Exhibit 10.22
AMENDMENT
This is an amendment ("Amendment") of the Contract for Services
relating to Medicaid STAR + PLUS for ▇▇▇▇▇▇ County between the Texas Department
of Human Services ("TDHS") and Amerigroup Texas, Inc. ("HMO") executed on August
30, 2002, to be effective on September 1, 2002 ("STAR + PLUS Contract"). TDHS
and HMO agree to amend the STAR + PLUS Contract as follows:
1. Without Cause Termination. Either TDHS or HMO may terminate the STAR +
PLUS Contract without cause. The party terminating the STAR + PLUS
Contract must give the other party 90 days written notice of intent to
terminate. The termination date will be calculated as the last day of
the month following 90 days from the date the notice of intent to
terminate is received by TDHS. Notwithstanding any other provision of
this Amendment of the STAR + PLUS Contract, neither TDHS nor HMO can
exercise this termination provision until after midnight on February
28, 2003.
2. Transition Period. If either party terminates the STAR + PLUS
Contract pursuant to Paragraph 1 above, TDHS and HMO must prepare a
transition plan, which is acceptable to and approved by TDHS, to
ensure that Members are reassigned to other plans without interruption
of services. That transition plan shall be implemented during the
90-day period between receipt of notice and the termination date. HMO
must continue to perform services under the transition plan until the
last day of the month following 90 days from the date of receipt of
notice.
3. Effective Date. The effective date of this Amendment is September 1,
2002.
IN WITNESS HEREOF, TDHS and the HMO have each caused this Amendment to be signed
and delivered by its duly authorized representative.
AMERIGROUP TEXAS, INC. TEXAS DEPARTMENT OF HUMAN SERVICES
By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. By: /s/ [ILLEGIBLE]
-------------------------- ------------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇▇▇ ▇. ▇▇▇▇
President and CEO Commissioner
Date: 8/30/2002 Date: 6/30/02
TDHS ▇▇▇▇▇▇▇▇ ▇▇. ▇▇▇▇▇▇▇▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇
▇▇▇▇▇▇ OF ▇▇▇▇▇▇
AMENDMENT FY03-03
TO THE AGREEMENT BETWEEN THE
TEXAS DEPARTMENT OF HUMAN SERVICES
AND
AMERIGROUP TEXAS INC
FOR HEALTH SERVICES
TO THE
MEDICAID STAR+PLUS PROGRAM
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
TEXAS DEPARTMENT of HUMAN SERVICES ("TDHS") 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 ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇,
▇▇▇▇▇. TDHS and CONTRACTOR may be referred to in this Amendment individually as
a "Party" and collectively as the "Parties. " The effective date of this
amendment is November 1, 2002. The parties agree to amend the Contract as
follows:
ARTICLE 13.1.2 CAPITATION AMOUNTS
---------------------------------------------------------------------------------
FY 2003
Monthly Capitation Amounts
Member Risk Groups 11/1/2002 - 8/31/2003
---------------------------------------------------------------------------------
CBA Waiver Clients-Dual Eligible $ 1,294.50
---------------------------------------------------------------------------------
CBA Waiver Clients-Medicaid Only $ 2,917.06
---------------------------------------------------------------------------------
Other Community Clients-Dual Eligible $ 128.77
---------------------------------------------------------------------------------
Other Community Clients-Medicaid Only $ 608.43
---------------------------------------------------------------------------------
Nursing Home-Dual Eligible (4 months) $ 128.77
---------------------------------------------------------------------------------
Nursing Home-Medicaid Only (4 months) $ 608.43
---------------------------------------------------------------------------------
This Amendment is executed by the Parties in accordance with Article 15.2
of the Agreement.
ARTICLE 1. 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.
POST-IT(TM) brand fax transmittal memo 7671 # OF PAGE 5
To ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇ From ▇▇▇ ▇▇▇▇
Co. AMERIGROUP Co. HHSC
Dept. Phone # (▇▇▇)▇▇▇-▇▇▇▇
Fax # (▇▇▇)▇▇▇-▇▇▇▇ Fax #
TDHS Contract 65M1015HPC
Page 1 of 2
IN WITNESS HEREOF, TDHS and the CONTRACTOR have each caused this Amendment
to be signed and delivered by its duly authorized representative.
AMERIGROUP TEXAS INC TEXAS DEPARTMENT OF HUMAN
SERVICES
By: /s/ ▇▇▇ ▇▇▇▇▇▇▇ By: /s/ [ILLEGIBLE]
--------------- ---------------------
▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇
President Commissioner
Date : 11/4/2002 Date:____________________
Approved as to Form:
/s/ K. O.
-------------------------
Office of General Counsel
TDHS Contract 65M1015HPC
Page 2 of 2
TDHS ▇▇▇▇▇▇▇▇ ▇▇. ▇▇▇▇▇▇▇▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇
▇▇▇▇▇▇ OF ▇▇▇▇▇▇
AMENDMENT FY03-04
TO THE AGREEMENT BETWEEN THE
TEXAS DEPARTMENT OF HUMAN SERVICES
AND
AMERIGROUP TEXAS, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR+PLUS PROGRAM
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the TEXAS
DEPARTMENT OF HUMAN SERVICES ("TDHS"), 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 ▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇,
▇▇▇▇▇ ▇▇▇▇▇. TDHS 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 TDHS described in Section 13.2. The
Contract Period consists of the following Experience Rebate
Periods:
- September 1, 1999 through August 31, 2001 (1st
Experience Rebate Period)
- September 1, 2001 through August 31, 2002 (2nd
Experience Rebate Period)
- September 1, 2002 through August 31, 2003 (3rd
Experience Rebate Period)
TDHS Contract No. 65M1015HPC
Page 1 of 3
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 TDHS 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 Attachment F. The HMO's
calculations are subject to TDHS' approval, and TDHS 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 TDHS 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 Deleted in its entirety.
13.2.2.1 Deleted in its entirety.
13.2.3 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.
13.2.3.1 HMO shall calculate the experience rebate by
applying the experience rebate formula in Article 13.2.1, as
follows:
For the 1st and 2nd Experience Rebate Periods, to the Net
Income Before Taxes for the STAR+PLUS Medicaid service area
contracted between TDHS and HMO.
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 the Health and Human
Services Commission (HHSC) or TDHS and HMO.
13.2.4 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 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 for the 1st and
TDHS Contract No. 65M1015HPC
Page 2 of 3
2nd Experience Rebate Periods are payable to the Texas Department
of Human Services. Settlement payments for the 3rd Experience
Rebate Period are payable to the 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 TDHS 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 TDHS for that specified time
period if the adjustment is a payment from HMO to TDHS. If the
adjustment is a payment from TDHS to HMO, TDHS shall pay such
adjustment to HMO within thirty (30) days of receipt of the
second Final MCFS Report. TDHS or its agent may audit the MCFS
Reports. If TDHS determines that corrections to the MCFS Reports
are required, based on an audit of other documentation acceptable
to TDHS, 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 the 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 12.1.2. TDHS may adjust the experience
rebate if TDHS 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. TDHS will have 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.
IN WITNESS HEREOF, TDHS and the CONTRACTOR have each caused this Amendment
to be signed and delivered by its duly authorized representative.
AMERIGROUP TEXAS, INC. TEXAS DEPARTMENT OF HUMAN SERVICES
By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. By: /s/ [ILLEGIBLE]
------------------------- ------------------------------
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. ▇▇▇▇▇ ▇. ▇▇▇▇
President and CEO Commissioner
Date: 11/04/2002 Date: ____________________________
Approved as to Form:
/s/ K.O.
-------------------------
Office of General Counsel
TDHS Contract No. 65M1015HPC
Page 3 of 3
AMENDMENT 5
TO THE AGREEMENT BETWEEN
THE HEALTH & HUMAN SERVICES COMMISSION
AND AMERIGROUP
FOR HEALTH SERVICES
TO THE
MEDICAID STAR+PLUS PROGRAM
STAR+PLUS BBA Amendment Health and Human Services Commission
AMENDMENT 5
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION AND AMERIGROUP
FOR HEALTH SERVICES TO THE MEDICAID STAR+PLUS PROGRAM
TABLE OF CONTENTS
ARTICLE 1 . PURPOSE............................................................................................. 1
Section 1.01 Authorization................................................................................ 1
Section 1.02 Modifications................................................................................ 1
Section 1.03 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 to Article 1 Parties and Authority to Contract.................................. 1
Section 2.03 Modification of Article 2, Definitions....................................................... 2
Section 2.04 Modification of Article 3, Plan Administrative and Human Resource Requirements............... 4
Section 2.05 Modification of Section 3.7, Requirements for Education, Training and
Advisory Committee Activities................................................................ 5
Section 2.06 Modification to Section 4.10, Claims Processing Requirements................................. 6
Section 2.07 Modification of Article 5, Statutory and Regulatory Compliance Requirements.................. 7
Section 2.08 Modification to Section 6.1, Scope of Services............................................... 9
Section 2.09 Section 2.09 Addition to Section 6.4, Continuity of Care and Out-of-Network Providers........ 10
Section 2.10 Modification of Section 6.5, Emergency Services.............................................. 11
Section 2.11 Section 2.11 Modification of Section 6.6, Behavioral Health Services
- Specific Requirements..................................................................... 12
Section 2.12 Modifications to Section 6.8, Texas Health Steps............................................. 13
Section 2.13 Modification of Section 6.9, Perinatal Services.............................................. 14
Section 2.14 Modification of 6.11 Special, Supplemental Nutrition Program for Women,
Infants and Children (WIC) - Specific Requirements........................................... 15
Section 2.15 Modification of Section 6.12.4.3, Tuberculosis............................................... 15
Section 2.16 Modification of Section 6.13, Health Education and Wellness and Prevention Plan.............. 15
Section 2.17 Modification to Section 6.14, Care Coordination and Transition Plan for
Long Term Care Services...................................................................... 17
Section 2.18 Modification of Section 6.15, 1915(c) Waiver Service (Community Based Alternatives).......... 18
Section 2.19 Modification of Section 6.16, Blind and Disabled Members..................................... 19
Section 2.20 Addition to Article 6, Scope of Services..................................................... 20
Section 2.21 Addition to-Article 6, Scope of Services..................................................... 23
Section 2.22 Addition to Article 6, Scope of Services..................................................... 24
Section 2.23 Modification of Section 7.1, Network Provider Directory...................................... 25
Section 2.24 Modification of Section 7.2, Provider Accessibility.......................................... 26
Section 2.25 Modification to Section 7.3, Provider Contracts.............................................. 29
Section 2.26 Modification to Section 7.4, Physician Incentive Plan........................................ 30
Section 2.27 Modification to Section 7.5, Provider Manual and Provider Training........................... 31
Section 2.28 Modification to Section 7.6, Member Panel Reports............................................ 31
Section 2.29 Modification of Section 7.7, Provider Complaint and Appeal Procedures........................ 31
Section 2.30 Modification of Section 7.8, Provider Qualifications - General............................... 33
Section 2.31 Modification to Section 7.9, Primary Care Providers.......................................... 36
Section 2.32 Modification to Section 7.10, OB/GYN Providers............................................... 37
Section 2.33 Modification to Section 7.11, Specialty Care Providers....................................... 38
Section 2.34 Modification to Section 7.11, Special Hospitals And Specialty Care Facilities................ 38
Section 2.35 Modification to Section 7.13, Behavioral health- Local Mental Health Authority (LMHA)........ 39
Section 2.36 Modification Of Section 7.14, Significant Traditional Providers (STPS)....................... 40
Section 2.37 Addition to Article 7, Provider Network Requirements......................................... 40
STAR+PLUS Amendment
Page i of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
Section 2.38 Addition to Article 7, Provider Network Requirements......................................... 42
Section 2.39 Addition to Article 7, Provider Network Requirements......................................... 43
Section 2.40 Modification of Section 8.2, Member Handbook................................................. 44
Section 2.41 Modification of Section 8.5, Member Hotline.................................................. 45
Section 2.42 Modification to Section 8.6, Member Complaint Process........................................ 46
Section 2.43 Modification of Section 8.7, Member Notices, Appeals, and Fair Hearings...................... 47
Section 2.44 Addition to Article 8, Member Services Requirements.......................................... 48
Section 2.45 Modification to Section 9.2 Adherence to Marketing Guidelines With
Marketing Orientation and Training........................................................... 48
Section 2.46 Addition to Article 9, Marketing and Prohibited Practices.................................... 48
Section 2.47 Modification of Section 10.1, Model MIS Requirements......................................... 50
Section 2.48 Modification of Section 10.7, Utilization/Quality Improvement Subsystem...................... 50
Section 2.49 Modification of Article 11, Quality Assessment and Performance Improvement Program........... 50
Section 2.50 Modification of Section 12.1, Financial Reports.............................................. 51
Section 2.51 Modification of Section 12.2, Statistical Reports............................................ 53
Section 2.52 Modification of Section 12.8, Utilization Management Reports -- Behavioral Health............ 54
Section 2.53 Section 2.53 Modification of Section 12.9, Utilization Managements Reports --
Physical Health.............................................................................. 54
Section 2.54 Modification of Section 12.10 Utilization Management Reports -- Long Term Care............... 54
Section 2.55 Modification of Section 12.11 Quality Improvement Reports.................................... 55
Section 2.56 Modification of Section 12.12, HUB Quarterly Reports......................................... 55
Section 2.57 Modification of Section 11.13 THSTEPS Reports................................................ 55
Section 2.58 Modification of Section 12.14, CBA Status Report............................................. 55
Section 2.59 Modification of Section 12.15, Submission of STAR+PLUS Deliverables/Reports.................. 56
Section 2.60 Addition to Article 12, Reporting Requirements............................................... 57
Section 2.61 Modification to Section 13.2, Capitation Amounts............................................. 57
Section 2.62 Modification to Section 13.2, Experience Rebate to State..................................... 57
Section 2.63 Modification to Section 13.3, Adjustments to Premium......................................... 59
Section 2.64 Modification to Section 13.4, CBA Reassessment Packet........................................ 59
Section 2.65 Addition to Article 13, Payment Provisions................................................... 60
Section 2.66 Modification of Section 14.1, Eligibility Determination...................................... 60
Section 2.67 Modification of Section 14.3, Plan Changes from HMO and Disenrollment
from Managed Care............................................................................ 62
Section 2.68 Modification of Section 14.4, Automatic Re-enrollment........................................ 62
Section 2.69 Modification of Section 14.5, Enrollment Reports............................................. 63
Section 2.70 Addition to Article 14, Eligibility, Enrollment, and Disenrollment........................... 63
Section 2.71 Addition to Article 15, General Provisions................................................... 63
Section 2.72 Modification of Section 16.3, Default by HMO................................................. 64
Section 2.73 Modification to Appendix A, Value Added Services............................................. 64
Section 2.74 Modification of Appendix E, Cost Principles for Administrative Expenses...................... 64
Section 2.75 Modification to Appendix K, Performance Objectives........................................... 64
Section 2.76 Addition of Appendix L, Value Added Services................................................. 64
Section 2.77 Addition of Appendix M, Cost Principles for Administrative Expenses.......................... 64
Section 2.78 Addition of New Appendix O, Standard for Medical Records..................................... 64
STAR+PLUS Amendment
Page ii of 65
HHSC CONTRACT NO. 65M1015HPC
STATE OF TEXAS
COUNTY OF ▇▇▇▇▇▇
AMENDMENT 5
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMERIGROUP _________
FOR HEALTH SERVICES
TO THE
STAR+PLUS PROGRAM
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, 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 MODIFICATIONS.
The Parties amend the Agreement to provide for HHSC's recoupment of certain
duplicate premium payments for Members concurrently enrolled in Medicaid
and CHIP.
SECTION 1.03 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective August 13, 2003 and terminates on August 31,
2004, unless extended or terminated sooner by HHSC in accordance with the
Agreement.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
This Amendment is to incorporate the Department of Health and Human
Services rules pertaining to the Balanced Budget Act found in 42 CFR Parts
400, 430, 431, 434, 435, 438, 440, and 447 . This amendment also replaces
the Texas Department of Human Services (TDHS) with the Health and Human
Services Commission (HHSC).
SECTION 2.02 MODIFICATION TO ARTICLE 1 PARTIES AND AUTHORITY TO CONTRACT
Article 1, Parties and Authority to Contract, is replaced with the
following language, Substituted current contract language to match STAR
contract language as follows:
STAR+PLUS BBA Amendment
STAR+PLUS BBA Amendment Health and Human Services Commission
1.1.1 The Texas Legislature has designated the Texas Health and Human
Services Commission (HHSC) as the single State agency to administer the
Medicaid program in the State of Texas. HHSC has authority to contract
with HMO to carry out the duties and functions of the Medicaid managed
care program under Health and Safety Code, Title 2, Section 12.011 and
Section 12.021 and Texas Government Code Section 533.001 et seq.
1.4.2 Substituted current contract language to match STAR contract
language as follows: HHSC will provide HMO with at least 30 days
written notice prior to conducting an HMO renewal review. A report of
the results of the renewal review findings will be provided to HMO
within 10 weeks from the completion of the renewal review. The renewal
review report will include any deficiencies, which must be corrected
and the timeline within which the deficiencies must be corrected.
1.4.3 Substituted current contract language to match STAR contract
language as follows: HHSC reserves the right to conduct on-site
inspections of any or all of HMO's systems and processes as often as
necessary to ensure compliance with contract requirements. HHSC may
conduct at least one complete on-site inspection of all systems and
processes every three years. HHSC will provide six weeks advance notice
to HMO of the three-year on-site inspection, unless HHSC enters into an
MOU with the TDI to accept the TDI report in lieu of a HHSC on-site
inspection. HHSC will notify HMO prior to conducting an onsite visit
related to a regularly scheduled review specifically described in this
contract. Even in the case of a regularly scheduled visit, HHSC
reserves the right to conduct an onsite review without advance notice
if HHSC believes there may be potentially serious or life-threatening
deficiencies.
1.5 Substituted current contract language to match STAR contract
language as follows: AUTHORITY OF HMO TO ACT ON BEHALF OF HHSC. HMO is
given express, limited authority to exercise the State's right of
recovery as provided in Article 4.9, and to enforce provisions of this
contract which require providers or subcontractors to produce records,
reports, encounter data, public health data, and other documents to
comply with this contract and which HHSC has authority to require under
State or federal laws.
SECTION 2.03 MODIFICATION OF ARTICLE 2, DEFINITIONS
The following terms amend and modify the definitions set forth in Article
2:
ACTION, also known as an adverse determination, is the denial
or limited authorization of a requested service, including the type or
level of service; the reduction, suspension, or termination of a
previously authorized service; the denial in whole or in part, of
payment for service; the failure of an HMO to act within the
timeframes; or for a resident of a rural area with only one HMO, the
denial of a Medicaid members request to exercise his or her right, to
obtain services outside of the network.
DISABILITY-RELATED ACCESS means that facilities are readily
accessible to and usable by individuals with disabilities, and that
auxiliary aids and services are provided to ensure effective
communication, in compliance with Title III of the Americans with
Disabilities Act.
APPEAL means the formal process by which a request for review
of an action as defined above.
CONTRACTOR means any entity that contracts with the State
agency, under the State plan, in return for a payment, to process
claims, to provide or pay for medical services, or to enhance the State
agency's capability for effective administration of the program.
COMPLAINT, also known as a grievance, is an expression of
dissatisfaction about any matter that does not result in an adverse
action.
STAR+PLUS BBA Amendment
Page 2 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
CONTRACT ANNIVERSARY DATE means September 1 of each year after
the first year of this contract, regardless of the date of execution or
effective date of the contract.
EMERGENCY BEHAVIORAL HEALTH CONDITION means any condition,
without regard to the nature or cause of the condition, which in the
opinion of a prudent layperson possessing an average knowledge of
health and medicine requires immediate intervention and/or medical
attention without which Members would present an immediate danger to
themselves or others or which renders Members incapable of controlling,
knowing or understanding the consequences of their actions.
EMERGENCY SERVICES means covered inpatient and outpatient
services that are furnished by a provider that is qualified to furnish
such services under this contract and are needed to evaluate or
stabilize an emergency medical condition and/or an emergency behavioral
health condition.
EMERGENCY MEDICAL CONDITION means a medical condition
manifesting itself by acute symptoms of 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 a woman or her unborn child.
ENCOUNTER means a covered service or group of services
delivered by a provider to a Member during a visit between the Member
and provider. This also includes value-added services.
ENCOUNTER DATA means data elements from fee-for-service claims
or capitated services proxy claims that are submitted to HHSC by HMO in
accordance with HHSC's "HMO Encounter Data Claims Submission Manual".
