." The
written plan must include a description of the plan's criteria
for establishing bonus and/or incentive payments, the methodology
to calculate bonus and/or incentive payments, and the timing as
to when these bonus and/or incentive payments are to be paid. The
plan and description must be submitted to HHSC for approval no
later than 30 days after the execution of the contract and any
contract renewal. If the HMO revises the Bonus and/or Incentive
Payment Plan, the HMO must submit the revised plan to HHSC for
approval prior to implementing the plan."
SECTION 2.26 MODIFICATION OF SECTION 12.4, SUMMARY REPORT OF PROVIDER COMPLAINTS
Section 12.4 is replaced with the following language:
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"12.4 HMO must submit a Summary Report of Provider
Complaints. HMO must also reports complaints submitted to its
subcontracted risk groups (e.g., IPAs). The complaint report
format must be submitted not later than 45 days following the end
of the state fiscal quarter in a format specified by HHSC."
SECTION 2.27 MODIFICATION OF SECTION 12.6, MEMBER COMPLAINTS
Section 12.6 is replaced with the following language:
"12.6 HMO must submit a quarterly summary report of
Member complaints. HMO must also report complaints submitted to
its subcontracted risk groups (e.g., IPAs). The complaint report
must be submitted not later than 45 days following the end of the
state fiscal quarter in a format specified by HHSC."
SECTION 2.28 MODIFICATION OF SECTION 12.13, EXPEDITED PRENATAL OUTREACH REPORT
Section 12.13 is deleted in its entirety.
SECTION 2.29 ADDITION OF SECTION 12.14, MEMBER HOTLINE PERFORMANCE REPORT
Section 12.14 is added as follows:
"12.14 MEMBER HOTLINE PERFORMANCE REPORT
HMO must submit, on a monthly basis, a Member Hotline
Performance Report that contains all required elements set out in
Article 3.7 of this Agreement in a formant approved by HHSC. The
report is due on the 30th of the month following the end of each
month."
SECTION 2.30 ADDITION OF SECTION 12.15, SUBMISSION OF STAR DELIVERABLES/REPORTS
Section 12.15 is added as follows:
"12.15 SUBMISSION OF STAR DELIVERABLES/REPORTS
12.15.1 Electronic Mail. STAR deliverables and reports
should be submitted to HHSC via electronic mail unless HHSC
expressly provides that they must be submitted in a different
manner. Reports and deliverables that may not be submitted
electronically include, but are not limited to: Encounter Data,
Supplemental Delivery Payment data, UDT data, and certain Member
Materials.
12.15.1.1 The e-mail address for deliverables submission
is ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇.▇▇.▇▇. 12. 15. 1.2 Electronic Mail
Restrictions:
File Size: E-mail file size is limited to 2.5 MB. Files
larger than that will need to be compressed (zip file) or split
into multiple files for submission.
Confidentiality: Routine STAR deliverables/reports should
not contain any member specific data that would be considered
confidential.
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12.15.2 FOHC and RHC Deliverables. HMO may submit FQHC
and RHC deliverables by uploading the required information to the
Claims Administrator's Bulleting Board System (BBS). The uploaded
data must contain a unique 8-digit control number. HMO should
format the 8-digit control number as follows:
2 digit plan code identification number;
Julian date; and then
- HMO's 3-digit report number (i.e., HMO's first
report will be 001).
After uploading the data to the BBS, the HMO must notify
HHSC via e-mail that it has uploaded the data, and include the
name of the file and recipient directory. HMO must also mail
signed original report summaries, including the corresponding
8-digit control number, to HHSC within three (3) business days
after uploading the data to the BBS.
12.15.3 Special Submission Needs. In special cases
where other submission methods are necessary, HMO must contact
the assigned Health Plan Manager for authorization and
instructions.
