EXHIBIT 10.8
HEALTHCHOICES SOUTHEAST AGREEMENT
EFFECTIVE OCTOBER 1, 2001
TABLE OF CONTENTS
SECTION I: INCORPORATION OF DOCUMENTS..............................................................................1
A. Operative Documents...............................................................................1
SECTION II: DEFINITIONS............................................................................................1
AGREEMENT AND RFP ACRONYMS:........................................................................................21
SECTION III: RELATIONSHIP OF PARTIES..............................................................................24
A. Basic Relationship...............................................................................24
B. Nature of Contract...............................................................................24
SECTION IV: APPLICABLE LAWS AND REGULATIONS.......................................................................24
A. Certification and Licensing......................................................................24
B. Specific to MA Program...........................................................................25
C. General Laws and Regulations.....................................................................25
D. Limitation on the Department's Obligations.......................................................26
SECTION V: PROGRAM REQUIREMENTS...................................................................................26
A. In-Plan Services.................................................................................26
1. Amount, Duration and Scope.................................................................26
2. Program Exceptions.........................................................................27
3. Expanded Benefits..........................................................................27
4. Referrals..................................................................................28
5. Self Referral/Direct Access................................................................28
6. Behavioral Health Services.................................................................29
7. Pharmacy Services..........................................................................29
8. EPSDT Services.............................................................................33
9. Emergency Room (ER) Services...............................................................33
10. Post-Stabilization Services...............................................................34
11. Examinations to Determine Abuse or Neglect................................................34
12. Hospice Services..........................................................................35
13. Organ Transplants.........................................................................35
14. Transportation............................................................................35
15. Waiver Services/State Plan Amendments.....................................................36
16. Nursing Facility Services.................................................................37
B. Prior Authorization of Services..................................................................38
1. General Prior Authorization Requirements...................................................38
2. Prior Authorization for Outpatient Prescription Drugs......................................39
C. Continuity of Care...............................................................................41
D. Coordination of Care.............................................................................41
1. Nursing Facility Care......................................................................41
2. Special Services...........................................................................42
3. Out-of-Plan Services.......................................................................42
4. Coordination of Care/Letters of Agreement..................................................43
5. PH-MCO and BH-MCO Coordination.............................................................44
E. Contractor Responsibility for Reportable Conditions..............................................45
F. Member Enrollment and Disenrollment..............................................................45
1. General....................................................................................45
2. Contractor Outreach Materials..............................................................46
3. Contractor Outreach Activities.............................................................47
4. Alternative Language Requirement...........................................................50
5. Contractor Enrollment Procedures...........................................................50
6. Enrollment of Newborns.....................................................................51
7. Transitioning Members Between PH-MCOs......................................................51
8. Change in Status...........................................................................51
9. Monthly Membership.........................................................................52
10. Enrollment and Disenrollment Updates......................................................52
11. Services for New Members..................................................................53
12. New Member Orientation....................................................................54
13. Eligibility Verification System (EVS).....................................................54
14. Contractor Identification Cards...........................................................55
15. Member Handbook...........................................................................55
16. Provider Directories......................................................................56
17. Member Disenrollment......................................................................57
G. Member Services..................................................................................57
1. General....................................................................................57
2. Contractor Internal Member Dedicated Hotline...............................................57
3. Education and Outreach Health Education Advisory Committee.................................58
4. Informational Materials....................................................................59
5. Member Encounter Listings..................................................................60
H. Additional Addressee.............................................................................61
I. Member Complaint, Grievance and DPW Fair Hearing Process.........................................61
1. Member Complaint, Grievance and DPW Fair Hearing Process...................................61
2. DPW Fair Hearing Process for Members.......................................................62
J. Clinical Sentinel................................................................................63
K. Provider Dispute Resolution System...............................................................63
L. Certification of Authority.......................................................................64
M. Executive Management.............................................................................64
N. Other Administrative Components..................................................................66
O. Administration...................................................................................67
1. Responsibility to Employ MA Consumers......................................................68
2. Recipient Restriction Program..............................................................68
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3. Contracts and Subcontracts.................................................................68
4. Lobbying Disclosure........................................................................69
5. Records Retention..........................................................................69
6. Fraud and Abuse............................................................................70
7. Information Systems and Encounter Data.....................................................72
8. Department Access and Availability.........................................................74
P. Special Needs Unit (SNU).........................................................................74
1. Establishment of Special Needs Unit........................................................74
2. Special Needs Coordinator..................................................................76
3. Responsibilities of Special Needs Unit Staff...............................................76
Q. Assignment of PCPs...............................................................................76
R. Provider Services................................................................................78
1. Provider Manual............................................................................79
2. Provider Education.........................................................................79
S. Provider Network/Services Access.................................................................80
1. Network Composition........................................................................80
2. Provider Agreements........................................................................85
3. Cultural Competence........................................................................88
4. Primary Care Practitioner (PCP) Responsibilities...........................................88
5. Specialists as PCPs........................................................................89
6. Any Willing Pharmacy.......................................................................90
7. Hospital Related Party.....................................................................90
8. Mainstreaming..............................................................................90
9. Network Changes............................................................................91
10. Other Provider Enrollment Standards.......................................................92
11. Twenty-Four Hour Coverage.................................................................93
12. Appointment Standards.....................................................................93
13. Policies and Procedures for Appointment Standards.........................................96
14. Compliance With Access Standards..........................................................96
T. QM and UM Program Requirements...................................................................97
1. Overview...................................................................................97
2. General....................................................................................97
3. Additional Utilization Management Program Requirements.....................................98
4. Healthplan Employer Data Information Set (HEDIS)...........................................99
5. External Quality Review (EQR)..............................................................99
6. QM/UM Program Reporting Requirements......................................................100
7. Collaboration Between Contractor QM and UM Departments and Special Needs Units............101
8. Delegated Quality Management and Utilization Management Functions.........................101
9. Consumer Involvement in the Quality Management and Utilization Management Programs........101
10. Confidentiality..........................................................................101
11. Department Oversight.....................................................................102
SECTION VI: PROGRAM OUTCOMES AND DELIVERABLES....................................................................102
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SECTION VII: FINANCIAL REQUIREMENTS..............................................................................103
A. Financial Standards.............................................................................103
1. Risk Protection Reinsurance for High Cost Cases...........................................103
2. Equity Requirements and Insolvency Protection.............................................104
3. Secondary Liability.......................................................................105
4. Limitation of Liability...................................................................106
5. Medical Cost Accruals.....................................................................106
6. Claims Processing and MIS.................................................................106
7. DSH/GME Payment for Disproportionate Share Hospitals (DSH)/ Graduate Medical
Education (GME)...........................................................................107
8. Member Liability..........................................................................107
B. Commonwealth Capitation Payments................................................................107
1. Payments For In-Plan Services.............................................................107
2. Maternity Care Payment....................................................................110
3. Program Changes...........................................................................111
C. HIV/AIDS Risk Pool..............................................................................111
D. Claims Processing Standards, Monthly Report and Penalties.......................................111
1. Timeliness Standards......................................................................111
2. Sanctions.................................................................................113
3. Physician Incentive Arrangements..........................................................115
4. Retroactive Eligibility Period............................................................117
5. In-Network Services.......................................................................117
6. Payments for Out-of-Network Providers.....................................................117
7. Payments to FQHCs and Rural Health Centers (RHCs).........................................118
8. Liability During an Active Grievance or Appeal............................................118
9. Financial Responsibility for Dual Eligibles...............................................118
10. Third Party Liability (TPL)..............................................................119
11. Health Insurance Premium Payment (▇▇▇▇) Program..........................................122
12. Requests for Additional Data.............................................................122
13. Accessibility to TPL Data................................................................123
14. Damage Liability.........................................................................123
15. Estate Recovery..........................................................................123
16. Audits...................................................................................123
17. Restitution..............................................................................123
SECTION VIII: REPORTING REQUIREMENTS.............................................................................124
A. General.........................................................................................124
B. Systems Reports.................................................................................124
1. Encounter Data and Subcapitation Data Reports.............................................124
2. Federalizing GA Data Reporting............................................................127
3. Third Party Resource Identification.......................................................127
C. Operations Reports..............................................................................128
1. Continuous Quality Improvement............................................................128
2. Federal Waiver Reporting Requirements.....................................................128
3. Complaint, Grievance and DPW Fair Hearing Data............................................128
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4. EPSDT Reports.............................................................................129
5. Healthy Beginnings Plus Reporting.........................................................129
6. Member Hotline Activities Report..........................................................130
7. Fraud and Abuse...........................................................................130
8. Provider Network..........................................................................130
9. Provider Dispute Resolution System........................................................130
10. Reports Submission Schedule..............................................................130
11. HEDIS including CAHPS....................................................................131
12. SERB.....................................................................................131
D. Financial Reports...............................................................................131
E. Equity..........................................................................................131
F. Claims Processing Reports.......................................................................132
G. Presentation of Findings........................................................................132
H. Reference Information...........................................................................132
I. Sanctions.......................................................................................133
J. Non-Duplication of Financial Penalties..........................................................134
SECTION IX: REPRESENTATIONS AND WARRANTIES OF THE CONTRACTOR.....................................................134
A. Accuracy of Proposal............................................................................135
B. Disclosure of Interests.........................................................................135
C. Disclosure of Change in Circumstances...........................................................135
D. SERB Commitment.................................................................................136
SECTION X: DURATION OF AGREEMENT AND RENEWAL.....................................................................136
A. Initial Term....................................................................................136
B. Renewal.........................................................................................137
SECTION XI: TERMINATION AND DEFAULT..............................................................................137
A. Termination by the Department...................................................................137
1. Termination for Convenience Upon Notice...................................................137
2. Termination for Cause.....................................................................137
3. Termination Due to Unavailability of Funds/Approvals......................................138
B. Termination by the Contractor...................................................................138
C. Responsibilities of the Contractor Upon Termination.............................................139
1. Continuing Obligations....................................................................139
2. Notice to Members.........................................................................139
3. Submission of Invoices....................................................................139
4. Failure to Perform........................................................................139
D. Transition at Expiration and/or Termination of Agreement........................................140
SECTION XII: RECORDS.............................................................................................141
A. Financial Records Retention.....................................................................141
B. Operational Data Reports........................................................................142
C. Medical Records Retention.......................................................................142
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D. REVIEW OF RECORDS...............................................................................142
SECTION XIII: SUBCONTRACTUAL RELATIONSHIPS.......................................................................143
A. Compliance with Program Standards...............................................................143
B. Consistency with Policy Statements..............................................................144
SECTION XIV: CONFIDENTIALITY.....................................................................................144
SECTION XV: INDEMNIFICATION AND INSURANCE........................................................................145
A. Indemnification.................................................................................146
B. Insurance.......................................................................................146
SECTION XVI: DISPUTES............................................................................................146
SECTION XVII: FORCE MAJEURE......................................................................................147
SECTION XVIII: GENERAL...........................................................................................148
A. Suspension From Other Programs..................................................................148
B. Rights of the Department and the Contractor.....................................................148
C. Waiver..........................................................................................148
D. Invalid Provisions..............................................................................148
E. Governing Law...................................................................................148
F. Expansion of the Zone...........................................................................149
G. Notice..........................................................................................149
H. Counterparts....................................................................................149
I. Headings........................................................................................150
J. Assignment......................................................................................150
K. No Third Party Beneficiaries....................................................................150
L. News Releases...................................................................................150
M. Entire Agreement: Modification..................................................................150
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APPENDICES
1--------HealthChoices RFP
2--------Proposal
3--------Capitated Rates
4--------Contractor Information
5--------Contractor SERB Committment
AGREEMENT EXHIBITS
A--------General Guidelines for Managed Care Regulatory Review
B--------HCFA Waiver Approval Letter
C--------HealthChoices Proposers' Library
D--------Standard Contract Terms and Conditions for Services
E--------DPW Addendum to Standard Contract Terms and Conditions
F--------Family Planning Services Procedures
G--------Drug Formulary Guidelines
H--------Prior Authorization Guidelines for Participating Managed Care
Organizations
I--------Drug Utilization Review Guidelines
J--------EPSDT Guidelines
K--------Emergency Room Services
L--------Medical Assistance Transportation Program
M--------Reserved -- See M(1)
M(1)-----Quality Management and Utilization Management Program Requirements
M(2)-----External Quality Review
M(3)-----Quality Management/Utilization Management Deliverables
M(4)-----Health Plan Employer Data Information Set (HEDIS)
N--------Denial Notices
O--------Description of Special Services
P--------Out-of-Plan Services
Q--------Sample Model Agreement
R--------Coordination with BH-MCOs
S--------Written Agreements Between PH-MCO and Service Providers
T--------PH/BH Provider Agreements
U--------Behavioral Health Services
V--------Requirements Covering Medications Prescribed by PH-MCOs
W--------PH-MCO Guidelines for Outreach Materials
X--------HealthChoices PH-MCO Guidelines for Advertising, Sponsorships, and
Outreach
Y--------Managed Care Enrollment/Disenrollment Dating Rules
Z--------Automatic Assignment
AA-------Category/Program Status Coverage Chart
BB-------HealthChoices PH-MCO Recipient Coverage Document
CC-------Data Support for PH-MCOs
DD-------HealthChoices PH-MCO Member Handbook
EE-------Automated Provider Directory File Layout
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FF-------PCP, Dentists, Specialists, and Providers of Ancillary Services
Directories
GG-------Complaints, Grievances, and Fair Hearing Process
HH-------Contractor's Responsibility to Employ MA Consumers
II-------Required Contract Terms for Providers and Administrative Subcontractors
JJ-------Lobbying Certification and Disclosure of Lobbying Activities
KK-------Standardized Referral Process To The Department
LL-------Guidelines for Sanctions Regarding Fraud and Abuse
MM-------Management Information System and System Performance Review Standards
NN-------Special Needs Unit
OO-------Coordination of Care Entities
PP-------Provider Manuals
QQ-------Federally Qualified Health Centers and Rural Health Clinics
RR------- Reserved
SS-------Reserved
TT-------Reserved -- See M(2)
UU-------Reserved -- See M(3)
VV-------HIV/AIDS Risk Pool
WW-------HealthChoices Audit Clause
XX-------Encounter and Subcapitation Data Penalty Occurrences
YY-------MCO Obstetrical Reporting Form
ZZ-------Reserved -- See M(4)
AAA------Managed Care Contract Monitoring Manual - Internal Operations
Copies of Appendices and Agreement Exhibits are available by request from
the Commonwealth of Pennsylvania Department of Public Welfare
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SECTION I: INCORPORATION OF DOCUMENTS
A. OPERATIVE DOCUMENTS
The RFP, a copy of which is attached hereto as Appendix 1, and
the Proposal, a copy of which is attached hereto as Appendix 2,
are incorporated herein and are made a part of this Agreement.
With regard to the governance of such documents, it is agreed
that:
1. In the event that any of the terms of this Agreement
conflict with, are inconsistent with, or are in addition
to the terms of the RFP, the terms of this Agreement
shall govern;
2. In the event that any of the terms of this Agreement
conflict with, are inconsistent with, or are in addition
to the terms of the Proposal, the terms of this
Agreement shall govern;
3. In the event that any of the terms of the RFP conflict
with, are inconsistent with, or are in addition to the
terms of the Proposal, the terms of the RFP shall
govern.
SECTION II: DEFINITIONS
ABUSE -- Any Provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary cost to the
MA Program, or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards or
contractual obligations (including the terms of the RFP, Agreement, and
the requirements of state or federal regulations) for health care in a
managed care setting. The abuse can be committed by the Contractor,
subcontractor, Provider, State employee, or a Member, among others.
Abuse also includes enrollee practices that result in unnecessary cost
to the MA Program, the Contractor, a subcontractor, or Provider.
ACCESS CARD -- Medical Assistance Identification (MAID) card. The
individual card issued to enrolled consumers in the MA Program.
ACCESS PROGRAM -- A system used by school districts, intermediate units,
state-owned schools or approved private schools to ▇▇▇▇ Medicaid for
services for special education students who are enrolled in the MA
Program.
ADJUDICATED CLAIM -- A Claim that has been processed to payment or
denial.
AFFILIATE -- Any individual, corporation, partnership, joint venture,
trust, unincorporated organization or association, or other similar
organization (hereinafter "Person"), controlling, controlled by or under
common control with
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the Contractor or its parent(s), whether such common control be direct
or indirect. Without limitation, all officers, or persons, holding five
percent (5%) or more of the outstanding ownership interests of
Contractor or its parent(s), directors or subsidiaries of Contractor or
parent(s) shall be presumed to be affiliates for purposes of the RFP and
Agreement. For purposes of this definition, "control" means the
possession, directly or indirectly, of the power (whether or not
exercised) to direct or cause the direction of the management or
policies of a person, whether through the ownership of voting
securities, other ownership interests, or by contract or otherwise
including but not limited to the power to elect a majority of the
directors of a corporation or trustees of a trust, as the case may be.
ALTERNATE PAYMENT NAME -- The person to whom benefits are issued on
behalf of an MA Consumer.
AMENDED CLAIM -- A Provider request to adjust the payment of a
previously adjudicated Claim. A Provider appeal is not an amended Claim.
AREA AGENCY ON AGING (AAA) -- The single local agency designated by the
Pennsylvania Department of Aging within each planning and service area
to administer the delivery of a comprehensive and coordinated plan of
social and other services and activities.
BEHAVIORAL HEALTH MANAGED CARE ORGANIZATION (BH-MCO) -- An entity,
operated by county government or licensed by the Commonwealth as a
risk-bearing Health Maintenance Organization (HMO) or Preferred Provider
Organization (PPO), which manages the purchase and provision of
behavioral health services under a contract with the Department.
BEHAVIORAL HEALTH REHABILITATION SERVICES FOR CHILDREN AND ADOLESCENTS
(FORMERLY EPSDT "WRAPAROUND") -- Individualized, therapeutic mental
health, substance abuse or behavioral interventions/services developed
and recommended by an interagency team and prescribed by a physician or
licensed psychologist.
BEHAVIORAL HEALTH (BH) SERVICES -- Mental health and/or drug and alcohol
services which are provided by the BH-MCO.
BUSINESS DAYS -- A business day includes Monday through Friday except
for those days recognized as federal holidays and/or Pennsylvania State
holidays.
CAPITATION -- A fee the Department pays periodically to a Contractor for
each MA Consumer enrolled under a contract for the provision of medical
services, whether or not the MA Consumer receives the services during
the period covered by the fee.
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CASE MANAGEMENT SERVICES -- Services which will assist individuals in
gaining access to necessary medical, social, educational and other
services.
CASE PAYMENT NAME -- The person in whose name benefits are issued.
CERTIFICATE OF AUTHORITY -- A document issued jointly by the Departments
of Health and Insurance authorizing a corporation to establish, maintain
and operate an HMO in Pennsylvania.
CERTIFIED NURSE MIDWIFE -- An individual licensed under the laws within
the scope of Chapter 6 of Professions & Occupations, 63 P.S. 171-176.
CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) -- A registered nurse
licensed in the Commonwealth of Pennsylvania who is certified by the
boards in a particular clinical specialty area and who, while
functioning in the expanded role as a professional nurse, performs acts
of medical diagnosis or prescription of medical therapeutic or
corrective measures in collaboration with and under the direction of a
physician licensed to practice medicine in Pennsylvania.
CHILDREN IN SUBSTITUTE CARE -- Children who have been adjudicated
dependent or delinquent and who are in the legal custody of a public
agency and/or under the jurisdiction of the juvenile court and are
living outside their homes, in any of the following settings: shelter
homes, ▇▇▇▇▇▇ homes, group homes, supervised independent living, and
Residential Treatment Facilities for Children (RTFs).
CLAIM -- A ▇▇▇▇ from a provider of a medical service or product that is
assigned a unique identifier (i.e. Claim reference number). A Claim does
not include an encounter form for which no payment is made or only a
nominal payment is made.
CLEAN CLAIM -- A Claim that can be processed without obtaining
additional information from the provider of the service or from a third
party. A Clean Claim includes a Claim with errors originating in the
Contractor's Claims system. Claims under investigation for fraud or
abuse or under review to determine if they are Medically Necessary are
not Clean Claims.
CLIENT INFORMATION SYSTEM (CIS) -- The Department's database of MA
Consumers. The data base contains demographic and eligibility
information for all MA Consumers.
COMPLAINT -- A dispute or objection regarding a participating health
care provider or the coverage, operations, or management policies of a
managed care plan, which has not been resolved by the managed care plan
and has been filed with the plan or with the Department of Health or the
Insurance Department of the Commonwealth. The term does not include a
Grievance.
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CONCURRENT REVIEW -- A review conducted by the Contractor during a
course of treatment to determine whether the prescribed services should
continue in amount, duration and scope or whether a modification is
necessary.
CONTRACTOR -- A successful proposer or its successor approved by the
Department.
COUNTY ASSISTANCE OFFICE (CAO) -- The county offices of the Department
that administer all benefit programs, including MA, on the local level.
Department staff in these offices perform necessary functions such as
determining and maintaining MA Consumer eligibility.
CULTURAL COMPETENCY -- The ability of individuals, as reflected in
personal and organizational responsiveness, to understand the social,
linguistic, moral, intellectual and behavioral characteristics of a
community or population, and translate this understanding systematically
to enhance the effectiveness of healthcare delivery to diverse
populations.
DAILY MEMBERSHIP FILE - An electronic file generated by the Department
using CIS on a daily basis, exclusive of weekends and Pennsylvania state
holidays, that is transmitted to the Contractor. The Daily Membership
File contains information on changes made to MA Consumer records on CIS,
and may include retroactive, current or prospective MA eligibility, and
PH-MCO coverage information.
DELIVERABLES -- Those documents, records and reports required to be
furnished to the Department for review and/or approval pursuant to the
terms of the RFP and this Agreement.
DENIAL OF SERVICES -- Any determination made by the Contractor in
response to a Provider's request for approval to provide MA covered
services of a specific duration and scope which: disapproves the request
completely; approves provision of the requested service(s), but for a
lesser scope or duration than requested by the provider; or disapproves
provision of the requested service(s), but approves provision of an
alternative service(s). An approval of a requested service which
includes a requirement for a concurrent review by the Contractor during
the authorized period does not constitute a denial of service.
DENIED CLAIM -- An Adjudicated Claim that does not result in a payment
to a Provider.
DEPARTMENT -- The Department of Public Welfare (DPW) of the Commonwealth
of Pennsylvania.
DEPRIVATION QUALIFYING CODE -- The code specifying the condition which
determines an MA Consumer to be eligible in nonfinancial criteria.
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DEVELOPMENTAL DISABILITY -- A severe, chronic disability of an
individual that is:
- Attributable to a mental or physical impairment or
combination of mental or physical impairments.
- Manifested before the individual attains age twenty-two
(22).
- Likely to continue indefinitely.
- Manifested in substantial functional limitations in
three or more of the following areas of life activity:
- Self care;
- Receptive and expressive language;
- Learning;
- Mobility;
- Capacity for independent living; and
- Economic self-sufficiency.
- Reflective of the individual's need for special,
interdisciplinary or generic services, supports, or
other assistance that is of lifelong or extended
duration, except in the cases of infants, toddlers, or
preschool children who have substantial developmental
delay or specific congenital or acquired conditions with
a high probability of resulting in developmental
disabilities if services are not provided.