ENROLLMENT BROKER means an entity contracting with HHSC to
carry out specific functions related to Member services (i.e.,
enrollment/disenrollment, complaints, etc.) under HHSC's Medicaid
managed care program.
ENROLLMENT REPORT/ENROLLMENT FILE means the daily or monthly
list of Medicaid recipients who are enrolled with an HMO as Members on
the day or for the month the report is issued.
EPSDT means the federally mandated Early and Periodic
Screening, Diagnosis and Treatment program contained at 42 USC 1396d(r)
(see definition for Texas Health Steps). The name has been changed to
Texas Health Steps (THSteps) in the State of Texas.
EXPERIENCE REBATE means the portion of the HMO's net income
before taxes (financial Statistical Report, Part 1, Line 7) this is
returned to the state in accordance with Article 13.2.1.
EXPEDITED APPEAL means an appeal where 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. An
expedited appeal must be heard in no more than 3 working days of an
approved request.
LINGUISTIC ACCESS means translation and interpreter services,
for written and spoken language to ensure effective communication.
Linguistic access includes sign language interpretation, and the
provision of other auxiliary aids and services to persons with
disabilities.
PERFORMANCE PREMIUM means an amount, which may be paid to a
managed care organization as a bonus for accomplishing a portion or all
of the performance objectives contained in this contract.
STAR+PLUS BBA Amendment
Page 3 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
PCP stands for primary care physician.
PROVIDER means either of the following:
(1) For the fee-for-service program, any individual or
entity furnishing Medicaid services under an agreement
with the Medicaid agency.
(2) For the managed care program, any individual or entity
that is engaged in the delivery of health care services
and is legally authorized to do so by the State in
which it delivers the services.
REPRESENTATIVE has the meaning given the term by each State
consistent with its laws, regulations, and policies.
SPECIAL NEEDS means an increased prevalence of risk of
disability.
SECTION 2.04 MODIFICATION OF ARTICLE 3, PLAN ADMINISTRATIVE AND HUMAN RESOURCE
REQUIREMENTS
STAR Program is the name of the State of Texas Medicaid managed care
program. "STAR" stands for the State of Texas Access Reform. Renumbered
Article 3 to reflect STAR contract and added STAR+PLUS changes at the end
of the appropriate section. Section 3. 1 to 3.1.6 in the STAR+PLUS contract
was replaced with 3.1 through 3.1.6.1 of the STAR contract for consistency
as follows:
3.1.1 HMO must maintain the organizational and administrative capacity
and capabilities to carry out all duties and responsibilities under
this contract.
3.1.2 HMO must maintain assigned staff with the capacity and capability
to provide all services to all Members under this contract.
3.1.3 HMO must maintain an administrative office in the service area
(local office). The local office must comply with the American with
Disabilities Act (ADA) requirements for public buildings. Member
Advocates for the service area must be located in this office (see
Article 8.8).
3.1.4 HMO must provide training and development programs to all
assigned staff to ensure they know and understand the service
requirements under this contract including the reporting requirements,
the policies and procedures, cultural and linguistic requirements and
the scope of services to be provided.
3.1.5 HMO must notify HHSC no later than 30 days after the effective
date of this contract of any changes in its organizational chart as
previously submitted to HHSC.
3.1.5.1 HMO must notify HHSC within fifteen (15) working days of any
change in key managers or behavioral health subcontractors. This
information must be updated whenever there is a significant change in
organizational structure or personnel.
3.1.6 Participation in Regional Advisory Committee. HMO must
participate on a Regional Advisory Committee established in the service
area in compliance with the Texas Government Code, Section
533.021-533.029. The Regional Advisory Committee in each managed care
service area must include representatives from at least the following
entities: hospitals; managed care organizations; primary care
providers; state agencies; consumer advocates; Medicaid recipients;
rural providers; long-term care providers; specialty care providers,
including pediatric providers; and political subdivisions with a
constitutional or statutory obligation to provide health care to
indigent patients. HHSC will determine the composition of each Regional
Advisory Committee.
The Regional Advisory Committee is required to meet at least quarterly
for the first year after appointment of the committee and at least
annually in subsequent years. The actual frequency may vary depending
on the needs and requirements of the committee.
STAR+PLUS BBA Amendment
Page 4 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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."
3.4.8 Delete from STAR+PLUS contract
SECTION 2.05 MODIFICATION OF SECTION 3.7, REQUIREMENTS FOR EDUCATION, TRAINING
AND ADVISORY COMMITTEE ACTIVITIES
Section 3.7, Requirements for Education, Training and Advisory Committee
Activities, is replaced by Section 3.7, HMO Telephone Access Requirements,
to be consistent with the STAR contract as follows:
3.7.1 For all HMO telephone access (including Behavioral Health
telephone services), HMO must ensure adequately-staffed telephone
lines. Telephone personnel must receive customer service telephone
training. HMO must ensure that telephone staffing is adequate to
fulfill the standards of promptness and quality listed below:
1. 80% of all telephone calls must be answered within an
average of 30 seconds;
2. The lost (abandonment) rate must not exceed 10%;
3. HMO cannot impose maximum call duration limits but must
allow calls to be of sufficient length to ensure adequate
information is provided to the Member or Provider.
4. Telephone services must meet cultural competency
requirements (see Article 8.8) 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.
3.7.2 Member Helpline: The HMO must furnish a toll-free phone line
which members may call 24 hours a day, 7 days a week. An answering
service or other similar mechanism, which allows callers to obtain
information from a live person, may be used for after-hours and weekend
coverage.
3.7.2.1 HMO must provide coverage for the following services at least
during HMO's regular business hours (a minimum of 9 hours a day,
between 8 a.m. and 6 p.m.), Monday through Friday:
1. Member ID information
2. PCP Change
3. Benefit understanding
4. PCP verification
5. Access issues (including referrals to specialists)
6. Unavailability of PCP
7. Member eligibility
8. Complaints
9. Service area issues (including when member is temporarily
out-of-service area)
STAR+PLUS BBA Amendment
Page 5 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
10. Other services covered by member services.
3.7.2.2 HMO must provide HHSC with policies and procedures indicating
how the HMO will meet the needs of members who are unable to contact
HMO during regular business hours.
3.7.3 HMO must ensure that PCPs are available 24 hours a day, 7 days a
week (see Article 7.8). This includes PCP telephone coverage (see 28
TAC 11.2001(a)1A).
3.7.4 Behavioral Health Hotline Services. HMO must have emergency and
crisis Behavioral Health hotline services available 24 hours a day, 7
days a week, toll-free throughout the service area. Crisis hotline
staff must include or have access to qualified behavioral health
professionals to assess behavioral health emergencies. Emergency and
crisis behavioral health services may be arranged through mobile crisis
teams. It is not acceptable for an emergency intake line to be answered
by an answering machine. Hotline services must meet the requirements
described in Article 3.7.1
SECTION 2.06 MODIFICATION TO SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS
Section 4.10, Claims Processing Requirements, is modified to be consistent
with the STAR contract, as follows:
4.10.1 HMO and claims processing subcontractors must comply with 28 TAC
Sections 21.2801 through 21.2816 "Submission of Clean Claims", to the
extent they are not in conflict with provisions of this contract.
4.10.2 HMO must use a HHSC approved or identified claim format that
contains all data fields for final adjudication of the claim. The
required data fields must be complete and accurate. The HHSC required
data fields are identified in HHSC's "HMO Encounter Data Claims
Submission Manual."
4.10.3 HMO and claims processing subcontractors must comply with HHSC's
Texas Medicaid Managed Care Claims Manual (Claims Manual), which
contains HHSC's claims processing requirements. HMO must comply with
any changes to the Claims Manual with appropriate notice of changes
from HHSC.
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"/0 of all clean claims paid or denied
within 90 days of receipt. Failure to meet these performance levels is
a default under this contract and could lead to damages or sanctions as
outlined in Article 17. The performance levels are subject to changes
if required to comply with federal and state laws or regulations.
4.10.6.1 All claims and appeals submitted to HMO and claims processing
subcontractors must be paid-adjudicated (clean claims),
denied-adjudicated (clean claims), or denied for additional
STAR+PLUS BBA Amendment
Page 6 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 HHSC.
4.10.7 HMO is subject to Article 16, Default and Remedies, for claims
that are not processed on a timely basis as required by this contract
and the Claims Manual. Notwithstanding the provisions of 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 16 of this contract.
4.10.8 HMO must comply with the standards adopted by the U.S.
Department of Health and Human Services under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191,
regarding submitting and receiving claims information through
electronic data interchange (EDI) that allows for automated processing
and adjudication of claims within two or three years, as applicable,
from the date the rules promulgated under HIPAA are adopted (see 45 CFR
parts 160 through 164).
4.10.9 For claims requirements regarding retroactive PCP changes for
mandatory Members, see Article 7.8.12.2.
SECTION 2.07 MODIFICATION OF ARTICLE 5, STATUTORY AND REGULATORY COMPLIANCE
REQUIREMENTS
Article 5, Statutory and Regulatory Compliance Requirements, is modified as
follows:
5.5. NON-DISCRIMINATION
5.5.1 Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, the Americans with Disabilities Act of
1990, and all requirements imposed by the regulations implementing
these acts and all amendments to the laws and regulations. The
regulations provide in part that no person in the United States shall
on the grounds of race, color, national origin, sex, age, disability,
political beliefs or religion be excluded from participation in, or
denied, any aid, care, service or other benefits, or be subjected to
any discrimination under any program or activity receiving federal
funds.
Section 5.6.2 of Section 5.6, Historically Under-utilized Business (HUBS)
is amended as follows.
5.6.2. HMO is required to submit HUB quarterly reports to HHSC as
required in Article 12.11.
STAR+PLUS BBA Amendment
Page 7 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
Section 5.7, Affirmative Action, is replaced 6y Section 5.7, Buy Texas to
be consistent with the STAR contract.
5.7 BUY TEXAS
HMO agrees to "Buy Texas" products and materials when they are
available at a comparable price and in a comparable period of time, as
required by Section 48 of Article 9 of the General Appropriations Act
of 1995.
Section 5.8, Buy Texas, is replaced by Section 5.8, Child Support.
5.8 CHILD SUPPORT
5.8.1 The Texas Family Code Section 231.006 requires HHSC to withhold
contract payments from any for-profit entity or individual who is at
least 30 days delinquent in child support obligations. It is HMO's
responsibility to determine and verify that no owner, partner, or
shareholder who has at least at 25% ownership interest is delinquent in
child support obligations. HMO must attach a list of the names and
Social Security numbers of all shareholders, partners or owners who
have at least a 25% ownership interest in HMO.
5.8.2 Under Section 231.006 of the Family Code, the contractor
certifies that the contractor is not ineligible to receive the
specified grant, loan, or payment and acknowledges that this contract
may be terminated and payment may be withheld if this certification is
inaccurate. A child support obligor who is more than 30 days delinquent
in paying child support or a business entity in which the obligor is a
sole proprietor, partner, shareholder, or owner with an ownership
interest of at least 25% is not eligible to receive the specified
grant, loan or payment.
5.8.3 If HHSC is informed and verifies that a child support obligor who
is more than 30 days delinquent is a partner, shareholder, or owner
with at least a 25% ownership interest, it will withhold any payments
due under this contract until it has received satisfactory evidence
that the obligation has been satisfied or that the obligor has entered
into a written repayment request.
Section 5.9 Child Support, is replaced with Section 5.9, Request for Public
Information, to be consistent with the STAR contract.
5.9 REQUESTS FOR PUBLIC INFORMATION
5.9.1 This contract and all network provider and subcontractor
contracts are subject to public disclosure under the Public Information
Act (Texas Government Code, Chapter 552). HHSC may receive Public
Information requests related to this contract, information submitted as
part of the compliance of the contract and HMO's application upon which
this contract was awarded. HHSC agrees that it will promptly deliver a
copy of any request for Public Information to HMO.
5.9.2 HHSC may, in its sole discretion, request a decision from the
Office of the Attorney General (AG opinion) regarding whether the
information requested is excepted from required public disclosure. HHSC
may rely on HMO's written representations in preparing any AG opinion
request, in accordance with Texas Government Code Section 552.305. HHSC
is not liable for failing to request an AG opinion or for releasing
information that is not deemed confidential by law, if HMO fails to
provide HHSC with specific reasons why the requested information is
exempt from the required public disclosure. HHSC or the Office of the
Attorney General will notify all interested parties if an AG opinion is
requested.
5.93 If HMO believes that the requested information qualifies as a
trade secret or as commercial or financial information, HMO must notify
HHSC within three (3) working days after HHSC gives notice that a
request has been made for public information and request HHSC to submit
the request for public information to the Attorney General for an Open
Records Opinion. The HMO
STAR+PLUS BBA Amendment
Page 8 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
will be responsible for presenting all exceptions to public disclosure
to the Attorney General if an opinion is requested.
Section 5.9 Request for Public Information is renumbered 5.8 to reflect
STAR contract. Section 5.11 Notice and Appeal is renumbered 5.10 to
reflect STAR contract. Section 5.11 is added as follows:
Section 5.10, Request for Public Information, is replaced by Section 5.10,
Notice and Appeals to be consistent with the STAR contract.
5.10 NOTICE AND APPEAL
5.10 HMO must comply with the notice requirements contained in 1 TAC
Section 354.2211, and the maintaining benefits and services contained
in 1 TAC Section 354.2213, whenever HMO intends to take an action
affecting the Member benefits and services under this contract. Also
see the Member appeal requirements contained in Article 8.6 of this
Agreement.
Article 5, Statutory and Regulatory Compliance Requirements, is modified by
adding Section 5.11, Data Certification, to be consistent with the STAR
contract.
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 2.08 MODIFICATION TO SECTION 6.1, SCOPE OF SERVICES
Section 6.1.2, Scope of Services, is being replaced with Section 6.1.2,
Scope of Services.
Section 6.1.2 Not applicable to STAR+PLUS.
Section 6.1.3 through 6.1.3.2 is being replaced with 6.1.3, Scope of
Services, to be consistent with the STAR contract.
6.1.3 HMO must provide covered services described in the 1999 Texas
Medicaid Provider Procedures Manual (Provider Procedures Manual),
subsequent editions of the Provider Procedures Manual also in effect
during the contract period, and all Texas Medicaid Bulletins which
update the 1999 Provider Procedures Manual and subsequent editions of
the Provider Procedures Manual published during the contract period.
STAR+PLUS BBA Amendment
Page 9 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
Section 6.1.9, Scope of Services, is added 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 enrollee members.
6.1.9.2 In order to meet the requirements of Section 6.1.9.1, HMO must
notify HHSC of grounds for and provide detail concerning its moral or
religious objections and the specific services covered under the
objection, no less than 120 days prior to the proposed effective date
of the policy change.
6.1.9.3 HMO must notify all current Members of the intent to change
covered services at least 30 days prior to the effective date of the
change in accordance with 42 C.F.R Section 438.102(bxii)(B).
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 6.1.10, Scope of Services, is added (this section was formerly
6.1.3 through 6.3.1.2) to be consistent with the STAR contract.
6.1.10 Long Term Care covered services include attendant care, day
activity and health services, and required services under the 1915 (R)
waiver.
6.1.10.1 HMO is responsible for the Medicare co-payments for days
21-100 in a skilled nursing facility.
6.1.10.2 HMO must provide covered services described in the 2002 Texas
Medicaid Procedures Manual (Provider Procedures Manual), subsequent
editions of the Provider Procedures Manual also in effect during the
contract period, and all Texas Medicaid Bulletins which update the 2002
Provider Procedures Manual and subsequent editions of the Provider
Manual published during the contract period.
SECTION 2.09 SECTION 2.09 ADDITION TO SECTION 6.4, CONTINUITY OF CARE AND
OUT-OF-NETWORK PROVIDERS
Section 6.4, Continuity of Care and Out-of-Network Providers, is
modified to add new Sections 6.4.6 and 6.4.7 as follows:
6.4.6 HMO must provide Members with timely and adequate access to
out-of-network services for as long as those services are necessary and
covered benefits not available within the network, in accordance with
42 C.F.R. Section 438.206(6)(4). or until services can be covered by a
network provider. 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(6)(3)."
STAR+PLUS BBA Amendment
Page 10 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.10 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5, Emergency Services, is deleted in its entirety and replaced
with the following language to be consistent with the STAR contract as
follows:
6.5.1 HMO policy and procedures, covered benefits, claims adjudication
methodology, and reimbursement performance for emergency services must
comply with all applicable state and federal laws and regulations
including 42 C.F.R. Section 438.114, whether the provider is in network
or out of network.
6.5.2 HMO must pay for the professional, facility, and ancillary
services that are medically necessary to perform the medical screening
examination and stabilization of HMO Member presenting as an emergency
medical condition or an emergency behavioral health condition to the
hospital emergency department, 24 hours a day, 7 days a week, rendered
by either HMO's in-network or out-of-network providers.
6.5.2.1. For all out-of-network emergency services providers, HMO will
pay a reasonable and customary amount for emergency services. HMO
policies and procedures must be consistent with this agreement's
prudent lay person definition of an emergency medical condition and
claims adjudication processes required under Section 7.6 of this
agreement and 42 C.F.R. Section 438.114.
HMO will pay a reasonable and customary amount for services for all
out-of-network emergency services provider claims with dates of service
between September 1, 2002 and November 30, 2002. HMO must forward any
complaints submitted by out-of-network 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
enrollee Member's primary care provider or HMO of the enrollee Member's
screening and treatment within 10 calendar days of presentation for
emergency services. HMO may not hold the enrollee 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 enrollee Member is sufficiently stabilized
for transfer or discharge.
STAR+PLUS BBA Amendment
Page 11 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.5.5 Medical Screening Examination for emergency services. A medical
screening examination needed to diagnose an emergency medical condition
shall be provided in a hospital based emergency department that meets
the requirements of the Emergency Medical Treatment and Active Labor
Act (EMTALA) 42 C.F.R. Section 489.20, Section 489.24 and Section
438.114(b) & (c). HMO must pay for the emergency medical screening
examination, as required by 42 U.S.C. Section 1395dd. HMOs must
reimburse for both the physician's services and the hospital's
emergency services, including the emergency room and its ancillary
services.
6.5.6 Stabilization Services. When the medical screening examination
determines that an emergency medical condition exists, HMO must pay for
emergency services performed to stabilize the Member. To stabilize is
to provide such medical care as to assure within reasonable medical
probability that no deterioration of the condition is likely to result
from, or occur from, or occur during discharge, transfer, or admission
of 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
enrollee/ Member's stabilized condition if:
(a) the HMO does not respond to a request for pre-approval within 1
hour;
(b) the HMO cannot be contacted;
(c) or the HMO representative and the treating physician cannot reach
an agreement concerning the enrollee 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 enrollee Member's care; the HMO
physician assumes responsibility for the enrollee Member's care through
transfer; the HMO representative and the treating physician reach an
agreement concerning the enrollee Member's care; or the enrollee 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 2.11 SECTION 2.11 MODIFICATION OF SECTION 6.6, BEHAVIORAL HEALTH
SERVICES - SPECIFIC REQUIREMENTS
Section 6.6.12, Behavioral Health Services - Specific Requirements, is
replaced with the following language and 6.6.13 is added to be consistent
with the STAR contract, as follows:
HMO must comply with 28 TAC Section 3.8001 et seq., regarding
utilization review of chemical dependency treatment.
6.6.13 Chemical dependency treatment must conform to the standards set
forth in the Texas Administrative Code, Title 28, Part 1, Chapter 3,
Subchapter HH.
STAR+PLUS BBA Amendment
Page 12 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.12 MODIFICATIONS TO SECTION 6.8, TEXAS HEALTH STEPS
Section 6.8.7 through 6.8.11 is replaced with the following language to be
consistent with the STAR contract, as follows:
6.8.7 Newborn Checkups. HMO must have mechanisms in place to ensure
that all newborn Members have an initial newborn checkup before
discharge from the hospital and again within two weeks from the time of
birth. HMO must require providers to send all THSteps newborn screens
to the TDH Bureau of Laboratories or a TDH certified laboratory.
Providers must include detailed identifying information for all
screened newborn Members and the Member's mother to allow HHSC to link
the screens performed at the hospital with screens performed at the
two-week follow-up.
Laboratory Tests: All laboratory specimens collected as a required
component of a THSteps checkup (see Medicaid Provider Procedures Manual
for age-specific requirements) must be submitted to the HHSC Laboratory
for analysis. HMO must educate providers about THSteps program
requirements for submitting laboratory tests to the HHSC Bureau of
Laboratories.