12.15.4 Deliverables due via Mail. HMO should mail
reports and deliverables that must be submitted by mail to the
following address:
General Mail:
Texas Health & Human Services Commission
HEDS Contract Deliverables
▇.▇. ▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
Overnight Mail:
Texas Health & Human Services Commission
HEDS Contract Deliverables
▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
12.15.5 Texas Department of Insurance (TDI). The
submission of deliverables/reports to HHSC does not relieve the
Plan of any reporting requirements/responsibility with TDI. The
Plan should continue to report to TDI as they have in the past."
SECTION 2.31 MODIFICATIONS TO SECTION 13.1, CAPITATION AMOUNTS
Section 13.1.7.1 is added:
"13.1.7.1 HMO rates for FY 2002 and FY 2003 include pass
through funds for providers, as appropriated by the 77th Texas
Legislature. HMO must file reports on pass through methodology
expenditures as requested by HHSC."
SECTION 2.32 MODIFICATION OF SECTION 13.2, EXPERIENCE REBATE TO THE STATE
Sections 13.2.1,13.2.2.1,13.2.3, and 13.2.5 are replaced with the following
language:
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 13 of 17
"13.2.1 For the Contract Period, HMO must pay to HHSC
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 set forth in
Appendix I, as reviewed and confirmed by HHSC. HHSC 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 for all STAR
Medicaid service areas contracted between the State and HMO.
13.2.3 Experience rebate will be based on a pre-tax
basis. Expenses for value-added services are excluded from the
determination of Net Income Before Taxes reported in the Final
MCFS Report; however, HMO may subtract from Net Income Before
Taxes, expenses incurred for value added services for the
experience rebate calculations.
13.2.5 There will be two settlements for payment(s) of
the experience rebate for SFY 2000-2001, two settlements for
payment(s) for the experience rebate for SFY 2002, and two
settlements for payment(s) for the experience rebate for SFY
2003. The first settlement for the specified contract period
shall equal 100 percent of the experience rebate as derived from
Net Income Before Taxes less the value-added services expenses in
the first final 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 the MCFS
report. If HHSC determines that corrections to the MCFS reports
are required, based on a 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
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
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 14 of 17
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."
SECTION 2.33 SECTION 13.3, PERFORMANCE OBJECTIVES
Section 13.3.9 is replaced with the following language:
"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 17%
-------------------------------------------------------------------
5. 12 To 24 Months 12%
-------------------------------------------------------------------
PERCENT OF PERFORMANCE
PREGNANCY VISITS OBJECTIVE INCENTIVE FUND
-------------------------------------------------------------------
6. Initial prenatal exam 15%
-------------------------------------------------------------------
7. Postpartum visit 12%
-------------------------------------------------------------------
SECTION 2.34 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS
Sections 13.6.1.1, 13.6.3 and 13.6.6 are replaced with the following
language:
"13.6.1.1 The mother of the newborn Member may request
that the newborn's health plan coverage be changed to another HMO
during the first 90 days following the date of birth, but may
only do so through the Medicaid managed care Enrollment Broker.
13.6.3 All non-TP45 newborns whose mothers are HMO
Members at the time of the birth will be retroactively enrolled
into the HMO by TDHS Data Control except as outlined in Article
13.6.4.
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 15 of 17
13.6.5 HMO is responsible for payment for all covered
services provided to TP40 members by in-network or out-of-network
providers from the date of enrollment in HMO, but prior to HMO
receiving TP40 Member on monthly capitation file. HMO must waive
requirement for prior authorization (or grant retroactive prior
authorization) for medically necessary services provided from the
date of enrollment in HMO, but prior to HMO receiving TP40 member
on monthly capitation file."
SECTION 2.35 MODIFICATION OF 14.3, NEWBORN ENROLLMENT
Section 14.3.1.1 is replaced with the following language:
"14.3.1.1 A mother of a newborn Member may request a plan
change for her newborn during the first 90 days by contacting
the Enrollment Broker. If a change is approved, the Enrollment
Broker will notify both plans involved in the process. If no
alternative to the plan change can be reached, the Enrollment
Broker will notify the HMO of the newborn plan change request
received from the mother."