DISEASE MANAGEMENT -- An integrated treatment approach that includes the
collaboration and coordination of patient care delivery systems and that
focuses on measurably improving clinical outcomes for a particular
medical condition through the use of appropriate clinical resources such
as preventive care, treatment guidelines, patient counseling, education
and outpatient care; and that includes evaluation of the appropriateness
of the scope, setting and level of care in relation to clinical outcomes
and cost of a particular condition.
DPW FAIR HEARING -- A hearing conducted by the Department of Public
Welfare, Bureau of Hearings and Appeals or its subcontractor, based on a
PH-MCO Member's filing of an appeal from a termination, suspension or a
reduction in MA eligibility or MA covered services.
DRUG EFFICACY STUDY IMPLEMENTATION (DESI) -- Drug products that have
been classified as less-than-effective by the Food and Drug
Administration (FDA).
DUAL ELIGIBLES -- An individual who is eligible to receive services
through both Medicare and the MA Program (Medicaid).
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EARLY INTERVENTION PROGRAM --The provision of specialized services
through family-centered intervention for a child, birth to age three
(3), who has been determined to have a developmental delay of
twenty-five percent (25%) of the child's chronological age or has
documented test performance of 1.5 standard deviation below the mean in
standardized tests in one or more areas: cognitive development; physical
development, including vision and hearing; language and speech
development; psycho-social development; or self-help skills or has a
diagnosed condition which may result in developmental delay.
ELIGIBILITY PERIOD -- A period of time during which a consumer is
eligible to receive MA benefits. An eligibility period is indicated by
the eligibility start and end dates on CIS. A blank eligibility end date
signifies an open-ended eligibility period.
ELIGIBILITY VERIFICATION SYSTEM (EVS) -- An automated system available
to Providers and other specified organizations for on-line verification
of MA eligibility, prepaid capitation, PH-MCO or BH-MCO enrollment,
third party resources, and the applicable benefit package under the MA
Fee-for-Service (FFS) Program.
EMERGENCY MEDICAL CONDITION -- A medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) such that
a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical
attention to result in: (a) placing the health of the individual (or
with respect to a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy, (b) serious impairment to bodily functions,
or (c) serious dysfunction of any bodily organ or part.
EMERGENCY MEMBER ISSUE -- A problem of a PH-MCO Member (including
problems related to whether an individual is a Member), the resolution
of which should occur immediately or before the beginning of the next
business day in order to prevent a denial or significant delay in care
to the Member that could precipitate a Medical Emergency Condition or
need for urgent care.
EMERGENCY SERVICES -- Covered inpatient and outpatient services that:
(a) are furnished by a Provider that is qualified to furnish such
service under Title XIX of the Social Security Act and (b) are needed to
evaluate or stabilize an Emergency Medical Condition.
ENCOUNTER DATA -- Any health care service provided to a PH-MCO Member.
Encounters whether reimbursed through capitation, fee-for-service, or
another method of compensation must result in the creation and
submission of an encounter record to the Department. The information
provided on these records represents the encounter data provided by the
MCO.
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ENROLLEE -- A person eligible to receive services under the MA Program
in the Commonwealth of Pennsylvania and who is mandated to be enrolled
in the HealthChoices Program.
ENROLLMENT -- The process by which a Member's coverage by a PH-MCO is
initiated.
ENROLLMENT SPECIALIST -- The individual responsible to assist MA
Consumers with selecting a PH-MCO and PCP as well as providing
information regarding physical and behavioral health services and
service providers under the HealthChoices Program.
EPSDT -- Early and Periodic Screening, Diagnosis and Treatment. Items
and services which must be made available to persons under the age of
twenty-one (21) upon a determination of medical necessity and required
by federal law at 42 U.S.C. Section 1396d(r).
EXPANDED SERVICES -- Any Medically Necessary service,covered under Title
XIX of the Social Security Act, 42 U.S.C.A. 1396 et seq., but not
included in the State's Medicaid Plan, which is provided to an enrollee.
EXPEDITED GRIEVANCE -- A process for reviewing and resolving Grievances
within forty-eight (48) hours.
EXPERIMENTAL TREATMENT -- A course of treatment, procedure, device or
other medical intervention that is not yet recognized by the
professional medical community as an effective, safe and proven
treatment for the condition for which it is being used.
EXTERNAL QUALITY REVIEW (EQR) -- A requirement under Section
1902(a)(30)(C) of Title XIX of the Social Security Act, 42 U.S.C.A.
1396a(a)(30)(C) for states to obtain an independent, external review
body to perform an annual review of the quality of services furnished
under state contracts with managed care organizations, including the
evaluation of quality outcomes, timeliness and access to services.
FAMILY PLANNING SERVICES -- Services which enable individuals
voluntarily to determine family size, to space children and to prevent
or reduce the incidence of unplanned pregnancies. They are made
available without regard to marital status, age, sex or parenthood.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC) -- An entity which is receiving
a grant as defined under the Social Security Act, 42 U.S.C.A. 1396d(l)
or is receiving funding from such a grant under a contract with the
recipient of such a grant, and meets the requirements to receive a grant
under the above-mentioned sections of the Act.
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FEE-FOR-SERVICE (FFS) -- Payment by the Department to providers on a
per-service basis for health care services provided to MA Consumers.
FORMULARY -- An exclusive list of drug products for which the Contractor
will provide coverage to its Members, as approved by the Department.
FRAUD -- Any type of intentional deception or misrepresentation made by
an entity or person with the knowledge that the deception could result
in some unauthorized benefit to the entity, him/herself, or some other
person in a managed care setting. The fraud can be committed by many
entities, including the Contractor, a subcontractor, a Provider, a State
employee, or a Member, among others.
GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP) -- A technical term in
financial accounting. It encompasses the conventions, rules, and
procedures necessary to define accepted accounting practice at a
particular time.
GOVERNMENT LIAISON -- The Department's primary point of contact within
the PH-MCO. This individual acts as the day to day manager of
contractual and operational issues and works within PH-MCO and with DPW
to facilitate compliance, solve problems, and implement corrective
action. The Government Liaison negotiates internal plan, policy and
operational issues.
GRIEVANCE -- A request by an enrollee or a health care provider, with
written consent of the enrollee, to have the managed care plan or
utilization review entity reconsider a decision solely concerning
medical necessity and appropriateness of health care services. If the
managed care plan is unable to resolve the matter, a Grievance may be
filed regarding a decision that: (1) disapproves full or partial payment
for requested health care services; (2) approves a provision of a
requested health care service for a lesser scope or duration than
requested; or (3) disapproves payment for provisions of a requested
health care service but approves payment for provision of an alternative
health care service. The term does not include a Complaint.
HEALTH CARE FINANCING ADMINISTRATION (HCFA) -- The federal agency within
the Department of Health and Human Services responsible for oversight of
MA programs.
HEALTH CARE PROFESSIONAL -- A physician or other health care
provider/practitioner whose professional services are covered and
provided for under the professional scope of practice, and are included
under the contract for the services of the professional. This term
includes, but is not limited to: podiatrist, optometrist, chiropractor,
psychologist, dentist, pharmacist, physician assistant, physical or
occupational therapist and therapy assistant, speech-language
pathologist, audiologist, registered or licensed practical nurse
8
(including nurse practitioner, clinical nurse specialist, certified
registered nurse anesthetist and certified nurse-midwife), licensed
certified social worker, registered respiratory therapist and certified
respiratory therapy technician.
HEALTH MAINTENANCE ORGANIZATION (HMO) -- A Commonwealth licensed
risk-bearing entity which combines delivery and financing of health care
and which provides basic health services to enrolled Members for a
fixed, prepaid fee.
HEALTHCHOICES DISENROLLMENT -- Action taken by the Department to remove
a Member's name from the monthly Enrollment Report following the
Department's receipt of a determination that the Member is no longer
eligible for enrollment in HealthChoices.
HEALTHCHOICES SOUTHEAST (HC-SE) PROGRAM -- The mandatory Medical
Assistance managed care program in Bucks, Chester, Delaware, ▇▇▇▇▇▇▇▇▇▇
and Philadelphia counties.
HEALTHCHOICES PROPOSERS' LIBRARY -- A collection of reference documents
and materials, relevant to the HealthChoices Program, available for use
by proposers.
HEALTHCHOICES PROGRAM -- The name of Pennsylvania's 1915(b) waiver
program to provide mandatory managed health care to MA Consumers.
HIV/AIDS WAIVER PROGRAM -- A home and community based waiver that
provides for expanded services to MA Consumers who are diagnosed with
Acquired Immunodeficiency Syndrome (AIDS) or symptomatic Human
Immunodeficiency Virus (HIV) as a cost-effective alternative to
inpatient care.
HOME AND COMMUNITY WAIVER PROGRAM -- Necessary and cost effective
services, not otherwise furnished under the State's Medicaid Plan, or
services already furnished under the State's Medicaid Plan but in
expanded amount, duration, or scope which are furnished to an individual
in his/her home or community in order to prevent institutionalization.
Such services must be authorized under the provisions of Section 1915(c)
of P.L. 74-271, as amended, and codified at 42 U.S.C. 1396n.
IMMEDIATE NEED -- A situation in which, in the professional judgment of
the dispensing registered pharmacist and/or prescriber, the dispensing
of the drug at the time when the prescription is presented is necessary
to reduce or prevent the occurrence or persistence of a serious adverse
health condition.
INDEPENDENT ENROLLMENT ASSISTANCE PROGRAM (IEAP) -- The program that
provides enrollment specialists to assist MA Consumers in selecting the
PH-MCO and Primary Care Practitioner (PCP) and obtaining information
regarding HealthChoices physical and behavioral health services and
service providers.
9
IN-PLAN SERVICES -- Services which are the payment responsibility of the
Contractor under the HealthChoices Program.
INQUIRY -- Any Member's request for administrative service, information
or to express an opinion.
INTERAGENCY TEAM FOR ADULTS -- A multi-system planning team consisting
of the individual, family member(s), legal guardian, advocate(s), county
mental health/mental retardation and/or drug and alcohol case
manager(s), PCP, treating specialist(s), residential and/or day service
provider(s) and any other participant(s) necessary and appropriate to
assess the needs and strengths of the individual, formulate treatment
and service goals, approaches and methods, recommend and monitor
services and develop discharge plans. Representation on the team is
based on expertise necessary to determine and meet each individual's
needs and, therefore, is developed on a case-by-case basis.
INTERAGENCY TEAM FOR INDIVIDUALS UNDER THE AGE OF TWENTY-ONE (21) -- A
multi-system planning team comprised of the child, when appropriate, at
least one (1) accountable family member, a representative of the County
Mental Health and/or Drug and Alcohol Program, the case manager, the
prescribing physician or psychologist, and as applicable, the County
Children and Youth, Juvenile Probation, Mental Retardation, and Drug and
Alcohol agencies, a representative of the school district, BH-MCO,
PH-MCO and/or PCP, other agencies that are providing services to the
child, and other community resource persons identified by the family.
The purpose of the interagency team is to collaboratively assess the
needs and strengths of the child and family, formulate the measurable
goals for treatment, recommend the services, treatment approaches and
methods, intensity and frequency of interventions and develop the
discharge goals and plans.
INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED AND OTHER RELATED
CONDITIONS (ICF/MR/ORC) -- An institution (or distinct part of an
institution) that 1) is primarily for the diagnosis, treatment or
rehabilitation for persons with mental retardation or persons with other
related conditions; and 2) provides, in a residential setting, ongoing
evaluation, planning, twenty-four (24) hour supervision, coordination
and integration of health or rehabilitative services to help each
individual function at his/her maximum capacity.
ISSUING OFFICE -- The Department's Division of Procurement.
JUVENILE DETENTION CENTER -- A publicly or privately administered,
secure residential facility for:
- Children alleged to have committed delinquent acts who
are awaiting a court hearing;
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- Children who have been adjudicated delinquent and are
awaiting disposition or awaiting placement; and
- Children who have been returned from some other form of
disposition and are awaiting a new disposition (i.e.,
court order regarding custody of child, placement of
child, or services to be provided to the child upon
discharge from the Juvenile Detention Center).
LOCK-IN -- If a MA Consumer is involved in fraudulent activities or is
identified as abusing services provided under the MA Program, they are
restricted (locked-in) to a specific Provider(s) to obtain all of
his/her services to ensure they receive comprehensiveness of care.
MA CONSUMER -- A person enrolled to receive services under the MA
Program in the Commonwealth of Pennsylvania.
MANAGED CARE ORGANIZATION (MCO) -- An entity which manages the purchase
and provision of physical or behavioral health services under the
HealthChoices Program.
MARKET SHARE -- The percentage of Members enrolled with a particular
PH-MCO when compared to the total of Members enrolled in all the PH-MCOs
within a zone.
MEDICAL ASSISTANCE (MA) -- The Medical Assistance Program authorized by
Title XIX of the federal Social Security Act, 42 U.S.C.A 1396 et seq.,
and regulations promulgated thereunder, and 62 P.S. 101 et seq.
MEDICAL ASSISTANCE TRANSPORTATION PROGRAM (MATP) -- A non-emergency
medical transportation service provided to eligible persons who need to
make trips to/from a MA reimbursable service for the purpose of
receiving treatment, medical evaluation, or purchasing prescription
drugs or medical equipment.
MEDICALLY NECESSARY -- A service or benefit is medically necessary if it
is compensable under the MA Program and if it meets any one of the
following standards:
- The service or benefit will, or is reasonably expected
to, prevent the onset of an illness, condition or
disability.
- The service or benefit will, or is reasonably expected
to, reduce or ameliorate the physical, mental or
developmental effects of an illness, condition, injury
or disability.
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- The service or benefit will assist the Member to achieve
or maintain maximum functional capacity in performing
daily activities, taking into account both the
functional capacity of the Member and those functional
capacities that are appropriate for Members of the same
age.
Determination of medical necessity for covered care and services,
whether made on a prior authorization, concurrent review,
post-utilization, or exception basis, must be in writing.
The determination is based on medical information provided by the
Member, the Member's family/caretaker and the primary care practitioner,
as well as any other providers, programs, agencies that have evaluated
the Member.
All such determinations must be made by qualified and trained providers.
MEMBER -- An individual who is enrolled with a PH-MCO under the
HealthChoices Program and for whom the PH-MCO is responsible to provide
physical health services under the provisions of the HealthChoices
Program.
MEMBER RECORD -- A record contained on the Daily Membership File or the
Monthly Membership File that contains information on MA eligibility,
managed care coverage, and the category of assistance, which help
establish the covered services for which a MA Consumer is eligible.
MENTAL RETARDATION -- An impairment in intellectual functioning which is
lifelong and originates during the developmental period (birth to
twenty-two (22) years). It results in substantial limitations in three
or more of the following areas: learning, self-direction; self care;
expressive and/or receptive language; mobility; capacity for independent
living; and economic self-sufficiency.
▇▇▇▇▇▇▇ DALLAS WAIVER (MDW) -- A program operating under a federal
waiver that provides essential home care services to
technology-dependent individuals.
MIDWIFERY PRACTICE -- Management of the care of essentially healthy
women and their healthy neonates (initial twenty-eight [28] day period).
This includes intrapartum, postpartum and gynecological care.
MINORITY BUSINESS ENTERPRISE -- A business concern that is:
- A sole proprietorship, owned and controlled by a
minority;
- A partnership or joint venture controlled by minorities
in which fifty-one percent (51%) of the beneficial
ownership interest is held by minorities; or
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- A corporation or other entity controlled by minorities
in which fifty-one percent (51%) of the voting interest
and fifty-one percent (51%) of the beneficial ownership
interest are held by minorities.
MONTHLY MEMBERSHIP FILE -- An electronic file generated by the
Department using CIS that is transmitted to the Contractor. The Monthly
Membership File lists retroactive, current and prospective Members,
specifying for each Member the corresponding eligibility period, PH-MCO
coverage and BH-MCO coverage.
NETWORK -- All contracted or employed providers in the PH-MCO who are
providing covered services to Members.
NETWORK PROVIDER -- A health care professional who has a written
Provider Agreement with a HealthChoices PH-MCO and is credentialed by
and who participates in the PH-MCO's Provider Network to serve
HealthChoices Members.
NET WORTH (EQUITY) -- The residual interest in the assets of an entity
that remains after deducting its liabilities.
NURSING FACILITY -- A facility licensed by the DOH as a MA provider type
35 or type 36 or a facility licensed by DOH as such and certified for
Medicare participation.
ONGOING MEDICATION -- A medication that has been previously dispensed to
the Member for the treatment of an illness that is chronic in nature or
for an illness for which the medication is required for a length of time
to complete a course of treatment, until the medication is no longer
considered necessary by the physician/prescriber, and that has been used
by the Member without a gap in treatment. If the current prescription is
for a higher dosage than previously prescribed, the prescription is for
an ongoing medication at least to the extent of the previous dosage.
When payment is authorized due to the obligation to cover pre-existing
services while a grievance of fair hearing is pending, a request to
refill that prescription, made after the grievance or fair hearing has
been finally concluded in favor of the MCO, is not an ongoing
medication.
OPEN-ENDED -- A period of time that has a start date but no definitive
end date.
OPTIONS -- The long-term care pre-admission assessment program operated
by the Department of Aging under contract with the Department of Public
Welfare.
OTHER RELATED CONDITIONS (ORC) -- A physical disability such as cerebral
palsy, epilepsy, ▇▇▇▇▇ bifida or similar conditions which occur before
the age of twenty-two (22), is likely to continue indefinitely and
results in three (3) or more substantial functional limitations.
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OTHER RESOURCES -- All other resources include, but are not limited to,
recoveries from personal injury Claims, liability insurance, first-party
automobile medical insurance, accident-indemnity insurance, and the
assigned Claims plan.
OUT-OF-AREA COVERED SERVICES -- Medical services provided to MA
Consumers that meet one (1) or more of the following criteria:
- An emergency medical condition that occurs while outside
the zone;
- The health of the MA consumer would be endangered if the
MA consumer returned to the zone for needed services;
- The provider is located outside the zone, but is
nonetheless a subcontractor regularly providing medical
services to MA consumers at the request of the PH-MCO;
or
- The needed medical services are not available in the
zone.
OUT-OF-NETWORK PROVIDER -- A health care professional who has not been
credentialed by and does not have a signed Provider Agreement with a
HealthChoices PH-MCO.
OUT-OF-PLAN SERVICES -- Services which are non-plan, non-capitated and
are not the responsibility of the Contractor under the HealthChoices
Program comprehensive benefit package.
PHYSICAL HEALTH MANAGED CARE ORGANIZATION (PH-MCO) -- A risk bearing
entity, also referred to as the "plan", which has contracted with the
Department to manage the purchase and provision of physical health
services under the HealthChoices Program.
PH-MCO COVERAGE PERIOD -- A period of time during which an individual is
eligible for MA coverage and a PH-MCO coverage period exists on CIS.
PH-MCO DISENROLLMENT -- The process by which a Member's ability to
receive services from a PH-MCO is terminated.
PHYSICAL HEALTH (PH) SERVICES -- Medical and other related services
which the Contractor is responsible to provide to its Members.
PHYSICIAN INCENTIVE PLAN -- Any compensation arrangement between an MCO
and a physician or physician group that may directly or indirectly have
the effect of reducing or limiting services furnished to Medicaid
recipients enrolled in the MCO.
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POSNET -- The Pennsylvania Open Systems Network (POSNet) which is a
peer-to-peer network based on open systems products and protocols.
POST-STABILIZATION SERVICES -- Medically necessary non-emergency
services furnished to a Member after the Member is stabilized following
an Emergency Medical Condition.
PREFERRED PROVIDER ORGANIZATION (PPO) -- A Commonwealth licensed person,
partnership, association or corporation which establishes, operates,
maintains or underwrites in whole or in part a preferred provider
arrangement as defined in 31 Pa. Code 152.2.
PRIMARY CARE CASE MANAGEMENT (PCCM) -- A program under which the
Department contracts directly with primary care providers who agree to
be responsible for the provision and/or coordination of medical services
to MA Consumers under their care.
PRIMARY CARE PRACTITIONER (PCP) -- A specific physician, physician group
or a CRNP operating under the scope of his/her licensure who has
received an exception from the Department of Health, and who is
responsible for supervising, prescribing, and providing primary care
services; locating, coordinating and monitoring other medical care and
rehabilitative services and maintaining continuity of care on behalf of
an MA Consumer.
PRIOR AUTHORIZATION -- A determination made by a Contractor to approve
or deny payment for a Provider's request to provide a service or course
of treatment of a specific duration and scope to a Member prior to the
Provider's initiating provision of the requested service.
PRIOR AUTHORIZATION REVIEW PANEL (PARP) -- A panel of representatives
from within the Department who have been assigned organizational
responsibility for the review, approval and denial of all PH-MCO prior
authorization policies and procedures.
PRIOR AUTHORIZED SERVICES -- In-plan services, the utilization of which
the PH-MCO manages in accordance with Department-approved prior
authorization policies and procedures.
PROVIDER -- A person, firm or corporation, enrolled in the Pennsylvania
MA Program, which provides services or supplies to MA Consumers.
PROVIDER AGREEMENT -- Any Department-approved written agreement between
the Contractor and a Provider to provide medical or professional
services to MA Consumers to fulfill the requirements of this Agreement.
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PROVIDER APPEAL -- A request from a Provider for reversal of a denial by
the Contractor, with regard to the three (3) major types of issues that
are to be addressed in a provider appeal system as outlined in this
Agreement at Section V.K, Provider Dispute Resolution System. The three
(3) types of Provider appeals issues are:
- Provider credentialing denial by the PH-MCO;
- Claims denied by the PH-MCO for Providers participating in the
PH-MCO's Network. This includes payment denied for services
already rendered by the Provider to the Member; and
- Provider termination by the PH-MCO.
PROVIDER DISPUTE -- A written communication to a PH-MCO, made by a
Provider, expressing dissatisfaction with a PH-MCO decision that
directly impacts the Provider. This does not include decisions
concerning medical necessity.
QUALITY MANAGEMENT -- An ongoing, objective and systematic process of
monitoring, evaluating and improving the quality, appropriateness and
effectiveness of care.
RECIPIENT - A person eligible to receive physical and/or behavioral
health services under the MA Program of the Commonwealth of
Pennsylvania.
RECIPIENT MONTH -- One MA Consumer covered by the HealthChoices Program
for one (1) calendar month.
REJECTED CLAIM -- A non-HealthChoices Claim or a Claim that has
erroneously been assigned a unique identifier and is removed from the
Claims processing system prior to adjudication.
RELATED PARTIES -- Any entity that is related to the Contractor or
subcontracting PH-MCO by common ownership or control, (see definition of
"Affiliate"), and (1) performs some of the Contractor or subcontracting
PH-MCO's management functions under contract or delegation; (2)
furnishes services to Members under a written agreement; or (3) leases
real property or sells materials to the Contractor or subcontracting
PH-MCO at a cost of more than $2,500.00 during any year of a
HealthChoices physical health contract with the Department.
RESIDENTIAL TREATMENT FACILITY (RTF) -- A facility licensed by the
Department of Public Welfare that provides twenty-four (24) hour
out-of-home care, supervision and medically necessary mental health
services for individuals under twenty-one (21) years of age with a
diagnosed mental illness or severe emotional disorder.