6.8.8 Coordination and Cooperation. HMO must make an effort to
coordinate and cooperate with existing community and school-based
health and education programs that offer services to school-aged
children in a location that is both familiar and convenient to the
Members. HMO must make a good faith effort to comply with Head Start's
requirement that Members participating in Head Start receive their
THSteps checkup no later than 45 days after enrolling into either
program.
6.8.9 Immunizations. HMO must educate providers on the Immunization
Standard Requirements set forth in Chapter 161, Health and Safety Code;
the standards in the ACIP Immunization Schedule; and the AAP
Periodicity Schedule.
6.8.9.1 ImmTrac Compliance. HMO must educate providers about and
require providers to comply with the requirements of Chapter 161,
Health and Safety Code, relating to the Texas Immunization Registry
(ImmTrac), to include parental consent on the Vaccine Information
Statement.
6.8.10 Claim Forms. HMO must require all THSteps providers to submit
claims for services paid (either on a capitated or fee-for service
basis) on the HCFA 1500 claim form and use the unique procedure coding
required by HHSC.
6.8.11 Compliance with THSteps Performance Benchmark. HHSC will
establish performance benchmarks against which HMO's full compliance
with the THSteps periodicity schedule will be measured. The performance
benchmarks will establish minimum compliance measures, which will
increase over time. HMO must meet all performance benchmarks required
for THSteps services.
6.8.12 Validation of Encounter Data. Encounter data will be validated
by chart review of a random sample of THSteps eligible Members against
monthly encounter data reported by HMO. Chart reviews will be conducted
by HHSC to validate that all screens are performed when due and as
reported, and that reported data is accurate and timely. Substantial
deviation between reported and charted encounter data could result in
HMO and/or network providers being investigated for potential fraud and
abuse without notice to HMO or the provider.
STAR+PLUS BBA Amendment
Page 13 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.13 MODIFICATION OF SECTION 6.9, PERINATAL SERVICES
Section 6.9.3, Perinatal Services, is replaced with the following language:
6.9.3 HMO must have a process to expedite scheduling a prenatal
appointment for an obstetrical exam for a TP40 member no later than two
weeks after receiving the daily enrollment file verifying enrollment of
the member into the HMO.
Section 6.9.3.1 of Section 6.9, Perinatal Services, is modified as follows:
6.9.3.1 [Deleted]
Section 6.9.3.2 of Section 6.9, Perinatal Services, is modified as follows:
6.9.3.2 [Deleted]
6.9.4 HMO must have procedures in place to contact and assist a
pregnant/delivering Member in selecting a PCP for her baby either
before the birth or as soon as the baby is born.
Section 6.9, Perinatal Services, is modified to add the following sections
(6.9.5 through 6.9.6.2) to be consistent with the STAR contract:
6.9.5 HMO must provide inpatient care and professional services related
to labor and delivery for its pregnant/delivering members and neonatal
care for its newborn members (see Article 14.3.1) at the time of
delivery and for up to 48 hours following an uncomplicated vaginal
delivery and 96 hours following an uncomplicated Caesarian delivery.
6.9.5.1 HMO must reimburse in-network providers, out-of-network
providers, and specialty physicians who are providing call coverage,
routine, and/or specialty consultation services for the period of time
covered in Article 6.9.5.
6.9.5.1.1 HMO must adjudicate provider claims for services provided to
a newborn member in accordance with HHSC's claims processing
requirements using the proxy ID number or State-issued Medicaid ID
number (see Article 4.10). HMO cannot deny claims based on provider
non-use of State-issued Medicaid ID number for a newborn member. HMO
must accept provider claims for newborn services based on mother's name
and/or Medicaid ID number with accommodations for multiple births, as
specified by the HMO.
6.9.5.2 HMO cannot require prior authorization or PCP assignment to
adjudicate newborn claims for the period of time covered by Article
6.9.5
6.9.6 HMO may require prior authorization requests for hospital or
professional services provided beyond the time limits in Article 6.9.5.
HMO must respond to these prior authorizations within the requirements
of 28 TAC 19.1710 - 19.1712 and Article 21.58a of the Texas Insurance
Code.
6.9.6.1 HMO must notify providers involved in the care of
pregnant/delivering women and newborns (including out-of-network
providers and hospitals) regarding the HMO's prior authorization
requirements.
6.9.6.2 HMO cannot require a prior authorization for services provided
to a pregnant/delivering Member or newborn Member for a medical
condition which requires emergency services, regardless of when the
emergency condition arises (see Article 6.5.6).
STAR+PLUS BBA Amendment
Page 14 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.14 MODIFICATION OF 6.11 SPECIAL, SUPPLEMENTAL NUTRITION PROGRAM FOR
WOMEN, INFANTS AND CHILDREN (WIC) - SPECIFIC REQUIREMENTS
Section 6.11.1, Special, Supplemental Nutrition Program for Women, Infants
and Children (WIC) - Specific Requirements, was amended as follows to be
consistent with STAR Language:
6.11.1 HMO must coordinate with WIC to provide certain medical
information which is necessary to determine WIC eligibility, such as
height, weight, hematocrit or hemoglobin (see Article 7.16.3.2).
SECTION 2.15 MODIFICATION OF SECTION 6.12.4.3, TUBERCULOSIS.
Section 6.12.4.3, Tuberculosis, was amended to be consistent with STAR
contract language as follows:
6.12.4.3 HMO may contract with the local TB control programs to perform
any of the capitated services required in Article 6.12.
SECTION 2.16 MODIFICATION OF SECTION 6.13, HEALTH EDUCATION AND WELLNESS AND
PREVENTION PLAN
Section 6.13, Health Education and Wellness and Prevention Plan, is
replaced with 6.13, People with Disabilities, Special Health Care Needs, or
Chronic or Complex Conditions to be consistent with the STAR contract.
6.13.1 HMO shall provide the following services to persons with
disabilities, special health care needs, or chronic or complex
conditions. These services are in addition to the covered services
described in detail in the Texas Medicaid Provider Procedures Manual
(Provider Procedures Manual) and the Texas Medicaid Bulletin, which is
the bi-monthly update to the Provider Procedures Manual. Clinical
information regarding covered services is published by the Texas
Medicaid program in the Texas Medicaid Service Delivery Guide.
6.13.2 HMO must develop and maintain a system and procedures for
identifying Members who have disabilities, special health care needs or
chronic or complex medical and behavioral health conditions. Once
identified, HMO must have effective health delivery systems to provide
the covered services to meet the special preventive, primary acute, and
specialty health care needs appropriate for treatment of the
individual's condition. The guidelines and standards established by the
American Academy of Pediatrics, the American College of
Obstetrics/Gynecologists, the U.S. Public Health Service, and other
medical and professional health organizations and associations'
practice guidelines whose standards are recognized by HHSC must be used
in determining the medically necessary services, assessment and plan of
care for each individual.
6.13.2.1 In accordance with 42 C.F.R. 438.208(b)(3), HMO shall provide
information that identifies Members who the HMO has assessed as special
health care needs Members to the State's enrollment broker. The
information will be provided in a format to be specified by HHSC and
updated by the 10th day of each month. In the event that a special
health care needs Member changes health plans, HMO will work with
receiving HMO to provide information 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
STAR+PLUS BBA Amendment
Page 15 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
the primary care provider's medical records, that Member agrees to that
plan of care, and that the plan is updated as often as the Member's
needs change, but at least annually.
6.13.4 HMO must provide a primary care and specialty care provider
network for persons with disabilities, special health care needs, or
chronic or complex conditions. Specialty and subspecialty providers
serving all Members must be Board Certified/Board Eligible in their
specialty. HMO may request exceptions from HHSC for approval of
traditional providers who are not board-certified or board-eligible but
who otherwise meet HMO's credentialing requirements.
6.13.5 HMO must have in its network PCPs and specialty care providers
that have documented experience in treating people with disabilities,
special health care needs, or chronic or complex conditions, including
children. For services to children with disabilities, special health
care needs, or chronic or complex conditions, HMO must have in its
network PCPs and specialty care providers that have demonstrated
experience with children with disabilities, special health care needs,
or chronic or complex conditions in pediatric specialty centers such as
children's hospitals, medical schools, teaching hospitals and tertiary
center levels.
6.13.6 HMO must provide information, education and training programs to
Members, families, PCPs, specialty physicians, and community agencies
about the care and treatment available in HMO's plan for Members with
disabilities, special health care needs, or chronic or complex
conditions.
HMO must ensure Members with disabilities, special health care needs,
or chronic or complex conditions have direct access to a specialist.
6.13.7 HMO must coordinate care and establish linkages, as appropriate
for a particular Member, with existing community-based entities and
services, including but not limited to: Maternal and Child Health,
Children with Special Health Care Needs (CSHCN), the Medically
Dependent Children Program (MDCP), Community Resource Coordination
Groups (CRCGs), Interagency Council on Early Childhood Intervention
(ECI), Home and Community-based 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
STAR+PLUS BBA Amendment
Page 16 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.13.9.5 HMO must develop and implement training programs for primary
care providers, community agencies, ancillary care providers, and
families concerning the care and treatment of a Member with a
disability or chronic or complex conditions.
6.13.10 HMO must identify coordinators of medical care to assist
providers who serve Members with disabilities and chronic or complex
conditions and the Members and their families in locating and accessing
appropriate providers inside and outside HMO's network.
6.13.11 HMO must assist, through information and referral, eligible
Members in accessing providers of non-capitated Medicaid services
listed in Article 6.1.8, as applicable.
6.13.12 HMO must ensure that Members who require routine or regular
laboratory and ancillary medical tests or procedures to monitor
disabilities, 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 2.17 MODIFICATION TO SECTION 6.14, CARE COORDINATION AND TRANSITION PLAN
FOR LONG TERM CARE SERVICES
Section 6.14, Care Coordination and Transition Plan for Long Term Care
Services, is replaced with Section 6.14, Health Education and Wellness and
Prevention Plan to be consistent with the STAR contract as follows:
6.14 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.14.1 Health Education Plan. HMO must develop and implement a Health
Education plan. The health education plan must tell Members how HMO
system operates, how to obtain services, including emergency care and
out-of-plan services. The plan must emphasize the value of screening
and preventive care and must contain disease-specific information and
educational materials.
6.14.2 Wellness Promotion Programs. HMO must conduct wellness promotion
programs to improve the health status of its Members. HMO may
cooperatively conduct Health Education classes for all enrolled STAR
Members with one or more HMOs also contracting with HHSC in the service
area to provide services to Medicaid recipients in all counties of the
service area. Providers and HMO staff must integrate health education,
wellness and prevention training into the care of each Member. HMO must
provide a range of health promotion and wellness information and
activities for Members in formats that meet the needs of all Members.
HMO must:
1. develop, maintain and distribute health education services
standards, policies and procedures to providers;
2. monitor provider performance to ensure the standards for health
education services are complied with;
3. inform providers in writing about any non-compliance with the plan
standards, policies or procedures;
4. establish systems and procedures that ensure that provider's medical
instruction and education on preventive services provided to the Member
are documented in the Member's medical record; and
5. establish mechanisms for promoting preventive care services to
Members who do not access care, e.g. newsletters, reminder cards, and
mail-outs.
STAR+PLUS BBA Amendment
Page 17 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.14.3 Health Education Activities Report. HMO must submit, upon
request, a Health Education Activities Schedule to HHSC or its designee
listing the time and location of classes, health fairs or other events
conducted during the time period of the request.
SECTION 2.18 MODIFICATION OF SECTION 6.15, 1915(c) WAIVER SERVICE (COMMUNITY
BASED ALTERNATIVES)
Section 6.15, 1915(c) Waiver Service (Community Based Alternatives), is
replaced with Section 6.15, Sexually Transmitted Diseases (STDS) and Human
Immunodeficiency Virus (HIV), to be consistent with the STAR contract.
6.15 SEXUALLY TRANSMITTED DISEASES (STDS) AND HUMAN IMMUNODEFICIENCY
VIRUS (HIV)
HMO must provide STD services that include STD/HIV prevention,
screening, counseling, diagnosis, and treatment. HMO is responsible for
implementing procedures to ensure that Members have prompt access to
appropriate services for STDs, including HIV.
6.15.1 HMO must allow Members access to STD services and HIV diagnosis
services without prior authorization or referral by PCP. HMO must
comply with Texas Family Code '32.003, relating to consent to treatment
by a child.
6.15.2 HMO must provide all covered services required to form the basis
for a diagnosis and treatment plan for STD/HIV by the provider.
6.15.3 HMO must consult with TDH regional public health authority to
ensure that Members receiving clinical care of STDs, including HIV, are
managed according to a protocol, which has been approved by HHSC (see
Article 7.16.1 relating to cooperative agreements with public health
authorities).
6.15.4 HMO must make education available to providers and Members on
the prevention, detection and effective treatment of STDs, including
HIV.
6.15.5 HMO must require providers to report all confirmed cases of
STDs, including HIV, to the local or regional health authority
according to 25 TAC Section 97.131 - 97.134, using the required forms
and procedures for reporting STDs.
6.15.6 HMO must coordinate with the HHSC regional health authority to
ensure that Members with confirmed cases of syphilis, chancroid,
gonorrhea, chlamydia and HIV receive risk reduction and partner
elicitation/notification counseling. Coordination must be included in
the subcontract required by Article 7.16.1. HMO may contract with local
or regional health authorities to perform any of the covered services
required in Article 6.15.
6.15.7 HMO's PCPs may enter into contracts or agreements with
traditional HIV service providers in the service area to provide
services such as case management, psychosocial support and other
services. If the service provided is a covered service under this
contract, the contract or agreement must include payment provisions.
6.15.8 The subcontract with the respective HHSC regional offices and
city and county health departments, as described in Article 7.16.1,
must include, but not be limited to, the following topics:
6.15.8.1 Access for Case Investigation. Procedures must be established
to make Member records available to public health agencies with
authority to conduct disease investigation, receive confidential Member
information, and follow up.
STAR+PLUS BBA Amendment
Page 18 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.15.8.2 Medical Records and Confidentiality. HMO must require that
providers have procedures in place to protect the confidentiality of
Members provided STD/HIV services. These procedures must include, but
are not limited to, the manner in which medical records are to be
safeguarded; how employees are to protect medical information; and
under what conditions information can be shared. HMO must inform and
require its providers who provide STD/HIV services to comply with all
state laws relating to communicable disease reporting requirements. HMO
must implement policies and procedures to monitor provider compliance
with confidentiality requirements.
6.15.8.3 Partner Referral and Treatment. Members who are named as
contacts to an STD, including HIV, should be evaluated and treated
according to HMO's protocol. All protocols must be approved by HHSC.
HMO's providers must coordinate referral of non-Member partners to
local and regional health department STD staff.
6.15.8.4 Informed Consent and Counseling. HMO must have policies and
procedures in place regarding obtaining informed consent and counseling
Members. The subcontracts with providers who treat HIV patients must
include provisions requiring the provider to refer Members with HIV
infection to public health agencies for in-depth prevention counseling,
ongoing partner elicitation and notification services and other
prevention support services. The subcontracts must also include
provisions that require the provider to direct-counsel or refer an
HIV-infected Member about the need to inform and refer all sex and/or
needle-sharing partners that might have been exposed to the infection
for prevention counseling and antibody testing.
SECTION 2.19 MODIFICATION OF SECTION 6.16, BLIND AND DISABLED MEMBERS
Section 6.16, Blind and Disabled Members, is amended with the language
below to be consistent with the STAR contract.
6.16 BLIND AND DISABLED MEMBERS
6.16.1 Blind and disabled Members' SSI status is effective the date of
State's eligibility system, SAVERR, identifies the Member as Type
Program 13 (TP13). On this effective date, the Member becomes a
voluntary STAR Member.
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).
6.16.2 HMO must perform the same administrative services and functions
as are performed for mandatory Members under this contract. These
administrative services and functions include, but are not limited to:
6.16.2.1 Prior authorization of services;
6.16.2.2 All customer services functions offered Members in mandatory
participation categories, including the complaint process, enrollment
services, and hotline services;
6.16.2.3 Linguistic services, including providing Member materials in
alternative formats for the blind and disabled;
6.16.2.4 Health education;
6.16.2.5 Utilization management using HHSC Claims Administrator
encounter data to provide appropriate interventions for Members through
administrative case management;
Quality assurance activities as needed and Focused Studies as required
by HHSC; and
STAR+PLUS BBA Amendment
Page 19 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.16.2.7 Coordination to link Blind and Disabled Members with
applicable community resources and targeted case management programs
(see Non-Capitated Services in Article 6.1.8).
6.16.3 HMO must require network providers to submit claims for health
and health-related services to HHSC's Claims Administrator for claims
adjudication and payment.
6.16.4 HMO must provide services to Blind and Disabled Members within
HMO's network unless necessary services are unavailable within network.
HMO must also allow referrals to out-of-network providers if necessary
services are not available within HMO's network. Records must be
forwarded to Member's PCP following a referral visit.
SECTION 2.20 ADDITION TO ARTICLE 6, SCOPE OF SERVICES
Article 6, Scope of Services, is amended by adding Section 6.17, Care
Coordination and Transition Plans for Long Term Care Services as follows:
6.17 Care Coordination and Transition Plans For Long Term Care Services
6.17.1 For STAR+PLUS Members that are receiving all preventive,
primary, acute, and long term care services from the same HMO (this
includes Members that are eligible for Medicaid only and Members that
are Medicare eligible who select the STAR+PLUS HMO to also provide
Medicare covered services), HMO shall ensure that each Member has a
qualified PCP who is responsible for overall clinical direction and
serves as a central point of integration and coordination of covered
primary, acute, and long term care services. HMO will furnish a Care
Coordinator to all Members who request one, or when HMO has determined
through an assessment of the Member's health and support needs, that a
Care Coordinator is required. The Care Coordinator shall be responsible
for working with the Member or his representative and service providers
to develop a seamless package of care in which primary, acute, and long
term care service needs are met through a single, understandable,
rational plan. Each Member's plan must also be well coordinated with
the Member's family and community support systems. The Care Coordinator
shall work as a team with the PCP, and coordinate all STAR+PLUS
services with the PCP. HMO must identify and train certain Members or
their families to coordinate their own care, to the extent of the
Member's capability. HMO must empower its Care Coordinators to
authorize and refer Members for all long term care services.
6.17.2 For dually eligible Members who obtain their Medicare services
outside the STAR+PLUS HMO's Medicare network, HMO is responsible for
meeting the Member's long term care service needs. HMO's Care
Coordinator shall be responsible for providing a seamless package of
long term care services for each Member, and for coordinating
preventive, primary, and acute care services provided elsewhere into an
integrated, single, understandable, rational plan. Each Member's plan
must also be coordinated with the Member's family and community support
systems. In integrating each Member's care, the Care Coordinator shall
work with the Members physician as a team in furnishing and
coordinating a comprehensive long term care package. HMO must empower
its Care Coordinators to authorize and refer Members for all long term
care services. In order to integrate the Members acute and primary
care, and stay abreast of the Members needs and condition, the Care
Coordinator shall also actively involve and coordinate with the Members
primary and specialty care providers and work cooperatively together.
6.17.3 HMO shall provide information about and referral to community
organizations that may not be providing STAR+PLUS covered services, but
are otherwise important to the health and well-being of Members. These
organizations include, but are not limited to:
1) State/Federal agencies (e.g., those agencies with jurisdiction over
children's services, aging, protective services, public health,
substance abuse, mental health/retardation, rehabilitation,
STAR+PLUS BBA Amendment
Page 20 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
developmental disabilities, income support, nutritional assistance,
school districts, family support agencies, etc.);
2) Social Service agencies (e.g., Area Agencies on Aging, residential
support agencies, independent living centers, supported employment
agencies, etc.) and ECI providers;
3) City and County agencies (e.g., welfare departments, Women, Infants,
and Children (WIC), housing programs, etc.);
4) Civic and religious organizations; and
5) Consumer groups, advocates, and councils (e.g., legal aid offices,
consumer/family support groups, permanency planning, etc.).
6.17.4 HMO must have a protocol for quickly assessing the needs of
Members who are discharged from a hospital or other care or treatment
facility. HMO must ensure that social workers and discharge planners in
hospitals and hospital care coordinators are knowledgeable about the
mandatory requirement for Medicaid Members to receive their long term
care services under managed care. HMO Care Coordinator must work with
the Members PCP (whether or not the PCP is in HMOs network), the
hospital discharge planner(s), the Member, and the Members family to
assess and plan for the Members discharge. When long term care is
needed, HMO must ensure that the Members discharge plan includes
arrangements for receiving community-based care whenever possible. HMO
must ensure that the Member, the Members family, and the Members PCP
are all well-informed of all service options that are available to meet
the Members needs in the community.