SECTION 2.36 MODIFICATION OF SECTION 15.12, NOTICES
Section 15.12 is replaced with the following language:
"Notice may be given by registered mail, facsimile, and/or
hand delivery. All notices to HHSC shall be addressed to:
Medicaid HMO Contract Deliverables Manager, HEDS Division, Texas
Health and Human Services Commission, ▇.▇. ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇,
▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇, with a copy to the Contract Administrator.
Notices to HMO shall be addressed to President/CEO, ▇▇▇▇ ▇.
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇."
SECTION 2.37 MODIFICATION OF SECTION 18.1.6, TERMINATION BY HMO
Section 18.1.6 is replaced with the following language:
"18.1.6 HMO may terminate this contract if HHSC fails
to pay HMO as required under Article 13 of this contract or
otherwise materially defaults in its duties and responsibilities
under this contract, or by giving notice no later than 30 days
after receiving the capitation rates for the Contract Period.
Retaining premium, recoupment, sanctions, or penalties that are
allowed under this contract or that result from HMO's failure to
perform or HMO's default under the terms of this contract is not
cause for termination."
SECTION 2.38 MODIFICATION OF SECTION 18.10, REVIEW OF REMEDY OR REMEDIES TO BE
IMPOSED
Section 18.10 is replaced with the following language:
"18.10.2 HMO and HHSC must attempt to informally resolve
a dispute. If HMO and HHSC are unable to informally resolve a
dispute, HMO must notify the HEDS Manager and Director of
Medicaid/CHIP Operations that HMO and HHSC cannot agree. The
Director of Medicaid/CHIP Operations will refer the dispute to
the State Medicaid
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 16 of 17
Director who will appoint a committee to review the dispute
under HHSC's dispute resolution procedures. The decision of the
dispute resolution committee will be HHSC's final administrative
decision. "
SECTION 1.01 MODIFICATION OF SECTION 19.1, CONTRACT TERM
Section 19.1 is replaced with the following language:
"19.1 The effective date of this contract is
September 1, 2000. This contract will terminate on August
31, 2003 unless extended or terminated earlier as provided for
elsewhere in this contract."
SECTION 1.02 MODIFICATIONS TO CONTRACT APPENDICES.
The following appendices are replaced with the versions attached to this
Amendment:
- Appendix B, HUB
- Appendix C, Value-added Services
- Appendix F, Texas Trauma Facilities
- Appendix G, Texas Hemophilia Centers
- Appendix I, Financial Statistical Report
- Appendix K, Preventive Health Performance Objectives
ARTICLE 2. 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 HMO HAVE EACH CAUSED THIS AMENDMENT TO BE
SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
AMERIGROUP TEXAS, INC. HEALTH & HUMAN SERVICES COMMISSION
By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. By: /s/ [ILLEGIBLE]
------------------------------ ------------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇ ▇▇▇▇▇▇▇
President and CEO FOR Commissioner
Date: 8/27/2002 Date: 8.29.02
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 17 of 17
HHSC ▇▇▇▇▇▇▇▇ ▇▇. ▇▇▇-▇▇-▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇
▇▇▇▇▇▇ OF ▇▇▇▇▇▇
AMENDMENT 7
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
DALLAS 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)
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 1 of 4
- September 1, 2002 through August 31, 2003 (3rd
Experience Rebate Period)"
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.
HHSC Contract ▇▇▇-▇▇-▇▇▇
Page 2 of 4
13.2.3 Experience rebate will be based on a pre-tax
basis. Expenses for value-added services are excluded from the
determination of Net Income Before Taxes reported in the Final
MCFS Report; however, HMO may subtract from Net Income Before
Taxes, expenses incurred for value added services for the
experience rebate calculations.
13.2.4 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 payment(s) 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 8
TO THE AGREEMENT
BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP TEXAS, INC.