16
RETROSPECTIVE REVIEW -- A review conducted by the Contractor to
determine whether services were delivered as prescribed and consistent
with the Contractor's payment policies and procedures.
RURAL -- Consists of territory, persons and housing units in areas
throughout the Commonwealth which are designated as having less than
2,500 persons.
SCHOOL-BASED HEALTH CENTER -- A health care site located on school
building premises which provides, at a minimum, on-site, age-appropriate
primary and preventive health services with parental consent, to
children in need of primary health care and which participate in the MA
Program and adhere to EPSDT standards and periodicity schedule.
SCHOOL-BASED HEALTH SERVICES -- An array of Medically Necessary health
services performed by licensed professionals that may include, but are
not limited to, immunization, well child care and screening examinations
in a school-based setting.
SOCIALLY/ECONOMICALLY RESTRICTED BUSINESS (SERB) -- A business whose
economic growth and development has been restricted based on social and
economic bias.
SPECIAL NEEDS -- The circumstances for which a Member will be classified
as having a special need will be based on a non-categorical or generic
perspective that identifies key attributes of physical, developmental,
emotional or behavioral conditions, as determined by DPW and as
described in this Agreement at Section V.P, Special Needs Unit (SNU) and
Exhibit NN, Special Needs Unit.
SPEND-DOWN -- A process of establishing eligibility for MA whereby
consumers spend their excess net income on certain incurred or paid
medical expenses. Eligibility may need to be redetermined monthly.
START DATE -- The first date on which MA Consumers are eligible for
medical services under this Agreement, and on which the Contractors are
operationally responsible and financially liable for providing Medically
Necessary services to MA Consumers.
STOP-LOSS PROTECTION -- Coverage designed to limit the amount of
financial loss experienced by a health care provider.
SUBCAPITATION -- A fixed per capita amount that is paid by the PH-MCO to
a Network provider for each Member identified as being in their
capitation group, whether or not the Member received medical services.
SUBCONTRACT -- Any contract between the PH-MCO and an individual,
business, university, governmental entity, or nonprofit organization to
perform part or all of
17
the PH-MCO's responsibilities under this Agreement. Exempt from this
definition are salaried employees, utility agreements and Provider
Agreements, which are not considered Subcontracts for the purpose of
this Agreement and, unless otherwise specified herein, are not subject
to the provisions governing Subcontracts.
SUSTAINED IMPROVEMENT -- Improvement in performance documented through
continued measurement of quality indicators after the performance
project/study/quality initiative is completed.
SUBSTANTIAL FINANCIAL RISK -- Financial risk set at greater than
twenty-five percent (25%) of potential payments for covered services,
regardless of the frequency of assessment (i.e., collection) or
distribution of payments. The term "potential payments" means simply the
maximum anticipated total payments that the physician or physician group
could receive if the use or cost of referral services were significantly
low. The cost of referrals, then, must not exceed that twenty-five
percent (25%) level, or else the financial arrangement is considered to
put the physician or group at substantial financial risk.
TARGETED CASE MANAGEMENT (TCM) PROGRAM -- A case management program for
MA Consumers who are diagnosed with AIDS or symptomatic HIV.
THIRD PARTY LIABILITY (TPL) -- The financial responsibility for all or
part of a Member's healthcare expenses of an individual entity or
program (e.g., Medicare) other than the Contractor.
THIRD PARTY RESOURCE (TPR) -- Any individual, entity or program that is
liable to pay all or part of the medical cost of injury, disease or
disability of a MA Consumer. Examples of third party resources include:
government insurance programs such as Medicare or CHAMPUS (Civilian
Health and Medical Program of the Uniformed Services); private health
insurance companies, or carriers; liability or casualty insurance; and
court-ordered medical support.
TITLE XVIII (MEDICARE) -- A federally-financed health insurance program
administered by the Health Care Financing Administration (HCFA) pursuant
to 42 U.S.C.A. 1395 et seq., covering almost all Americans sixty-five
(65) years of age and older and certain individuals under sixty-five
(65) who are disabled or have chronic kidney disease.
TRANSITIONAL CARE HOME -- A tertiary care center which provides medical
and personal care services to children upon discharge from the hospital
who require intensive medical care for an extended period of time. This
transition allows for the caregiver to be trained in the care of the
child, so that the child can eventually be placed in the caregiver's
home.
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URBAN -- Consists of territory, persons and housing units in places
which are designated as 2,500 persons or more. These places must be in
close proximity to one another.
URGENT MEDICAL CONDITION -- Any illness, injury or severe condition
which under reasonable standards of medical practice, would be diagnosed
and treated within a twenty-four (24) hour period and if left untreated,
could rapidly become a crisis or Emergency Medical Condition. The terms
also include situations where a person's discharge from a hospital will
be delayed until services are approved or a person's ability to avoid
hospitalization depends upon prompt approval of services.
UTILIZATION MANAGEMENT -- An objective and systematic process for
planning, organizing, directing and coordinating health care resources
to provide Medically Necessary, timely and quality health care services
in the most cost-effective manner.
UTILIZATION REVIEW CRITERIA -- Detailed standards, guidelines, decision
algorithms, models, or informational tools that describe the clinical
factors to be considered relevant to making determinations of medical
necessity including, but not limited to, level of care, place of
service, scope of service, and duration of service.
VENTILATOR DEPENDENT -- A person who requires respiratory support
through the use of a mechanical ventilator in order to replace or
support normal musculo-skeletal respiratory function to support the
adequate exchange of oxygen and carbon dioxide. A Member is considered
ventilator dependent if s/he:
- Demonstrates an inability to maintain adequate respiratory
function without the assistance of a mechanical ventilator and
therefore the mechanical ventilator is needed for its cyclic
mechanical support or replacement of the inspiratory phase of
respiration,
- Requires more than twelve hours per day of continuous support
from the mechanical ventilator to sustain life in order to
prevent significant abnormalities in the physiologic parameters
associated with respiration, and
- Is maintained on a mechanical ventilatory support via a
tracheostomy.
VOIDED MEMBER RECORD -- A Member Record used by the Department to advise
the Contractor that a certain related Member Record previously submitted
by the Department to the Contractor should be voided. A Voided Member
Record can be recognized by its illogical sequence of PH-MCO membership
start and end dates with the end date preceding the Start Date.
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WOMEN'S BUSINESS ENTERPRISE -- A business concern that is:
- A sole proprietorship, owned and controlled by a woman;
- A partnership or joint venture controlled by women in which
fifty-one percent (51%) of the beneficial ownership interest is
held by women; or
- A corporation or other entity controlled by women in which
fifty-one percent (51%) of the voting interest and fifty-one
percent (51%) of the beneficial ownership interest are held by
women.
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AGREEMENT AND RFP ACRONYMS:
For the purpose of this Agreement and RFP, the acronyms set forth shall
apply.
AAA -- Area Agency on Aging.
AIDS -- Acquired Immunodeficiency Syndrome.
ADA -- Americans with Disabilities Act.
BBS -- Bulletin Board System.
BCABD -- Bureau of Contract Administration and Business Development.
BH -- Behavioral Health.
BHA -- Bureau of Hearings and Appeals.
BH-MCO -- Behavioral Health Managed Care Organization.
CAHPS -- Consumer Assessment of Health Plans Study.
CAO -- County Assistance Office.
CASSP -- Children and Adolescent Support Services Program.
CDC -- Centers for Disease Control (and Prevention).
CFO -- Chief Financial Officer.
CFR -- Code of Federal Regulations.
CIS -- Client Information System.
CLIA -- Clinical Laboratory Improvement Amendment.
CLPPP -- Childhood Lead Poisoning Prevention Project.
COB -- Coordination of Benefits.
CSP -- Community Support Program.
CRNP -- Certified Registered Nurse Practitioner.
CRR -- Community Residential Rehabilitation.
DEA -- Drug Enforcement Agency.
DESI -- Drug Efficacy Study Implementation.
DSH -- Disproportionate Share.
DME -- Durable Medical Equipment.
DOH -- Department of Health (of the Commonwealth of Pennsylvania).
DOI -- Department of Insurance (Pennsylvania Insurance Department).
DPW -- Department of Public Welfare.
DUR -- Drug Utilization Review.
EMS -- Emergency Medical Services.
EQR -- External Quality Review.
EVS -- Eligibility Verification System.
EPSDT -- Early and Periodic Screening, Diagnosis and Treatment.
ER -- Emergency Room.
ERISA -- Employees Retirement Income Security Act of 1974.
FDA -- Food and Drug Administration.
FFS -- Fee-for-Service.
FQHC -- Federally Qualified Health Center.
FTE -- Full Time Equivalent.
FTP -- File Transfer Protocol.
GA -- General Assistance.
GAAP -- Generally Accepted Accounting Principles.
21
GME -- Graduate Medical Education.
HBP -- Healthy Beginnings Plus.
HCFA -- Health Care Financing Administration.
HEDIS -- Healthplan Employer Data and Information Set.
HC-SE -- HealthChoices Southeast (Program).
HIPAA -- Health Insurance Portability and Accountability Act.
▇▇▇▇ -- Health Insurance Premium Payment.
HIV -- Human Immunodeficiency Virus.
HMO -- Health Maintenance Organization.
IBNP -- Incurred But Not Paid.
ICF/MR -- Intermediate Care Facility for the Mentally Retarded.
ICF/ORC -- Intermediate Care Facility/Other Related Conditions.
IGC -- Initial Grievance Committee.
IEAP -- Independent Enrollment Assistance Program.
JCAHO -- Joint Commission for the Accreditation of Healthcare
Organizations.
JDC -- Juvenile Detention Center.
LAAM -- Levo-Alpha-acetyl-Methadol, now known as Levomethadyl Acetate
Hydrochloride.
LTCCAP -- Long Term Care Capitation.
MA -- Medical Assistance.
MAAC -- Medical Assistance Advisory Committee.
MAID -- Medical Assistance Identification Number.
MATP -- Medical Assistance Transportation Program.
MBE -- Minority Business Enterprise.
MCO -- Managed Care Organization.
MDW -- ▇▇▇▇▇▇▇ Dallas Waiver.
MIS -- Management Information System.
NCQA -- National Committee for Quality Assurance.
NPDB -- National Practitioner Data Bank.
OBRA -- Omnibus Budget Reconciliation Act.
OCYF -- Office of Children, Youth and Families.
OIP -- Other Insurance Paid.
OMAP -- Office of Medical Assistance Programs.
OMHSAS -- Office of Mental Health and Substance Abuse Services.
OMR -- Office of Mental Retardation.
ORC -- Other Related Conditions.
OSP -- Office of Social Programs.
PARP -- Prior Authorization Review Panel.
PBM -- Pharmacy Benefit Manager.
PCP -- Primary Care Practitioner.
PDA -- Pennsylvania Department of Aging.
PERT -- Program Evaluation and Review Technique.
PH -- Physical Health.
PH-MCO -- Physical Health Managed Care Organization.
PMPM -- Per Member, Per Month.
QARI -- Quality Assurance Reform Initiative.
22
QM -- Quality Management.
QMC -- Quality Management Committee.
QM/UMP -- Quality Management and Utilization Management Program.
RBUC -- Reported But Unpaid Claim.
RFP -- Request for Proposal.
RHC - Rural Health Clinic
RPAA -- Risk Pool Allocation Amount.
RTF -- Residential Treatment Facility.
SAP -- Statutory Accounting Principles.
SERB -- Socially/Economically Restricted Business.
SNU -- Special Needs Unit.
SPR -- Systems Performance Review.
SSA -- Social Security Act.
SSI -- Supplemental Security Income.
STD -- Sexually Transmitted Disease.
TANF -- Temporary Assistance for Needy Families.
TCM -- Targeted Case Management.
TPL -- Third Party Liability.
TTY -- Text Telephone Typewriter.
UM -- Utilization Management.
URCAP -- Utilization Review Criteria Assessment Process.
U.S. DHHS -- United States Department of Health and Human Services.
WBE -- Women's Business Enterprise.
WIC -- Women's, Infants' and Children (Program).
23
SECTION III: RELATIONSHIP OF PARTIES
A. BASIC RELATIONSHIP
The relationship between the Department and the Contractor is
that of independent contracting parties. The Contractor, its
employees, servants, agents, and representatives shall not be
considered and shall not hold themselves out as the employees,
servants, agents or representatives of the Department or the
Commonwealth of Pennsylvania. The Contractor, its employees,
servants, agents and representatives do not have the authority
to bind the Department or the Commonwealth of Pennsylvania and
they shall not make any claim or demand for any right or
privilege applicable to an officer or employee of the Department
or the Commonwealth of Pennsylvania. In furtherance of the
foregoing, the Contractor acknowledges that no workers'
compensation or unemployment insurance coverage shall be
provided by the Department to the Contractor's employees,
servants, agents and representatives. The Contractor shall be
responsible for maintaining for its employees, and for requiring
of its agents and representatives, malpractice, workers'
compensation and unemployment compensation insurance in such
amounts as required by law.
The Contractor acknowledges and agrees that it shall have full
responsibility for all taxes and withholdings of all of its
employees. In the event that any employee or representative of
the Contractor is deemed an employee of the Department by any
taxing authority or other governmental agency, the Contractor
agrees to indemnify the Department for any taxes, penalties or
interest imposed upon the Department by such taxing authority or
other governmental agency.
B. NATURE OF CONTRACT
Pursuant to this Agreement, the Contractor shall arrange for the
provision of medical and related services to MA Consumers
through qualified health care Providers in accordance with the
terms and conditions of this Agreement. In administering the
HealthChoices Program, the Contractor shall comply fully with
the terms and conditions set forth in this Agreement, including
but not limited to, the operational and financial standards.
SECTION IV: APPLICABLE LAWS AND REGULATIONS
A. CERTIFICATION AND LICENSING
During the term of this Agreement, the Contractor shall require
that each of the health care professionals with which it
contracts comply with all
24
certification and licensing laws and regulations applicable to
the profession. The Contractor agrees not to employ or enter
into a contractual relationship with a Provider or practitioner
who is precluded from participation in the MA program.
B. SPECIFIC TO MA PROGRAM
The Contractor agrees to participate in the MA Program and to
arrange for the provision of those medical and related services
essential to the medical care of those individuals being served,
and to comply with all federal and Pennsylvania laws generally
and specifically governing participation in the MA Program. The
Contractor agrees that all services provided hereunder shall be
provided in the manner prescribed by 42 U.S.C.A. 300e(b), and
warrants that the organization and operation of the Contractor
is in compliance with 42 U.S.C.A. 300e(c). The Contractor agrees
to comply with all applicable rules, regulations, and Bulletins
promulgated under such laws including, but not limited to, 42
U.S.C.A. 300e, 1396 et seq.; 62 P.S. 101 et. seq.; 42 C.F.R.
Parts 431 through 481 and 45 C.F.R. Parts 74, 80, and 84, and
the Department of Public Welfare regulations as specified in
Exhibit A of this Agreement, General Guidelines for Managed Care
Regulatory Review, and, the HealthChoices Proposers' Library,
Exhibit C of this Agreement for a list of applicable
regulations.
C. GENERAL LAWS AND REGULATIONS
The Contractor must comply with Titles VI and VII of the Civil
Rights Act of 1964, 42 U.S.C.A. Section 2000d et seq. and 2000e
et seq.; Section 504 of the Rehabilitation Act of 1973, 29
U.S.C.A. Section 701 et seq.; the Age Discrimination Act of
1975, 42 U.S.C.A. 6101 et seq.; the Americans with ▇▇▇▇▇▇▇▇▇▇▇▇
▇▇▇, ▇▇ ▇.▇.▇.▇. ▇▇▇▇▇ et seq.; and the Pennsylvania Human
Relations Act of 1955, 71 P.S. 941 et seq.; and Article XXI of
the Insurance Company Law of 1921, as amended, 40 P.S. 991.2102
et seq.
The Contractor must comply with the Commonwealth's Contract
Compliance Regulations that are set forth at 16 Pa. Code 49.101
and on file with the Contractor.
The Contractor must comply with the Standard Contract Terms and
Conditions found in Exhibit D of this Agreement, Standard
Contract Terms and Conditions for Services.
The Contractor must comply with all applicable laws,
regulations, and policies of the Pennsylvania Department of
Health and the Pennsylvania Insurance Department.
25
In addition, the Contractor and its subcontractors must respect
the conscience rights of individual providers and provider
organizations, and comply with the current Pennsylvania laws
prohibiting discrimination on the basis of the refusal or
willingness to participate in certain abortion and
sterilization-related activities as outlined in 43 P.S. 955.2
and 18 Pa. C.S.A. 3213(d).
Nothing in this Agreement shall be construed to permit or
require the Department to pay for any services or items which
are not or have ceased to be compensable under the laws, rules
and regulations governing the MA Program at the time such
services are provided.
The Contractor shall maintain the highest standards of integrity
in the performance of this Agreement and shall take no action in
violation of state or federal laws, regulations, or other
requirements that govern contracting with the Commonwealth. The
requirements regarding Contractor Integrity Provisions, are
contained in Exhibit D of this Agreement, Standard Contract
Terms and Conditions for Services.
D. LIMITATION ON THE DEPARTMENT'S OBLIGATIONS
The obligations of the Department under this Agreement are
limited and subject to the availability of funds appropriated by
the General Assembly of the Commonwealth of Pennsylvania, and
certified by the Comptroller for Public Health and Human
Services.
SECTION V: PROGRAM REQUIREMENTS
A. IN-PLAN SERVICES
The Contractor must ensure that all services provided are
Medically Necessary.
1. AMOUNT, DURATION AND SCOPE
At a minimum, In-Plan Services shall be provided in the
amount, duration and scope set forth in the MA FFS
Program and be based on the MA Consumer's benefit
package, unless otherwise specified by the Department.
If new services or eligible consumers are added to the
Pennsylvania MA Program, or if covered services or
eligible consumers are expanded or eliminated,
implementation by the Contractor shall be on the same
day as the Department's, unless the Contractor is
notified by the Department of an alternative
implementation date. When new services are added, the
Department shall conduct an actuarial analysis including
appropriate input by the Contractor, to determine if
there is a need
26
for a rate change and if necessary, adjust the rates to
appropriately reflect the addition of the new services.
The Department has established benefit packages based on
category of assistance, program status code, age, and,
for some packages, the existence of Medicare coverage or
a deprivation qualifying code. In cases where the Member
benefits are determined by the benefit package, the most
comprehensive package is to be honored.
2. PROGRAM EXCEPTIONS
The Contractor is also required to establish a process,
reviewed and approved by the Department, whereby a
Provider may request coverage for items or services,
which while included under the MA Consumer's benefit
package, are not currently listed on the MA Program Fee
Schedule. These requests are recognized by the
Department as a Program Exception and described in 55
Pa. Code 1150.63.
3. EXPANDED BENEFITS
The Contractor may provide expanded benefits subject to
advance written approval by the Department. These must
be benefits that are generally considered to have a
direct relationship to the maintenance or enhancement of
a Member's health status. Examples of potentially
approvable benefits include various seminars and
educational programs promoting healthy living or illness
prevention, memberships in health clubs and/or
facilities promoting physical fitness and expanded
eyeglass or eye care benefits. These benefits must be
generally available to all Members and must be made
available at all appropriate Contractor Network
Providers. Such benefits cannot be tied to specific
Member performance. However, the Department may grant
exceptions in areas where it believes that such tie-ins
shall produce significant health improvements for
Members.
In order for information about expanded benefits to be
included in any Member information provided by the
Contractor, the expanded benefits must apply for a
minimum of one full year or until the Member information
is revised, whichever is later. Upon sixty (60) days
advance notice to the Department, the Contractor may
modify or eliminate any expanded benefits, which exceed
the benefits provided for under the MA FFS Program. Such
benefit(s) as modified or eliminated shall supersede
those specified in the Proposal. The Contractor must
send written notice to Members
27
and affected Providers at least thirty (30) days prior
to the effective date of the change in covered benefits
and shall simultaneously amend all written materials
describing its covered benefit or Provider Network. A
change in covered benefits includes any reduction in
benefits or a substantial change to the Provider
Network.
For information to be included in materials to be used
by the Independent Enrollment Assistance Program (IEAP),
the expanded benefits must be in effect for the full
calendar year for which the IEAP information applies.
IEAP information will be updated annually on a calendar
year basis.
4. REFERRALS
The Contractor is required to establish and maintain a
referral process to effectively utilize and manage the
care of its Members. The Contractor may require a
referral for any medical services, which cannot be
provided by the PCP except where specifically provided
for in this Agreement.
5. SELF REFERRAL/DIRECT ACCESS
There are some services, which can be accessed without a
referral from the PCP. Vision, dental care, obstetrical
and gynecological (OB/GYN) services may be
self-referred, providing the Member obtains the services
from the PH-MCO's Provider Network. Chiropractic
services may be accessed in accordance with the process
set forth in Medical Assistance Bulletin 99-00-03.
Neither the referral process nor the prior authorization
process can be employed to manage the utilization of
family planning services. The right of the Member to
choose a provider for family planning services shall not
be restricted. Members may access at a minimum, health
education and counseling necessary to make an informed
choice about contraceptive methods, pregnancy testing
and counseling, breast cancer screening services, basic
contraceptive supplies such as oral birth control pills,
diaphragms, foams, creams, jellies, condoms (male and
female), Norplant, injectibles, intrauterine devices,
and other family planning procedures as described in
Exhibit F of this Agreement, Family Planning Services
Procedures, and the Contractor must pay for the
Out-of-Plan Services.
Under Section 2111(7) of the Insurance Company Law of
1921, as amended, 40 P.S. 991.72111(7), Members are to
be provided
28
direct access to OB/GYN services. The Contractor must
have a system in place that does not erect barriers to
care for pregnant women and does not involve a
time-consuming authorization process or unnecessary
travel.
Members must be permitted to select a healthcare
Provider, including nurse midwives participating in the
PH-MCO's Network, to obtain maternity and gynecological
care without prior approval from a PCP. This includes
selecting a healthcare Provider to provide Medically
Necessary follow-up care, an annual well-woman
gynecological visit, primary and preventive gynecology
care, including a PAP smear and referrals for diagnostic
testing related to maternity and gynecological care.
In situations where a new (and pregnant) enrollee is
already receiving care from an out-of-network OB-GYN
specialist at the time of enrollment, the Member may
continue to receive services from that specialist
throughout the pregnancy and postpartum care related to
the delivery.
6. BEHAVIORAL HEALTH SERVICES
The Contractor is not responsible to provide any
services as set forth in the contracts between the
Department and the Behavioral Health Managed Care
Organizations (BH-MCOs) in effect at the same time as
this Agreement.
7. PHARMACY SERVICES
a. GENERAL
The Contractor must cover, at a minimum, those
therapeutic categories currently covered by the
Department's FFS Pharmaceutical Services
Program.
Under no circumstances will the Contractor
permit the therapeutic substitution of a
prescription drug by a pharmacist without
explicit authorization from the licensed
prescriber.
The Contractor must also comply with the
requirements for Prior Authorization for
Outpatient Prescription Drugs, Section V. B.2 of
this Agreement.
b. FORMULARIES
29
Formulary guidelines and approval criteria are
listed in Exhibit G of this Agreement, Drug
Formulary Guidelines.