6.17.5 Within thirty (30) days of receiving the Member's enrollment
package, HMO must review the screening information and any existing
care plan, and develop a transition plan for that Member Until such
time as HMO contacts the Member and coordinates modifications to the
Members current treatment/long term care services plan, HMO must ensure
that the current services continue and that there are no breaks in
services/treatment.
6.17.6 HMO must have assessment instruments. For infants and children,
HMO must have an instrument appropriate for the assessment of children.
The instrument(s) must be used to identify Members with significant
health problems, requiring immediate attention, and which can be used
to identify Members who need or are at risk of needing long term care
services. The appropriate Minimum Data Set (MDS) instrument must be
completed and electronically submitted to the State in the specified
format initially and annually for every Member receiving long term care
services, either in the community or in a facility, in addition to any
assessment instrument HMO might use with the exception that for
children under 21 do not have to be assessed using the MDS-HC. The
instrument may be completed by HMO Subcontractor, or service provider,
but HMO remains responsible for the data recorded. As specialized MDS
instruments are developed for other living arrangements (e.g., assisted
living), TDHS will notify HMO of the availability of the instrument and
the date by which data collection for using the instrument would be
required.
6.17.7 For Members residing in nursing facilities, HMO must ensure that
the NF provider uses the MDS version required by CMS regulations for
assessment and care planning and submits the MDS data electronically to
TDHS
6.17.8 All Members who qualify for nursing facility level of care must
be given the freedom to choose their setting of care, i.e., nursing
facility, within HMO's network. HMO shall ensure that the Member or his
representative is aware of all available options.
6.17.9 HMO must ensure that Members needing home and community based
long term care services are identified and referred to services in a
timely manner.
STAR+PLUS BBA Amendment
Page 21 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
No individual under 21 should be admitted to a nursing facility without
completion of the following:
1) Information about all available community-based long-term care
services appropriate to the individual's needs provided to the
individual and parent/guardian; and
2) A Community Resource Coordination Group (CRCG) meeting has been held
in which all other available options have been considered and rejected.
6.17.10 When a need for nursing facility level of care is indicated,
HMO must refer the Member to TDHS for determination of Members
eligibility. HMO, at its discretion, may provide this level of rare to
Members not determined eligible by TDHS.
6.17.11 HMO must develop a system to have a centralized record for each
Member reflecting current service plan and showing all services
received by the Member from providers within HMO network and from
providers external to the network. The centralized record will ensure
that all Plan providers, including specialty and long term care service
providers, make appropriate and timely entries regarding care provided,
diagnosis, medications prescribed, and treatment plans developed. The
PCP, or when applicable, the Care Coordinator, shall determine the
appropriate physical location of the Member record. In most cases, the
most appropriate location will be with the PCP or the Care Coordinator.
However, the location may vary depending on residence (e.g., nursing
homes or group homes) and particular care needs of the Member. The HMO
shall ensure that the organization of and documentation included in the
centralized Member record shall meet all applicable professional
standards ensuring confidentiality of Member records, referrals, and
documentation of information.
HMO must have a systematic process for generating or receiving
referrals and sharing confidential medical, treatment, and planning
information across providers.
6.17.12 HMO must assure that the Member is involved in the assessment
process and fully informed about options, is included in the
development of the service plan and is in agreement with the plan of
care that is developed. 6.17.13 HMO must provide a transition plan for
Members currently receiving Medicaid services. TDHS and/or previous
health plan will provide current HMO with detailed service plans, names
of current providers, etc. for Members receiving long term care
services at the time of enrollment. The transition planning process
includes, but is not limited to, the following:
(a) Review of existing TDHS care plans;
(b) Preparation of a transition plan that ensures continuous care under
the Member's current care plan during the transfer into HMO's network
while HMO conducts an appropriate assessment and development of a new
plan if needed; and
(c) If Durable Medical Equipment had been ordered prior to enrollment
but not received by the time of enrollment, coordination and follow
through to ensure that the Member receives other necessary supportive
equipment and supplies without undue delay.
6.17.14 HMO will hire Care Coordinators persons experienced in meeting
the needs of vulnerable populations who have chronic or complex
conditions. These include, but are not limited to, persons with an
undergraduate and/or graduate degree in either social work or nursing
with relevant work experience. HMO may subcontract the Care
Coordination function to other entities or agencies, as long as the
Subcontractor's Care Coordinators meet these requirements. HMO staff
providing Care Coordination functions must be located within the
STAR+PLUS Service Delivery Area.
STAR+PLUS BBA Amendment
Page 22 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.17.15 The HMO will ensure that Home and Community Support Services
(HCSS) agencies providing services to members will hire personal
assistance services and community support services providers chosen by
the participant, or the participants legal authorized representative
provided the individual who will provide the services:
(1) meets minimum qualifications for the service,
(2) is willing to be employed as an attendant by the HCSS provider
agency; and
(3) is willing, and determined competent by the HCSS nurse, to deliver
the service(s) according to the clients individual service plan (ISP)
(4) HMO staff providing Care Coordination functions must be located
within the STAR+PLUS Service Delivery Area.
SECTION 2.21 ADDITION TO-ARTICLE 6, SCOPE OF SERVICES
Article 6, Scope of Services, is amended to add Section 6.18, 1915 (c)
Waiver Service (Community Based Alternatives) as follows:
6.18 The HMO must provide to members the array of services allowable
through the CMS approved 1915 (c) waiver. TDHS and the HMO mutually
agree to the terms and conditions set forth herein and to the
provisions of the applicable state and federal regulations, applicable
licensure, to the terms set forth in the Community Based Alternative
(CBA) Provider Manual, a copy of which has been furnished to HMO and
that is incorporated herein by reference as part of this contract, and
to any subsequent additions, deletions or amendments to such
regulations, to any policy letters and/or subsequent revisions to the
CBA Provider Manual that are provided to HMO, and the pertinent rules
published by TDHS and/or the single state Medicaid agency.
6.18.1.1 1915 (c) Waiver services must be available to all members who
meet Community Based Alternatives (CBA) eligibility requirements based
on their assessment and medical necessity.
6.18.1.2 1915 (c) Waiver services may be made available to members who
do not meet the CBA eligibility requirements based on assessment and
medical necessity as a value added service.
6.18.2 Waiver Service eligibility for members of the HMO
6.18.2.1 The HMO must notify TDHS when CBA eligibility testing is
initiated on a member of the HMO.
6.18.2.2 The HMO must apply risk criteria, complete the Form 3652 for
medical necessity determination, complete the assessment documentation
and prepare a CBA Individual Service Plan (ISP) for each member
requesting CBA services or for members identified as needing CBA
services.
6.18.2.3 The HMO must provide TDHS the results of the assessment
activities.
6.18.2.4 TDHS will notify the member and the HMO of the results of
their eligibility determination based on the information provider by
the HMO.
6.18.2.4.1 If the member is eligible, the member will be notified of
the effective date of eligibility. A copy of the notice will be sent to
the HMO.
6.18.2.4.2 If the member is not eligible, the notification will provide
information on the member's right to appeal the adverse determination.
A copy of the notice will be sent to the HMO.
STAR+PLUS BBA Amendment
Page 23 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.18.3 Waiver Service eligibility for Medical Assistance Only
non-member applicants.
6.18.3.1 TDHS will inform the applicant that services are provided
through an HMO and allow the applicant to select the HMO.
6.19.3.2 TDHS will notify the selected HMO to initiate pre-enrollment
assessment services required under the waiver for the non-member.
6.18.3.3 The HMO must complete Form 3652 for medical necessity
determination, complete the assessment documentation and prepare a CBA
Individual Service Plan (ISP) for each applicant referred by TDHS.
6.18.3.4 The HMO must provide information to TDHS reflecting the
results of the assessment activities.
6.18.3.5 The HMO will be authorized payment for the assessment
activities in accordance with the fee-for-services schedule in effect
at the time of the assessment regardless of final determination of
applicant eligibility.
6.18.3.6 TDHS will notify the client and the HMO of the results of
their eligibility determination.
6.18.3.6.1 If the applicant is eligible,
6.18.3.6.1.1 The HMO will be notified of their eligibility and the
effective date of eligibility will be the first day of the month
following the determination of eligibility.
6.18.3.6.1.2 The HMO will be notified of client eligibility and the
client will be enrolled in the HMO on the date that eligibility is
effective. The HMO will initiate the ISP on the date of enrollment.
6.18.3.6.2 If the applicant is not eligible, the notification will
provide information on the applicant's right to appeal the adverse
determination. Notification will be sent to the HMO if the client is
not eligible for CBA services.
6.18.3.7 Rider 7 applies to ongoing current CBA Members receiving
STAR+PLUS services. Rider 7 does not apply to initial STAR+PLUS
applicants. The HMO may not disallow or jeopardize community services
for CBA eligible members currently receiving STAR+PLUS services if
those services are required for that Member to live in the most
integrated setting and the exemption complies with the CMS
cost-effectiveness requirement.
6.18.4 Annual Reassessment. Prior to the end date of the annual ISP,
the HMO must initiate the annual reassessment to determine and validate
continued eligibility for CBA services for each CBA client. The HMO
will be expected to complete the same activities and submit the same
documentation to TDHS for the annual reassessment as required for the
initial determination of eligibility. The HMO is responsible for
assessment activities for members and no additional compensation will
be paid for the annual reassessment for members.
SECTION 2.22 ADDITION TO ARTICLE 6, SCOPE OF SERVICES
Article 6, Scope of Services, is amended to add Section 6.19, Consumer
Directed Services, as follows:
6.19 CONSUMER DIRECTED SERVICES
6.19.1 The HMO must make available the Consumer Directed Services (CDS)
option to all members desiring that option. The HMO will provide
information on CDS.
STAR+PLUS BBA Amendment
Page 24 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
6.19.1.1 At initial assessment for attendant care services,
6.19.1.2 At annual reassessment for attendant care services,
6.19.1.3 And at any time when a member/client so requests that
information.
6.19.2 The HMO must contract with providers who are able to offer
Consumer Directed Services. To participate as a provider of Consumer
Directed Services, the provider must:
6.19.2.1 Have entered into a contract with TDHS for the delivery of
those services.
6.19.2.2 Be licensed for the delivery of attendant care services.
6.19.3 The HMO must assure compliance with the Texas Administrative
Code as found at Title 40, Social Services & Assistance, Part I, Texas
Department of Human Services Chapter 41, Vendor Fiscal Intermediary
Payments - TAC Section Numbers 41.101, 41.103, and 41.105. In addition,
the HMO must comply with the Consumer Directed Services in STAR+PLUS
Guidelines which are hereby incorporated by reference.
SECTION 2.23 MODIFICATION OF SECTION 7.1, NETWORK PROVIDER DIRECTORY
Section 7.1, Network Provider Directory, is replaced with Section 7.1,
Provider Accessibility, to be consistent with the STAR contract and to be
compliant with BBA.
7.1 PROVIDER ACCESSIBILITY
7.1.1 HMO must enter into written contracts with properly credentialed
health care service providers. The names of all providers must be
submitted to HHSC as part of HMO subcontracting process. HMO must have
its own credentialing process to review, approve and periodically
recertify the credentials of all participating providers in compliance
with 28 TAC 11.1902, relating to credentialing of providers in HMOs.
7.1.2 HMO must require tax I.D. numbers from all providers. HMO is
required to do backup withholding from all payments to providers who
fail to give tax I.D. numbers or who give incorrect numbers.
7.1.3 Timeframes for Access Requirements. HMO must have sufficient
network providers and establish procedures to ensure Members have
access to routine, urgent, and emergency services; telephone
appointments; advice and Member service lines. These services must be
accessible to Members within the following timeframes:
7.1.3.1 Urgent Care within 24 hours of request;
7.1.3.2 Routine care within 2 weeks of request;
7.1.3.3 Physical Wellness Exams for adults must be provided within 8 to
10 weeks of the request;
7.1.3.4 HMO must establish policies and procedures to ensure that
THSteps Checkups be provided within 90 days of new enrollment, except
newborn Members should be seen within 2 weeks of enrollment, and in all
cases for all Members be consistent with the American Academy of
Pediatrics and THSteps periodicity schedule which is based on the
American Academy of Pediatrics schedule and delineated in the Texas
Medicaid Provider Procedures Manual and the Medicaid bi-monthly
bulletins (see Article 6.1, Scope of Services). If the Member does not
request a checkup, HMO must establish a procedure for contacting the
Member to schedule the checkup.
STAR+PLUS BBA Amendment
Page 25 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.1.3.5 Prenatal Care within 2 weeks of request.
7.1.4 HMO is prohibited from requiring a provider or provider group to
enter into an exclusive contracting arrangement with HMO as a condition
for participation in its provider network.
SECTION 2.24 MODIFICATION OF SECTION 7.2, PROVIDER ACCESSIBILITY
Section 7.2, Provider Accessibility is replaced with Section 7.2, Provider
Contracts to be consistent with STAR contract as follows:
7.2 PROVIDER CONTRACTS
7.2.1 All providers must have a written contract, either with an
intermediary entity or an HMO, to participate in the Medicaid program
(provider contract). HMO must make all contracts available to HHSC upon
request, at the time and location requested by HHSC. All standard
formats of provider contracts must be submitted to HHSC for approval no
later than 60 days after the effective date of this contract, unless
previously filed with HHSC. HMO must submit one paper copy and one
electronic copy in a form specified by HHSC. Any change to the standard
format must be submitted to HHSC for approval no later than 30 days
prior to the implementation of the new standard format. All provider
contracts are subject to the terms and conditions of this contract and
must contain the provisions of Article 5, Statutory and Regulatory
Compliance, and the provisions contained in Article 3.2.4.
7.2.1.1 HHSC has 15 working days to review the materials and recommend
any suggestions or required changes. If HHSC has not responded to HMO
by the fifteenth day, HMO may execute the contract. HHSC reserves the
right to request HMO to modify any contract that has been deemed
approved.
7.2.2 Primary Care Provider (PCP) contracts and specialty care
contracts must contain provisions relating to the requirements of the
provider types found in this contract. For example, PCP contracts must
contain the requirements of Article 7.8 relating to Primary Care
Providers.
7.2.3 Provider contracts that are requested by any agency with
authority to investigate and prosecute fraud and abuse must be produced
at the time and place required by HHSC or the requesting agency.
Provider contracts requested in response to a Public Information
request must be produced within 48 hours of the request. Requested
contracts and all related records must be provided free-of-charge to
the requesting agency.
7.2.4 The form and substance of all provider contracts are subject to
approval by HHSC. HHSC retains the authority to reject or require
changes to any contract that do not comply with the requirements or
duties and responsibilities of this contract. HMO REMAINS RESPONSIBLE
FOR PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES,
RESPONSIBILITIES AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER
THE DUTY, RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL
PERFORMANCE.
7.2.5 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.
7.2.6 HMO must not restrict a provider's ability to provide opinions or
counsel to a Member with respect to benefits, treatment options, and
provider's change in network status.
STAR+PLUS BBA Amendment
Page 26 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.2.7 To the extent feasible within HMO's existing claims processing
systems, HMO should have a single or central address to which providers
must submit claims. If a central processing center is not possible
within HMO's existing claims processing system, HMO must provide each
network provider a complete list of all entities to whom the providers
must submit claims for processing and/or adjudication. The list must
include the name of the entity, the address to which claims must be
sent, explanation for determination of the correct claims payer based
on services rendered, and a phone number the provider may call to make
claims inquiries. HMO must notify providers in writing of any changes
in the claims filing list at least 30 days prior to effective date of
change. If HMO is unable to provide 30 days notice, providers must be
given a 30-day extension on their claims filing deadline to ensure
claims are routed to correct processing center.
7.2.8 HMO, all IPAs, and other intermediary entities must include
contract language which substantially complies with the following
standard contract provisions in each Medicaid provider contract. This
language must be included in each contract with an actual provider of
services, whether through a direct contract or through intermediary
provider contracts:
7.2.8.1 [Provider] is being contracted to deliver Medicaid managed care
under the HHSC STAR program. HMO must provide copies of the HHSC/HMO
Contract to the [Provider] upon request. [Provider] understands that
services provided under this contract are funded by State and federal
funds under the Medicaid program. [Provider] is subject to all state
and federal laws, rules and regulations that apply to all persons or
entities receiving state and federal funds. [Provider] understands that
any violation by a provider of a State or federal law relating to the
delivery of services by the provider under this HMO/Provider contract,
or any violation of the HHSC/HMO contract could result in liability for
money damages, and/or civil or criminal penalties and sanctions under
state and/or federal law.
7.2.8.2 [Provider] understands and agrees that HMO has the sole
responsibility for payment of covered services rendered by the provider
under HMO/Provider contract. In the event of HMO insolvency or
cessation of operations, [Provider's] sole recourse is against HMO
through the bankruptcy, conservatorship, or receivership estate of HMO.
7.2.8.2.1 [Provider] understands and agrees that the HMO's Medicaid
enrollee Members 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).
7.2.8.3 [Provider] understands and agrees HHSC is not liable or
responsible for payment for any Medicaid covered services provided to
mandatory Members under HMO/Provider contract. Federal and State laws
provide severe penalties for any provider who attempts to collect any
payment from or ▇▇▇▇ a Medicaid recipient for a covered service.
7.2.8.4 [Provider] agrees that any modification, addition, or deletion
of the provisions of this contract will become effective no earlier
than 30 days after HMO notifies HHSC of the change in writing. If HHSC
does not provide written approval within 30 days from receipt of
notification from HMO, changes can be considered provisionally
approved, and will become effective. Modifications, additions or
deletions which are required by HHSC or by changes in state or federal
law are effective immediately.
7.2.8.5 This contract is subject to all state and federal laws and
regulations relating to fraud and abuse in health care and the Medicaid
program. [Provider] must cooperate and assist HHSC and any state or
federal agency that is charged with the duty of identifying,
investigating, sanctioning or prosecuting suspected fraud and abuse.
[Provider] must provide originals and/or copies of any and all
information, allow access to premises and provide records to HHSC or
its authorized agent(s), HHSC, CMS, the U.S. Department of Health and
Human Services, FBI, TDI, and the Texas Attorney General's Medicaid
Fraud Control Unit, upon request, and free-of-charge. [Provider] must
report any suspected fraud or abuse including any suspected fraud and
abuse committed by HMO or a Medicaid recipient to HHSC for referral to
HHSC.7.2.8.6 [Provider] is
STAR+PLUS BBA Amendment
Page 27 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
required to submit proxy claims forms to HMO for services provided to
all STAR Members that are capitated by HMO in accordance with the
encounter data submissions requirements established by HMO and HHSC.
7.2.8.7 HMO is prohibited from imposing restrictions upon the
[Provider's] free communication with Members about a Member's medical
conditions, treatment options, HMO referral policies, and other HMO
policies, including financial incentives or arrangements and all STAR
managed care plans with whom [Provider] contracts.
7.2.8.8 The Texas Medicaid Fraud Control Unit must be allowed to
conduct private interviews of [Providers] and the [Providers']
employees, contractors, and patients. Requests for information must be
complied with, in the form and language requested. [Providers] and
their employees and contractors must cooperate fully in making
themselves available in person for interviews, consultation, grand jury
proceedings, pre-trial conference, hearings, trial and in any other
process, including investigations. Compliance with this Article is at
HMO's and [Provider's] own expense.
7.2.8.9 HMO must include the method of payment and payment amounts in
all provider contracts.
7.2.8.10 All provider clean claims must be adjudicated within 30 days.
HMO must pay provider interest on all clean claims that are not paid
within 30 days at a rate of 1.5% per month (18% annual) for each month
the claim remains unadjudicated.
7.2.8.11 HMO must prohibit network providers from interfering with or
placing liens upon the state's right or HMO's right, acting as the
state's agent, to recovery from third party resources. HMO must
prohibit network providers from seeking recovery in excess of the
Medicaid payable amount or otherwise violating state and federal laws.
7.2.9 HMO must follow the procedures outlined in article 20A.18A of the
Texas Insurance Code if terminating a contract with a provider,
including an STP. At least 30 days before the effective date of the
proposed termination of the provider's contract, HMO must provide a
written explanation to the provider of the reasons for termination. HMO
may immediately terminate a provider contract if the provider presents
imminent harm to patient health, actions against a license or practice,
or fraud.