FOR
HEALTH SERVICES TO
THE MEDICAID STAR PROGRAM
IN THE
DALLAS SERVICE DELIVERY AREA
AMENDMENT 8
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION AND AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES TO THE MEDICAID STAR PROGRAM
IN THE DALLAS SERVICE DELIVERY AREA
TABLE OF CONTENTS
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........................................... 1
SECTION 2.03 MODIFICATION TO ARTICLE 3.2, NON-PROVIDER SUBCONTRACTS........................... 3
SECTION 2.04 MODIFICATION TO SECTION 3.5, RECORDS REQUIREMENTS AND RECORDS RETENTION.......... 3
SECTION 2.05 MODIFICATION TO SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS..................... 3
SECTION 2.06 ADDITION TO ARTICLE 5, STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS ......... 4
SECTION 2.07 SECTION 6.1, SCOPE OF SERVICES................................................... 4
SECTION 2.08 ADDITION TO SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS......... 5
SECTION 2.09 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES.................................. 5
SECTION 2.10 MODIFICATION OF SECTION 6.13, PEOPLE WITH DISABILITIES, SPECIAL HEALTH CARE
NEEDS OR CHRONIC OR COMPLEX CONDITIONS.................................................... 7
SECTION 2.11 MODIFICATION OF SECTION 7.1.3, TIMEFRAMES FOR ACCESS REQUIREMENTS................ 10
SECTION 2.12 MODIFICATION OF SECTION 7.2, PROVIDER CONTRACTS.................................. 10
SECTION 2.13 MODIFICATION OF SECTION 7.7, PROVIDER QUALIFICATIONS - GENERAL................... 10
SECTION 2.14 MODIFICATION OF SECTION 7.8, PRIMARY CARE PROVIDERS.............................. 13
SECTION 2.15 MODIFICATION OF SECTION 8.2, MEMBER HANDBOOK..................................... 13
SECTION 2.16 MODIFICATION OF SECTION 8.5, MEMBER COMPLAINTS................................... 14
SECTION 2.17 DELETION OF SECTION 8.6, MEMBER NOTICE, APPEALS AND FAIR HEARINGS................ 21
SECTION 2.18 MODIFICATION OF SECTION 9.01, MARKETING MATERIAL MEDIA AND DISTRIBUTION.......... 21
SECTION 2.19 MODIFICATION OF SECTION 10.7, UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM.......... 21
SECTION 2.20 MODIFICATION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.......................:............................. 22
SECTION 2.21 MODIFICATION OF SECTION 11.1, QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM....................................................................... 22
SECTION 2.22 MODIFICATION TO ARTICLE 11, QUALITY ASSURANCE AND QUALITY IMPROVEMENT
PROGRAM................................................................................... 22
SECTION 2.23 MODIFICATION OF ARTICLE 12, REPORTING REQUIREMENTS............................... 23
SECTION 2.24 MODIFICATION OF SECTION 12.10, QUALITY IMPROVEMENT REPORTS....................... 23
SECTION 2.25 MODIFICATION OF SECTION 13.1, CAPITATION AMOUNTS................................. 24
SECTION 2.26 MODIFICATION OF SECTION 13.3, PERFORMANCE OBJECTIVES............................. 24
SECTION 2.27 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS................................................................................ 25
SECTION 2.28 MODIFICATION OF SECTION 14.1, ELIGIBILITY DETERMINATION.......................... 25
SECTION 2.29 MODIFICATION OF ARTICLE 15, GENERAL PROVISIONS................................... 25
SECTION 2.30 MODIFICATION OF SECTION 16.3, DEFAULT BY HMO..................................... 25
SECTION 2.31 MODIFICATION OF SECTION 18.8, CIVIL MONETARY PENALTIES........................... 26
SECTION 2.32 MODIFICATION OF ARTICLE 19, TERM................................................. 26
SECTION 2.33 MODIFICATION TO APPENDIX A, STANDARDS FOR QUALITY IMPROVEMENT PROGRAMS........... 26
SECTION 2.34 MODIFICATION TO APPENDIX D, CRITICAL ELEMENTS.................................... 26
SECTION 2.35 MODIFICATION OF APPENDIX E, TRANSPLANT FACILITIES................................ 26
SECTION 2.36 ADDITION OF NEW APPENDIX O, STANDARD FOR MEDICAL RECORDS......................... 26
SECTION 2.37 MODIFICATION TO APPENDIX K, PERFORMANCE OBJECTIVES............................... 26
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES.......................................... 27
i
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.