The Contractor may use a formulary as long as it
meets the clinical needs of the MA population
and allows access to all other MA FFS drug
products not on the formulary through some
exception process such as prior authorization in
accordance with Exhibit H of this Agreement,
Prior Authorization Guidelines. The Contractor
must submit the request for advance written
approval by the Department of the exception or
prior authorization process related to pharmacy
services together with the request for formulary
approval. Pharmacy prior authorization policies
and procedures must be submitted to the Prior
Authorization Review Panel (PARP) for review and
approval prior to implementation. Clinical
guidelines to prior authorize non-formulary
drugs require advance written approval under the
Department's Utilization Review Criteria
Assessment Process (URCAP) process which can be
found in the HealthChoices Proposers' Library.
All formularies must conform to the formulary
guidelines and approval criteria established by
the Department and may not be implemented prior
to receiving advance written approval from the
Department. For additional clarification on
formulary guidelines, see Exhibit G of this
Agreement, Drug Formulary Guidelines.
c. COVERAGE EXCLUSIONS
In accordance with Section 1927 of the Social
Security Act, 42 U.S.C.A. 1396r-8, the
Contractor must exclude coverage for any drug
marketed by a drug company (or labeler) who does
not participate in the MA FFS Medicaid Drug
Rebate Program. Therefore, the Contractor is not
permitted to provide coverage for any drug
product, brand name or generic, legend or
non-legend, sold or distributed by a company
that did not sign an agreement with the federal
government to provide rebates to the Medicaid
agency.
In addition, the Contractor must allow access to
all drug products covered by the MA FFS Program.
This includes brand name and generic products,
as well as all outpatient legend drugs, sold or
distributed by companies that participate in the
rebate program for all medically accepted
indications, as described in Section 1927(k)(6)
of the Social Security Act, 42 U.S.C.A.
1396r-8(k)(6). The Contractor
30
must include coverage for non-legend drugs as
required under formulary guidelines and covered
by the MA FFS Program. This includes any use
which is approved under the Federal Food, Drug,
and Cosmetic Act, 21 U.S.C.A. 301 et seq. or,
whose use is supported by the American Hospital
Formulary Service - Drug Information, American
Medical Association Drug Evaluations, United
States Pharmacopoeia - Drug Information, and
DRUGDEX.
d. DESI DRUGS
The Contractor shall not provide coverage for
Drug Efficacy Study Implementation (DESI) drugs
under any circumstances.
e. PHARMACY REBATE PROGRAM
Under the provisions of Section 1927 of the
Social Security Act 42 U.S.C.A. 1396r-8, drug
companies that wish to have their products
covered through the MA Program (both
fee-for-service and managed care) must sign an
agreement with the federal government to provide
rebates to the State. Any drug company that does
not sign a rebate agreement may not have their
products covered through the MA Program.
The Contractor must negotiate with drug
companies to collect rebates for pharmaceutical
products.
f. DRUG UTILIZATION REVIEW (DUR) PROGRAM
The Contractor must have written polices and
procedures to adhere to a DUR Program prior
approved by the Department. This system must be
based on federal law and regulation at Section
1927 of the Social Security Act, 42
U.S.C.A.1396r-8 and 42 C.F.R. 456 and state
guidelines adopted from the existing MA FFS DUR
Program. DUR state guidelines can be found in
Exhibit I of this Agreement, Drug Utilization
Review Guidelines.
The Contractor must have a procedure to compare
pharmacy encounter data use against
predetermined therapeutic drug criteria
standards consistent with the official compendia
and the peer-reviewed medical literature. The
official compendia shall consist of the American
Hospital Formulary Service Drug Information, the
United States Pharmacopoeia - Drug Information,
the DRUGDEX
31
Information System, and the American Medical
Association Drug Evaluations. These standards
must be consistent with medical practices that
have been developed by unbiased, independent
experts through an open professional consensus
process. This procedure must also include an
ongoing review for current drug criteria
standards. All drug criteria standards must be
submitted to the Department for advance written
approval before its usage by the Contractor,
under the Utilization Review Criteria Assessment
Process (URCAP). The URCAP manual may be found
in the HealthChoices Proposers' Library.
The Contractor must have a process for the
communication of counseling for Members based on
standards established by state pharmacy law
related to patient counseling and to the
maintenance of patient profiles.
The Contractor must have procedures for
retrospective DUR through mechanized drug Claims
processing and an information retrieval system
in accordance with Exhibit I of this Agreement,
Drug Utilization Review Guidelines.
In no case shall the Contractor's DUR Program
provide any financial or other incentive to a
pharmacist for encouraging the physician to
change his/her prescription order. A change to a
prescription order is only acceptable when
warranted by clinical reasons of Member safety
and approved efficacy.
g. PHARMACY BENEFIT MANAGER (PBM)
The Contractor may use a PBM to process
prescription Claims only if the PBM Subcontract
has received advance written approval by the
Department. The Contractor must indicate the
intent to use a PBM, identify the proposed PBM
Subcontract and the ownership of the proposed
PBM subcontractor. If the PBM is owned wholly or
in part by a retail pharmacy Provider, chain
drug store or pharmaceutical manufacturer, the
Contractor will submit a written description of
the assurances and procedures that shall be put
in place under the proposed PBM Subcontract,
such as an independent audit, to assure
confidentiality of proprietary information.
These assurances and procedures must be
submitted and receive advance written approval
by the Department prior to initiating the PBM
Subcontract. The Department will allow the
continued operation of pre-existing
32
PBM subcontracts while the Department is
reviewing such pre-existing contracts.
8. EPSDT SERVICES
The Contractor must comply with the requirements
regarding EPSDT services as set forth in Exhibit J of
this Agreement, EPSDT Guidelines.
The Contractor must also adhere to specific Department
regulations at 55 Pa. Code Chapters 3700 and 3800 as
they relate to EPSDT examination for individuals under
the age of 21 and entering substitute care or a child
residential facility placement.
9. EMERGENCY ROOM (ER) SERVICES
The Contractor agrees to comply with the program
standards regarding Emergency Room (ER) Services that
are set forth in Exhibit K of this Agreement, Emergency
Room Services.
The Contractor must comply with the provisions of the
Balanced Budget Act of 1997 (BBA) and Sections 2102 and
2116 of the Insurance Company Law of 1921 as amended, 40
P.S. 991.2102 and 991.2116, pertaining to coverage and
payment of Medically Necessary Emergency Services. In
addition:
- Emergency Providers may initiate the necessary
intervention to stabilize an Emergency Medical
Condition of the patient without seeking or
receiving prospective authorization by the
Contractor.
- The Contractor shall be responsible for all ER
services including those categorized as mental
health or drug and alcohol. Exception: ER
evaluations for voluntary and involuntary
commitments pursuant to the Mental Health
Procedures Act of 1976, 50 P.S. 7101 et seq.
shall be the responsibility of the BH-MCO.
Nothing in the above section shall be construed to imply
that the Contractor shall not:
- track, trend and profile ER utilization;
- retrospectively review and where appropriate,
deny payment for inappropriate ER use;
33
- use all appropriate methods to encourage Members
to use PCPs rather than ERs for minor acute
conditions; or
- use a recipient restriction methodology for
Members with a history of significant
inappropriate ER usage.
10. POST-STABILIZATION SERVICES
The Contractor must cover Post-Stabilization Services,
pursuant to 42 C.F.R. 422.100(b)(iv).
The Contractor must cover Post-Stabilization Services
without requiring authorization, and regardless of
whether the Member obtains the services within or
outside the Contractor's Provider Network if any of the
following situations exist:
a. The Post-Stabilization Services were
pre-approved by the Contractor.
b. The Post-Stabilization Services were not
pre-approved by the Contractor because the
Contractor did not respond to the Provider's
request for these Post-Stabilization Services
within one (1) hour of the request.
c. The Post-Stabilization Services were not
pre-approved by the Contractor because the
Contractor could not be reached by the Provider
to request pre-approval for these
Post-Stabilization Services.
11. EXAMINATIONS TO DETERMINE ABUSE OR NEGLECT
a. The Contractor must ensure that Members who are
MA Consumers under evaluation for suspected
child abuse or neglect by the County Children
and Youth Agency system, and who present for
physical examinations for determination of abuse
or neglect, shall receive such services. These
services must be performed by trained examiners
in a timely manner according to the Child
Protective Services Law, 23 Pa. C.S.A. 6301 et
seq. and Department regulations.
b. The Contractor is responsible to ensure that ER
staff and physicians know the procedures for
reporting suspected abuse and neglect in
addition to performing exams for the county.
This requirement must be included in all
applicable Provider Agreements.
34
c. Should the PCP determine that a mental health
assessment is needed, s/he must inform the MA
consumer or the County Children and Youth Agency
representative how to access these mental health
services and coordinate access to these
services, when necessary.
12. HOSPICE SERVICES
The Contractor must provide hospice care and use
certified hospice providers in accordance with the
provisions outlined at 42 C.F.R. 418.1 et seq.
MA Consumers who are enrolled in the Department's
Hospice Program and were not previously enrolled in the
HealthChoices Program will not be enrolled in
HealthChoices. However, if a PH-MCO Member is determined
eligible for the Department's Hospice Program after
being enrolled in the PH-MCO, the Member will remain the
responsibility of the PH-MCO and will not be disenrolled
from HealthChoices.
13. ORGAN TRANSPLANTS
The Contractor is responsible to pay for transplants to
the extent that the MA FFS Program pays for such
transplants. When Medically Necessary, the following
transplants shall be the responsibility of the
Contractor: Kidney (cadaver and living donor),
kidney/pancreas, cornea, heart, heart/lung, single lung,
double lung, liver (cadaver and living donor),
liver/pancreas, small bowel, pancreas/small bowel, bone
marrow, stem cell, pancreas, liver/small bowel
transplants, and multivisceral transplants.
14. TRANSPORTATION
The Contractor is financially responsible for the cost
of all Medically Necessary emergency transportation and
all Medically Necessary non-emergency ambulance
transportation.
Regulations set forth at 55 Pa. Code 1245.52(l) outline
the conditions required for ambulance transportation to
be considered Medically Necessary.
Any non-emergency transportation (excluding Medically
Necessary non-emergency ambulance) for Members to and
from MA compensable services must be arranged through
the Medical Assistance Transportation Program (MATP). A
complete
35
description of MATP responsibilities can be found in
Exhibit L of this Agreement, Transportation.
15. WAIVER SERVICES/STATE PLAN AMENDMENTS
a. HIV/AIDS WAIVER PROGRAM
The Contractor must arrange for and provide
services to persons with AIDS or symptomatic HIV
the same as those provided under the
Department's AIDS Waiver Program. Individuals
enrolled in the Department's AIDS Waiver Program
who would not otherwise be eligible for MA, are
included in HealthChoices. The Contractor shall
be responsible for tracking these Members in
accordance with federal reporting requirements.
A full description of the AIDS Waiver Program
can be found in the HealthChoices Proposers'
Library.
b. HIV/AIDS TARGETED CASE MANAGEMENT (TCM) PROGRAM
The Contractor must ensure the provision of TCM
services for persons with AIDS or symptomatic
HIV, including access to needed medical and
social services using the existing TCM program
standards of practice followed by the Department
or comparable standards approved by the
Department. In addition, individuals within the
PH-MCO who provide the TCM services must meet
the same qualifications as those under the
Department's TCM Program. A full description of
the TCM Program including practice standards for
case managers, can be found in the HealthChoices
Proposers' Library.
c. MICHAEL DALLAS WAIVER (MDW) PROGRAM
MA Consumers who are currently receiving home
and community based services through the MDW,
will be enrolled in the HealthChoices Program
but all waiver services will be covered under
the MA FFS delivery system. All other non-waiver
services will be covered under the HealthChoices
PH-MCO.
MA Consumers currently receiving home and
community based services through the MDW Program
and deemed MA eligible solely through the MDW
will be exempt from the HealthChoices Program.
36
d. HEALTHY BEGINNINGS PLUS (HBP) PROGRAM
The Contractor must provide services that meet
or exceed HBP standards in effect as defined in
current MA Bulletins. The Contractor must also
assure that the coordinated prenatal activities
of the HBP Program continue by utilizing
enrolled HBP Providers or developing comparable
resources. Such comparable programs will be
subject to review and approval by the Department
based on the likelihood that such programs will
be of greater effectiveness in meeting the goals
of the HBP Program. The Contractor must provide
a full description of its plan to provide
prenatal care for pregnant women and infants in
fulfillment of the HBP Program objectives for
review and advance written approval by the
Department. This plan must include comprehensive
postpartum care.
e. PENNSYLVANIA DEPARTMENT OF AGING (PDA) WAIVERS
The Department reserves the right to expand the
scope of services to include MA Consumers in the
PDA Waiver in HealthChoices. Please refer to
Section VII.B.3 of this Agreement for further
information on program changes.
16. NURSING FACILITY SERVICES
The PH-MCO is responsible for payment for up to thirty
(30) days of nursing home care (including hospital
reserve or bed hold days) if a Member is admitted to a
Nursing Facility. Members are disenrolled from
HealthChoices thirty (30) days following the admission
date to the Nursing Facility as long as the Member has
not been discharged (from the Nursing Facility).
A PH-MCO may not deny or otherwise limit Medically
Necessary services, such as home health services, on the
grounds that the Member needs, but is not receiving, a
higher level of care. A PH-MCO may not offer financial
or other incentives to obtain or expedite a Member's
admission to a Nursing Facility except as short-term
nursing care, not to exceed thirty (30) days.
The PH-CMO must abide by the decision of the OPTIONS
assessment process determination letter related to the
need for Nursing Facility services.
MA Consumers who are placed into a Nursing Facility from
a hospital and who were not previously enrolled in the
HealthChoices
37
Program or individuals who enter a Nursing Facility from
a hospital and are then determined eligible for MA will
not be enrolled in HealthChoices. However, should an
individual leave the Nursing Facility to reside in the
HealthChoices zone and then be determined eligible for
enrollment into HealthChoices, they will then be
required to enroll into the HealthChoices Program.
Individuals who are residing in Nursing Facilities and
are subsequently found eligible for MA will not be
enrolled in the HealthChoices Program. Individuals
eligible for MA, but not mandated into the HealthChoices
Program when they enter Nursing Facilities, or MA
Consumers who are placed in Nursing Facilities inside
the HealthChoices zone, who previously resided outside
the HealthChoices zone, will not be enrolled in the
HealthChoices Program.
B. PRIOR AUTHORIZATION OF SERVICES
1. GENERAL PRIOR AUTHORIZATION REQUIREMENTS
The Contractor must provide Emergency Services without
regard to prior authorization or the emergency care
provider's contractual relationship with the Contractor.
If the Contractor wishes to require prior authorization
of any services which are not required to be prior
authorized under the MA FFS Program, the Contractor must
establish and maintain written policies and procedures
which must have advance written approval by the
Department. In addition, the Contractor must include a
list and scope of services for referral and prior
authorization, which must be included in the
Contractor's Provider manual and Member handbook.
Contractors must receive advance written approval of the
list and scope of services to be referred or prior
authorized by the Department as outlined in Exhibit H of
this Agreement, Prior Authorization Guidelines and
Exhibit M(1) of this Agreement, Quality Management and
Utilization Management Program Requirements. Prior
authorization policies and procedures approved under
previous HealthChoices contracts will be considered
approved under this Agreement.
The Contractor shall not implement prior authorization
policies without having sought and obtained advance
written approval by the Department. Denials issued under
unapproved prior authorization policies may be subject
to retrospective review and reversal at the Department's
sole discretion. The Department may, at its discretion,
impose sanctions and/or corrective action plans in
38
the event that the Contractor improperly implements any
prior authorization policy or procedure.
The Department will make its best efforts to review and
provide feedback to the Contractor (e.g., written
approval, request for corrective action plan, denial,
etc.) within sixty (60) days from the date the
Department receives the request for review by the
Contractor. For minor updates to existing approved prior
authorization plans, the Department will make its best
efforts to review updates within forty-five (45) days
from the date the Department receives the request for
review by the Contractor.
The Contractor is required to process each request for
prior authorization of a covered service and ensure that
the Member is notified, at least verbally, of the
decision within two (2) business days of receiving the
request. If additional information is needed to review
the request, the Contractor must request such
information from the appropriate Provider within
forty-eight (48) hours of receiving the request for
prior authorization of a covered service. If the
Contractor requests additional information, the request
may be pended for a reasonable time period. However,
a. a prior authorization (prospective utilization
review) decision must be communicated to the
Member within two (2) business days of the
receipt of all supporting information reasonably
necessary to complete the review.
b. the Member must receive written notification of
a decision on a request for a covered service or
item within twenty-one (21) days of the date the
Contractor received the request. If not, the
service or item is automatically approved. To
satisfy the twenty-one (21) day time period, the
Contractor must mail to the Member, the Member's
PCP, and the prescribing Provider a notice of
partial approval or denial of the request on or
before the eighteenth (18th) day from the date
the request is received. If the notice is not
mailed by the eighteenth (18th) day after the
request is received, the request is
automatically authorized (i.e., deemed
approved).
The Contractor may waive the prior authorization
requirements for services which are required by the
Department to be prior authorized.
2. PRIOR AUTHORIZATION FOR OUTPATIENT PRESCRIPTION DRUGS
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The Contractor may require prior authorization as a
condition of coverage or payment for an outpatient
prescription drug provided that 1) a decision whether to
approve or deny the prescription is made within
twenty-four (24) hours, and 2) if a Member's
prescription for a medication is not filled when a
prescription is presented to the pharmacist, the PH-MCO
must allow the pharmacist to dispense either a fifteen
(15) day supply if the prescription qualifies as an
Ongoing Medication, or a seventy-two (72) hour supply in
other instances where this is an Immediate Need for the
medication.
The Contractor must issue a written denial notice, in
the form attached as Exhibit N of this Agreement, Denial
Notices, within twenty-four (24) hours from the time
that the prescription is presented at the pharmacy. In
the event that the Contractor cannot issue a written
denial notice within twenty-four (24) hours, the
Contractor must have procedures in place so as to permit
the Member to receive a supply of the new medication
such that the supply will not be exhausted prior to
receipt of the notice. For drugs not able to be divided
and dispensed into individual doses, the Contractor will
make provisions to allow the pharmacist to dispense the
smallest amount that will provide at least a seventy-two
(72) hour or fifteen (15) day supply, whichever is
applicable. The Department will waive the seventy-two
(72) hour supply requirement for medications and
treatments under concurrent clinical review and
treatments that are outside the parameter of use
approved by the FDA or accepted standards of care.
The Contractor must have procedures in place to assure
that if a prescription for an Ongoing Medication is not
authorized when presented at the pharmacy, the
pharmacist shall dispense a fifteen (15) day supply of
the prescription, unless the Contractor or its
designated subcontractor issued a proper written notice
of benefit reduction or termination at least ten (10)
days prior to the end of the period for which the
medication was previously authorized and a Grievance or
DPW Fair Hearing request has not been filed. If the
Member files a Grievance or DPW Fair Hearing request
from a denial of an Ongoing Medication, the Contractor
must authorize the medication until the Grievance or DPW
Fair Hearing request is resolved. When medication is
authorized due to the Contractor's obligation to
continue services while a Member's Grievance or Fair
Hearing is pending, and the final binding decision is in
favor of the Contractor, a request for subsequent refill
of the prescribed medication does not constitute an
ongoing medication.
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The requirement that the Member be given at least a
seventy-two (72) hour supply for a new medication or a
fifteen (15) day supply for an Ongoing Medication does
not apply when a pharmacist determines that the taking
of the prescribed medication, either alone or along with
other medication that the Member may be taking, would
jeopardize the health or safety of the Member. In such
event, the Contractor and/or its subcontractor must
require that its participating pharmacist make good
faith efforts to contact the prescriber. In such
instances, however, the requirement that the Contractor
issue a written denial notice within twenty-four (24)
hours still applies.
C. CONTINUITY OF CARE
The Contractor must comply with the procedures outlined in MA
Bulletin #99-96-01, Continuity of Prior Authorized Services
Between FFS and Managed Care Plans and Between Managed Care
Plans for Individuals Under Twenty-One (21), to ensure
continuity of prior authorized services whenever an individual
under the age of twenty-one (21) transfers from one PH-MCO to
another, from a PH-MCO to the MA FFS Program, or from the MA FFS
Program to a PH-MCO.
The PH-MCO must comply with Section 2117 of Article XXI of the
Insurance Company Law of 1921, as amended, 40 P.S. 991.2117
regarding continuity of care requirements. A bulletin detailing
the continuity of care requirements applicable to prior
authorized services to adult Members, as well as continuity of
treatment for non-prior authorized services for all Members will
be issued by the Department in the near future. A draft of this
bulletin can be found in the HealthChoices Proposers' Library.
D. COORDINATION OF CARE
The PH-MCO is responsible for coordination of care for
individuals enrolled in HealthChoices. The PH-MCO must ensure
seamless and continuous coordination of care across a continuum
of services for the individual Member with a focus on improving
health care outcomes. The continuum of services may include the
in-plan comprehensive benefits package, out-of-plan benefits,
and non-MA covered services provided by other community
resources such as:
1. NURSING FACILITY CARE
The PH-MCO must ensure the decisions related to
placement in Nursing Facilities are coordinated with the
Member and, where appropriate, the Member's family.
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2. SPECIAL SERVICES
Through a variety of mechanisms including Quality
Management and Utilization Management (QM/UM) and
Special Needs Unit (SNU) functions, the PH-MCO is
responsible to coordinate special In-Plan Services.
Special In-Plan Services include but are not limited to:
- ICF/MR/ORC Intermediate Care Facility for the
Mentally Retarded/Other Related Conditions
- Residential Treatment Facility (RTF)
- Acute and Extended Acute Psychiatric Facilities
- Non-Hospital Residential Detoxification,
Rehabilitation, and Half-Way House Facilities
for Drug/Alcohol Dependence/ Addiction
- Area Agencies on Aging (AAA)/OPTIONS Assessment
and Pre-admission Screening Requirements
- Pennsylvania Department of Aging (PDA) Waiver
- Members Admitted to Juvenile Detention Centers
(JDCs)
- Children in Substitute Care Transition
- Adoption Assistance Children/Adolescents
- Dual Eligibles (Medicare/Medicaid)
The HealthChoices Program requirements covering special
services are outlined in Exhibit O of this Agreement,
Description of Special Services.
3. OUT-OF-PLAN SERVICES
The PH-MCO is responsible to interact/coordinate with
the entity responsible for the Out-of-Plan Services to
promote a seamless continuum of care coordination.
Out-of-Plan Services include, but are not limited to:
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- Transitional Care Homes
- Medical ▇▇▇▇▇▇ Care Services
- Early Intervention Services
- The Home and Community Based Waiver Program for
Nursing Facility Residents with other related
conditions (OSP/OBRA Waiver)
- The Home and Community Based Waiver Program for
Nursing Facility Applicants with other related
conditions (OSP/Independence Waiver)
- Home and Community Based Waiver for Attendant
Care Services (OSP/AC Waiver)
- Home and Community Based Waiver for Persons with
Mental Retardation
Out-of-Plan Services are described in Exhibit P of this
Agreement, Out-of-Plan Services.