7.2.9.1 Within 60 days of the termination notice date, a provider may
request a review of HMO's proposed termination by an advisory review
panel, except in a case in which there is imminent harm to patient
health, an action against a private license, or fraud. The advisory
review panel must be composed of physicians and providers, as those
terms are defined in article 20A.02(r) and (t), including at least one
representative in the provider's specialty or a similar specialty, if
available, appointed to serve on the standing quality assurance
committee or utilization review committee of HMO. The decision of the
advisory review panel must be considered by HMO but is not binding on
HMO. HMO must provide to the affected provider, on request, a copy of
the recommendation of the advisory review panel and HMO's
determination.
7.2.9.2 A provider who is terminated is entitled to an expedited review
process by HMO on request by the provider. HMO must provide
notification of the provider's termination to HMO's Members receiving
care from the terminated provider at least 30 days before the effective
date of the termination. If a provider is terminated for reasons
related to imminent harm to patient health, HMO may notify its Members
immediately.
7.2.10 HMO must notify HHSC no later than 90 days prior to terminating
any subcontract affecting a major performance function of this
contract. If HMO seeks to terminate a provider's contract for imminent
harm to patient health, actions against a license or practice, or
fraud, contract termination may be immediate. HHSC will require
assurances that any contract termination will not result in an
interruption of an essential service or major contract function.
STAR+PLUS BBA Amendment
Page 28 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.2.11 HMO must include a complaint and appeals process which complies
with the requirements of Article 20A.12 of the Texas Insurance Code
relating to Complaint Systems in all provider contracts. HMO's
complaint and appeals process must 6e the same for all providers.
7.2.12 Notice to Rejected Providers. In accordance with 42
C.F.R.Section 438.129(a)(2), if an HMO declines to include individual
or groups of providers in its network, it must give the affected
providers written notice of the reason for its decision.
SECTION 2.25 MODIFICATION TO SECTION 7.3, PROVIDER CONTRACTS
Section 7.3, Provider Contracts, is replaced with Section 7.3, Physician
Incentive Plans, to be consistent with the STAR contract.
7.3 PHYSICIAN INCENTIVE PLANS
7.3.1 HMO may operate a physician incentive plan only if: (1) no
specific payment may be made directly or indirectly under a physician
incentive plan to a physician or physician group as an inducement to
reduce or limit medically necessary services furnished to a Member; and
(2) the stop-loss protection, enrollee surveys and disclosure
requirements of this Article are met.
7.3.2 HMO must disclose to HHSC information required by federal
regulations found at 42 C.F.R. Section 417.479. The information must be
disclosed in sufficient detail to determine whether the incentive plan
complies with the requirements at 42 C.F.R.'417.479. The disclosure
must contain the following information:
7.3.2.1 Whether services not furnished by a physician or physician
group (referral services) are covered by the incentive plan. If only
services furnished by the physician or physician group are covered by
the incentive plan, disclosure of other aspects of the incentive plan
are not required to be disclosed.
7.3.2.2 The type of incentive arrangement (e.g. withhold, bonus,
capitation).
7.3.2.3 The percent of the withhold or bonus, if the incentive plan
involves a withhold bonus.
7.3.2.4 Whether the physician or physician group has evidence of a
stop-loss protection, including the amount and type of stop-loss
protection.
7.3.2.5 The panel size and the method used for pooling patients, if
patients are pooled.
7.3.2.6 The results of Member and disenrollee surveys, if HMO is
required under 42 C.F.R. '417.479 to conduct Member and disenrollee
surveys.
7.3.3 HMO must submit the information required in Articles 7.3.2.1 -
7.3.2.5 to HHSC by the effective date of this contract and each
anniversary date of the contract.
7.3.4 HMO must submit the information required in Article 7.3.2.6 one
year after the effective date of initial contract or effective date of
renewal contract, and annually each subsequent year under the contract.
HMO's who put physicians or physician groups at substantial financial
risk must conduct a survey of all Members who have voluntarily
disenrolled in the previous year. A list of voluntary disenrollees may
be obtained from the Enrollment Broker.
7.3.5 HMO must provide Members with information regarding Physician
Incentive Plans upon request. The information must include the
following:
7.3.5.1 whether HMO uses a physician incentive plan that covers
referral services;
STAR+PLUS BBA Amendment
Page 29 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.3.5.2 the type of incentive arrangement (i.e., withhold, bonus,
capitation);
7.3.5.3 whether stop-loss protection is provided; and
7.3.5.4 results of enrollee and disenrollee surveys, if required under
42 C.F.R '417.479.
7.3.5.5 HMO must ensure that IPAs and ANHCs with whom HMO contracts
comply with the requirements above. HMO is required to meet the
requirements above for all levels of subcontracting.
SECTION 2.26 MODIFICATION TO SECTION 7.4, PHYSICIAN INCENTIVE PLAN
Section 7.4, Physician Incentive Plan, is replaced with Section 7.4,
Provider Manual and Provider Training to be consistent with the STAR
contract as follows:
7.4 PROVIDER MANUAL AND PROVIDER TRAINING
7.4.1 HMO must prepare and issue a Provider Manual(s), including any
necessary specialty manuals (e.g. behavioral health) to the providers
in the HMO network and to newly contracted providers in the HMO network
within five (5) working days from inclusion of the provider into the
network. The Provider Manual must contain sections relating to special
requirements of the STAR Program as required under this contract. See
Appendix D, Required Critical Elements, for specific details regarding
content requirements.
Provider Manual and any revisions must be approved by HHSC prior to
publication and distribution to providers (see Article 3.4.1 regarding
the process for plan materials review).
7.4.2 HMO must provide training to all network providers and their
staff regarding the requirements of the HHSC/HMO contract and special
needs of STAR Members.
7.4.2.1 HMO training for all providers must be completed no later than
30 days after placing a newly contracted provider on active status. HMO
must provide on-going training to new and existing providers as
required by HMO or HHSC to comply with this contract.
7.4.2.2 HMO must include in all PCP training how to screen for and
identify behavioral health disorders, HMO's referral process to
behavioral health care services and clinical coordination requirements
for behavioral health. HMO must include in all training for behavioral
health providers how to identify physical health disorders, HMO's
referral process to primary care and clinical coordination requirements
between physical medicine and behavioral health providers. HMO must
include training on coordination and quality of care such as behavioral
health screening techniques for PCPs and new models of behavioral
health interventions.
7.4.3 HMO must provide primary care and behavioral health providers
with screening tools and instruments approved by HHSC.
7.4.4 HMO must maintain and make available upon request enrollment or
attendance rosters dated and signed by each attendee or other written
evidence of training of each network provider and their staff.
7.4.5 HMO must have its written policies and procedures for the
screening, assessment and referral processes between behavioral health
providers and physical medicine providers available for HHSC review
prior to the effective date of the contract.
STAR+PLUS BBA Amendment
Page 30 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.27 MODIFICATION TO SECTION 7.5, PROVIDER MANUAL AND PROVIDER
TRAINING
Section 7.5, Provider Manual and Provider Training, is replaced with
Section 7.5, Member Panel Reports to be consistent with the STAR contract.
7.5 MEMBER PANEL REPORTS
HMO must furnish each PCP with a current list of enrolled Members
enrolled or assigned to that Provider no later than 5 working days
after HMO receives the Enrollment File from the Enrollment Broker each
month.
SECTION 2.28 MODIFICATION TO SECTION 7.6, MEMBER PANEL REPORTS
Section 7.6, Member Panel Reports is replaced with Section 7.6, Provider
Complaint and Appeal Procedures.
7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.6.1 HMO must develop, implement and maintain a provider complaint
system. The complaint and appeal procedures must be in compliance with
all applicable state and federal law or regulations. All Member
complaints and/or appeals of an adverse determination requested by the
enrollee, or any person acting on behalf of the enrollee, or a
physician or provider acting on behalf of the enrollee must comply with
the provisions of this Article. Modifications and amendments to the
complaint system must be submitted to HHSC no later than 30 days prior
to the implementation of the modification or amendment.
7.6.2 HMO must include the provider complaint and appeal procedure in
all network provider contracts or in the provider manual.
7.6.3 HMO's complaint and appeal process cannot contain provisions
requiring a provider to submit a complaint or appeal to HHSC for
resolution in lieu of the HMO's process.
7.6.4 HMO must establish mechanisms to ensure that network providers
have access to a person who can assist providers in resolving issues
relating to claims payment, plan administration, education and
training, and complaint procedures.
SECTION 2.29 MODIFICATION OF SECTION 7.7, PROVIDER COMPLAINT AND APPEAL
PROCEDURES
Section 7. 7, Provider Complaint and Appeal Procedures, is replaced with
Section 7.7, Provider Qualifications-General. Section 7.7 is retitled
Section 7.7.1 and new Section 7.7.2, Provider Credentialing and
Recredentialing is added:
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 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.
--------------------------------------------------------------------------------
STAR+PLUS BBA Amendment
Page 31 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.7.2 PROVIDER CREDENTIALING AND RECREDENTIALING
In accordance with 42 C.F.R Section 438.214, HMO's standard
credentialing and recredentialling 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.
7.7.2.2.1 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;
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;
1) 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;
STAR+PLUS BBA Amendment
Page 32 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 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 2.30 MODIFICATION OF SECTION 7.8, PROVIDER QUALIFICATIONS - GENERAL
Section 7.8. Provider Qualifications- General, is replaced with
Sections 7.8, Primary Care Providers, to be consistent with STAR
contract.
7.8 PRIMARY CARE PROVIDERS
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).
STAR+PLUS BBA Amendment
Page 33 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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."
7.8.1 HMO must have a system for monitoring Member enrollment into its
plan to allow HMO to effectively plan for future needs and recruit
network providers as necessary to ensure adequate access to primary
care and specialty care. The Member enrollment monitoring system must
include the length of time required for Members to access care within
the network. The monitoring system must also include monitoring
after-hours availability and accessibility of PCPs.
7.8.2 HMO must maintain a primary care provider network in sufficient
numbers and geographic distribution to serve a minimum of forty-five
percent (45%) of the mandatory STAR eligibles in each county of the
service area. HMO is required to increase the capacity of the network
as necessary to accommodate enrollment growth beyond the forty-fifth
percentile (45%).
7.8.3 HMO must maintain a provider network that includes pediatricians
and physicians with pediatric experience in sufficient numbers and
geographic distribution to serve eligible children and adolescents in
the service area and provide timely access to the full scope of
benefits, especially THSteps checkups and immunizations.
7.8.4 HMO must comply with the access requirements as established by
the Texas Department of Insurance for all HMOs doing business in Texas,
except as otherwise required by this contract.
7.8.5 HMO must have physicians with board eligibility/certification in
pediatrics available for referral for Members under the age of 21.
7.8.5.1 Individual PCPs may serve more than 2,000 Members. However, if
HHSC determines that a PCP's Member enrollment exceeds the PCP's
ability to provide accessible, quality care, HHSC may prohibit the PCP
from receiving further enrollments. HHSC may direct HMOs to assign or
reassign Members to another PCP's panel.
7.8.6 HMO must have PCPs available throughout the service area to
ensure that no Member must travel more than 30 miles to access the PCP,
unless an exception to this distance requirement is made by HHSC.
7.8.7 HMO's primary care provider network may include providers from
any of the following practice areas: General Practitioners; Family
Practitioners; Internists; Pediatricians; Obstetricians/Gynecologists
(OB/GYN); Pediatric and Family Advanced Practice Nurses (APNs), and
Certified Nurse Midwives Women Health (CNMs) practicing under the
supervision of a physician; Physician Assistants (PAs) practicing under
the supervision of a physician specializing
STAR+PLUS BBA Amendment
Page 34 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
in Family Practice, Internal Medicine, Pediatrics or
Obstetrics/Gynecology who also qualifies as a PCP under this contract;
or Federally Qualified Health Centers (FQHCs), Rural Health Clinics
(RHCs) and similar community clinics; and specialists who are willing
to provide medical homes to selected Members with special needs and
conditions (see Article 7.9.4).
7.8.8 The PCP for a Member with disabilities or chronic or complex
conditions may be a specialist who agrees to provide PCP services to
the Member. The specialty provider must agree to perform all PCP duties
required in the contract and PCP duties must be within the scope of the
specialist's license. Any interested person may initiate the request
for a specialist to serve as a PCP for a Member with disabilities or
chronic or complex conditions.
7.8.9 PCPs must either have admitting privileges at a hospital, which
is part of HMO network of providers, or make referral arrangements with
an HMO provider who has admitting privileges to a network hospital.
7.8.10 HMO must require, through contract provisions, that PCPs are
accessible to Members 24 hours a day, 7 days a week. The following are
acceptable and unacceptable phone arrangements for contacting PCPs
after normal business hours.
Acceptable:
1. Office phone is answered after-hours by an answering service,
which meets language requirements of the major population groups
and which can contact the PCP or another designated medical
practitioner. All calls answered by an answering service must be
returned within 30 minutes.
2. Office phone is answered after normal business hours by a
recording in the language of each of the major population groups
served directing the patient to call another number to reach the
PCP or another provider designated by the PCP. Someone must be
available to answer the designated provider's phone. Another
recording is not acceptable.
3. Office phone is transferred after office hours to another location
where someone will answer the phone and be able to contact the PCP
or another designated medical practitioner, who can return the
call within 30 minutes.
Unacceptable:
1. Office phone is only answered during office hours.
2. Office phone is answered after-hours by a recording which tells
patients to leave a message.
3. Office phone is answered after-hours by a recording which directs
patients to go to an Emergency Room for any services needed.
4. Returning after-hours calls outside of 30 minutes.
7.8.11 HMO must require PCPs, through contract provisions or provider
manual, to provide primary care services and continuity of care to
Members who are enrolled with or assigned to the PCP. Primary care
services are all services required by a Member for the prevention,
detection, treatment and cure of illness, trauma, disease or disorder,
which are covered and/or required services under this contract. All
services must be provided in compliance with generally accepted medical
and behavioral health standards for the community in which services are
rendered. HMO must require PCPs, through contract provisions or
provider manual, to provide children under the age of 21 services in
accordance with the American Academy of Pediatric recommendations and
STAR+PLUS BBA Amendment
Page 35 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
the THSteps periodicity schedule and provide adults services in
accordance with the U.S. Preventive Services Task Force's publication
"Put Prevention Into Practice".
7.8.11.1 HMO must require PCPs, through contract provisions or provider
manual, to assess the medical needs of Members for referral to
specialty care providers and provide referrals as needed. PCP must
coordinate care with specialty care providers after referral.
7.8.11.2 HMO must require PCPs, through contract provisions or provider
manual, to make necessary arrangements with home and community support
services to integrate the Member's needs. This integration may be
delivered by coordinating the care of Members with other programs,
public health agencies and community resources that provide medical,
nutritional, behavioral, educational and outreach services available to
Members.
7.8.11.3 HMO must require, through contract provisions or provider
manual, that the Member's PCP or HMO provider through whom PCP has made
arrangements, be the admitting or attending physician for inpatient
hospital care, except for emergency medical or behavioral health
conditions or when the admission is made by a specialist to whom the
Member has been referred by the PCP. HMO must require, through contract
provisions or provider manual, that PCP assess the advisability and
availability of outpatient treatment alternatives to inpatient
admissions. HMO must require, through contract provisions or provider
manual, that PCP provide or arrange for pre-admission planning for
non-emergency inpatient admissions, and discharge planning for Members.
PCP must call the emergency room with relevant information about the
Member. PCP must provide or arrange for follow-up care after emergency
or inpatient care.
7.8.11.4 HMO must require PCPs for children under the age of 21 to
provide or arrange to have provided all services required under Article
6.8 relating to Texas Health Steps, Article 6.9 relating to Perinatal
Services, Article 6.10 relating to Early Childhood Intervention,
Article 6.11 relating to WIC, Article 6.13 relating to People With
Disabilities or Chronic or Complex Conditions, and Article 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.
7.8.12 PCP Selection and Changes. All Medicaid recipients who are
eligible for participation in the STAR program have the right to select
their PCP and HMO.-Medicaid recipients who are mandatory STAR
participants who do not select a PCP and/or HMO during the time period
allowed will be assigned to a PCP and/or HMO using the HHSC default
process. Members may change PCPs at any time, but these changes are
limited to four (4) times per year.
7.8.12.1 Voluntary SSI Members. PCP changes cannot be performed
retroactively for voluntary SSI Members. If an SSI Member requests a
PCP change on or before the 15th of the month, the change will be
effective the fast day of the next month. If an SSI Member requests a
PCP change after the 15th of the month, the change will be effective
the first day of the second month that follows. Exceptions to this
policy will be allowed for reasons of medical necessity or other
extenuating circumstances.
7.8.12.2 Mandatory Members. Retroactive changes to a Member's PCP
should only be made if it is medically necessary or there are other
circumstances which necessitate a retroactive change. HMO must pay
claims for services provided by the original PCP. If the original PCP
is paid on a capitated basis and services were provided during the
period for which capitation was paid, HMO cannot recoup the capitation.
SECTION 2.31 MODIFICATION TO SECTION 7.9, PRIMARY CARE PROVIDERS
Section 7.9, Primary Care Providers, is being replaced with Section 7.9,
OB/GYN Providers, to be consistent with the STAR contract
STAR+PLUS BBA Amendment
Page 36 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.9 OB/GYN PROVIDERS
HMO must allow a female Member to select an OB/GYN within its provider
network or within a limited provider network in addition to a PCP, to
provide health care services within the scope of the professional
specialty practice of a properly credentialed OB/GYN. See Article
21.53D of the Texas Insurance Code and 28 TAC Sections 11.506, 11.1600
and 11.1608. A Member who selects an OB/GYN must be allowed direct
access to the health care services of the OB/GYN without a referral by
the woman's PCP or a prior authorization or precertification from HMO.
HMO must allow Members to change OB/GYNs up to four times per year.
Health care services must include, but not be limited to:
7.9.1 One well-woman examination per year;
7.9.2 Care related to pregnancy;
7.9.3 Care for all active gynecological conditions; and
7.9.4 Diagnosis, treatment, and referral for any disease or condition
within the scope of the professional practice of a properly
credentialed obstetrician or gynecologist.
7.9.5 HMOs which allow its Members to directly access any OB/GYN
provider within its network, must ensure that the provisions of
Articles 7.9.1 through 7.9.4 continue to be met.
7.9.6 OB/GYN providers must comply with HMO's procedures contained in
HMO's provider manual or provider contract for OB/GYN providers,
including but not limited to prior authorization procedures.
SECTION 2.32 MODIFICATION TO SECTION 7.10, OB/GYN PROVIDERS
Section 7.10, OB/GYN Providers, is being replaced with Section 7.10,
Specialty Care Providers consistent with the STAR contract.
7.10 SPECIALTY CARE PROVIDERS
7.10.1 HMO must maintain specialty providers, actively serving within
that specialty, including pediatric specialty providers and chemical
dependency specialty providers, within the network in sufficient
numbers and areas of practice to meet the needs of all Members
requiring specialty care services.
7.10.2 HMO must require, through contract provisions or provider
manual, that specialty providers send a record of consultation and
recommendations to a Member's PCP for inclusion in Member's medical
record and report encounters to the PCP and/or HMO.
7.10.3 HMO must ensure availability and accessibility to appropriate
specialists.
7.10.4 HMO must ensure that no Member is required to travel in excess
of 75 miles to secure initial contact with referral specialists;
special hospitals, psychiatric hospitals; diagnostic and therapeutic
services; and single service health care physicians, dentists or
providers. Exceptions to this requirement may be allowed when an HMO
has established, through utilization data provided to HHSC, that a
normal pattern for securing health care services within an area exists
or HMO is providing care of a higher skill level or specialty than the
level which is available within the service area such as, but not
limited to, treatment of cancer, bums, and cardiac diseases.
STAR+PLUS BBA Amendment
Page 37 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.33 MODIFICATION TO SECTION 7.11, SPECIALTY CARE PROVIDERS
Section 7.11, Specialty Care Providers is being replaced with Section 7.11,
Special Hospitals and Specialty Care Facilities to be consistent with the
STAR contract.
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).
7.11.2 HMO must include requirements for pre-admission and discharge
planning in its contracts with network hospitals. Discharge plans for a
Member must be provided by HMO or the hospital to the Member/family,
the PCP and specialty care physicians.
7.11.3 HMO must have appropriate multidisciplinary teams for people
with disabilities or chronic or complex medical conditions. These teams
must include the PCP and any individuals or providers involved in the
day-to-day or on-going care of the Member.
7.11.4 HMO must include in its provider network a HHSC-designated
perinatal care facility, as established by Section 32.042, Texas Health
and Safety Code, once the designated system is finalized and perinatal
care facilities have been approved for the service area (see Article
6.9.1).