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 the STAR Program.
POST-STABILIZATION CARE SERVICES means covered services,
related to an emergency medical condition that are provided after
an Member is
HHSC Contract 529-03-037-H
2 of 27
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.
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."
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
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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
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 date for implementation of the requested changes to
the requirements related to covered services. The work plan will
include timeframes for completing the necessary contract and
waiver amendments, adjustments to capitation rates,
identification of HMO and enrollment materials needing revision,
and notifications to Members.
6.1.9.2 In order to meet the requirements of Section
6.1.9.1, HMO must notify HHSC of grounds for and provide detail
concerning its moral or religious objections and the specific
services covered under the objection, no less than 120 days prior
to the proposed effective date of the policy change.
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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(b)(4). HMO
will not be obligated to provide a Member with access to
out-of-network services if such services become available from a
network provider.
6.4.7 HMO must require through contract provisions or
the provider manual that each Member have access to a second
opinion regarding the use of any health care service. A Member
must be allowed access to a second opinion from a network
provider or out-of-network provider if a network provider is not
available, at no additional cost to the Member, in accordance
with 42 C.F.R. Section 438.206(b)(3)."
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,
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2002. HMO must forward any complaints submitted by out-of-network
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 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,
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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 post-stabilization care services
obtained within or outside the network that are not pre-approved
by a plan provider or other HMO representative, but administered
to maintain, improve, or resolve the Member's stabilized
condition if:
(a) the HMO does not respond to a request for preapproval
within 1 hour;
(b) the HMO cannot be contacted;
(c) or the HMO representative and the treating physician
cannot reach an agreement concerning the Member's care and a plan
physician is not available for consultation. In this situation,
the HMO must give the treating physician the opportunity to
consult with a plan physician and the treating physician may
continue with care of the patient until an HMO physician is
reached or the HMO's financial responsibility ends as follows:
the HMO physician with privileges at the treating hospital
assumes responsibility for the Member's care; the HMO physician
assumes responsibility for the Member's care through transfer;
the HMO representative and the treating physician reach an
agreement concerning the Member's care; or the Member is
discharged.
6.5.8 HMO must provide access to the HHSC-designated
Level I and Level II trauma centers within the State or hospitals
meeting the equivalent level of trauma care. HMOs may make
out-of-network reimbursement arrangements with the
HHSC-designated Level I and Level II trauma centers to satisfy
this access requirement."
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
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conditions. Once identified, HMO must have effective health
delivery systems to provide the covered services to meet the
special preventive, primary acute, and specialty health care
needs appropriate for treatment of the individual's condition.
The guidelines and standards established by the American Academy
of Pediatrics, the American College of Obstetrics/Gynecologists,
the U.S. Public Health Service, and other medical and
professional health organizations and associations' practice
guidelines whose standards are recognized by HHSC must be used in
determining the medically necessary services, assessment and plan
of care for each individual.
6.13.2.1 In accordance with 42 C.F.R. 438.208(b)(3), HMO
shall provide information that identifies Members who the HMO has
assessed as special health care needs Members to the State's
enrollment broker. The information will be provided in a format
to be specified by HHSC and updated by the 10th day of each
month. In the event that a special health care needs Member
changes health plans, HMO will work with receiving HMO to provide
information concerning the results of the HMO's identification
and assessment of that Member's needs, to prevent duplication of
those activities.
6.13.3 HMO must require that the PCP for all persons with
disabilities, special health care needs or chronic or complex
conditions develop a plan of care to meet the needs of the
Member. The plan of care must be based on health needs,
specialist(s) recommendations, and periodic reassessment of the
Member's developmental and functional status and service delivery
needs. HMO must require providers to maintain record keeping
systems to ensure that each Member who has been identified with a
disability or chronic or complex condition has an initial plan of
care in the primary care provider's medical records, that Member
agrees to that plan of care, and that the plan is updated as
often as the Member's needs change, but at least annually.