4. COORDINATION OF CARE/LETTERS OF AGREEMENT
The Contractor is responsible to coordinate the
comprehensive in-plan package of services with entities
providing Out-of-Plan Services. To clearly define the
roles of the entities involved in the coordination of
services, the Contractor must enter into coordination of
care letters of agreement with all school districts,
County Children and Youth Agencies (CCYAs) and Juvenile
Probation Offices (refer to Sample Model Agreement,
Exhibit Q of this Agreement), and the BH-MCOs (refer to
Exhibit R of this Agreement, Coordination with BH-MCOs).
The Department encourages the Contractor to make a good
faith effort to enter into coordination of care letters
of agreement with other public, governmental, county,
and community-based service providers.
Should the Contractor be unable to enter into
coordination of care letters of agreement as required
under this Agreement, the Contractor must submit written
justification to the Department. Justification must
include all the steps taken by the Contractor to attempt
to secure coordination of care letters of agreement, or
must demonstrate an existing, ongoing, and cooperative
relationship with the entity. The Department will then
determine whether or not this requirement will be deemed
met.
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All written coordination documents developed and
maintained by the Contractor must have advance written
approval by the Department and must be reviewed/revised
at least annually by the Contractor. Coordination
documents must be available for review by the Department
at the time of Readiness Review and upon request
thereafter. All written coordination documents entered
into between a service Provider and the Contractor must
also be approved by the Department. These written
coordination documents, including the operational
procedures, must be submitted for final review and
approval at least thirty (30) days prior to the
operational date of the Initial Term of the Contract.
Any written coordination documents entered into between
the Contractor and service Providers must contain, but
are not limited to, the provisions outlined in Exhibit S
of this Agreement, Written Agreements Between PH-MCO and
Service Providers. Under no circumstances may these
coordination documents contain any definition of
Medically Necessary other than the definition found in
this Agreement.
5. PH-MCO AND BH-MCO COORDINATION
The HealthChoices PH-MCOs and the BH-MCOs are required
to develop and implement written agreements regarding
the interaction and coordination of services provided to
MA Consumers enrolled in the HealthChoices Program.
These agreements must be submitted and approved by the
Department. The PH Contractors and BH Contractors in the
zone are encouraged to develop uniform coordination
agreements to promote consistency in the delivery and
administration of services.
Program requirements covering PH/BH Provider Agreements
are outlined in Exhibit T of this Agreement, PH/BH
Provider Agreements. The HealthChoices Program
requirements covering behavioral health services
requirements are outlined in Exhibit U of this
Agreement, Behavioral Health Services.
The Contractor agrees to comply with the requirements
regarding Coordination with Out-of-Plan Services, which
are set forth in Section V.D.3 of this Agreement,
including those pertaining to behavioral health.
a. The Contractor agrees, and the Department will
use its best efforts to require HealthChoices
BH-MCOs to agree, to submit to a binding
independent arbitration process in the
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event of a dispute between the Contractor and
any such BH-MCOs concerning their respective
obligations pursuant to this Agreement and a
Behavioral HealthChoices contract. The mutual
agreement of the Contractor and a BH-MCO to such
an arbitration process must be evidenced by and
included in the written agreement between the
Contractor and the BH-MCO.
b. All pharmacy services, except those otherwise
assigned, are the payment responsibility of the
Member's PH-MCO. The only exception is that the
BH-MCO is responsible for the payment of
methadone and Levomethadyl Acetate Hydrochloride
(LAAM). All prescribed medications are to be
dispensed through the Contractor's Network
pharmacies. This includes drugs prescribed by
both the PH-MCO and the BH-MCO Providers. The
Contractor must follow the PH/BH Pharmacy
Services guidelines in Exhibit V of this
Agreement, PH-MCO Pharmacy Guidelines. The
Department will issue a list of BH-MCO Providers
to the Contractor prior to the effective date of
this Agreement. Should the Contractor receive a
request to dispense medication from a BH
Provider not listed on the BH-MCO's Provider
file, the Contractor must work through the
appropriate BH-MCO to identify the Provider. The
Contractor is prohibited from denying prescribed
medications solely in cases where the BH-MCO
Provider is not clearly identified on the BH-MCO
Provider file.
E. CONTRACTOR RESPONSIBILITY FOR REPORTABLE CONDITIONS
The Contractor will work with State Department of Health (DOH)
State and District Office Epidemiologists in partnership with
the designated county/municipal health department staffs to
ensure that reportable conditions are appropriately reported in
accordance with Department regulations, in accordance with 28
Pa. Code 27.1 et seq. The Contractor will designate a single
contact person to facilitate the implementation of this
requirement.
The Contractor is not responsible for the payment of
Environmental Lead Investigations.
F. MEMBER ENROLLMENT AND DISENROLLMENT
1. GENERAL
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The Contractor is prohibited from restricting its
Members from changing PH-MCOs for any reason. The MA
Consumer has the right to initiate a change in PH-MCOs
at any time.
The Contractor is prohibited from offering or exchanging
financial payments, incentives, commissions, etc., to
any other PH-MCO (not receiving a contract to operate
under the HealthChoices Program or not choosing to
continue a contractual relationship with the Department)
for the exchange of information on the terminating
PH-MCO's membership. This includes offering incentives
to a terminating PH-MCO to recommend that its membership
join the PH-MCO offering the incentives.
The Department will disenroll Members from a PH-MCO when
there is a change in residence which places the Member
outside the HC zone covered by this Agreement, as
indicated on the individual county file maintained by
the Department's Office of Income Maintenance.
The Department is developing procedures to support
enrolling HC Members transferring from one HC zone to
another with the same Plan, provided that the Plan
operates in both zones.
2. CONTRACTOR OUTREACH MATERIALS
The Contractor must develop outreach materials such as
pamphlets and brochures which can be used by the IEAP
contractor to assist MA Consumers in choosing a PH-MCO
and PCP. These materials must be developed in the form
and context required by the Department. The Department
must approve of such materials in writing prior to their
use. The Department's review will be conducted within
thirty (30) days and approval will not be unreasonably
withheld. The Contractor is required to print and
provide to the IEAP contractor an adequate supply of
previously approved materials within five (5) business
days from the request of the IEAP contractor. The
Contractor brochure must follow the guidelines outlined
in Exhibit W of this Agreement, PH-MCO Guidelines for
Outreach Materials.
The Contractor is prohibited from distributing directly
or through any agent or independent contractor, outreach
materials without advance written approval of the
Department. In addition, the Contractor must comply with
the following guidelines and/or restrictions.
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a. The Contractor may not seek to influence an
individual's enrollment with the PH-MCO in
conjunction with the sale of any other
insurance.
b. The Contractor must comply with the enrollment
procedures established by the Department in
order to ensure that, before the individual is
enrolled with the PH-MCO, the individual is
provided accurate oral and written information
sufficient to make an informed decision on
whether to enroll.
c. In accordance with the federal Balanced Budget
Act of 1997, Section 1932(d)(2)(E), the
Contractor shall not directly or indirectly
conduct door-to-door, telephone or other
cold-call marketing activities.
d. The Contractor must ensure that all outreach
plans, procedures and materials are accurate and
do not mislead, confuse or defraud either the MA
Consumer or the Department.
3. CONTRACTOR OUTREACH ACTIVITIES
The Contractor must comply with the following principles
for all Contractor outreach activities:
a. Due to the Department's use of HealthChoices
Enrollment Specialists, the Contractor will be
prohibited from engaging in any marketing
activities associated with enrollment into a
PH-MCO in any HealthChoices zone. The Contractor
will be prohibited from engaging in any
marketing activities associated with enrollment
into their PH-MCO program upon notification by
the Department prior to commencement of this
Agreement, but in no case after the IEAP
contractor commences enrollment activities.
The Contractor is also prohibited from
subcontracting with an outside entity to engage
in marketing activities associated with any form
of enrollment to eligible or potential MA
Consumers. The Contractor must not engage in
marketing activities associated with
enrollments, which include but are not limited
to, the following locations and activities:
- County Assistance Offices (CAOs)
- Providers' offices
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- Malls/Commercial or retail
establishments
- Hospitals
- Check cashing establishments
- Door-to-door visitations
- Telemarketing
- Community Centers
- Churches
- Direct Mail
b. The Contractor may use but not be limited to
commonly accepted media methods to advertise.
These include television, radio, billboard, the
Internet and printed media. All such advertising
is subject to advance written approval by the
Department.
c. The Contractor may participate in or sponsor
health fairs or community events. The Department
reserves the right to set limits on
contributions and/or payments made to non-profit
groups in connection with health fairs or
community events. Advance written approval is
required for contributions of $2,000.00 or more.
The Department will make every reasonable effort
to respond to the Contractor's request for
advance written approval within ten (10)
business days. All contributions are subject to
financial audit by the Department.
d. Items of little or no intrinsic value (i.e.,
trinkets with promotional Contractor logos), may
be offered at health fairs or other approved
community events. Such items must be made
available to the general public, not to exceed
$3.00 in retail value and must not be connected
in any way to Contractor enrollment activity.
All such items are subject to advance written
approval by the Department.
e. The Contractor will be permitted to offer
Members health-related benefits in excess of
those required by the Department, and are
permitted to feature such expanded benefits in
approved outreach materials. All such expanded
benefits are subject to advance written approval
by the
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Department and must meet the requirements of
Section V.A.3 of this Agreement, Expanded
Benefits.
f. Contractors may not offer Member coupons for
products of value.
g. Unless approved by the Department, Contractors
are not permitted to directly provide products
of value unless they are health related and are
prescribed by a licensed Provider.
h. The PH-MCO will be responsible for bearing the
cost of reprinting HealthChoices outreach
materials, if a major change involving content
is made prior to the IEAP's annual revision of
materials. These changes include, but are not
limited to, change in product names, program
benefits and services.
i. The Department reserves the right to review any
and all outreach activities and advertising
materials and procedures used by the Contractor
for the HealthChoices program. In addition to
any other sanctions, the Department may impose
monetary or restricted enrollment penalties
should the Contractor be found to be using
marketing materials or engaging in marketing
practices. The Department reserves the right to
suspend all outreach activities and the
completion of applications for new Members. Such
suspensions may be imposed for a period of sixty
(60) days from notification by the Department to
the Contractor citing the violation.
j. The Contractor is prohibited from distributing,
directly or through any agent or independent
Contractor, outreach materials that contain
false or misleading information.
k. The Contractor must not, under any conditions
use the Department's Client Information System
(CIS) to identify and market to MA Consumers
participating in the MA FFS Program or enrolled
in another PH-MCO. The Contractor shall not
share or sell MA Consumer lists with other
organizations for any purpose.
l. The Contractor must submit a plan for
advertising, sponsorship, and outreach
procedures to the Department for advance written
approval in accordance with the guidelines
outlined in Exhibit X of this Agreement,
HealthChoices PH-
49
MCO Guidelines for Advertising, Sponsorship, and
Outreach.
4. ALTERNATIVE LANGUAGE REQUIREMENT
During the enrollment process, the Department and/or its
HealthChoices Enrollment Specialists shall seek to
identify program Members who speak a language other than
English as their first language. The Department and/or
its HealthChoices Enrollment Specialists shall notify
the Contractor when it knows of Members who do not speak
English as a first language and who have either selected
or been assigned to the Contractor.
If five percent (5%) or more of MA Consumers in a County
Assistance/District Office speak a language other than
English as a first language, the Contractor must make
available in that language all information that is
disseminated to English speaking Members. This
information includes, but is not limited to, Member
handbooks, hardcopy provider directories, education and
outreach materials, written notifications, etc.
Materials must include appropriate instructions on how
to access or receive assistance with accessing desired
materials in an alternate language or format.
5. CONTRACTOR ENROLLMENT PROCEDURES
The Contractor must have in effect written
administrative policies and procedures for newly
enrolled Members. The Contractor must also provide
written policies and procedures for coordinating
enrollment information with the Department's IEAP
contractor. The Contractor must receive advance written
approval from the Department regarding these policies
and procedures. The Contractor's submission of new or
revised policies and procedures for review and approval
by the Department shall not act to void any pre-existing
policies and procedures which have been prior approved
by the Department for operation in a HC zone. Unless
otherwise required by law, the Contractor may continue
to operate under such pre-existing policies and
procedures until such time as the Department approves
the new or revised version thereof.
The Contractor must take necessary administrative steps
consistent with the Enrollment/Disenrollment Dating
Rules that are determined by and provided by the
Department in Exhibit Y of this Agreement, Managed Care
Enrollment/Disenrollment Dating Rules.
The Contractor must enroll any eligible MA Consumer who
selects the Contractor or is assigned in accordance with
Exhibit Z of this
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Agreement, Automatic Assignment, to the Contractor
regardless of the MA Consumer's race, color, creed,
religion, age, sex, national origin, ancestry, marital
status, sexual orientation, income status, program
membership, Grievance status, MA category status, health
status, pre-existing condition, physical or mental
handicap or anticipated need for health care. See
Exhibit AA of this Agreement, Category/Program Status
Coverage Chart.
6. ENROLLMENT OF NEWBORNS
The Contractor must have written administrative policies
and procedures to enroll and provide all necessary
services to newborn infants of Members, effective from
the time of birth, without delay, in accordance with
Section V.F.11 of this Agreement, Services for New
Members, and Exhibit BB of this Agreement, PH-MCO
Recipient Coverage Document. The Contractor must receive
advance written approval from the Department regarding
these policies and procedures.
The Contractor is not responsible for the payment of
newborn metabolic screenings.
7. TRANSITIONING MEMBERS BETWEEN PH-MCOS
It may be necessary to transition a Member between
PH-MCOs. Members with Special Needs should be assisted
by the SNU(s) to facilitate a seamless transition. The
Contractor must follow the Department's established
procedures as outlined in Exhibit BB of this Agreement,
PH-MCO Recipient Coverage Document.
8. CHANGE IN STATUS
The Contractor must report to the Department on a weekly
enrollment/disenrollment file the following:
- Pregnancies not on CIS;
- Death Reports;
- Newborns not on CIS; and
- Return mail.
The Contractor must report to the appropriate CAO any
changes in the status of families or individual Members
within ten (10) business
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days of their becoming known, including changes in
family size and residence, and new phone numbers.
9. MONTHLY MEMBERSHIP
The Department will provide an electronic file, on a
monthly basis, that lists program eligibles who are
prior, current or future Contractor Members. The
Contractor agrees to reconcile this membership list
against its internal membership information and notify
the Department of any discrepancies found within the
data on the file within thirty (30) business days, in
order to resolve problems.
MA Consumers not included on this file with an
indication of prospective coverage will not be the
responsibility of the PH-MCO unless a subsequent Daily
Membership File indicates otherwise. Those with an
indication of future month coverage will not be the
responsibility of the PH-MCO if a Daily Membership File
received by the PH-MCO prior to the beginning of the
future month indicates otherwise.
10. ENROLLMENT AND DISENROLLMENT UPDATES
a. DAILY FILE
The Department will provide to the Contractor by
electronic file transmission, a daily file that
lists demographic changes, eligibility changes,
enrollment changes and Members enrolled through
the automatic assignment process.
The Contractor must reconcile this file against
its internal membership information and notify
the Department within thirty (30) business days
in order to resolve problems.
b. WEEKLY ENROLLMENT/DISENROLLMENT RECONCILIATION
FILE
The Department will provide, every week by
electronic file transmission, information on
Members voluntarily enrolled or disenrolled.
This file also provides dispositions on alerts
submitted by the Contractor.
c. DISENROLLMENT EFFECTIVE DATES
Member disenrollments will become effective on
the date specified by the Department. The
Contractor must have
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written policies and procedures for complying
with Department disenrollment orders.
d. DISCHARGE/TRANSITION PLANNING
When any Member is disenrolled from the PH-MCO
because of:
admission to or length of stay in a facility,
a waiver program eligibility, or
a child's placement in substitute care outside
the HealthChoices zone,
the Contractor from which the Member disenrolled
must remain responsible for participating in
discharge/transition planning for up to six (6)
months from the initial date of disenrollment.
The Contractor will remain the MA Consumer's
PH-MCO upon discharge (upon returning to the
HealthChoices zone), unless the MA Consumer
chooses a different PH-MCO or is determined to
no longer be eligible for participation in
HealthChoices.
If the MA Consumer chooses a different PH-MCO,
that PH-MCO must participate in the
discharge/transition planning upon notification
that the MA Consumer is enrolled.
11. SERVICES FOR NEW MEMBERS
The Contractor must make available the full scope of
benefits to which a Member is entitled from the
effective enrollment date provided by the Department.
Detailed descriptions of those services can be found in
the HealthChoices Proposers' Library in the materials
describing the MA FFS Program for those services.
The Contractor must ensure that pertinent demographic
information about the MA Consumer, i.e., Special Needs
data collected through the IEAP or directly indicated to
the Contractor by the MA Consumer after enrollment, will
be used by the Contractor upon the new Member's
effective enrollment date in the PH-MCO. If a Special
Need is indicated, the Contractor is required to place a
Special Needs indicator on the Member's record and must
outreach to that Member to identify their Special Need
or circumstance. For any Member with a Special Needs
indicator, the Contractor must arrange for a health
needs assessment within forty-five (45) days; provide
results of the same to the assigned PCP; and track and
follow-up outcomes to assure the Member's needs are
adequately addressed.
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The Contractor must comply with access standards as
required in Section V.S of this Agreement, Provider
Network/Services Access and follow the appointment
standards described in Section V.S.12 of this Agreement,
Appointment Standards, when an appointment is requested
by a Member.
12. NEW MEMBER ORIENTATION
The Contractor must have written policies and procedures
for:
- Orienting new Members to their benefits (e.g.,
prenatal care, dental care, and specialty care),
- Educational and preventative care programs,
- The proper use of the PH-MCO identification card
and the Department's ACCESS card,
- The role of the PCP,
- What to do in an emergency or urgent medical
situation,
- How to utilize services in other circumstances,
and
- How to register a Complaint, file a Grievance or
request a DPW Fair Hearing.
These policies and procedures must receive advance
written approval by the Department.
The Contractor is prohibited from contacting a potential
enrollee who is identified on the daily file with an
automatic assignment indicator (either an "A" auto
assigned or "M" member assigned) until ten (10) business
days before the effective date of the Member enrollment
unless it is the Contractor's responsibility under this
Agreement.
13. ELIGIBILITY VERIFICATION SYSTEM (EVS)
The Contractor must provide a file via the Department's
Pennsylvania Open Systems Network (POSNet), to the
Department's EVS contractor, of PCP assignments for all
its Members. The Contractor must provide this file at
least weekly or more frequently if requested by the
Department. The Contractor must ensure that the PCP
assignment information is consistent with
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all requirements specified by the Department. The file
layout and data dictionary for this file are located in
the Exhibit CC of this Agreement, Data Support for
PH-MCOs.
14. CONTRACTOR IDENTIFICATION CARDS
The Contractor may issue its own identification card to
enrolled Members. However, the Department issues an
identification card, called an ACCESS card, to each MA
Consumer, which the Member is required to use when
accessing services. Providers must use this card to
access the Department's EVS and to verify the Member's
eligibility. The ACCESS card shall allow the Provider
the capacity to access the most current eligibility
information without contacting the Contractor directly.
15. MEMBER HANDBOOK
The Contractor agrees to mail a Member handbook, or
other written materials, with information on how to
access services, in the appropriate language or
alternate format to Members within five (5) business
days of being notified of a Member's enrollment. The
Contractor must maintain documentation verifying that
the Member handbook is reviewed for accuracy at least
once a year, and that all necessary modifications have
been made and all Members notified.
a. MEMBER HANDBOOK REQUIREMENTS
The Contractor must ensure that the Member
handbook is written at no higher than a fourth
grade level and include, at a minimum, the
information outlined in Exhibit DD of this
Agreement, HealthChoices PH-MCO Member Handbook.
b. DEPARTMENT APPROVAL
The Contractor must submit Member handbook
language to the Department for advance written
approval prior to distribution to Members. The
Contractor must make modifications in the
language contained in the Member handbook if
ordered by the Department so as to comply with
the requirements described in a., Member
Handbook Requirements, above.
c. LANGUAGES OTHER THAN ENGLISH
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The Contractor must follow the Member access
standards for Member handbooks outlined in
Section V.F.4 of this Agreement, Alternative
Language Requirement.
16. PROVIDER DIRECTORIES
Directories must be available for all types of Providers
in the Contractor's Network, including, but not limited
to: PCPs, hospitals, specialists, providers of ancillary
services, Nursing Facilities, etc. The Contractor must
provide the IEAP contractor with an adequate supply of
hardcopy provider directories (including updates) on a
continual basis. Hardcopy provider directories must be
updated annually.
The Contractor must provide the IEAP contractor with an
updated electronic version of their provider directory
on a weekly basis. This will provide information
regarding terminations, additions, PCPs and specialists
not accepting new assignments, and other information
determined by the Department to be necessary. The
Contractor must provide the file layout and format
specified by the Department. The format shall include,
but not be limited to the following:
- Correct Provider Medical Assistance
Identification (MAID) number
- All providers in the Contractor's Network
- Wheel chair accessibility of provider sites
- Language indicators
A Contractor will not be certified as "ready" without
the completion of the electronic provider directory
component. See Exhibit EE of this Agreement, Online
Provider Directory File Layout.
The Contractor must provide its Members with directories
for PCPs, dentists, specialists and providers of
ancillary services, upon request, which include, at a
minimum, the information listed in Exhibit FF of this
Agreement, PCP, Dentists, Specialists and Providers of
Ancillary Services Directories. The Contractor must
submit PCP, specialists, and provider of ancillary
services directories to the Department for advance
written approval before distribution to its Members. The
Contractor must submit provider directories to the
Department for review and approval thirty (30) days
prior to the program commencement or as determined by
the
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Department. The Contractor also agrees to make
modifications to its provider directories if ordered by
the Department to do so.
17. MEMBER DISENROLLMENT
The PH-MCO may not reassign or remove Members
involuntarily from Network Providers who are willing and
able to serve the Member.
G. MEMBER SERVICES
1. GENERAL
The Contractor's Member services functions shall be
operational at least during regular business hours (9:00
a.m. to 5:00 p.m., Monday through Friday) and one (1)
evening per week (5:00 p.m. to 8:00 p.m.) or one (1)
weekend per month to address non-emergency problems
encountered by Members. Arrangements must be made to
receive, identify, and timely resolve Emergency Member
Issues on a twenty-four (24) hour, seven (7) day-a-week
basis. The Contractor's Member services functions shall
include, but are not limited to, the following Member
services standards:
- Explaining the operation of the Contractor and
assisting Members in the selection of a PCP.
- Assisting Members with making appointments and
obtaining services.
- Assisting with arranging transportation for
Members through the MATP. See Section V.A.14 of
this Agreement, Transportation and Exhibit L of
this Agreement, Transportation.
- Receiving, identifying and resolving Emergency
Member Issues.
- Under no circumstances will unlicensed members
services staff provide health-related advice to
Members requesting clinical information. The
Contractor must ensure that all such inquires
are addressed by clinical personnel acting
within the scope of their licensure to practice
a health related profession.