SECTION 2.34 MODIFICATION TO SECTION 7.11, SPECIAL HOSPITALS AND SPECIALTY
CARE FACILITIES
Section 7.12, Special Hospitals And Specialty Care Facilities, is being
replaced with Section 7.12 Behavioral health- Local Mental Health
Authority (LMHA,) to be consistent with the STAR contract.
7.12 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)
7.12.1 Assessment to determine eligibility for rehabilitative and
targeted MHMR case management services is a function of the LMHA. HMO
must provide all covered services described in detail in the Texas
Medicaid Provider Procedures Manual (Provider Procedures Manual) and
the Texas Medicaid Bulletins which is the bi-monthly update to the
Provider Procedures Manual. Clinical information regarding covered
services are published by the Texas Medicaid program in the Texas
Medicaid Service Delivery Guide. Covered services must be provided to
Members with SPMI and SED, when medically necessary, whether or not
they are also receiving targeted case management or rehabilitation
services through the LMHA.
7.12.2 HMO will coordinate with the LMHA and state psychiatric facility
regarding admission and discharge planning, treatment objectives and
projected length of stay for Members committed by a court of law to the
state psychiatric facility.
7.12.3 HMO must enter into written agreements with all LMHAs in the
service area which describes the process(es) which HMO and LMHA will
use to coordinate services for STAR Members with SPMI or SED. The
agreement will contain the following provisions:
7.12.3.1 Describe the behavioral health covered services indicated in
detail in the Provider Procedures Manual and the Texas Medicaid
Bulletins which is the bi-monthly update to the Provider Procedures
Manual. Clinical information regarding covered services are published
by the Texas Medicaid program in the Texas Medicaid Service Delivery
Guide. Also include the amount, duration, and scope of basic and
value-added services, and HMO's responsibility to provide these
services;
STAR+PLUS BBA Amendment
Page 38 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.12.3.2 Describe criteria, protocols, procedures and instrumentation
for referral of STAR Members from and to HMO and LMHA;
7.12.3.3 Describe processes and procedures for referring Members with
SPMI or SED to LMHA for assessment and determination of eligibility for
rehabilitation or targeted case management services;
7.12.3.4 Describe how the LMHA and HMO will coordinate providing
behavioral health care services to Members with SPMI or SED;
7.12.3.5 Establish clinical consultation procedures between HMO and
LMHA including consultation to effect referrals and on-going
consultation regarding the Member's progress;
7.12.3.6 Establish procedures to authorize release and exchange of
clinical treatment records;
7.12.3.7 Establish procedures for coordination of assessment,
intake/triage, utilization review/utilization management and care for
persons with SPMI or SED;
7.12.3.8 Establish procedures for coordination of inpatient psychiatric
services (including court ordered commitment of Members under 21) in
state psychiatric facilities within the LMHA's catchment area;
7.12.3.9 Establish procedures for coordination of emergency and urgent
services to Members; and
7.123.10 Establish procedures for coordination of care and transition
of care for new HMO Members who are receiving treatment through the
LMHA.
7.12.4 HMO must offer licensed practitioners of the healing arts, who
are part of the Member's treatment team for rehabilitation services,
the opportunity to participate in HMO's network. The practitioner must
agree to accept the standard provider reimbursement rate, meet the
credentialing requirements, comply with all the terms and conditions of
the standard provider contract of HMO.
7.12.5 Members receiving rehabilitation services must be allowed to
choose the licensed practitioners of the healing arts who are currently
a part of the Member's treatment team for rehabilitation services . If
the Member chooses to receive these services from licensed
practitioners of the healing arts who are part of the Member's
rehabilitation services treatment team, HMO must reimburse the LMHA at
current Medicaid fee-for-service amounts.
SECTION 2.35 MODIFICATION TO SECTION 7.13, BEHAVIORAL HEALTH- LOCAL MENTAL
HEALTH AUTHORITY (LMHA)
Section 7.13, Behavioral health- Local Mental Health Authority (LMHA), is
being replaced with Section 7.13, Significant Traditional Providers (STPS)
to be consistent with the STAR contract.
7.13 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must seek participation in its provider network from:
7.13.l Each health care provider in the service area who has
traditionally provided care to Medicaid recipients;
7.13.2 Each hospital in the service area that has been designated as a
disproportionate share hospital under Medicaid; and
7.13.3 Each specialized pediatric laboratory in the service area,
including those laboratories located in children's hospitals.
STAR+PLUS BBA Amendment
Page 39 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.36 MODIFICATION OF SECTION 7.14, SIGNIFICANT TRADITIONAL
PROVIDERS (STPS)
Section 7.14, Significant Traditional Providers (STPS), is being replaced
with Section 7.14, Rural Health Providers, to be consistent with the STAR
contract.
7.14 RURAL HEALTH PROVIDERS
7.14.1 In rural areas of the service area, HMO must seek the
participation in its provider network of rural hospitals, physicians,
home and community support service agencies, and other rural health
care providers who:
7.14.1.1 are the only providers located in the service area; and
7.14.1.2 are Significant Traditional Providers.
7.14.2 In order to contract with HMO, rural health providers must:
7.142.1 agree to accept the prevailing provider contract rate of HMO
based on provider type; and
7.142.2 have the credentials required by HMO, provided that lack of
board certification or accreditation by JCAHO may not be the only
grounds for exclusion from the provider network.
7.14.3 HMO must reimburse rural hospitals with 100 or fewer licensed
beds in counties with fewer than 50,000 persons for acute care services
at a rate calculated using the higher of the prospective payment system
rate or the cost reimbursed methodology authorized under the Tax Equity
and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals reimbursed
under TEFRA cost principles shall be paid without the imposition of the
TEFRA cap.
7.14.4 HMO must reimburse physicians who practice in rural counties
with fewer than 50,000 persons at a rate using the current Medicaid fee
schedule, including negotiated fee-for-service.
SECTION 2.37 ADDITION TO ARTICLE 7, PROVIDER NETWORK REQUIREMENTS
Article 7 is amended to add Section 7.16, Coordination with Public Health,
to be consistent with the STAR contract.
7.16 COORDINATION WITH PUBLIC HEALTH
7.16.1 REIMBURSED ARRANGEMENTS. HMO must make a good faith effort to
enter into a subcontract for the covered health care services as
specified below with HHSC Public Health Regions, city and/or county
health departments or districts in each county of the service area that
will be providing these services to the Members (Public Health
Entities), who will be paid for services by HMO, including any or all
of the following services or any covered service which the public
health department and HMO have agreed to provide:
7.16.1.1 Sexually Transmitted Diseases (STDs) Services (see Article
6.15);
7.16.1.2 Confidential HIV Testing (see Article 6.15);
7.16.1.3 Immunizations;
7.16.1.4 Tuberculosis (TB) Care (see Article 6.12);
7.16.1.5 Family Planning Services (see Article 6.7);
STAR+PLUS BBA Amendment
Page 40 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.16.1.6 THSteps checkups (see Article 6.8); and
7.16.1.7 Prenatal services (see Article 6.9).
7.16.2 HMO must make a good faith effort to enter into subcontracts
with public health entities in the service area. The subcontracts must
be available for review by HHSC or its designated agent(s) on the same
basis as all other subcontracts. If any changes are made to the
contract, it must be resubmitted to HHSC. If an HMO is unable to enter
into a contract with public health entities, HMO must document current
and past efforts to HHSC. Documentation must be submitted no later than
120 days after the execution of this contract. Public health
subcontracts must include the following areas:
7.16.2.1 The general relationship between HMO and the Public Health
entity. The subcontracts must specify the scope and responsibilities of
both parties, the methodology and agreements regarding billing and
reimbursements, reporting responsibilities, Member and provider
educational responsibilities, and the methodology and agreements
regarding sharing of confidential medical record information between
the public health entity and the PCP.
7.16.2.2 Public Health Entity responsibilities:
(1) Public health providers must inform Members that confidential
health care information will be provided to the PCP.
(2) Public health providers must refer Members back to PCP for any
follow-up diagnostic, treatment, or referral services.
(3) Public health providers must educate Members about the importance
of having a PCP and accessing PCP services during office hours
rather than seeking care from Emergency Departments, Public Health
Clinics, or other Primary Care Providers or Specialists.
(4) Public health entities must identify a staff person to act as
liaison to HMO to coordinate Member needs, Member referral, Member
and provider education, and the transfer of confidential medical
record information.
7.16.2.3 HMO Responsibilities:
(1) HMO must identify care coordinators who will be available to
assist public health providers and PCPs in getting efficient
referrals of Members to the public health providers, specialists,
and health-related service providers either within or outside
HMO's network.
(2) HMO must inform Members that confidential healthcare information
will be provided to the PCP.
(3) HMO must educate Members on how to better utilize their PCPs,
public health providers, emergency departments, specialists, and
health-related service providers.
7.16.2.4 Existing contracts must include the provisions in Articles
7.16.2.1 through 7.16.2.3.
7.16.3 NON-REIMBURSED ARRANGEMENTS WITH PUBLIC HEALTH ENTITIES.
7.16.3.1 Coordination with Public Health Entities. HMOs must make a
good faith effort to enter into a Memorandum of Understanding (MOU)
with Public Health Entities in the service area regarding the provision
of services for essential public health care services. These MOUs must
be entered into in each service area and are subject to HHSC approval.
If any changes are made to the MOU, it must be resubmitted to HHSC. If
an HMO is unable to enter into an MOU with a public health entity, HMO
must document current and past efforts to HHSC. Documentation must be
submitted no later than 120 days after the execution of this contract.
MOUs must contain the roles and responsibilities of HMO and the public
health department for the following services:
STAR+PLUS BBA Amendment
Page 41 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
(1) Public health reporting requirements regarding communicable
diseases and/or diseases which are preventable by immunization as
defined by state law;
(2) Notification of and referral to the local Public Health Entity, as
defined by state law, of communicable disease outbreaks involving
Members;
(3) Referral to the local Public Health Entity for TB contact
investigation and evaluation and preventive treatment of persons
whom the Member has come into contact;
(4) Referral to the local Public Health Entity for STD/HIV contact
investigation and evaluation and preventive treatment of persons
whom the Member has come into contact; and,
(5) Referral for WIC services and information sharing;
(6) Coordination and follow-up of suspected or confirmed cases of
childhood lead exposure.
7.16.3.2 Coordination with Other Health and Human Services (HHS)
Programs. HMOs must make a good faith effort to enter into a Memorandum
of Understanding (MOU) with other HHSC programs regarding the provision
of services for essential public health care services. These MOUs must
be entered into in each service area and are subject to HHSC approval.
If any changes are made to the MOU, it must be resubmitted to HHSC. If
an HMO is unable to enter into an MOU with other HHSC programs, HMO
must document current and past efforts to HHSC. Documentation must be
submitted no later than 120 days after the execution of this contract.
MOUs must delineate the roles and responsibilities of HMO and the HHSC
programs for the following services:
(1) Use of the TDH laboratory for THSteps newborn screens; lead
testing; and hemoglobin/hematocrit tests;
(2) Availability of vaccines through the Vaccines for Children
Program;
(3) Reporting of immunizations provided to the statewide ImmTrac
Registry including parental consent to share data;
(4) Referral for WIC services and information sharing;
(5) Pregnant, Women and Infant (PWI) Targeted Case Management;
(6) THSteps outreach, informing and Medical Case Management;
(7) Participation in the community based coalitions with the
Medicaid-funded case management programs in MHMR, ECI, TCB, and
TDH (PWI, CIDC and THSteps Medical Case Management);
(8) Referral to the TDH Medical Transportation Program;
(9) Cooperation with activities required of public health authorities
to conduct the annual population and community based needs
assessment; and
(10) Coordination and follow-up of suspected or confirmed cases of
childhood lead exposure.
7.16.4 All public health contracts must contain provider network
requirements in Article VII, as applicable.
SECTION 2.38 ADDITION TO ARTICLE 7, PROVIDER NETWORK REQUIREMENTS
Article 7 is amended to add Section 7.17, Coordination with Texas
Department of Protective and Regulatory Services, to be consistent with the
STAR contract.
7.17 COORDINATION WITH TEXAS DEPARTMENT OF PROTECTIVE AND REGULATORY
SERVICES
7.17.1 HMO must cooperate and coordinate with the Texas Department of
Protective and.
Regulatory Services (TDPRS) for the care of a child who is receiving
services from or has been placed in the conservatorship of TDPRS.
7.17.2 HMO must comply with all provisions of a Court Order or TDPRS
Service Plan with respect to a child in the conservatorship of TDPRS
(Order) entered by a Court of Continuing
STAR+PLUS BBA Amendment
Page 42 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
Jurisdiction placing a child under the protective custody of TDPRS or a
Service Plan voluntarily entered into by the parents or person having
legal custody of a minor and TDPRS, which relates to the health and
behavioral health care services required to be provided to the Member.
7.17.3 HMO cannot deny, reduce, or controvert the medical necessity of
any health or behavioral health care services included in an Order
entered by a court. HMO may participate in the preparation of the
medical and behavioral care plan prior to TDPRS submitting the health
care plan to the Court. Any modification or termination of court
ordered services must be presented and approved by the court with
jurisdiction over the matter.
7.17.4 A Member or the parent or guardian whose rights are subject to
an Order or Service Plan cannot appeal the necessity of the services
ordered through HMO's complaint or appeal processes, or to HHSC for a
Fair Hearing.
7.17.5 HMO must include information in its provider training and
manuals regarding:
7.17.5.1 providing medical records;
7.17.5.2 scheduling medical and behavioral health appointments within
14 days unless requested earlier by TDPRS; and
7.17.5.3 recognition of abuse and neglect and appropriate referral to
TDPRS.
7.17.6 HMO must continue to provide all covered services to a Member
receiving services from or in the protective custody of TDPRS until the
Member has been disenrolled from HMO as a result of loss of eligibility
in Medicaid managed care or placement into ▇▇▇▇▇▇ care.
SECTION 2.39 ADDITION TO ARTICLE 7, PROVIDER NETWORK REQUIREMENTS
Article 7, Provider Network Requirements, is amended to add Section 7.18,
Delegated Networks (IPAs, Limited Provider Networks, and ANHCs)
7.18 DELEGATED NETWORKS (IPAs, LIMITED PROVIDER NETWORKS AND ANHCs)
7.18.1 All HMO contracts with any of the entities described in Texas
Insurance Code Article 20A.02(ce) and a group of providers who are
licensed to provide the same health care services or an entity that is
wholly-owned or controlled by one or more hospitals and physicians
including a physician-hospital organization (delegated network
contracts) must:
7.18.1.1 contain the mandatory contract provisions for all
subcontractors in Article 3.2 of this contract;
7.18.1.2 comply with the requirements, duties and responsibilities of
this contract;
7.18.1.3 not create a barrier for full participation to significant
traditional providers;
7.18.1.4 not interfere with HHSC's oversight and audit responsibilities
including collection and validation of encounter data; or
7.18.1.5 be consistent with the federal requirement for simplicity in
the administration of the Medicaid program.
7.18.2 In addition to the mandatory provisions for all subcontracts
under Articles 3.2. and 7.2, all HMO/delegated network contracts must
include the following mandatory standard provisions:
STAR+PLUS BBA Amendment
Page 43 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
7.18.2.1 HMO is required to include subcontract provisions in its
delegated network contracts which require the UM protocol used by a
delegated network to produce substantially similar outcomes, as
approved by HHSC, as the UM protocol employed by the contracting HMO.
The responsibilities of an HMO in delegating UM functions to a
delegated network will be governed by Article 16.3.12 of this contract.
7.18.2,2 Delegated networks that are delegated claims payment
responsibilities by HMO must also have the responsibility to submit
encounter, utilization, quality, and financial data to HMO. HMO remains
responsible for integrating all delegated network data reports into
HMO's reports required under this contract. If HMO is not able to
collect and report all delegated network data for HMO reports required
by this contract, HMO must not delegate claims processing to the
delegated network.
7.18.2.3 The delegated network must comply with the same records
retention and production requirements, including Open Records
requirements, as the HMO under this contract.
7.18.2.4 The delegated network is subject to the same marketing
restrictions and requirements as the HMO under this contract.
7.18.2.5 HMO is responsible for ensuring that delegated network
contracts comply with the requirements and provisions of the HHSC/HMO
contract. HHSC will impose appropriate sanctions and remedies upon HMO
for any default under the HHSC/HMO contract which is caused directly or
indirectly by the acts or omissions of the delegated network.
7.18.3 HMO cannot enter into contracts with delegated networks to
provide services under this contract which require the delegated
network to enter into exclusive contracts with HMO as a condition for
participation with HMO.
7.18.3.1 Article 17.18.3 does not apply to providers who are employees
or participants in limited provider networks.
7.18.4 All delegated networks that limit Member access to those
providers contracted with the delegated network (closed or limited
panel networks) with whom HMO contracts must either independently meet
the access provisions of 28 Texas Administrative Code '11.1607,
relating to access requirements for those Members enrolled or assigned
to the delegated network, or HMO must provide for access through other
network providers outside the closed panel delegated network.
7.18.5 HMO cannot delegate to a delegated network the enrollment,
re-enrollment, assignment or reassignment of a Member.
7.18.6 In addition to the above provision HMO and approved Non-Profit
Health Corporations must comply with all of the requirements contained
in 28 TAC Section 11.1604, relating to Requirements of Certain
Contracts between Primary HMOs and ANHCs and Primary HMOs and Provider
HMOs.
7.18.7 HMO remains responsible for performing all duties,
responsibilities and services under this contract regardless of whether
the duty, responsibility or service is contracted or delegated to
another. HMO must provide a copy of the contract provisions that set
out HMO's duties, responsibilities, and services to any provider
network or group with whom HMO contracts to provide health care
services on a risk sharing or capitated basis or to provide health care
services.
SECTION 2.40 MODIFICATION OF SECTION 8.2, MEMBER HANDBOOK
Section 8.2.4 is amended to add the following language to be consistent
with the STAR contract.
STAR+PLUS BBA Amendment
Page 44 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
8.2.4 In accordance with 42 C.F.R. Section 438.100, HMO must maintain
written policies and procedures for informing Members of their rights
and responsibilities. HMO must notify its Members of their right to
request a copy of these rights and responsibilities.
SECTION 2.41 MODIFICATION OF SECTION 8.5, MEMBER HOTLINE
Current Section 8.5, Member Hotline, is replaced with Section 8.5,
Member Complaint Process, to be consistent with the STAR Contract.
8.5 MEMBER COMPLAINT PROCESS
8.5.1 HMO must develop, implement and maintain a Member complaint
system that complies with the requirements of Article 20A.12 of the
Texas Insurance Code, relating to the Complaint System, except where
otherwise provided in this contract and in applicable federal law. The
complaint and appeals procedure must be the same for all Members and
must comply with Texas Insurance Code, Article 20A.12 or applicable
federal law. Modifications and amendments must be submitted to HHSC at
least 30 days prior to the implementation of the modification or
amendment.
8.5.2 HMO must have written policies and procedures for receiving,
tracking, reviewing, and reporting and resolving of Member complaints.
The procedures must be reviewed and approved in writing by HHSC. Any
changes or modifications to the procedures must be submitted to HHSC
for approval thirty (30) days prior to the effective date of the
amendment.
8.5.3 HMO must designate an officer of HMO who has primary
responsibility for ensuring that complaints are resolved in compliance
with written policy and within the time required. An "officer" of HMO
means a president, vice president, secretary, treasurer, or chairperson
of the board for a corporation, the sole proprietor, the managing
general partner of a partnership, or a person having similar executive
authority in the organization.
8.5.4 HMO must have a routine process to detect patterns of complaints
and disenrollments and involve management and supervisory staff to
develop policy and procedural improvements to address the complaints.
HMO must cooperate with HHSC and HHSC's Enrollment Broker in Member
complaints relating to enrollment and disenrollment.
8.5.5 HMO's complaint procedures must be provided to Members in writing
and in alternative communication formats. A written description of
HMO's complaint procedures must be in appropriate languages and easy
for Members to understand. HMO must include a written description in
the Member Handbook. HMO must maintain at least one local and one
toll-free telephone number for making complaints.
8.5.6 HMO's process must require that every complaint received in
person, by telephone or in writing, is recorded in a written record and
is logged with the following details: date; identification of the
individual filing the complaint; identification of the individual
recording the complaint; nature of the complaint; disposition of the
complaint; corrective action required; and date resolved.
8.5.7 HMO's process must include a requirement that the Governing Body
of HMO reviews the written records (logs) for complaints and appeals.
8.5.8 HMO is prohibited from discriminating against a Member because
that Member is making or has made a complaint.