6.13.4 HMO must provide a primary care and specialty care
provider network for persons with disabilities, special health
care needs, or chronic or complex conditions. Specialty and
subspecialty providers serving all Members must be Board
Certified/Board Eligible in their specialty. HMO may request
exceptions from HHSC for approval of traditional providers who
are not board-certified or board-eligible but who otherwise meet
HMO's credentialing requirements.
6.13.5 HMO must have in its network PCPs and specialty
care providers that have documented experience in treating people
with disabilities, special health care needs, or chronic or
complex conditions, including children. For services to children
with disabilities, special health care needs, or chronic or
complex conditions, HMO must have in its network PCPs and
specialty care providers that have demonstrated experience with
children with disabilities, special health care needs, or chronic
or complex conditions in pediatric specialty centers such as
children's hospitals, medical schools, teaching hospitals and
tertiary center levels.
6.13.6 HMO must provide information, education and
training programs to Members, families, PCPs, specialty
physicians, and community agencies about the care and treatment
available in
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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 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.
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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, 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, TIMEFRAMES 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 7.2.8.2.1 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
--------------------------------------------------------------------------------
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
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PROVIDER QUALIFICATION
--------------------------------------------------------------------------------
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 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;
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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 practitioner's current ability to practice.)
m) Any physical or mental health problems that may affect
current ability to provide health care;
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 practitioner's 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 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
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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.
7.7.2.14 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 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."
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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
submitted to HHSC at least 30 days prior to the implementation of
the modification or amendment.
For purposes of Section 8.5., an "authorized representative"
is any person or entity acting on behalf of the Member and with
the Member's written consent. A provider may be an "authorized
representative."
8.5.1 MEMBER COMPLAINT PROCESS
8.5.1.1 HMO must have written policies and procedures for
receiving, tracking, responding to, reviewing, reporting and
resolving complaints by Members or their authorized
representatives.
8.5.1.2 HMO must resolve complaints within 30 days from
the date that the complaint was received. The complaint procedure
must be the same for all Members 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
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publish in the Member Handbook, at least one local and one
toll-free telephone number with TeleTypewriter/Telecommunications
Device for the Deaf (TTY/TTD) and interpreter capabilities for
making complaints.
8.5.1.6 HMO's process must require that every complaint
received in person, by telephone or in writing must be
acknowledged and recorded in a written record and logged with the
following details: date; identification of the individual filing
the complaint; identification of the individual recording the
complaint; nature of the complaint; disposition of the complaint
(i.e., how the HMO resolved the complaint); corrective action
required; and date resolved.
8.5.1.7 HMO is prohibited from discriminating or taking
punitive action against a Member or his or her representative for
making a complaint.
8.5.1.8 If the Member makes a request for disenrollment,
the HMO shall give the Member information on the disenrollment
process and direct the Member to the Enrollment Broker. If the
request for disenrollment includes a complaint by the Member, the
complaint will be processed separately from the disenrollment
request, through the complaint process.
8.5.1.9 HMO will cooperate with the Enrollment Broker,
HHSC, and HHSC's Member resolution service contractors to resolve
all Member complaints. Such cooperation may include, but is not
limited to, providing information or assistance to internal
complaint committees.
8.5.1.10 HMO must provide designated staff to assist
Members in understanding and using HMO's complaint system. HMO's
designated staff must assist Members in writing or filing a
complaint and monitoring the complaint through the HMO's
complaint process until the issue is resolved.
8.5.2 STANDARD MEMBER APPEAL PROCESS
8.5.2.1 HMO must develop, implement and maintain an appeal
procedure that complies with the requirements in federal laws and
regulations, including 42 C.F.R. Section 431.200 and 42 C.F.R.