2. CONTRACTOR INTERNAL MEMBER DEDICATED HOTLINE
The Contractor must maintain and staff a twenty-four
(24) hour, seven (7) day-a-week toll-free dedicated
hotline to respond to Members' inquiries, Complaints and
problems raised regarding
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services. The Contractor's internal Member hotline staff
are required to ask the caller whether or not they are
satisfied with the response given to their call. All
calls must be documented and if the caller is not
satisfied, the Contractor must ensure that the call is
referred to the appropriate individual within the PH-MCO
for follow-up and/or resolution. This referral must take
place within forty-eight (48) hours of the call. The
Contractor must provide the Department with the
capability to monitor the Contractor's Member services
and internal Member dedicated hotline from both the
Department's headquarters and at each of the
Contractor's offices. The Department shall only monitor
calls from MA Program recipients and shall cease all
monitoring activity as soon as it becomes apparent that
the caller is not a MA Program recipient. The Contractor
is not permitted to utilize electronic call answering
methods, as a substitute for staff persons, to perform
this service. The Contractor must ensure that its
dedicated hotline meets the following Member services
performance standards:
- Provide for a dedicated phone line for its
Members.
- Provide for necessary translation assistance
including provisions for Members who have
hearing impairments.
- Be staffed by individuals trained in:
- cultural competence;
- addressing the needs of special populations;
- the availability of the functions of the SNU;
- the services which the Contractor is required
to make available to children; and
- the availability of social services within
the community.
- Be staffed with representatives familiar with
accessing medical transportation.
- Be staffed with adequate service representatives
to accommodate a delay in answering no greater
than five (5) rings and three (3) minutes hold
time.
- Provide for TTY and/or Pennsylvania
Telecommunication Relay Service availability.
3. EDUCATION AND OUTREACH HEALTH EDUCATION ADVISORY
COMMITTEE
The Contractor must develop and implement effective
Member education and outreach programs which may include
health
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education programs focusing on the leading causes of
hospitalization and emergency room use and health
initiatives which target Members with Special Needs
including but not limited to: HIV/AIDS, mental
retardation/developmental disabilities, eligibility
(Medicare/ Medicaid), etc.
The Contractor must establish and maintain a Health
Education Advisory Committee that includes MA Consumers
and Providers of the community to advise on the health
education needs of managed care Members. Representation
on this Committee shall include, but not be limited to,
women, minorities, persons with Special Needs and at
least one (1) person with expertise on the medical needs
of children with Special Needs.
The Contractor must provide for and document
coordination of health education materials, activities
and programs with public health entities, particularly
as they relate to public health priorities and
population-based interventions. The Contractor must also
work with the Department to ensure that its Health
Education Advisory Committees are provided with an
effective means to consult with each other and, when
appropriate, coordinate efforts and resources for the
benefit of the entire HealthChoices population in the
zone or populations with Special Needs. Provider
representation includes physical health, behavioral
health, and dental health providers on the Contractor's
Health Education Advisory Committees.
The Contractor must provide the Department with a
written description of all planned health education
activities and targeted implementation dates on an
annual basis.
4. INFORMATIONAL MATERIALS
All information given to Members and potential Members
must be easily understood and must comply with all
requirements outlined in the RFP and Agreement and the
provisions of Section 2136 of the Insurance Company Law
of 1921, as amended, 40 P.S. 991.2136. Informational
material distributed to HealthChoices Members, including
but not limited to provider directories and Member
handbooks, shall be available, upon request, in Braille,
large print, and audio tape and must be provided in the
format requested by the person with a visual impairment.
The information contained in the provider directories
may cover only those zip codes or other geographic
locations that the person with a visual impairment
requests. The Contractor must pay particular attention
for the provision of the following items:
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- Identity, location, qualifications and
availability of health care providers within the
organization.
- Members' rights and responsibilities.
- Complaint, Grievances, and DPW Fair Hearing
procedures.
- Instructions for Members to access or receive
assistance in accessing materials in an
alternate language or format. Instructions
should include both phone and TTY numbers.
- Information on services covered directly or
through referral and prior authorization.
- Information regarding how an individual who is
deaf can access interpreter services for medical
appointments.
The Contractor must obtain advance written approval from
the Department of all Member newsletters. In addition,
the Contractor must send Member newsletters to each
Member household.
The Contractor must obtain advance written approval from
the Department to use Member related HealthChoices
information, on their electronic web sites and bulletin
boards.
5. MEMBER ENCOUNTER LISTINGS
The Contractor must include, in its PCP Provider
Agreements, language which requires PCPs to contact new
Members identified in the quarterly encounter lists who
have not had an encounter during the first six (6)
months of enrollment, or who have not complied with the
scheduling requirements outlined in the RFP and this
Agreement. The Contractor must require the PCP to
contact Members identified in the quarterly encounter
lists as not complying with EPSDT periodicity and
immunization schedules for children. The PCP must be
required to identify to the Contractor any such Members
who have not come into compliance with the EPSDT
periodicity and immunization schedules within one (1)
month of such notification to the site by the
Contractor. The PCP must also be required to document
the reasons for non-compliance, where possible, and to
document its efforts to bring the Member's care into
compliance with the standards.
The Contractor must distribute quarterly lists to each
PCP in its Provider Networks which identify new Members
and Members who
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have not had an encounter during the previous six (6)
months or within the time frames set forth in Section
V.F.11 of this Agreement, Services for New Members, or
Members who have not complied with EPSDT periodicity and
immunization schedules for children. PCPs shall be
required to contact these Members to arrange
appointments. The Contractor is responsible for
contacting such Members, documenting the reasons for
noncompliance and documenting its efforts for bringing
the Member's care into compliance.
H. ADDITIONAL ADDRESSEE
The Contractor must have administrative mechanisms for sending
copies of information, notices and other written materials to a
third party upon the request and signed consent of the Member.
The Contractor must develop plans to process such individual
requests and for obtaining the necessary releases signed by the
Member to ensure that the Member's rights regarding
confidentiality are maintained.
I. MEMBER COMPLAINT, GRIEVANCE AND DPW FAIR HEARING PROCESS
1. MEMBER COMPLAINT, GRIEVANCE AND DPW FAIR HEARING PROCESS
The Contractor must develop, implement, and maintain a
Complaint and Grievance process that provides for
settlement of Members' Complaints and Grievances and the
processing of requests for DPW Fair Hearings as outlined
in Exhibit GG of this Agreement, Complaints, Grievances,
and DPW Fair Hearing Process. The Contractor must have
written policies and procedures approved by the
Department, for resolving Member Complaints and for
processing Grievances and DPW Fair Hearing requests,
that meet the requirements established by the Department
and the provisions of Article XXI of the Insurance
Company Law of 1921, as amended by the Act of June 17,
1998, (P.L. 464, No. 68), 40 P.S. 991.2101 (991.2361)
known as Act 68 and corresponding Act 68 regulations and
42 C.F.R. 431.200 et seq. of the Federal Regulations.
The Contractor must also comply with 55 Pa. Code 275 et
seq. regarding DPW Fair Hearing Requests.
The Contractor's submission of new or revised policies
and procedures for review and approval by the Department
shall not act to void any pre-existing policies and
procedures which have been prior approved by the
Department for operation in a HC zone. Unless otherwise
required by law, the Contractor may continue to operate
under such pre-existing policies and procedures until
such
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time as the Department approves the new or revised
version thereof.
The Contractor must require each of its subcontractors
to comply with the Member Complaint, Grievance, and DPW
Fair Hearing Process. This includes reporting
requirements established by the Contractor, which have
received advance written approval by the Department. The
Contractor must provide to the Department for approval,
its written procedures governing the resolution of
Complaints and Grievances and the processing of DPW Fair
Hearing requests.
The standard notice required and outlined in Exhibit N
of this Agreement, Denial Notices, must be used in the
Contractor's Complaint, Grievance and DPW Fair Hearing
process and must be in accessible formats for
individuals with vision impairments. In addition, the
notice must be available for persons who do not speak
English.
For children in substitute care, notices must be sent to
the County Children and Youth Agency with legal custody
of a child or to the court authorized juvenile probation
office with primary supervision of a juvenile provided
the PH-MCO knows that the child is in substitute care
and the address of the custodian of the child.
The Contractor must abide by the final decision of the
Departments of Health or Insurance (as applicable) when
a Member has filed an external appeal of a second level
complaint decision. When a Member files an external
appeal of a second level Grievance decision, the
Contractor must abide by the decision of the Department
of Health certified utilization review entity (URE),
which was assigned to conduct the independent external
review, unless appealed to the court of competent
jurisdiction. The Contractor must abide by the final
decision of the Department of Public Welfare's Bureau of
Hearings and Appeals for those cases when an MA Consumer
has requested a DPW Fair Hearing, unless requesting
reconsideration by the Secretary of the Department of
Public Welfare or appealing to the court of competent
jurisdiction.
2. DPW FAIR HEARING PROCESS FOR MEMBERS
During all phases of the PH-MCO Grievance process, and
in some instances involving Complaints, the Member has
the right to request a Fair Hearing with the Department.
The Contractor must comply with the DPW Fair Hearing
Process requirements defined in Exhibit
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GG of this Agreement, Complaints, Grievances and DPW
Fair Hearing Process.
A request for a DPW Fair Hearing does not prevent a
Member from also utilizing the plan's Grievance process.
J. CLINICAL SENTINEL
The Contractor agrees to cooperate with the functions of the
Department's Clinical Sentinel Hotline which is designed to
address clinically related systems issues encountered by MA
Consumers and their advocates or Providers. The Clinical
Sentinel Hotline facilitates resolution according to Contractor
policies and procedures and does not impose additional
obligations on the Contractor.
K. PROVIDER DISPUTE RESOLUTION SYSTEM
The Contractor shall develop, implement, and maintain a Provider
Dispute Resolution Process, which provides for informal
settlement of Providers' disputes at the lowest level and a
formal process for appeal. The resolution of all issues
regarding the interpretation of Department approved Provider
PH-MCO contracts shall be handled between the two entities and
shall not involve the Department. The Department's Bureau of
Hearings and Appeals or its designee is not an appropriate forum
for Provider disputes with the PH-MCO.
Prior to implementation, the PH-MCO shall submit to the
Department, their policies and procedures relating to the
resolution of Provider disputes/appeals for approval. Any
changes made to the Provider disputes/appeals policies and
procedures shall be submitted to the Department for approval
prior to implementation of the changes.
The PH-MCO's policies and procedures shall include at a minimum:
- Informal and formal processes for settlement of Provider
disputes;
- Acceptance and usage of the Department's
definition/delineation of disputes;
- Submission and resolution of timeframes for
disputes/appeals;
- Processes to ensure equitability for all Providers;
- Mechanisms and time-frames for reporting Provider appeal
decisions to PH-MCO administration, QM Provider
Relations and the Department; and
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- Establishment of a PH-MCO Committee to process provider
formal disputes/appeals which shall include:
- At least one-fourth (1/4th) of the membership of
the Committee shall be composed of
providers/peers;
- Committee members who have the authority,
training, and expertise to address and resolve
provider dispute/appeal issues;
- Access to data necessary to assist committee
members in making decisions; and
- Documentation of meetings and decisions of the
Committee.
The Contractor's submission of new or revised policies and
procedures for review and approval by the Department shall not
act to void any pre-existing policies and procedures which have
been prior approved by the Department for operation in a HC
zone. Unless otherwise required by law, the Contractor may
continue to operate under such pre-existing policies and
procedures until such time as the Department approves the new or
revised version thereof.
In addition to the Provider Dispute Resolution System covering
contractual issues between the Provider and the managed care
plan, Article XXI of the Insurance Company Law of 1921, as
amended,40 P.S. 991.2101 et seq. and the regulations promulgated
by the Pennsylvania Insurance Department, 31 Pa. Code Chapters
154 and 301, afford Providers the opportunity to file Clean
Claim disputes with the Insurance Department.
L. CERTIFICATION OF AUTHORITY
The Contractor will be required to maintain operating authority
in all HealthChoices counties in the zone throughout the term of
this Agreement. The Contractor must provide to the Department a
copy of Certificates of Authority verifying the counties in
which it is licensed to operate, upon request.
M. EXECUTIVE MANAGEMENT
The Contractor must provide the following management personnel:
- Designated administrator/program manager empowered to
make day-to-day decisions about the administration of
the program.
- Member services supervisor/manager and adequate
qualified member service staff to interact by phone or
in person with MA Consumers.
- Qualified medical personnel to oversee QA, UM, Special
Needs, Maternal Health/EPSDT functions.
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- Personnel with access to the MIS system and the ability
to produce ad hoc reports to assist in the
administration of the program.
The Contractor must document minority participation in executive
level decision making positions within its corporate structure.
In addition, the Contractor's staffing should represent the
cultural and ethnic diversity of the Program and comply with all
requirements of Exhibit D of this Agreement, Standard Contract
Terms and Conditions for Services. Cultural competency may be
reflected by the Contractor's pursuit to:
- Identify and value differences;
- Acknowledge the interactive dynamics of cultural
differences;
- Continually expand cultural knowledge and resources with
regard to the populations served;
- Recruit minority staff in proportion to the populations
served;
- Collaborate with the community regarding service
provisions and delivery; and
- Commit to cross-cultural training of staff and the
development of policies to provide relevant, effective
programs for the diversity of people served.
The Contractor must have in place sufficient administrative
staff and organizational components to comply with the
requirements of this Agreement. The Contractor must include in
its organizational structure, the components outlined below. The
functions must be staffed by qualified persons in numbers
appropriate to the PH-MCO's size of enrollment. The Department
has the right to make the final determination regarding whether
or not the Contractor is in compliance.
The Contractor may combine functions or split the responsibility
for a function across multiple departments, unless otherwise
indicated, as long as it can demonstrate that the duties of the
function are being carried out. Similarly, the Contractor may
contract with a third party to perform one (1) or more of these
functions, subject to the subcontractor conditions described in
Section XIII of this Agreement, Subcontractual Relationships.
The Contractor is required to keep the Department informed at
all times of the management individual(s) whose duties include
each of the responsibilities outlined in this section.
The Contractor must include in its Executive Management
structure:
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- A full-time Administrator with authority over the entire
operation of the PH-MCO.
- A full-time HealthChoices Program Manager to oversee the
operation of the Agreement, if different than the
Administrator of the PH-MCO.
- A full-time Medical Director who is a current
Pennsylvania-licensed physician. The Medical Director
must be actively involved in all major clinical program
components of the PH-MCO and directly accountable within
the organization for management of the QM Department, UM
Department, and Special Needs Unit. The Medical Director
and his/her staff/consultant physicians shall devote
sufficient time to the PH-MCO to ensure timely medical
decisions, including after-hours consultation, as
needed.
- A full-time Chief Financial Officer (CFO) to oversee the
budget and accounting systems implemented by the PH-MCO.
The CFO must ensure the timeliness and accurateness of
all financial reports.
- A full-time Information Systems (IS) Coordinator, who
would be the single point of contact for all information
systems issues with the Department. The IS Coordinator
must have a good working knowledge of the PH-MCO's
entire program and operation, as well as the technical
expertise to answer questions related to the operation
of the information system.
- Clerical and support staff to ensure appropriate
functioning of the PH-MCO's operation.
N. OTHER ADMINISTRATIVE COMPONENTS
The Contractor must address each of the administrative functions
listed below. These functions may be combined or split as long
as the Contractor can demonstrate that the duties of these
functions will conform to the work statement described herein.
- A QM Coordinator who is a Pennsylvania-licensed
physician, registered nurse or physician's assistant
with past experience or education in quality management
systems. The Department may consider other advanced
degrees relevant to quality management in lieu of
professional licensure.
- A UM Coordinator who is a Pennsylvania-licensed
physician, registered nurse or physician's assistant
with past experience or education in utilization
management systems. The Department may
66
consider other advanced degrees relevant to utilization
management in lieu of professional licensure.
- A full-time SNU Coordinator who is a
Pennsylvania-licensed or certified medical professional,
social worker, teacher or psychologist with a minimum of
three (3) years past experience in dealing with Specials
Needs populations similar to those served by Medicaid
and in implementing the principles of case management.
- A full-time Government Liaison who will serve as the
Department's primary point of contact with the PH-MCO
for the day-to-day management of contractual and
operational issues.
- A Maternal Health/EPSDT Coordinator who is a
Pennsylvania-licensed physician, registered nurse or
physician's assistant; or has a Master's degree in
Health Services, Public Health, or Health Care
Administration to coordinate maternity and prenatal care
services.
- A Member Services Manager who will oversee staff to
coordinate communications with Members and act as Member
advocates. There must be sufficient Member Services
staff to enable Members to receive prompt resolution to
their complaints, problems or inquiries.
- A Provider Services Manager who will oversee staff to
coordinate communications between the Contractor and its
Providers. There shall be sufficient Provider Services
staff to enable Providers to receive prompt resolution
to their complaints, problems or inquiries.
- A Grievance Coordinator whose qualifications demonstrate
the ability to manage and facilitate Member Grievances.
- A Member Advocate or Ombudsman whose qualifications
demonstrate the ability to exercise independent judgment
to assist Members in navigating the Grievance and DPW
Fair Hearing process.
- A Claims Administrator who will oversee staff to ensure
the timely and accurate processing of Claims, encounter
forms and other information necessary for meeting
contract requirements and the efficient management of
the PH-MCO.
The Contractor must ensure that all staff has appropriate
training, education, experience and orientation to fulfill the
requirements of the position.
O. ADMINISTRATION
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The Contractor agrees to comply with the program standards
regarding PH-MCO Administration, which are set forth in this
Agreement and in Exhibit D of this Agreement, Standard Contract
Terms and Conditions for Services and in Exhibit E of this
Agreement, DPW Addendum to Standard Contract Terms and
Conditions.
The Contractor must have an administrative office within the
zone from which the HealthChoices Program is operated. However,
exceptions to this requirement will be considered on an
individual basis if the Contractor has administrative offices
elsewhere in Pennsylvania and the Contractor is in compliance
with all standards set forth by the Departments of Health and
Insurance.
The Contractor must submit for approval by the Department its
organizational structure listing the function of each executive
as well as administrative staff members. Staff positions
outlined in this Agreement must be maintained in accordance with
the Department's requirements.
1. RESPONSIBILITY TO EMPLOY MA CONSUMERS
The Contractor must provide a plan approved by the CAO
Employment Unit Coordinator for the recruitment and
hiring of MA Consumers as described in Exhibit HH of
this Agreement, Contractor Responsibility to Employ MA
Consumers.
2. RECIPIENT RESTRICTION PROGRAM
The Contractor agrees to maintain a recipient
restriction program to interface with the Department's
recipient restriction program and provide for
appropriate professional resources to identify and
monitor Member fraud and Member abuse and perform the
necessary administrative activities to maintain accurate
records and comply with state and federal requirements.
A centralized recipient restriction process is in place
for the MA FFS Program and the managed care programs and
is managed by the Department. The Department maintains a
lock-in database that is accessible to all PH-MCOs. The
Contractor will cooperate with the Department in all
procedures necessary to restrict Members who are
misutilizing medical services or pharmacy benefits and
to provide the appropriate resources to enforce and
monitor the restrictions.
3. CONTRACTS AND SUBCONTRACTS
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In fulfilling its obligations hereunder, the Contractor
has the right to utilize the services of persons or
entities by means of subcontractual relationships. The
Contractor acknowledges and agrees that the execution of
Subcontracts does not diminish or alter the Contractor's
responsibilities under this Agreement.
The Contractor must make all Subcontracts available to
the Department within five (5) days of a request by the
Department. Contracts and Subcontracts entered into by
the Contractor do not terminate the Contractor's
obligations under this Agreement. All contracts and
Subcontracts must be in writing and must include, at a
minimum, the provisions contained in Exhibit II of this
Agreement, Required Contract Terms for Subcontractors.
Subcontracts which must be submitted to the Department
for advance written approval are:
Any subcontract between the Contractor and any
individual, firm, corporation or any other entity to
perform part or all of the selected Contractor's
responsibilities under this Agreement. This provision
includes, but is not limited to, contracts for vision
services, dental services, Claims processing, member
services, pharmacy services and lobbying activities.
This provision does not include, for example, purchase
orders.
Any transaction with a related party, regardless of its
stated purpose, including, but not limited to, loans,
advances and/or lease arrangements. The Contractor must
inform the Department that the subcontractor is a
related party at the time approval is requested.
4. LOBBYING DISCLOSURE
The Contractor agrees to the terms and conditions for
lobbying disclosure defined in Exhibit D of this
Agreement, Standard Contract Terms and Conditions for
Services.
The Contractor will be required to complete and return a
"Lobbying Certification Form" and a "Disclosure of
Lobbying Activities Form" found in Exhibit JJ of this
Agreement, Lobbying Certification and Disclosure of
Lobbying Activities Forms.
5. RECORDS RETENTION
The Contractor agrees to comply with the program
standards regarding records retention, which are set
forth in Exhibit D, Standard Terms and Conditions of
Services of this Agreement.
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Upon thirty (30) days notice from the Department, the
Contractor must provide copies of all records to the
Department at the Contractor's site, if requested, so
long as the Department requests access to those records
during the retention period prescribed by this
Agreement. This thirty (30) days notice does not apply
to records requested by the state or federal government
for purposes of fiscal audits or fraud and/or abuse. The
retention requirements in this section do not apply to
DPW-generated Remittance Advices.
6. FRAUD AND ABUSE
The Contractor shall be required to establish written
policies and procedures for the detection and prevention
of fraud and abuse in its program. Such written policies
and procedures must be reviewed and approved by the
Department.
Within the Contractor's written policies and procedures,
the Contractor shall identify the corporate officer
responsible for the proactive detection, prevention and
elimination of fraud or abuse in its program. The
designated corporate officer must have direct access to
the CEO and be granted independent authority to refer
instances of suspected fraud and abuse directly to the
Department.
The Contractor and its employees shall cooperate fully
with centralized oversight agencies responsible for
fraud and abuse detection and prosecution activities.
Such agencies include, but are not limited to, the
Department's Bureau of Program Integrity, the Governor's
Office of the Budget, the Office of the Attorney
General's Medicaid Fraud Control Section, the
Pennsylvania State Inspector General, the HCFA Office of
Inspector General, and the United States Justice
Department Such cooperation may include participation in
periodic fraud and abuse training sessions and joint
reviews of subcontracted Providers or Members.
The Contractor must also ensure that the Department's
toll-free fraud and abuse hotline and accompanying
explanatory statement (which will be established in the
near future) is distributed to its Members and Providers
through its Member and Provider handbooks.
Notwithstanding this requirement, the Contractor will
not be required to re-print handbooks for the sole
purpose of revising them to include fraud and abuse
hotline information. The Contractor must, however,
include such information in any new version of these
documents to be distributed to Members and Providers.
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The Contractor, including the designated corporate
officer, shall have an affirmative responsibility to
refer suspected fraud or abuse to relevant oversight
agencies. Contractors who do not report such information
are subject to sanctions, penalties, or other actions. A
standardized referral process is outlined in Exhibit KK
of this Agreement, Standardized Referrals, to expedite
information for appropriate disposition. The
requirements of the standardized referral process are
incorporated by reference into this Agreement.