8.5.9 HMO cannot process requests for disenrollments through HMO's
complaint procedures. Requests for disenrollments must be referred to
HHSC within five (5) business days after the Member makes a
disenrollment request.
STAR+PLUS BBA Amendment
Page 45 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
8.5.10 HMO must develop, implement and maintain an appeal of adverse
determination procedure that complies with the requirements of Article
21.58A of the Texas Insurance Code, relating to the utilization review,
except where otherwise provided in this contract and in applicable
federal law. The appeal of an adverse determination procedure must be
the same for all Members and must comply with Texas Insurance Code,
Article 21.58A or applicable federal law. Modifications and amendments
must be submitted to HHSC no less than 30 days prior to the
implementation of the modification or amendment. When an enrollee, a
person acting on behalf of an enrollee, or an enrollee's provider of
record expresses orally or in writing any dissatisfaction or
disagreement with an adverse determination, HMO or UR agent must regard
the expression of dissatisfaction as a request to appeal an adverse
determination.
8.5.11 If a complaint or appeal of an adverse determination relates to
the denial, delay, reduction, termination or suspension of covered
services by either HMO or a utilization review agent contracted to
perform utilization review by HMO, HMO must inform Members they have
the right to access the HHSC Fair Hearing process at any time in lieu
of the internal complaint system provided by HMO. HMO is required to
comply with the requirements contained in 1 TAC Chapter 357, relating
to notice and Fair Hearings in the Medicaid program, whenever an action
is taken to deny, delay, reduce, terminate or suspend a covered
service.
8.5.12 If Members utilize HMO's internal complaint or appeal of adverse
determination system and the complaint relates to the denial, delay,
reduction, termination or suspension of covered services by either HMO
or a utilization review agent contracted to perform utilization review
by HMO, HMO must inform the Member that they continue to have a right
to appeal the decision through the HHSC Fair Hearing process.
8.5.13 The provisions of Article 21.58A, Texas Insurance Code, relating
to a Member's right to appeal an adverse determination made by HMO or a
utilization review agent by an independent review organization, do not
apply to a Medicaid recipient. Federal fair hearing requirements
(Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200
et. seq.) require the agency to make a final decision after a fair
hearing, which conflicts with the State requirement that the IRO make a
final decision. Therefore, the State requirement is preempted by the
federal requirement.
8.5.14 HMO will cooperate with the Enrollment Broker and HHSC to
resolve all Member complaints. Such cooperation may include, but is not
limited to, participation by HMO or Enrollment Broker and/or HHSC
internal complaint committees.
8.5.15 HMO must have policies and procedures in place outlining the
role of HMO's Medical Director in the Member Complaint System and
appeal of an adverse determination. The Medical Director must have a
significant role in monitoring, investigating and hearing complaints.
8.5.16 HMO must provide Member Advocates to assist Members in
understanding and using HMO's complaint system and appeal of an adverse
determination.
8.5.17 HMO's Member Advocates must assist Members in writing or filing
a complaint or appeal of an adverse determination and monitoring the
complaint or appeal through the Contractor's complaint or appeal of an
adverse determination process until the issue is resolved.
SECTION 2.42 MODIFICATION TO SECTION 8.6, MEMBER COMPLAINT PROCESS
Section 8.6, Member Complaint Process, is replaced with Section 8.6, Member
Notice, Appeals and Fair Hearings, to be consistent with STAR contract
language.
8.6 MEMBER NOTICE, APPEALS AND FAIR HEARINGS
STAR+PLUS BBA Amendment
Page 46 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
8.6.1 HMO must send Members the notice required by 1 Texas
Administrative Code Section 357.5, whenever HMO takes an action to
deny, delay, reduce or terminate covered services to a Member. The
notice must be mailed to the Member no less than 10 days before HMO
intends to take an action. If an emergency exists, or if the time
within which the service must be provided makes giving 10 days notice
impractical or impossible, notice must be provided by the most
expedient means reasonably calculated to provide actual notice to the
Member, including by phone, direct contact with the Member, or through
the provider's office.
8.6.2 The notice must contain the following information:
8.6.2.1 Member's right to immediately access HHSC's Fair Hearing
process;
8.6.2.2 a statement of the action HMO will take;
8.6.2.3 the date the action will be taken; 8.6.2.4 an explanation of
the reasons HMO will take the action;
8.6.2.5 a reference to the state and/or federal regulations which
support HMO's action;
8.6.2.6 an address where written requests may be sent and a toll-free
number Member can call to: request the assistance of a Member
representative, or file a complaint, or request a Fair Hearing;
8.6.2.7 a procedure by which Member may appeal HMO's action through
either HMO's complaint process or HHSC's Fair Hearings process;
8.6.2.8 an explanation that Members may represent themselves, or be
represented by HMO's representative, a friend, a relative, legal
counsel or another spokesperson;
8.6.2.9 an explanation of whether, and under what circumstances,
services may be continued if a complaint is filed or a Fair Hearing
requested;
8.6.2.10 a statement that if the Member wants a HHSC Fair Hearing on
the action, Member must make the request for a Fair Hearing within 90
days of the date on the notice or the right to request a hearing is
waived;
8.6.2.11 a statement explaining that HMO must make its decision within
30 days from the date the complaint is received by HMO; and
8.6.2.12 a statement explaining that a final decision must be made by
HHSC within 90 days from the date a Fair Hearing is requested.
SECTION 2.43 MODIFICATION OF SECTION 8.7, MEMBER NOTICES, APPEALS, AND FAIR
HEARINGS
Section 8.7, Member Notices, Appeals, and Fair Hearings is replaced with
Section 8.7, Member Advocates, to be consistent with STAR language.
8.7 MEMBER ADVOCATES
8.7.1 HMO must provide Member Advocates to assist Members. Member
Advocates must be physically located within the service area. Member
Advocates must inform Members of their rights and responsibilities, the
complaint process, the health education and the services available to
them, including preventive services.
STAR+PLUS BBA Amendment
Page 47 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
8.7.2 Member Advocates must assist Members in writing complaints and
are responsible for monitoring the complaint through HMO's complaint
process until the Member's issues are resolved or a HHSC Fair Hearing
requested (see Articles 8.6.15, 8.6.16, and 8.6.17).
8.7.3 Member Advocates are responsible for making recommendations to
management on any changes needed to improve either the care provided or
the way care is delivered. Member Advocates are also responsible for
helping or referring Members to community resources available to meet
Member needs that are not available from HMO as Medicaid covered
services.
8.7.4 Member Advocates must provide outreach to Members and participate
in HHSC sponsored enrollment activities.
SECTION 2.44 ADDITION TO ARTICLE 8, MEMBER SERVICES REQUIREMENTS
Article 8, Member Services Requirements, is amended to add Section 8.9,
Certification ▇▇▇▇, to be consistent with STAR contract.
8.9 CERTIFICATION DATE
8.9.1 On the date of the new Member's enrollment, HHSC will provide
HMOs with the Member's Medicaid certification date.
Article 8, Member Services Requirements, is amended to add Section 8.10.
Member Hotline, to be consistent with STAR contract.
8.10 MEMBER HOTLINE.
8.10.1 HMO must maintain a toll-free Member telephone hotline 24 hours
a day, seven days a week for Members to obtain assistance in accessing
services under this contract.
SECTION 2.45 MODIFICATION TO SECTION 9.2 ADHERENCE TO MARKETING GUIDELINES
WITH MARKETING ORIENTATION AND TRAINING
Section 9.2, Adherence to Marketing Guidelines with Marketing Orientation
and Training, is being modified to be consistent with STAR contract
language as follows:
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 TDH'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.
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.
SECTION 2.46 ADDITION TO ARTICLE 9, MARKETING AND PROHIBITED PRACTICES
Article 9, Marketing and Prohibited Practices, is being amended to add
Section 9.3, Prohibited Marketing Practices, to be consistent with STAR
contract language.
9.3 PROHIBITED MARKETING PRACTICES
STAR+PLUS BBA Amendment
Page 48 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
9.3.1 HMO and its agents, subcontractors and providers are prohibited
from engaging in the following marketing practices:
9.3.1.1 conducting any direct-contact marketing to prospective Members
except through HHSC-sponsored enrollment events;
9.3.1.2 making any written or oral statement containing material
misrepresentations of fact or law relating to HMO's plan or the STAR
program;
9.3.1.3 making false, misleading or inaccurate statements relating to
services or benefits of HMO or the STAR program;
9.3.1.4 offering prospective Members anything of material or financial
value as an incentive to enroll with a particular PCP or HMO; and
9.3.1.5 discriminating against an eligible Member because of race,
creed, age, color, sex, religion, national origin, ancestry, marital
status, sexual orientation, physical or mental handicap, health status,
or requirements for health care services.
HMO may offer nominal gifts with a retail value of no more than $10
and/or free health screening to potential Members, as long as these
gifts and free health screenings are offered whether or not the
potential Member enrolls in their HMO. Free health screenings cannot be
used to discourage less healthy potential Members from joining HMO. All
gifts must be approved by HHSC prior to distribution to Members. The
results of free screenings must be shared with the Member's PCP if the
Member enrolls with HMO providing the screen.
9.3.3 Marketing representatives may not conduct or participate in
marketing activities for more than one HMO.
Article 9, Marketing and Prohibited Practices, is being amended to add
Section 9.4, Network Provider Directory, to be consistent with STAR
contract language.
9.4 NETWORK PROVIDER DIRECTORY
9.4.1 The provider directory and any revisions must be approved by HHSC
prior to publication and distribution to prospective Members (see
Article 3.4.1 regarding the process for plan materials review). The
directory must contain all critical elements specified by HHSC. See
Appendix D, Required Critical Elements, for specific details regarding
content requirements.
9.4.2 If HMO contracts with limited provider networks, the provider
directory must comply with the requirements of 28 TAC 11.1600(b)(11),
relating to the disclosure and notice of limited provider networks.
9.4.3 Updates to the provider directory must be provided to the
Enrollment Broker at the beginning of each State fiscal year quarter.
This includes the months of September, December, March and June. HMO is
responsible for submitting draft updates to HHSC only if changes other
than PCP information are incorporated. HMO is responsible for sending
three final paper copies and one electronic copy of the updated
provider directory to HHSC each quarter. If an electronic format is not
available, five paper copies must be sent. HHSC will forward two
updated provider directories, along with its approval notice, to the
Enrollment Broker to facilitate the distribution of the directories.
STAR+PLUS BBA Amendment
Page 49 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.47 MODIFICATION OF SECTION 10.1, MODEL MIS REQUIREMENTS
Section 10.1.3.3 of Section 10.1, Model MIS Requirements, is being
amended to be consistent with STAR contract language.
10.1.33 Desk Review. HMO must complete and pass systems desk review
prior to onsite systems testing conducted by HMO.
Section 10.1.7 of Section 10.1, Model MIS Requirements, is being
amended to be consistent with STAR contract language.
10.1.7 HMO must notify HHSC of any changes to HMO's MIS department
dedicated to or supporting this contract by Phase I of Renewal Review.
Any updates to the organizational chart and the description of
responsibilities must be provided to HHSC at least 30 days prior to the
effective date of the change. Official points of contact must be
provided to HHSC on an on-going basis. An Internet E-mail address must
be provided for each point of contact.
SECTION 2.48 MODIFICATION OF SECTION 10.7, UTILIZATION/QUALITY IMPROVEMENT
SUBSYSTEM
In Section 10.7, requirements 5 and 9 from the "Functions and Features"
provision are deleted.
SECTION 2.49 MODIFICATION OF ARTICLE 11, QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM
Section 11.1, Quality Improvement Program (QIP) System, is amended to be
consistent with the STAR contract as follows:
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM
HMO must develop, maintain, and operate a Quality Improvement Program
(QIP) system, which complies with federal regulations relating to
Quality Assurance systems, found at 42 C.F.R. Section 434.34. The
system must meet the Standards for Quality Improvement Programs
contained in Appendix A.
Section 11.2, Written QIP Plan, is amended to be consistent with the STAR
contract as follows:
11.2 WRITTEN QIP PLAN
HMO must have on file with HHSC an approved plan describing its Quality
Improvement Plan (QIP), including how HMO will accomplish the
activities pertaining to each Standard (I-XVI) in Appendix A.
Modifications and amendments must be submitted to HHSC no later than 60
days prior to the implementation of the modification or amendment.
Section 11.3, Q1P Subcontracting, is amended to be consistent with the STAR
contract as follows:
11.3 QIP SUBCONTRACTING
If HMO subcontracts any of the essential functions or reporting
requirements of QIP to another entity, HMO must maintain a file of the
subcontractors. The file must be available for review by HHSC or its
designee upon request. HMO must notify HHSC no later than 90 days prior
to terminating any subcontract affecting a major performance function
of this contract (see Article 3.2.1.2).
Section 11.4, Behavioral Health Integration into QIP, is amended to be
consistent with the STAR contract as follows.
STAR+PLUS BBA Amendment
Page 50 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
11.4 ACCREDITATION
If HMO is accredited by an external accrediting agency, documentation
of accreditation must be provided to HHSC. HMO must provide HHSC with
their accreditation status upon request.
Section 11.5, QIP Reporting Requirement, is amended to be consistent with
the STAR contract as follows.
11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP
HMO must integrate behavioral health into its QIP system and include a
systematic and ongoing process for monitoring, evaluating, and
improving the quality and appropriateness of behavioral health care
services provided to Members. HMO's QIP must enable HMO to collect
data, monitor and evaluate for improvements to physical health outcomes
resulting from behavioral health integration into the overall care of
the Member.
Article 11, Quality Assessment and Performance Improvement Program, is
amended to add Section 11.6, QIP Report Requirements, to be consistent with
STAR contract language.
11.6 QIP REPORTING REQUIREMENTS
HMO must meet all of the QIP Reporting Requirements contained in
Article XII.
SECTION 2.50 MODIFICATION OF SECTION 12.1, FINANCIAL REPORTS.
Sections 12.1, Financial Reports, is amended to be consistent with the STAR
contract as follows.
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.
12.1.2 Deleted.
12.1.3 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
- 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.
STAR+PLUS BBA Amendment
Page 51 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
12.1.5 Administrative expenses reported in the monthly and Final MCFS
Reports must be reported in accordance with Appendix L, Cost Principles
for Administrative Expenses. Indirect administrative expenses must be
based on an allocation methodology for Medicaid managed care activities
and services that is developed or approved by HHSC.
12.1.6 Affiliate Report. HMO must submit an Affiliate Report to HHSC if
this information has changed since the last report was submitted. The
report must contain the following information:
12.1.6.1 A listing of all Affiliates; and
12.1.6.2 A schedule of all transactions with Affiliates which, under
the provisions of this Contract, will be allowable as expenses in Part
1 of the MCFS Report for services provided to HMO by the Affiliates for
the prior approval of HHSC. Include financial terms, a detailed
description of the services to be provided, and an estimated amount,
which will be incurred by HMO for such services during the Contract
period.
12.1.7 Deleted.
12.1.8 Form HCFA-1513. HMO must file an updated Form HCFA-1513
regarding control, ownership, or affiliation of HMO 30 days prior to
the end of the contract year. An updated Form HCFA-1513 must also be
filed no later than 30 days after any change in control, ownership, or
affiliation of HMO. Forms may be obtained from HHSC.
12.1.9 Section 1318 Financial Disclosure Report. HMO must file an
updated CMS Public Health Service (PHS) "Section 1318 Financial
Disclosure Report" no later than 30 days after the end of the contract
year and no later than 30 days after entering into, renewing, or
terminating a relationship with an affiliated party. These forms may be
obtained from HHSC.
12.1.10 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.
12.1.12 Third Party Recovery (TPR) Reports. HMO must file quarterly
Third Party Recovery (TPR) Reports in accordance with the format
developed by HHSC. TPR reports must include total dollars recovered
from third party payers for services to HMO's Members for each month
and the total dollars recovered through coordination of benefits,
subrogation, and worker's compensation.
12.1.13 Each report required under this Article must be mailed to:
Medicaid HMO Contract Deliverables Manager, REDS 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
STAR+PLUS BBA Amendment
Page 52 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 2.51 MODIFICATION OF SECTION 12.2, STATISTICAL REPORTS
Sections 12.2, Statistical Reports, is amended to be consistent with the
STAR contract as follows.
12.2.1 HMO must electronically file the following monthly reports: (1)
encounter; (2) encounter detail; (3) institutional; (4) institutional
detail; and (5) claims detail for cost reimbursed services filed, if
any, with HMO. Encounter data must include the data elements, follow
the format, and use the transmission method specified by HHSC in the
Encounter Data Submission Manual. Encounters must be submitted by HMO
to HHSC no later than 45 days after the date of adjudication
(finalization) of the claims.
12.2.2 Monthly reports must include current month encounter data and
encounter data adjustments to the previous month's data.
12.2.3 Data quality standards will be developed jointly by HMO and
HHSC. Encounter data must meet or exceed data quality standards. Data
that does not meet quality standards must be corrected and returned
within the period specified by HHSC. Original records must be made
available to validate all encounter data.
12.2.4 HMO cannot submit newborn encounters to HHSC until the State
issued Medicaid ID number is received for a newborn. HMO must match the
proxy ID number issued by the HMO with the State issued Medicaid ID
number prior to submission of encounters to HHSC and submit the
encounter in accordance to the HMO Encounter Data Submission Manual.
The encounter must include the State issued Medicaid ID number.
Exceptions to the 45 day deadline will be granted in cases in which the
Medicaid ID number is not available for a newborn Member.
12.2.5 HMO must require providers to submit claims and encounter data
to HMO no later than 95 days after the date services are provided.
12.2.6 HMO must use the procedure codes, diagnosis codes and other
codes contained in the most recent edition of the Texas Medicaid
Provider Procedures Manual and as otherwise provided by HHSC.
Exceptions or additional codes must be submitted for approval before
HMO uses the codes.
12.2.7 HMO must use its HHSC-specified identification numbers on all
encounter data submissions. Please refer to the HHSC Encounter Data
Submission Manual for further specifications.
12.2.8 HMO must validate all encounter data using the encounter data
validation methodology prescribed by HHSC prior to submission of
encounter data to HHSC.
12.2.9 All Claims Summary Report. HMO must submit the "All Claims
Summary Report" identified in the Texas Managed Care Claims Manual as a
contract year-to-date report. The report must be submitted quarterly by
the last day of the month following the reporting period. The reports
must be submitted to HHSC in a format specified by HHSC.
12.2.10 Medicaid Disproportionate Share Hospital (DSH) Reports. HMO
must file preliminary and final Medicaid Disproportionate Share
Hospital (DSH) reports, required by HHSC to identify and reimburse
hospitals that qualify for Medicaid DSH funds. The preliminary and
final DSH reports must include the data elements and be submitted in
the form and format specified by HHSC. The preliminary DSH reports are
due on or before June 1 of the year following the state
STAR+PLUS BBA Amendment
Page 53 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
fiscal year for which data is being reported. The final DSH reports are
due no later than July 15 of the year following the state fiscal year
for which data is being reported.
SECTION 2.52 MODIFICATION OF SECTION 12.8, UTILIZATION MANAGEMENT REPORTS --
BEHAVIORAL HEALTH
Section 12.8, Utilization Management Reports -- Behavioral Health is
modified to reflect STAR contract language as follows:
Section 12.8 Behavioral health (BH) utilization management reports are
required on a semiannual basis. Refer to Appendix H for the
standardized reporting format for each report and detailed instructions
for obtaining the specific data required in the report.
Section 12.8.1 is added to reflect STAR contract language as follows:
12.8.1 In addition, data files are due to HHSC 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 HHSC to facilitate clear
communication to the health plans.
SECTION 2.53 SECTION 2.53 MODIFICATION OF SECTION 12.9, UTILIZATION MANAGEMENTS
REPORTS -- PHYSICAL HEALTH
Section 12.9, Utilization Management Reports -- Physical Health, is
modified to reflect STAR Contract as follows:
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are required on a
semi-annual basis. Refer to Appendix J for the standardized reporting
format for each report and detailed instructions for obtaining specific
data required in the report.
Section 12.91 added to reflect STAR Contract as follows:
12.9.1 In addition, data files are due to HHSC 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 HHSC to facilitate clear
communication to the health plan.
SECTION 2.54 MODIFICATION OF SECTION 12.10 UTILIZATION MANAGEMENT REPORTS --
LONG TERM CARE
Section 12.10, Utilization Management Reports- Long Term Care is replaced
with 12.10, Quality Improvement Report to be consistent with the STAR
contract.