Part 438, Subpart F, "Grievance System." An appeal is a
disagreement with an "action" as defined in Article 2 of the
Contract. The appeal procedure must be the same for all Members.
When a Member or his or her authorized representative expresses
orally or in writing any dissatisfaction or disagreement with an
action, the HMO must regard the expression of dissatisfaction as
a request to appeal an action.
8.5.2.2 A Member must file a request for an internal
appeal within 30 days from receipt of the notice of the action.
To ensure continuation of currently authorized services, however,
the Member must file the appeal on or before the later of: 10
days following the HMO's mailing of the notice of the action or
the intended effective date of the proposed action.
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8.5.2.3 HMO must designate an officer who has primary
responsibility for ensuring that appeals are resolved in
compliance with written policy and within the time required. An
"officer" of HMO means a president, vice president, secretary,
treasurer, or chairperson of the board for a corporation, the
sole proprietor, the managing general partner of a partnership,
or a person having similar executive authority in the
organization.
8.5.2.4 The provisions of Article 21.58A, Texas Insurance
Code, relating to a Member's right to appeal an adverse
determination made by HMO or a utilization review agent by an
independent review organization, do not apply to a Medicaid
recipient. Federal fair hearing requirements (Social Security Act
Section 1902a(3), codified at 42 C.F.R. Section 431.200 et. seq.)
require the agency to make a final decision after a fair hearing,
which conflicts with the State requirement that the IRO make a
final decision. Therefore, Article 21.58A is pre-empted by the
federal requirement.
8.5.2.5 HMO must have policies and procedures in place
outlining the role of HMO's Medical Director for an appeal of an
action. The Medical Director must have a significant role in
monitoring, investigating and hearing appeals. In accordance with
42 C.F.R. Section 438.406, the HMO's policies and procedures must
require that individuals who make decisions on appeals were not
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
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up in writing; identification of the individual filing; nature of
the appeal; disposition of the appeal; notice of disposition to
Member.
8.5.2.10 HMO must send a letter to the Member within 5
business days acknowledging receipt of the appeal request. Except
as provided in Section 8.5.3.2, HMO must complete the entire
appeal process within 30 calendar days after receipt of the
initial written or oral request for appeal. The timeframe may be
extended up to 14 calendar days if the Member requests an
extension; or the HMO shows that there is a need for additional
information and how the delay is in the Member's interest. If the
timeframe is extended, the HMO must give the Member written
notice of the reason for delay if the Member had not requested
the delay.
8.5.2.11 During the appeal process, HMO must provide the
Member a reasonable opportunity to present evidence, any
allegations of fact or law, in person as well as in writing. The
HMO must inform the Member of the time available for providing
this information, and in the case of an expedited resolution,
that limited time will be available (see Section 8.5.3.2).
8.5.2.12 HMO must provide the Member and his or her
representative opportunity, before and during the appeals
process, to examine the Member's case file, including medical
records and any other documents considered during the appeal
process. HMO must include, as parties to the appeal, the Member
and his or her representative or the legal representative of a
deceased Member's estate.
8.5.2.13 In accordance with 42.C.F.R. Section 438.420, HMO
must continue the Member's benefits currently being received by
the Member, including the benefit that is the subject of the
appeal, if all of the following criteria are met: 1) the Member
or his or her representative files the appeal timely (as defined
in Section 8.5.2.2); 2) the appeal involves the termination,
suspension, or reduction of a previously authorized course of
treatment; 3) the services were ordered by an authorized
provider; 4) the original period covered by the original
authorization has not expired; and 5) the Member requests an
extension of the benefits. If, at the Member's request, the HMO
continues or reinstates the Member's benefits while the appeal is
pending, the benefits must be continued until one of the
following occurs: the Member withdraws the appeal; 10 days pass
after the HMO mails the notice, providing the resolution of the
appeal against the Member, unless the Member, within the 10-day
timeframe, has requested a State fair hearing with continuation
of benefits until a State fair hearing decision can be reached; a
state fair hearing office issues a hearing decision adverse to
the Member; the time period or service limits of a previously
authorized service has been met.