The Department shall provide the Contractor with
immediate notice via electronic transmission or access
to Medicheck listings or upon request if a provider with
whom the Contractor has entered into an agreement is
subsequently suspended or terminated from participation
in the Medicaid or Medicare Programs. Such notification
will not include the basis for the departmental action,
due to confidentiality issues. Upon notification from
the Department that a provider with whom the Contractor
has entered into an agreement is suspended or terminated
from participation in the Medicaid or Medicare Programs,
the Contractor shall immediately act to terminate the
provider from participation. Terminations for loss of
licensure and criminal convictions must coincide with
the MA effective date of the action.
The Contractor must immediately notify the Department,
in writing, if a provider or subcontractor with whom the
Contractor has entered into an agreement is subsequently
suspended, terminated or voluntarily withdraws from
participation in the program as a result of suspected or
confirmed fraud or abuse. The Contractor must also
immediately notify the Department, in writing, if it
terminates or suspends an employee as a result of
suspected or confirmed fraud or abuse. The Contractor
shall inform the Department, in writing, of the specific
underlying conduct that lead to the suspension,
termination, or voluntary withdrawal. Provider
agreements shall carry notification of the prohibition
and sanctions for submission of false Claims and
statements. Contractors who fail to report such
information are subject to sanctions, penalties, or
other actions. The Department's enforcement guidelines
are outlined in Exhibit LL of this Agreeement,
Guidelines for Sanctions Regarding Fraud and Abuse in
the HealthChoices Program.
The Department reserves the right to impose sanctions,
penalties, or take other actions when it identifies
fraud and abuse within a Contractor's program.
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The Contractor agrees to ensure that all of the health
care providers and others with whom it subcontracts
agree to comply with the program standards regarding
Fraud and Abuse.
7. INFORMATION SYSTEMS AND ENCOUNTER DATA
The Contractor must have a comprehensive, automated and
integrated health management information system (MIS)
that is capable of meeting the requirements listed below
and throughout this Agreement.
a. The Contractor must ensure that its data system
is linked throughout all of its internal
departments. In addition, the Contractor must
have an authorization system that links with
Claims processing.
b. The membership management system must have the
capability to receive, update and maintain the
Contractor's membership files consistent with
information provided by the Department. The
Contractor must have the capability to provide
daily updates of membership information to
subcontractors or Providers with responsibility
for processing Claims or authorizing services
based on membership information.
c. The Contractor's Claims processing system must
have the capability to process Claims consistent
with timeliness and accuracy requirements
identified in this Agreement. Claims history
must be maintained with sufficient detail to
meet all Department reporting and encounter
requirements.
d. The Contractor's provider management system must
have the capability to receive, store, analyze,
and report on provider specific data sufficient
to meet the Provider credentialing, auditing,
quality improvement, and profiling requirements
of this Agreement.
e. The Contractor's Provider file must be
maintained with detailed information on each
Provider sufficient to meet the Department's
reporting and encounter data requirements.
f. The Contractor must have sufficient
telecommunication capabilities, including
electronic mail, to meet the requirements of
this Agreement.
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g. The Contractor must have the capability to
electronically transfer data files with the
Department and the IEAP contractor.
h. The encounter data system must be
bi-directionally linked to the other operational
systems listed in this Agreement, in order to
ensure that data captured in encounter records
accurately matches data in Member, provider and
Claims files, and in order to enable encounter
data to be utilized for Member profiling,
provider profiling, Claims validation, and fraud
and abuse monitoring activities.
i. The Contractor's MIS must be compatible with the
Department's POSNet system. The Contractor must
comply with the policies and procedures
governing the operation of the Department's
POSNet system, as defined in the POSNet
Interface Specifications and Data Exchange
Guidelines, which can be found in the
HealthChoices Proposers' Library. In addition,
the Contractor must comply with changes made to
the POSNet Interface Specifications and the Data
Exchange Guidelines of the Department. The
Contractor must make changes to their MIS
system, in order to remain compatible with the
Department's data system. Whenever possible, the
Department will provide advance notice of at
least sixty (60) days prior to the
implementation of changes. For more complex
changes, every effort will be made to provide
additional notice.
j. The Contractor must have a Claims processing
system and MIS sufficient to support the
Provider payment and data reporting requirements
specified in this Agreement. See Exhibit MM of
this Agreement, Management Information System
and System Performance Review Standards, for MIS
and Systems Performance Review (SPR) standards.
The Contractor must be prepared to document its
ability to expand Claims processing or MIS
capacity should either or both be exceeded
through the enrollment of program Members.
k. The Contractor will designate appropriate staff
to participate in DPW directed development and
implementation activities. The Contractor will
make all necessary systems changes to migrate to
the new EPSDT reporting system consistent with
timeframes to be established by the Department
to the extent possible, to be consistent with
federal reporting/claims formats and to avoid
duplication of data collection.
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l. Subcontractors must meet the same MIS
requirements as the Contractor and the
Contractor will be held responsible for MIS
errors or noncompliance resulting from the
action of a subcontractor.
m. The Contractor's MIS shall be subject to review
and approval during the Department's
HealthChoices Readiness Review process as
referenced in Section VI of this Agreement,
Program Outcomes and Deliverables.
8. DEPARTMENT ACCESS AND AVAILABILITY
The Contractor is responsible for providing Department
staff with access to appropriate on-site private office
space and equipment including, but not limited to, the
following:
- Two (2) desks and two (2) chairs;
- Two (2) telephones, one (1) of which has speaker
phone capabilities;
- One (1) personal computer and printer with
on-line access to the Contractor's MIS;
- FAX machine; and
- Bookcase.
The Contractor must ensure Department access to
administrative policies and procedures, including, but
not limited to;
- Personnel policies and procedures
- Procurement policies and procedures
- Public relations policies and procedures
- Operations policies and procedures
- Policies and procedures developed to ensure
compliance with requirements under this
Agreement.
P. SPECIAL NEEDS UNIT (SNU)
1. ESTABLISHMENT OF SPECIAL NEEDS UNIT
a. The Contractor must develop, train, and maintain
a "special" dedicated unit within its
organizational structure to deal with issues
relating to Members with Special Needs ("Special
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Needs Unit" [SNU]). The purpose of the SNU is to
ensure that each Member with Special Needs
receives access to PCPs, dentists, and
specialists trained and skilled in the Special
Needs of the Member; information about and
access to a specialist, as appropriate;
information about and access to all covered
services appropriate to the Member's condition
or circumstance, including pharmaceuticals and
Durable Medical Equipment (DME); access to sign
language interpreter services and access to
needed community services. The Contractor must
show evidence they can execute agreements with
individuals who have expertise in the treatment
of Special Needs to provide consultation to the
SNU staff, as needed.
b. The Contractor agrees to comply with the
Department's requirements and determination of
whether a Member shall be classified as having a
Special Need, which determination will be based
on criteria set forth in Exhibit NN of this
Agreement, Special Needs Unit.
c. It is the responsibility of the SNU to arrange
for and ensure coordination between the PH-MCO
and other health, education, and human service
systems for Members with Special Needs. See
Exhibit OO of this Agreement, Coordination of
Care Entities, for an example but not an
all-inclusive list. The Contractor is
responsible to coordinate the comprehensive
in-plan package of services with entities
providing Out-of-Plan Services.
d. The Contractor must assure that outpatient case
management for services for Members under age
twenty-one (21) are not provided through any
individual employed by the Contractor or through
a subcontractor of the Contractor if the
individual's responsibilities include outpatient
utilization review or otherwise include reviews
of requests for authorization of outpatient
benefits. In addition, if the Contractor
provides case management services to Members
under the age of twenty-one (21) through the
SNU, the Contractor must assure that the SNU
assists individuals in gaining access to
necessary medical, social, education, and other
services in accordance with Medical Assistance
Bulletin #1239-94-01 Medical Assistance Case
Management Services for Recipients Under the Age
of 21.
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e. The Contractor must comply with SNU reporting
requirements as specified by the Department and
described in Exhibit NN of this Agreement,
Special Needs Unit.
2. SPECIAL NEEDS COORDINATOR
The Contractor must employ a full-time SNU Coordinator
whose qualifications include, among other things;
experience with Special Needs populations similar to
those served by Medicaid. The SNU Coordinator must
report directly and be accountable to the Contractor's
Medical Director and be responsible for the management
and supervision of the SNU and SNU staff. The Contractor
agrees to notify the Department within thirty (30) days
of a change in the SNU Coordinator. See also Section V.M
of this Agreement, Executive Management.
3. RESPONSIBILITIES OF SPECIAL NEEDS UNIT STAFF
a. The Contractor agrees that the staff members
which it employs within the SNU must assist MA
Consumers in accessing services and benefits and
act as liaisons with various government offices,
providers, public entities, and county entities
which shall include, but shall not be limited to
the list of Providers in Exhibit OO of this
Agreement, Coordination of Care Entities.
b. The staff members of this unit must work in
close collaboration with the SNU operated by the
Department and the IEAP contractor's SNU.
c. The Contractor must demonstrate to the
Department that its SNU staff is qualified to
perform the functions outlined in Exhibit NN of
this Agreement, Special Needs Unit.
Q. ASSIGNMENT OF PCPS
The Contractor must have written policies and procedures for
Members, parents, guardians, or others acting as loco parens for
Special Needs populations, who require assistance in the
selection of a PCP. The Contractor must receive advance written
approval by the Department regarding these policies and
procedures. The Contractor's submission of new or revised
policies and procedures for review and approval by the
Department shall not act to void any pre-existing policies and
procedures which have been prior approved by the Department for
operation in a HC zone. Unless otherwise required by law, the
Contractor may continue to
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operate under such pre-existing policies and procedures until
such time as the Department approves the new or revised version
thereof.
The Contractor must ensure that the process includes at a
minimum the following features:
- The Contractor must ensure that a Member's selection of
a PCP through the IEAP contractor is honored upon
commencement of PH-MCO coverage. If the Contractor is
not able to honor the selection, the Contractor is
required to follow the guidelines described further
under this provision.
- Should the Contractor permit selection of a PCP group
and the Member has selected a PCP group in the PH-MCO's
Network through the Enrollment Specialist, the PH-MCO
must ensure that upon commencement of the PH-MCO
coverage, the Member's selection is honored. In
addition, the PH-MCO will have three (3) months to
outreach to this Member to make an individual PCP
selection within the PCP group. If the Member does not
make a selection within the three (3) month period, the
PH-MCO must ensure that the Member is assigned to a PCP
within that PCP group the Member initially selected. The
PH-MCO must then notify the Member by telephone or in
writing of his/her PCP's name, location and office
telephone number. In addition, at no time is the
Contractor permitted to assign a PCP group to a Member
if the Member has not selected a PCP or a PCP group at
the time of enrollment.
- If the Member has not selected a PCP through the
Enrollment Specialist, the PH-MCO must make contact with
the Member within seven (7) business days of his or her
enrollment and provide information on options for
selecting a PCP, unless the PH-MCO has information that
the Member should be immediately contacted due to a
medical condition requiring immediate care. To the
extent practical, the PH-MCO must offer freedom of
choice to Members in making a PCP selection.
- If a Member does not select a PCP within fourteen (14)
business days of enrollment, the PH-MCO must make an
automatic assignment. The Contractor must consider such
factors (to the extent they are known), as current
Provider relationships, need of children to be followed
by a pediatrician, special medical needs, physical
disabilities of the Member, language needs, area of
residence and access to transportation. The PH-MCO must
then notify the Member by telephone or in writing of
his/her PCP's name, location and office telephone
number. The PH-MCO must make every effort to determine
PCP choice and confirm this with the Member prior to the
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commencement of the PH-MCO coverage in accordance with
Section V.F of this Agreement, Member Enrollment and
Disenrollment, so that new Members do not go without a
PCP for a period of time after enrollment begins.
- The Contractor must take into consideration, language
and cultural compatibility between the Member and the
PCP.
- If a Member requests a change in his or her PCP
selection following the initial visit, the Contractor
must promptly grant the request and process the change
timely.
- The Contractor must have written policies and procedures
for allowing Members to select or be assigned to a new
PCP whenever requested by the Member, when a PCP is
terminated from the Contractor's Network or when a PCP
change is ordered as part of the resolution to a
Grievance or Complaint proceeding. The policies and
procedures must receive advance written approval by the
Department.
- In cases where a PCP has been terminated, the Contractor
must immediately inform Members assigned to that PCP in
order to allow them to select another PCP prior to the
PCP's termination effective date. In cases where an MA
Consumer fails to select a new PCP, re-assignment must
take place prior to the PCP's termination effective
date.
- The Contractor must consider that a Member with Special
Needs can request a specialist as a PCP. Denial of such
requests are appealable.
Should the Contractor choose to implement a process for the
assignment of a primary dentist, the Contractor must submit the
process for advance written approval from the Department prior
to its implementation.
R. PROVIDER SERVICES
Provider services functions shall be required to be operated at
least during regular business hours (9:00 a.m. to 5:00 p.m.,
Monday through Friday). Provider services functions include, but
are not limited to, the following:
- Assisting Providers with questions concerning Member
eligibility status.
- Assisting Providers with Contractor prior authorization
and referral procedures.
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- Assisting Providers with Claims payment procedures and
handling Provider complaints.
- Facilitating transfer of Member medical records among
medical Providers, as necessary.
- Providing to PCPs a monthly list of Members who are
under their care, including identification of new and
deleted Members. An explanation guide detailing use of
the list must also be provided to PCPs.
- Developing a process to respond to Provider inquiries
regarding current enrollment.
- Coordinating the administration of Out-of-Plan Services.
1. PROVIDER MANUAL
The Contractor must keep its Network Providers
up-to-date with the latest policy and procedures changes
as they affect the MA Program. The key to maintaining
this level of communication is the publication of a
Provider manual. Copies of the Provider manual shall be
distributed in a manner that makes them easily
accessible to all participating practitioners. The
Contractor may specifically delegate this responsibility
to large providers in its Provider Agreement. The
Provider manual must be updated annually. The Department
may grant an exception to this annual requirement upon
written request from the PH-MCO provided there are no
major changes to the manual. For a complete description
of the Provider manual contents and information
requirements, refer to Exhibit PP of this Agreement,
Provider Manuals.
2. PROVIDER EDUCATION
The Contractor must demonstrate that its Provider
Network is knowledgeable and experienced in treating
Members with Special Needs. The Contractor must submit a
plan to the Department that outlines its plans to
educate and train Providers. This training plan can be
done in conjunction with the SNU training requirements
as outlined in Section V.P of this Agreement, Special
Needs Unit, and must also include Special Needs MA
Consumers, advocates and family members in developing
the design and implementation of the training plan.
The Contractor must submit its plan for measuring
training outcomes including the tracking of training
schedules and Provider attendance to the Department for
approval at least annually.
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At a minimum, the Provider training must be conducted
for PCPs and dentists as appropriate, and include the
following areas:
a. EPSDT training for any Providers who serve
Members under age twenty-one (21).
b. Identification and appropriate referral for
mental health, drug and alcohol and substance
abuse services.
c. Sensitivity training on diverse and Special
Needs populations such as persons who are deaf
and hard of hearing.
d. Cultural competence.
e. Treating Special Needs populations, including
the right to treatment for individuals with
disabilities.
f. Administrative processes that include, but are
not limited to: coordination of benefits, dual
eligibles, and encounter reporting.
The Contractor may submit an alternate Provider training
and education plan should the Contractor wish to combine
its activities with other Contractors operating in the
HealthChoices zone or wish to develop and implement new
and innovative methods for Provider training and
education. However, this alternative plan must have
advance written approval by the Department. Should the
Department approve an alternative plan, the Contractor
must have the ability to track and report on the
components included in the Contractor's alternative
Provider training and education plan.
S. PROVIDER NETWORK/SERVICES ACCESS
The Contractor must establish and maintain adequate Provider
Networks to serve all of the eligible HealthChoices populations
in the zone. Provider Networks must include, but not be limited
to: hospitals, children's tertiary care hospitals, specialty
clinics, trauma centers, facilities for high-risk deliveries and
neonates, specialists, dentists, orthodontists, physicians,
pharmacies, emergency transportation services, long-term care
facilities, rehab facilities, home health agencies and DME
suppliers in sufficient numbers to make available all services
in a timely manner.
1. NETWORK COMPOSITION
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The Contractor must ensure that its Provider Network is
adequate to provide its Members in the HealthChoices
zone with access to quality Member care through
participating professionals, in a timely manner, and
without the need to travel excessive distances. Upon
request from the Department, the Contractor must supply
geographic access maps detailing the number, location
and specialties of their Provider Network to the
Department in order to verify accessibility of Providers
within their Network. The Department may require
additional numbers of specialists and ancillary
providers should it be determined that geographic access
is not adequate.
The Contractor must make all reasonable efforts to honor
a Member's choice of Providers who are credentialed in
the Network. Additional requirements for establishing
and maintaining an acceptable Provider Network are as
follows:
a. The Contractor must ensure the provision of
services to persons who have special health
needs or who face access barriers to health
care. If the Contractor does not have at least
two (2) specialists or sub-specialists qualified
to meet the particular needs of the individuals,
then the Contractor must allow Members to pick
an Out-of-Network Provider if not satisfied with
the Network Provider. The Contractor must
develop a system to determine prior
authorization for Out-of-Plan Services,
including provisions for informing the MA
Consumer of how to request this authorization
for Out-of-Plan Services. For children with
special health needs, the Contractor must offer
at least two (2) pediatric specialists or
pediatric sub-specialists.
b. The Contractor must ensure and must demonstrate
its ability to:
i. Make available to every Member a choice
of at least two (2) appropriate PCPs
whose offices are located within a
travel time no greater than thirty (30)
minutes (urban) and sixty (60) minutes
(rural). This travel time is measured
via public transportation, where
available. Members may, at their
discretion, select PCPs located further
from their homes.
ii. Ensure an adequate number of
pediatricians to permit all Members who
want a pediatrician as a PCP to have a
choice of two (2) for their child(ren)
within the travel time limits (30
minutes urban, 60 minutes rural).
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iii. Demonstrate its attempts to contract in
good faith with a sufficient number of
Certified Registered Nurse Practitioners
(CRNP) to ensure access to CRNP
services. While the Contractor may
contract with a primary care practice in
which the majority of primary care
services are performed by CRNP's, the
number of CRNPs in such practices may
not exceed 10 percent of the total
number of PCPs in the Contractor's
Network.
iv. Limit its PCP Network to appropriately
qualified Providers. The PH-MCO's PCP
Network must meet the following:
- Seventy-five to one hundred percent
(75-100%) of the Network consists of
PCPs who have completed an approved
primary care residency in family
medicine, osteopathic general
medicine, internal medicine or
pediatrics; and
- No more than twenty-five percent
(25%) of the Network consists of PCPs
without appropriate residencies but
who have, within the past seven (7)
years, five (5) years of
post-training clinical practice
experience in family medicine,
osteopathic general medicine,
internal medicine or pediatrics.
Post-training experience is defined
as having practiced at least as a 0.5
full-time equivalent in the practice
areas described; and
- No more than ten percent (10%) of the
Network consists of PCPs who were
previously trained as specialist
physicians and changed their areas of
practice to primary care, and who
have completed Department-approved
primary care retraining programs.
c. The Contractor must ensure a choice of at least
two (2) pharmacies (excluding mail-order
entities) within the travel time limits (30
minutes urban, 60 minutes rural).
d. The Contractor must ensure a choice of at least
two (2) hospitals within the Provider Network,
at least one (1) of which must be within the
travel limits (30 minutes urban, 60 minutes
rural).
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e. The Contractor must ensure a choice of at least
two (2) home health agencies within the
HealthChoices zone.
f. The Contractor must ensure a choice of at least
two (2) DME suppliers within the HealthChoices
zone.
g. The Contractor must ensure a choice of at least
two (2) rehabilitation facilities within the
Provider Network, at least one (1) of which must
be located within the HealthChoices zone.
h. The Contractor must ensure a choice of at least
two (2) nursing facilities within the Provider
Network.
i. The Contractor must ensure a choice of at least
two (2) general practice dentists within the
Provider Network. For Members needing anesthesia
for dental care, the Contractor must ensure a
choice of at least two (2) dentists within the
Provider Network with privileges or certificates
to perform specialized dental procedures under
general anesthesia.
j. The Contractor must ensure access to Certified
Nurse Midwives (CNMs) and CRNPs.
k. The Contractor must demonstrate its ability to
offer its Members freedom of choice in selecting
a PCP. At a minimum, the Contractor must have or
provide one (1) full-time equivalent (FTE) PCP
who serves no more than one thousand (1,000) MA
Consumers (cumulative across all HealthChoices
PH-MCO plans in the zone) and PCP sites which
serve no more than five thousand (5,000) MA
Consumers (cumulative across all HealthChoices
PH-MCO plans in the zone). The Department will
develop a system to notify the Contractor of a
Provider reaching maximum panel limits. The
number of Members assigned to a PCP may be
decreased by the Contractor if necessary to
maintain the appointment availability standards.
l. The Contractor and the Department will work
together to avoid the PCP having a caseload or
medical practice composed predominantly of HC
Members. In addition, the Contractor must
organize its PCP sites so as to ensure
continuity of care to Members and must identify
a specific PCP within the site for each Member.
The Contractor may apply to the Department for a
waiver of these requirements
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on a site-specific basis. The Department may
waive these requirements for good cause
demonstrated by the Contractor.
m. The Contractor must demonstrate its ability to
provide adequate access to physician specialists
for PCP referrals, and must employ or contract
with adult and pediatric specialists in
sufficient numbers to ensure that specialty
services are made available in a timely,
geographically, and physically accessible
manner, particularly for those Members in
Special Needs populations. The Contractor must
ensure Members a choice of at least two (2)
appropriate specialists.
n. The Contractor must contract with a sufficient
number of Federally Qualified Health Centers
(FQHCs) and Rural Health Clinics (RHCs) to
ensure access to FQHC and RHC services, provided
FQHC and RHC services are available, within a
travel time of thirty (30) minutes (urban) and
sixty (60) minutes (rural). If the Contractor's
primary care Network includes FQHCs and RHCs,
these sites may be designated as PCP sites. A
listing of FQHCs and RHCs for HealthChoices is
included in Exhibit QQ of this Agreement,
HealthChoices Federally Qualified Health Centers
and Rural Health Clinics. If a Contractor cannot
contract with a sufficient number of FQHCs and
RHCs, the Contractor must demonstrate in writing
it has attempted to reasonably contract in good
faith.
o. The Contractor must comply with the provisions
of Act 112 of 1996 (H.B. 1415, P.N. 3853, signed
July 11, 1996),the Balanced Budget
Reconciliation Act of 1997 and Act 68 of 1998,
the Quality Health Care Accountability and
Protection Provisions, 40 P.S. 991.2101 et seq.
pertaining to coverage and payment of Medically
Necessary Emergency Services. The definition of
such services is set forth herein at Section II.
p. The Contractor must inspect the office of any
PCP or dentist who seeks to participate in the
Contractor's Provider Network (excluding offices
located in hospitals) to determine whether the
office is architecturally accessible to persons
with mobility impairments. Architectural
accessibility means compliance with ADA
accessibility guidelines with reference to
parking (if any), path of travel to an entrance,
and the entrance to both the building and the
office of the provider, if different from the
building entrance. If the office or facility is
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not accessible under the terms of this
paragraph, the PCP or dentist may participate in
the Contractor's Provider Network provided that
the PCP or dentist: 1) requests and is
determined by the Contractor to qualify for an
exemption from this paragraph, consistent with
the requirements of the ADA, or 2) agrees in
writing to remove the barrier to make the office
or facility accessible to persons with mobility
impairments within six (6) months after the
Contractor identified the barrier.
q. The PH-MCO must ensure that all laboratory
testing sites providing services have either a
Clinical Laboratory Improvement Amendment (CLIA)
certificate of waiver or a certificate of
registration along with a CLIA identification
number in accordance with CLIA 1988. Those
laboratories with certificates of waiver will
provide only the eight (8) types of tests
permitted under the terms of their waiver.