12.10 QUALITY IMPROVEMENT REPORTS
12.10.1 Not applicable to STAR+PLUS
12.10.2 Not applicable to STAR+PLUS
12.10.3 Annual QIP Summary Report. An annual QIP summary report must be
conducted yearly based on the state fiscal year. The annual QIP summary
report must be submitted by March 31 of each year. This report must
provide summary information on HMO's QIP system and include the
following:
1. Executive summary of QIP - include results of all QI
reports and interventions.
STAR+PLUS BBA Amendment
Page 54 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
2. Activities pertaining to each standard (I through
XVI) in Appendix A. Report must list each standard.
3. Methodologies for collecting, assessing data and
measuring outcomes.
4. Tracking and monitoring quality of care.
5. Role of health professionals in QIP review.
6. Methodology for collection data and providing
feedback to provider and staff.
7. Outcomes and/or action plan.
12.10.4 Provider Medical Record Audit and Report. HMO is required to
conform to commonly accepted medical record standards such as those
used by, NCQA, JCAHO, or those used for credentialing review such as
the Texas Environment of Care Assessment Program (TECAP), and have
documentation on file at HMO for review by HHSC or its designee during
an on-site review.
SECTION 2.55 MODIFICATION OF SECTION 12.11 QUALITY IMPROVEMENT REPORTS
Section 12.11, Quality Improvement Reports is replaced with 12.11, HUB
Reports, to be consistent with the STAR contract.
12.11 HUB REPORTS
HMO must submit quarterly reports documenting HMO's HUB program efforts
and accomplishments. The report must include a narrative description of
HMO's program efforts and a financial report reflecting payments made
to HUB. HMO must use the format included in Appendix B for HUB
quarterly reports. For HUB Certified Entities: HMO must include the
General Service Commission (GSC) Vendor Number and the ethnicity/gender
under which a contracting entity is registered with GSC. For HUB
Qualified (but not certified) Entities: HMO must include the
ethnicity/gender of the major owner(s) (51%) of the entity. Any
entities for which HMO cannot provide this information, cannot be
included in the HUB report. For both types of entities, an entity will
not be included in the HUB report if HMO does not list ethnicity/gender
information.
SECTION 2.56 MODIFICATION OF SECTION 12.12, HUB QUARTERLY REPORTS
Section 12.12, HUB Quarterly Reports, is replaced with Section 11.12,
THSteps Reports, to be consistent with STAR contract language.
12.12 THSTEPS REPORTS
Minimum reporting requirements. HMO must submit, at a minimum, 80a/o of
all THSteps checkups on HCFA 1500 claim forms as part of the encounter
file submission to the HHSC Claims Administrator no later then thirty
(30) days after the date of final adjudication (finalization) of the
claims. Failure to comply with these minimum reporting requirements
will result in Article 18 sanctions and money damages.
SECTION 2.57 MODIFICATION OF SECTION 11.13 THSTEPS REPORTS
Section 12.13 THSteps Reports, is deleted.
SECTION 2.58 MODIFICATION OF SECTION 12.14, CBA STATUS REPORT
Section 11.14, CBA Status Report, is replaced with Section 12.14, Member
Hotline Performance Report to be consistent with STAR contract as follows:
12.14 MEMBER HOTLINE PERFORMANCE REPORT
STAR+PLUS BBA Amendment
Page 55 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 format approved by HHSC. The report is due on the
30th of the month following the end of each month.
SECTION 2.59 MODIFICATION OF SECTION 12.15, SUBMISSION OF STAR+PLUS
DELIVERABLES/REPORTS
Section 12.15, Submission of STAR+PLUS Deliverables/Reports, is being
modified to be consistent with STAR contract as follows.
Section 12.15.2 is renumbered to Section 12.15.1.2
Section 12.15.3 is renumbered to Section 12.15.2
Section 12.15.4 is renumbered to Section 12.15.3
Section 12.15.5 is renumbered to Section 12.15.4
Section 12.15.6 is renumbered to Section 12.15.5
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+PLUS deliverables/reports should not
contain any member specific data that would be considered confidential.
12.15.2 FDHC 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 I 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 TDHS
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 Department of Human Services
STAR+PLUS Contract Manager, MC-W-516
▇.▇.▇▇▇ 149030
▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
STAR+PLUS BBA Amendment
Page 56 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
Overnight Mail:
Texas Department of Human Services
STAR+PLUS Contract Manager, MC-W-516
▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇
12.15.5 Texas Department of Insurance (TDI). The submission of
deliverables/reports to TDHS 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 2.60 ADDITION TO ARTICLE 12, REPORTING REQUIREMENTS
Article 12, Reporting Requirements, is amended to add Section 12.16, CBA
Status Report to be consistent with the STAR contract as follows.
Section 12.16 CBA Status Report.
HMO will provide HHSC with a weekly report on initial CBA assessments.
HMO will provide HHSC with a monthly status report on annual CBA
reassessments in a format specified by the state.
SECTION 2.61 MODIFICATION TO SECTION 13.2, CAPITATION AMOUNTS
Section 13.1.2, Capitation Amounts, is modified to reflect the effective
capitation rates for FY 2004.
Section 13.1.2
The capitation amount by Member risk group has been calculated to be
less than the amount payable for providing the same services for an
actuarially equivalent population in the regular Medicaid
fee-for-service program. The following capitation payments will be
effective during the term of this contract amendment The monthly
capitation amounts for the ▇▇▇▇▇▇ County Service Area are as follows:
--------------------------------------------------------------------------------
FY 2004
MONTHLY CAPITATION
AMOUNTS INITIALS
MEMBER RISK GROUPS 9/1/2003-8/31/2004
--------------------------------------------------------------------------------
115 CBA Waiver Clients - Dual Eligible $1,504.10 MCO
-----------------------------------------------------------------------------------------
111 CBA Waiver Clients - Medicaid Only $3,553.50 HHSC
-----------------------------------------------------------------------------------------
114 Other Community Clients - Dual Eligible $ 152.12
--------------------------------------------------------------------------------
100 Other Community Clients - Medicaid Only $ 686.52
--------------------------------------------------------------------------------
119 Nursing Facility Clients - Dual Eligible $ 152.12
--------------------------------------------------------------------------------
118 Nursing Facility Clients - Medicaid Only $ 686.52
--------------------------------------------------------------------------------
SECTION 2.62 MODIFICATION TO SECTION 13.2, EXPERIENCE REBATE TO STATE
Section 13.2, Experience Rebate to State, is replaced with the following
language to be consistent with the STAR contract.
13.2 For the Contract Period, HMO must pay to HHSC as experience rebate
calculated in accordance with the tiered rebate method listed below
based on the excess of allowable HMO
STAR+PLUS BBA Amendment
Page 57 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 Not applicable to STAR+PLUS
13.2.2.1 Not applicable to STAR+PLUS
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 the State, expenses for
population-based health initiatives that have been approved by HHSC. A
population-based initiative (PBI) is a project or program designed to
improve some aspect of quality of care, quality of life, or health care
knowledge for the Medicaid population that may also benefit the
community as a whole. Value-added service does not constitute a PBI.
Contractually required services and activities do not constitute a PBI.
13.2.5 There will be two settlements for payment(s) of the experience
rebate for SFY 2000-2001, two settlements for payment(s) for the
experience rebate for SPY 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 Repot 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
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 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.
STAR+PLUS BBA Amendment
Page 58 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
SECTION 2.63 MODIFICATION TO SECTION 13.3, ADJUSTMENTS TO PREMIUM
Section 13.3, Adjustments to Premium, is replaced by Section 13.3,
Performance Objectives, to be consistent with the STAR contract.
13.3 PERFORMANCE OBJECTIVES
13.3.1 Not applicable to STAR+PLUS
13.3.2 Not applicable to STAR+PLUS
13.3.3 Not applicable to STAR+PLUS
13.3.4 Not applicable to STAR+PLUS
13.3.5 Not applicable to STAR+PLUS
13.3.6 Not applicable to STAR+PLUS
13.3.7 Not applicable to STAR+PLUS
13.3.8 Not applicable to STAR+PLUS
13.3.9 Not applicable to STAR+PLUS
13.3.10 Not applicable to STAR+PLUS
13.3.10.1 Not applicable to STAR+PLUS
SECTION 2.64 MODIFICATION TO SECTION 13.4, CBA REASSESSMENT PACKET
Section 13.4, CBA Reassessment Packet, is replaced with Section 13.4,
Adjustment to Premium, to be consistent with STAR contract language
13.4 ADJUSTMENTS TO PREMIUM
13.4.1 HHSC may recoup premiums paid to HMO in error. Error may be
either human or machine error on the part of HHSC or an agent or
contractor of HHSC. HHSC may recoup premiums paid to HMO if a Member is
enrolled into HMO in error, and HMO provided no covered services to
Member for the period of time for which premium was paid. If services
were provided to Member as a result of the error, recoupment will not
be made.
13.4.2 HHSC may recoup premium paid to HMO if a Member for whom premium
is paid moves outside the United States, and HMO has not provided
covered services to the Member for the period of time for which premium
has been paid. HHSC will not recoup premium if HMO has provided covered
services to the Member during the period of time for which premium has
been paid.
13.4.3 HHSC may recoup premium paid to HMO if a Member for whom premium
is paid dies before the first day of the month for which premium is
paid.
13.4.4 HHSC may recoup or adjust premium paid to HMO for a Member if
the Member's eligibility status or program type is changed, corrected
as a result of error, or is retroactively adjusted.
STAR+PLUS BBA Amendment
Page 59 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
13.4.5 Recoupment or adjustment of premium under Articles 13.4.1
through 13.4.4 may be appealed using the HHSC dispute resolution
process.
13.4.6 HHSC may adjust premiums for all Members within an eligibility
status or program type if adjustment is required by reductions in
appropriations and/or if a benefit or category of benefits is excluded
or included as a covered service. Adjustment must be made by amendment
as required by Article 15.2. Adjustment to premium under this
subsection may not be appealed using the HHSC dispute resolution
process.
SECTION 2.65 ADDITION TO ARTICLE 13, PAYMENT PROVISIONS
Article 13 is amended to add Section 13.5, Newborn and Pregnant Women
Payment Provisions.
13.5 NEWBORN AND PREGNANT WOMEN PAYMENT PROVISIONS
13.5.1 Not applicable to STAR+PLUS.
13.5.1.1 Not applicable to STAR+PLUS
13.5.2 Not applicable to STAR+PLUS
13.5.3 Not applicable to STAR+PLUS
13.5.4 Not applicable to STAR+PLUS
13.5.5 Not applicable to STAR+PLUS
13.5.6 Not applicable to STAR+PLUS
Article 13 is amended to add Section 13.6, CBA Reassessment Packet.
13.6 CBA Reassessment Packet
13.6.1 HMO must submit a complete CBA reassessment packet, including
approved Form 3652-A, Client Assessment, Review, and Evaluation (CARE,
for medical necessity, and the Individual Service Plan (ISP) and other
required assessment forms, 30 days prior to the annual renewal date to
receive the CBA capitation rate. The process to begin the annual CBA
assessment may be started as soon as four months prior to the annual
renewal date.
SECTION 2.66 MODIFICATION OF SECTION 14.1, ELIGIBILITY DETERMINATION
Section 14.1, Eligibility Determination, is being modified to be consistent
with the STAR contract:
14.1 ELIGIBILITY DETERMINATION
14.1.1 HHSC will identify Medicaid recipients who are eligible for
participation in the STAR+PLUS program using the eligibility status
described below.
14.1.2 MANDATORY - Individuals in the following categories who reside
in any part of the Service Area must enroll in one of the health plans
providing services in the Service Areas:
14.1.2.1 Not Applicable to STAR+PLUS
14.1.2.2 Not Applicable to STAR+PLUS
STAR+PLUS BBA Amendment
Page 60 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
14.1.2.3 Not Applicable to STAR+PLUS
14.1.2.4 Not Applicable to STAR+PLUS
14.1.2.5 Not Applicable to STAR+PLUS
14.1.2.6 Not Applicable to STAR+PLUS
14.1.2.7 Not Applicable to STAR+PLUS
14.1.2.8 Not Applicable to STAR+PLUS
14.1.2.9 Not Applicable to STAR+PLUS
14.1.2.10 SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS 21 AND OLDER
SSI Eligible clients 21 and older living in the community, except for
those individuals listed as "voluntary" or "non-participant."
14.1.2.11 CLIENTS IN SOCIAL SECURITY (RSDI) EXCLUSIONS PROGRAMS Clients
denied SSI because of specified increases (e.g., cost-of-living
adjustments, etc.) in Social Security (RSDI or Title II) benefits.
14.1.2.12 CLIENTS ENTERING TITLE XIX NURSING FACILITIES (NFs) HMO
members entering Title XIX NFs who qualify for nursing facility
level-of-care, as determined by TDHS after the date of implementation.
Eligibility will continue for 120 days after admission, then these
members will be disenrolled.
14.1.2.13 COMMUNITY BASED ALTERNATIVES (CBA) WAIVER Clients who qualify
for nursing facility level-of-care, as determined by TDHS, but who
elect to receive services in the community.
14.1.2.14 SPEND DOWN CLIENTS Adult clients in nursing facilities who
spend down the Medicaid eligibility (SSr/MAO) in less than twelve (12)
months after date of implementation and qualify for nursing facility
level-of-care as determined by TDHS.
14.1.3 VOLUNTARY - The following individuals are not required to enroll
in a STAR+PLUS HMO but have the option to enroll in an HMO. HMO will be
required to accept enrollment of those Medicaid recipients from this
group who elect to enroll in HMO.
14.1.3.1 Not Applicable to STAR+PLUS
14.1.3.2 Not Applicable to STAR+PLUS.
14.1.3.3 SSI ELIGIBLE CHILDREN
SSI eligible children under age 21 may choose two types of managed care
models (HMO or PCCM).
14.1.4 During the period after which the Medicaid eligibility
determination has been made but prior to enrollment in HMO, members
will be enrolled under the traditional Medicaid program. All
Medicaid-eligible recipients will remain in the fee-for-service
Medicaid program until enrolled in or assigned to an HMO.
14.1.5 NON-PARTICIPANTS - The following individuals are not affected by
STAR+PLUS and will not be included in the project:
STAR+PLUS BBA Amendment
Page 61 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
- COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES
(CLASS) WAIVER CLIENTS
- Individuals receiving CLASS waiver services.
- MEDICALLY DEPENDENT CHILDREN'S WAIVER PROGRAM (MDCP)
CLIENTS
- Individuals receiving MDCP waiver services.
- HOME AND COMMUNITY SERVICES (HCS and HCS-O) WAIVER
CLIENTS
- Individuals receiving HCS services.
- DEAF-BLIND MULTIPLE DISABLED (DBMD) WAIVER CLIENTS
- Individuals receiving DBMD services.
- HOSPICE - Individuals who exercise their option to
participate in a Hospice program who are not
receiving CBA services.
- NURSING FACILITIES - Clients who are in a nursing
facility prior to enrollment in STAR+PLUS.
- ICF/MR - Clients who are currently in an ICF/MR
facility.
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 2.67 MODIFICATION OF SECTION 14.3, PLAN CHANGES FROM HMO AND
DISENROLLMENT FROM MANAGED CARE
Section 14.3, Plan Changes from HMO and Disenrollment from Managed Care, is
replaced with Section 14.3, Newborn Enrollment to be consistent with STAR
contract as follows:
14.3 NEWBORN ENROLLMENT
14.3.1 Not Applicable to STAR+PLUS
14.3.1.1 Not Applicable to STAR+PLUS
14.3.2 Not Applicable to STAR+PLUS
14.3.2.1 Not Applicable to STAR+PLUS
14.3.2.2. Not Applicable to STAR+PLUS
14.3.2.3 Not Applicable to STAR+PLUS
14.3.3 Not Applicable to STAR+PLUS
SECTION 2.68 MODIFICATION OF SECTION 14.4, AUTOMATIC RE-ENROLLMENT
Section 14.4, Automatic Re-enrollment, is replaced by Section 14.4,
Disenrollment, to be consistent with the STAR contract.
14.4 DISENROLLMENT
14.4.1 HMO has a limited right to request a member be disenrolled from
HMO without the member's consent. HHSC must approve any HMO request for
disenrollment of a member for cause. Disenrollment of a member maybe
permitted under the following circumstances:
14.4.1.1 Member misuses or loans member's HMO membership card to
another person to obtain services.
STAR+PLUS BBA Amendment
Page 62 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
14.4.1.2 Member is disruptive, unruly, threatening or uncooperative to
the extent that member's membership seriously impairs HMO's or
provider's ability to provide services to member or to obtain new
members, and member's behavior is not caused by a physical or
behavioral health condition.
14.4.1.3 Member steadfastly refuses to comply with managed care
restrictions (e.g., repeatedly using emergency room in combination with
refusing to allow HMO to treat the underlying medical condition).
14.4.2.1 HMO must take reasonable measures to correct member behavior
prior to requesting disenrollment. Reasonable measures may include
providing education and counseling regarding the offensive acts or
behaviors.
14.4.3 HMO must notify the member of HMO's decision to disenroll the
member if all reasonable measures have failed to remedy the problem.
14.4.4 If the member disagrees with the decision to disenroll the
member from HMO, HMO must notify the member of the availability of the
complaint procedure and HHSC's Fair Hearing process.
14.4.5 HMO cannot request a disenrollment based on adverse change in
the member's health status or utilization of services that are
medically necessary for treatment of a member's condition.
SECTION 2.69 MODIFICATION OF SECTION 14.5, ENROLLMENT REPORTS
Section 14.5, Enrollment Reports, is replaced with Section 14.5, Automatic
Re-enrollment, to be consistent with the STAR contract.
14.5 AUTOMATIC RE-ENROLLMENT
14.5.1 Members who are disenrolled because they are temporarily
ineligible for Medicaid will be automatically re-enrolled into the same
health plan. Temporary loss of eligibility is defined as a period of 6
months or less.
14.5.2 HMO must inform its members of the automatic re-enrollment
procedure. Automatic re-enrollment must be included in the Member
Handbook (see Article 8.2.1).
SECTION 2.70 ADDITION TO ARTICLE 14, ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
Article 14, Eligibility, Enrollment, and Disenrollment, is amended by
adding Section 14.6, Enrollment Reports.
14.6 ENROLLMENT REPORTS
14.6.1 HHSC will provide HMO enrollment reports listing all STAR+PLUS
members who have enrolled in or were assigned to HMO during the initial
enrollment period.
14.6.2 HHSC will provide monthly HMO Enrollment Reports to HMO on or
before the first of the month.
14.6.3 HHSC will provide member verification to HMO and network
providers through telephone verification or TexMedNet.
SECTION 2.71 ADDITION TO ARTICLE 15, GENERAL PROVISIONS
Article 15, General Provisions, is modified by adding Section 15.14, Global
Drafting Conventions, as follows:
STAR+PLUS BBA Amendment
Page 63 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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 2.72 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 ▇.▇▇. 438.102(a).
SECTION 2.73 MODIFICATION TO APPENDIX A, VALUE ADDED SERVICES
Appendix A, Value Added Services is replaced with Appendix A, Quality
Assessment and Performance Improvement Programs and Appendix A-A to
remain consistent with the STAR contract.
SECTION 2.74 MODIFICATION OF APPENDIX E, COST PRINCIPLES FOR ADMINISTRATIVE
EXPENSES
Appendix E, Cost Principles for Administrative Expenses is replaced
with the attached Appendix E, Transplant Facilities for Texas Medicaid
to remain consistent with the STAR contract.
SECTION 2.75 MODIFICATION TO APPENDIX K, PERFORMANCE OBJECTIVES
Appendix K Not applicable to STAR+PLUS
SECTION 2.76 ADDITION OF APPENDIX L, VALUE ADDED SERVICES
Appendix L, Value Added Services is added to remain consist with the
STAR contract
SECTION 2.77 ADDITION OF APPENDIX M, COST PRINCIPLES FOR ADMINISTRATIVE EXPENSES
Appendix M, Cost Principles for Administrative Expenses is added to
remain consistent with the STAR contract.
SECTION 2.78 ADDITION OF NEW APPENDIX O, STANDARD FOR MEDICAL RECORDS
New Appendix O is added to the contract with the attached Appendix O.
STAR+PLUS BBA Amendment
Page 64 of 65
STAR+PLUS BBA Amendment Health and Human Services Commission
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.
HEALTH & HUMAN SERVICES COMMISSION
By: /s/ ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇. By: _______________________________
------------------------- ▇▇▇▇▇▇ ▇▇▇▇▇▇▇
Commissioner
Date: 8/7/2003______________________ Date: ______________________
STAR+PLUS BBA Amendment
Page 65 of 65