8.5.2.14 In accordance with 42 C.F.R. Section 438.420(d),
if the final resolution of the appeal is adverse to the Member,
and upholds the HMO's action, then to the extent that the
services were furnished to comply with Section 8.5.2.13, the HMO
may recover such costs from the Member.
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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.
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.
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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
8.5.4.1 HMO must inform Members that they generally have
the right to access the state fair hearing process in lieu of the
internal appeal system provided by HMO procedures set forth in
Sections 8.5.2 and 8.5.3. The notice must comply with the
requirements of 1 T.A.C. Chapter 357. In the case of an expedited
State Fair Hearing Process, the HMO must inform the Member that
he or she must first exhaust the HMO's internal expedited appeal
process.
8.5.4.2 HMO must notify Members that they may be
represented by an authorized representative in the state fair
hearing process.
8.5.5 NOTICES OF ACTION AND DISPOSITION OF APPEALS
8.5.5.1 NOTICE OF ACTION. HMO must notify the Member, in
accordance with 1 T.A.C. Chapter 357, whenever HMO takes an
action as defined in Article 2 of this contract. The notice must
contain the following information:
(a) the action the HMO or its contractor has taken or
intends to take;
(b) the reasons for the action;
(c) the Member's right to access the HMO internal appeal
process, as set forth in Sections 8.5.2 and 8.5.3, and/or to
access to the State Fair Hearing Process as provided in Section
8.5.4;
(d) the procedures by which Member may appeal HMO's action;
(e) the circumstances under which expedited resolution is
available and how to request it;
(f) the circumstances under which a Member can continue to
receive benefits pending resolution of the appeal (see Section
8.5.2.13), how to request that benefits be continued, and the
circumstances under which the Member may be required to pay the
costs of these services;
(g) the date the action will be taken;
(h) a reference to the HMO policies and procedures
supporting the HMO's action;
(i) an address where written requests may be sent and a
toll-free number that the Member can call to request the
assistance of a Member representative, file an appeal, or request
a Fair Hearing;
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(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).
(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
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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."
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.
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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 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 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."
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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.
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
12.10.6 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.
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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 amounts and the Delivery Supplemental
Payment (DSP) amount effective as of September 1, 2003 are
listed below.
-----------------------------------------------------------------------
DALLAS SDA MONTHLY
RISK GROUP CAPITATION AMOUNTS
-----------------------------------------------------------------------
TANF Children (> 1 year of age) $ 83.68
------------------------------------------------------------------
TANF Adults $ 197.70
------------------------------------------------------------------
Pregnant Women $ 301.91
------------------------------------------------------------------
Newborns* (up to 12 Months of Age) $ 337.98
------------------------------------------------------------------
Expansion Children (> 1 year of Age) $ 112.22
------------------------------------------------------------------
Federal Mandate Children $ 64.33
------------------------------------------------------------------
Disabled/Blind Administration $ 14.00
------------------------------------------------------------------
* Includes TANF Child & Expansion Children up to 12 months of Age.
----------------
[ILLEGIBLE] HMO
-----------
HHSC
-----------
----------------
Delivery Supplemental Payment. A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO
as provided below in the following amount: $3,076.23.
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]
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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 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 terms "include," "includes," and
"including" are terms of inclusion, and where used in the
Agreement, are deemed to be followed by the words "without
limitation."
15.14.2 Any references to "Sections," "Exhibits," or
"Attachments" are deemed to be references to Sections, Exhibits,
or Attachments to the Agreement.
15.14.3 Any references to agreements, contracts,
statutes, or administrative rules or regulations in the Agreement
are deemed references to these documents as amended, modified, or
supplemented from time to time during the term of the Agreement."
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 September
1, 2000. 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.
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: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. By:
----------------------------- --------------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇▇▇▇ ▇▇▇▇▇▇▇
President and CEO Commissioner
Date: 8/6/03 Date:
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