Laboratories with certificates of registration
may perform a full range of laboratory tests.
The PCP must provide all required demographics
to the laboratory when submitting a specimen for
analysis.
2. PROVIDER AGREEMENTS
The Contractor is required to have written Provider
Agreements with a sufficient number of Providers to
ensure Member access to all Medically Necessary services
covered by the HealthChoices Program.
The Contractor's Provider Agreements must include the
following provisions:
a. A requirement that the Contractor will not
exclude or terminate a Provider from
participation in the Contractor's Provider
Network due to the fact that the Provider has a
practice that includes a substantial number of
patients with expensive medical conditions.
b. A requirement that the Contractor will not
exclude a Provider from the Contractor's
Provider Network because the Provider advocated
on behalf of a Member for Medically Necessary
and appropriate health care consistent with the
degree of learning and skill ordinarily
possessed by a reputable health care Provider
practicing according to the applicable legal
standard of care.
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c. A provision that prohibits the Provider from
denying services to an MA Consumer during the MA
FFS eligibility window prior to the effective
date of the PH-MCO enrollment.
d. Notification of the prohibition and sanctions
for submission of false Claims and statements.
e. The definition of Medically Necessary as defined
in Section II of this Agreement, Definitions.
f. A requirement that the Contractor cannot
prohibit or restrict a health care professional
from discussing Medically Necessary and
appropriate care with or on behalf of an
enrollee, including information regarding the
nature of treatment; risks of treatment;
alternative treatments; or the availability of
alternative therapies, consultation or tests.
g. A requirement that the Contractor cannot
terminate a contract or employment with a health
care Provider for filing a Grievance on a
Member's behalf.
h. A clause which specifies that the agreement will
not be construed as requiring the Contractor to
provide, reimburse for, or provide coverage of,
a counseling or referral service if the Provider
objects to the provision of such services on
moral or religious grounds.
i. A requirement securing cooperation with the
QM/UM Program standards outlined in Exhibit M(1)
of this Agreement, Quality Management and
Utilization Management Program Requirements.
j. A requirement for cooperation for the submission
of encounter data for all services provided
within the timeframes required in Section VIII
of this Agreement, Reporting Requirements, no
matter whether reimbursement for these services
is made by the Contractor either directly or
indirectly through capitation.
k. A continuation of benefits provision which
states that the Provider agrees that in the
event of the Contractor's insolvency or other
cessation of operations, the Provider must
continue to provide benefits to the Contractor's
Members through the period for which the premium
has been paid, including Members in an inpatient
setting.
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l. A requirement that the PCPs who serve Members
under the age of twenty-one (21) are responsible
for conducting all EPSDT screens for individuals
on their panel under the age of twenty-one (21).
Should the PCP be unable to conduct the
necessary EPSDT screens, the PCP is responsible
for arranging to have the necessary EPSDT
screens conducted by another Network Provider
and ensure that all relevant medical
information, including the results of the EPSDT
screens, are incorporated into the Member's PCP
medical record. For details on access
requirements, see Section V.S.1 of this
Agreement, Network Composition.
m. A requirement that PCPs who serve Members under
the age of twenty-one (21) report encounter data
associated with EPSDT screens, using a format
approved by the Department, to the Contractor
within ninety (90) days from the date of
service.
n. A requirement that the Contractor include in all
capitated Provider Agreements a clause which
requires that should the Provider terminate its
agreement with the Contractor, for any reason,
that the Provider provide services to the
Members assigned to the Provider under the
contract up to the end of the month in which the
effective date of termination falls.
o. A requirement that the Contractor must not
discriminate with respect to participation,
reimbursement, or indemnification as to any
provider who is acting within the scope of the
Provider's license or certification under
applicable State law, solely on the basis of
such license or certification. This paragraph
must not be construed to prohibit an
organization from including Providers only to
the extent necessary to meet the needs of the
organization's enrollees or from establishing
any measure designed to maintain quality and
control costs consistent with the
responsibilities of the organization.
p. A requirement that ensures each physician
providing services to enrollees eligible for
medical assistance under the State Plan to have
a unique identifier in accordance with the
system established under section 1173(b) of the
Balanced Budget Act.
The Contractor must make all necessary revisions to its
Provider Agreements to be in compliance with the
requirements set forth in this section. Revisions may be
completed as Provider Agreements
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become due for renewal provided that all Provider
Agreements are amended within one (1) year of the
effective date of this Agreement with the exception of
the encounter data requirements which must be amended
immediately, if necessary, to ensure that all Providers
are submitting encounter data to the Contractor within
the timeframes specified in Section VIII.B.1 of this
Agreement, Encounter Data and Subcapitation Data
Reports.
3. CULTURAL COMPETENCE
Both the Contractor and Providers must demonstrate
cultural competency and must understand that cultural
differences between Provider and Member cannot be
permitted to present barriers to accessing and receiving
quality health care; must demonstrate the willingness
and ability to make the necessary distinctions between
traditional treatment methods and/or non-traditional
treatment methods that are consistent with the Member's
cultural background and which may be equally or more
effective and appropriate for the particular Member; and
demonstrate consistency in providing quality care across
a variety of cultures. For example, language, religious
beliefs, cultural norms, social-economic conditions,
diet, etc., may make one treatment method more palatable
to a Member of a particular culture than to another of a
differing culture.
4. PRIMARY CARE PRACTITIONER (PCP) RESPONSIBILITIES
The Contractor must have written policies and procedures
for assigning every Member to a PCP. The PCP must serve
as the Member's initial and most important point of
contact regarding health care needs. As such, PCP
responsibilities include at a minimum:
a. Providing primary and preventive care and acting
as the Member's advocate, providing,
recommending and arranging for care.
b. Documenting all care rendered in a complete and
accurate encounter record that meets or exceeds
the DPW data specifications.
c. Maintaining continuity of each Member's health
care.
d. Making referrals for specialty care and other
Medically Necessary services, both in and
out-of-plan.
e. Maintaining a current medical record for the
Member, including documentation of all services
provided to the
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Member by the PCP, as well as any specialty or
referral services.
f. Arranging for behavioral health services in
accordance with Exhibit U of this Agreement,
Behavioral Health Services.
The Contractor agrees to retain responsibility for
monitoring PCP actions to ensure they comply with the
provisions of this Agreement.
5. SPECIALISTS AS PCPS
A Member may qualify to select a specialist to act as
PCP if s/he has a disease or condition that is life
threatening, degenerative, or disabling.
The PH-MCO must adopt and maintain procedures by which
an enrollee with a life-threatening, degenerative or
disabling disease or condition shall, upon request,
receive an evaluation and, if the Contractor's
established standards are met, be permitted to receive:
- A standing referral to a specialist with
clinical expertise in treating the disease or
condition; or
- The designation of a specialist to provide and
coordinate the enrollee's primary and specialty
care.
The referral to or designation of a specialist must be
pursuant to a treatment plan approved by the Contractor,
in consultation with the PCP, the enrollee and, as
appropriate, the specialist. When possible, the
specialist must be a health care Provider participating
in the Contractor's Network.
Information for MA Consumers must include a description
of the procedures that a Member with a life-threatening,
degenerative or disabling disease or condition shall
follow and satisfy to be eligible for:
- A standing referral to a specialist with
clinical expertise in treating the disease or
condition; or
- The designation of a specialist to provide and
coordinate the enrollee's primary and specialty
care.
It is the responsibility of the Contractor to ensure
adequate Network capacity of qualified specialists as
PCPs. These physicians may be
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predetermined and listed in the directory but may also
be determined on an as needed basis. All determinations
must comply with specifications set out by Act 68
regulations. The Contractor must establish and maintain
its own credentialing and recredentialing policies and
procedures to ensure compliance with these
specifications.
The Contractor must ensure that Providers credentialed
as specialists and as PCPs agree to meet all of the
Contractor's standards for credentialing PCPs and
specialists, including compliance with record keeping
standards, the Department's access and availability
standards and other QM/UM Program standards. The
specialist as a PCP must agree to provide or arrange for
all primary care, consistent with Contractor preventive
care guidelines, including routine preventive care, and
to provide those specialty medical services consistent
with the Member's "special need" in accordance with the
Contractor's standards and within the scope of the
specialty training and clinical expertise. In order to
accommodate the full spectrum of care, the specialist as
a PCP also must have admitting privileges at a hospital
in the Contractor's Network.
6. ANY WILLING PHARMACY
The Contractor must contract on an equal basis with any
pharmacy qualified to participate in the MA FFS Program
that is willing to comply with the Contractor's payment
rates and terms and to adhere to quality standards
established by the Contractor as required by 62 P.S.
449.
7. HOSPITAL RELATED PARTY
The Department requires that a hospital that is a
Related Party to a Contractor shall be willing to
negotiate in good faith with other contractors regarding
the provision of services to MA Consumers. The
Department reserves the right to terminate this
Agreement with the Contractor if it determines that a
hospital related to the Contractor has refused to
negotiate in good faith with other contractors.
8. MAINSTREAMING
The Contractor must ensure that Network Providers do not
intentionally segregate their Members in any way from
other persons receiving services.
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The Contractor must investigate complaints and take
affirmative action so that Members are provided covered
services without regard to race, color, creed, sex,
religion, age, national origin, ancestry, marital
status, sexual orientation, language, MA status, health
status, disease or pre-existing condition, anticipated
need for health care or physical or mental handicap,
except where medically indicated. Example of prohibited
practices include, but are not limited to, the
following:
- Denying or not providing a Member any MA covered
service or availability of a facility within the
Contractor's Network. The Contractor must have
explicit policies to provide access to complex
interventions such as cardiopulmonary
resuscitations, intensive care, transplantation
and rehabilitation when medically indicated and
must educate its Providers on these policies.
Health care and treatment necessary to preserve
life shall be provided to all persons who are
not terminally ill or permanently unconscious,
except where a competent Member objects to such
care on his/her own behalf.
- Subjecting a Member to segregated, separate, or
different treatment, including a different place
or time from that provided to other Members,
public or private patients, in any manner
related to the receipt of any MA covered
service, except where Medically Necessary.
- The assignment of times or places for the
provision of services on the basis of the race,
color, creed, religion, age, sex, national
origin, ancestry, marital status, sexual
orientation, income status, program membership,
language, MA status, health status, disease or
pre-existing condition, anticipated need for
health care or physical or mental disability of
the participants to be served.
If the Contractor knowingly executes an agreement with a
Provider with the intent of allowing or permitting the
Provider to implement barriers to care (i.e. the terms
of the Provider Agreement are more restrictive than this
Agreement), the Contractor shall be in breach of this
Agreement.
9. NETWORK CHANGES
The Contractor must notify the Department promptly of
any changes to the composition of its Provider Network
that materially affects the Contractor's ability to make
available all services covered by this Agreement in a
timely manner. The Contractor also
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must have procedures to address changes in its Network
that negatively affect the ability of Members to access
services. Material changes in Network composition that
negatively affect Member access to services may be
grounds for termination of this Agreement.
a. For PCP terminations, the Contractor must
provide thirty (30) days advance written notice
to Members assigned to the PCP and must provide
for or assist with those assignments of the
Member to another PCP. The Contractor must
ensure the timely and complete transfer of
medical records to the new PCP.
b. For hospital terminations, the Contractor must
provide thirty (30) days advance notice to
Members assigned to any PCPs or PCP groups that
will be terminated as a result of the hospital
termination. In addition, the Department may
require notification to all Members of a
hospital change.
c. The Department will work with the Contractor to
identify those situations in which advance
notification to Members of an ancillary Provider
termination is necessary, with special
consideration given to Members with Special
Needs.
d. The advance notice requirement will not apply to
terminations by the Contractor due to quality of
care or other for cause reasons.
10. OTHER PROVIDER ENROLLMENT STANDARDS
The Contractor agrees to comply with the program
standards regarding Provider enrollment that are set
forth in this Agreement.
All Providers operating within the Contractor's Network
who provide services to MA Consumers must be enrolled in
the Commonwealth's MA Program and possess an active
Medical Assistance Identification (MAID) number.
The Contractor must enroll a sufficient number of
Providers qualified to conduct the specialty evaluations
necessary for conducting alleged physical and/or sexual
abuse investigations.
The Department encourages the use of Providers currently
contracting with the County Children and Youth Agencies
who have experience with the ▇▇▇▇▇▇ care population and
who have been
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providing services to children and youth MA Consumers
for many years.
11. TWENTY-FOUR HOUR COVERAGE
It is the responsibility of the Contractor to have
coverage available directly or through its PCPs either
directly or through on-call arrangements with other
qualified Providers for urgent or emergency care on a
twenty-four (24) hour, seven (7) day-a-week basis. The
Contractor shall not use answering services in lieu of
the above PCP emergency coverage requirements without
the knowledge of the Member. For Emergency or Urgent
Medical Conditions, the Contractor must have written
policies and procedures on how Members and Providers can
make contact to receive instruction or prior
authorization for treatment. If the PCP determines that
emergency care is not required, 1) the PCP must see the
Member in accordance with the timeframe specified in
Section V.S.12.a.ii, or 2) the member must be referred
to an urgent care clinic which can see the Member in
accordance with the timeframe specified in Section
V.S.12.a.ii.
12. APPOINTMENT STANDARDS
The Contractor agrees to require the PCP, dentist, or
specialist to conduct affirmative outreach whenever a
Member misses an appointment and to document this in the
medical record. Such an effort shall be deemed to be
reasonable if it includes three (3) attempts to contact
the Member. Such attempts may include, but are not be
limited to: written attempts, telephone calls and home
visits. At least one (1) such attempt must be written.
a. GENERAL
PCP scheduling procedures must ensure that:
i. Emergency cases must be seen or referred
to an emergency facility. If it is
determined that Emergency Medical
Condition care is not required, the
Member must be seen by the PCP or
referred to an open urgent care clinic.
ii. Urgent Medical Condition cases must be
scheduled within twenty-four (24) hours.
iii. Routine appointments must be scheduled
within ten (10) business days.
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iv. Health assessment/general physical
examinations and first examinations must
be scheduled within three (3) weeks of
enrollment.
v. The Contractor must provide the
Department with its protocol for
ensuring that a Member's average office
waiting time is no more than twenty (20)
minutes or at any time no more than up
to one (1) hour when the physician
encounters an unanticipated Urgent
Medical Condition visit or is treating a
Member with a difficult medical need.
The Member will be informed of
scheduling time frames through
educational outreach efforts.
vi. The Contractor must monitor the adequacy
of its appointment processes and reduce
the unnecessary use of emergency room
visits.
b. PERSONS WITH HIV/AIDS
The Contractor must have adequate PCP scheduling
procedures in place to ensure that an
appointment with a PCP or specialist must be
scheduled within seven (7) days from the
effective date of enrollment for any person
known to the Contractor to be HIV positive or
diagnosed with AIDS (e.g. self-identification),
unless the enrollee is already in active care
with a PCP or specialist.
c. SSI
The Contractor must make a reasonable effort to
schedule an appointment with a PCP or specialist
within forty-five (45) days of enrollment for
any Member who is an SSI or SSI-related consumer
unless the Member is already in active care with
a PCP or specialist.
d. SPECIALTY REFERRALS
For specialty referrals, the Contractor must be
able to provide:
i. Emergency Medical Condition appointments
immedi-ately upon referral.
ii. Urgent Medical Condition care
appointments within twenty-four (24)
hours of referral.
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iii. Routine appointments within ten (10)
business days of referral.
e. PREGNANT WOMEN
Should the IEAP contractor or Member notify the
Contractor that a new Member is pregnant or
there is a pregnancy indication on the files
transmitted to the Contractor by the Department,
the Contractor must contact the Member within
five (5) days of the effective date of
enrollment to assist the woman in obtaining an
appointment with an OB/GYN or Nurse Midwife. For
maternity care, the Contractor must be able to
provide initial prenatal care appointments for
enrolled pregnant Members as follows:
i. First trimester -- within ten (10)
business days of the Member being
identified as being pregnant.
ii. Second trimester -- within five (5)
business days of the Member being
identified as being pregnant.
iii. Third trimester -- within four (4)
business days of the Member being
identified as being pregnant.
iv. High-risk pregnancies -- within
twenty-four (24) hours of identification
of high risk to the Contractor or
maternity care provider, or immediately
if an emergency exists.
f. EPSDT
EPSDT screens for any new enrollee under the age
of twenty-one (21) must be scheduled within
forty-five (45) days from the effective date of
enrollment unless the child is already under the
care of a PCP and the child is current with
screens and immunizations.
The Contractor must ensure that PCPs follow-up with
those Members described in the above Section V.S.12 for
any missed appointments. The PCP or specialist must send
two (2) notices of missed appointments and make a
follow-up telephone call to the Member for any missed
appointments and the PCP or specialist must document
these in the medical record.
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13. POLICIES AND PROCEDURES FOR APPOINTMENT STANDARDS
The Contractor agrees to comply with the program standards
regarding service accessibility standards that are set
forth in Section V.S. of this Agreement, Provider
Network/Services Access.
The Contractor must have written policies and procedures
for disseminating its appointment standards to all Members
through its Member handbook and through other means. In
addition, the Contractor must have written policies and
procedures to educate its Provider Network about
appointment standard requirements. The Contractor must
monitor compliance with appointment standards and shall
have a corrective action plan when appointment standards
are not met.
14. COMPLIANCE WITH ACCESS STANDARDS
a. MANDATORY COMPLIANCE
The Contractor must comply with the access
standards in accordance with Section V.S of this
Agreement, Provider Network/Services Access. If the
Contractor fails to meet any of the access
standards by the dates specified by the Department,
the Department may terminate this Agreement.
a. REASONABLE EFFORTS AND ASSURANCES
The Contractor must make reasonable efforts to
honor a Member's choice of Providers among Network
Providers as long as:
i. The PH-MCO's agreement with the Network
Provider covers the services required by the
Member; and
ii. The Contractor has not determined that the
Member's choice is clinically inappropriate.
The Contractor must provide the Department adequate
assurances that the Contractor, with respect to the
HealthChoices zone, has the capacity to serve the
expected enrollment in the HealthChoices zone by
providing assurances that the Contractor offers the
full scope of covered services as set forth in this
Agreement and access to preventive and primary care
services and maintains a sufficient number, mix and
geographic distribution of Providers and services
in accordance with the standards set
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forth in Section V.S of this Agreement, Provider
Network/Services Access.
c. CONTRACTOR'S CORRECTIVE ACTION
The Contractor must take all necessary steps to
resolve, in a timely manner, its failure to comply
with the access standards. Prior to a termination
action or other sanction by the Department, the
Contractor will be given the opportunity to
institute a corrective action plan. The Contractor
must submit a corrective action plan to the
Department for approval within thirty (30) days of
notification of such failure to comply, unless
circumstances warrant and the Department demands a
shorter response time. The Department's approval of
the Contractor's corrective action plan will not be
unreasonably withheld. The Department will make its
best effort to respond to the Contractor within
thirty (30) days from the submission date of the
corrective action plan. If the Department rejects
the corrective action plan, the Contractor shall be
notified of the deficiencies of the corrective
action plan. In such event, the Contractor shall
submit a revised corrective action plan within
fifteen (15) days of notification. If the
Department does not receive an acceptable
corrective action plan, the Department may impose
sanctions against the Contractor, in accordance
with Section VIII.I of this Agreement, Sanctions.
Failure to implement the corrective action plan may
result in the imposition of a sanction as provided
in this Agreement.
T. QM AND UM PROGRAM REQUIREMENTS
1. OVERVIEW
The Contractor must comply with the Department's QM and UM
program standards and requirements described in Exhibit
M(1) of this Agreement, Quality Management and Utilization
Management Program Requirements. The Department retains
the right of advance written approval and to review on an
ongoing basis all aspects of the Contractor QM and UM
programs, including subsequent changes. The Contractor
must comply with all QM and UM program reporting
requirements and must submit data in formats to be
determined by the Department.
2. GENERAL
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The QM and UM programs must include a written program
description and annual work plan with a timetable of all
activities and performance improvement initiatives for the
coming year. The Department, in collaboration with the
Contractor, retains the right to determine and prioritize
QM and UM activities and initiatives based on areas
identified as being of importance to the Department and
areas identified through its analysis of external quality
review (EQR) findings, Health Plan Employer Data and
Information Set (HEDIS) measures, and encounter data
submitted by the Contractor. The Contractor must implement
and abide by the program description and work plan or
amended plan as approved by the Department. The QM and UM
programs must:
a. Include methodologies that allow for statistically
valid performance based monitoring of the QM and UM
programs and include documentation that all QM and
UM activities and initiatives undertaken by the
plan are selected through clinical and financial
analysis of encounter, Member demographic and other
data.
b. Provide evidence of evaluation and re-measurement
of the Contractor QM and UM activities and
initiatives in order to determine sustained
improvement or the need for further action.
c. Address development, implementation, and
performance measurement of disease management
programs that are intended for selected conditions
among targeted populations in order to improve
outcomes through the quality of care provided while
effectively managing utilization.
3. ADDITIONAL UTILIZATION MANAGEMENT PROGRAM REQUIREMENTS
The Contractor agrees to provide twenty-four (24) hour
staff availability to authorize weekend services,
including but not limited to: home health care, pharmacy,
DME, and medical supplies. The Contractor must have
written policies and procedures that address how Members
and Providers can make contact with the plan to receive
instruction or prior authorization, as necessary.
The Contractor must ensure that all utilization review
decisions are made using the HealthChoices definition of
Medically Necessary. In addition, the Contractor must take
steps to ensure that determinations made by individual
clinical reviewers on whether or not requested care and
services are Medically Necessary are consistent with
determinations for care and services that would be
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found to be Medically Necessary consistent with the
HealthChoices definition of Medically Necessary.
The Contractor must develop polices and procedures that
allow for prospective, concurrent, and retrospective
determination of Medically Necessary, which are based on
the HealthChoices Program's definition of Medically
Necessary and meet HealthChoices Program's timeframes for
the processing of requests, for elective, urgent and
Emergency Services as outlined in Exhibit H of this
Agreement, Prior Authorization Guidelines.
In addition, the Contractor must submit utilization review
criteria and policies/procedures that contain utilization
review criteria used to determine medical necessity to the
Department for evaluation under the Utilization Review
Criteria Assessment Process (URCAP).
4. HEALTHPLAN EMPLOYER DATA INFORMATION SET (HEDIS)
The Contractor must submit data to the Department by June
15th of the current year. The calendar year is the
standard measurement year for HEDIS data. HEDIS measures
are specified for one of three data collection
methodologies: administrative, hybrid or survey. The
administrative methodology requires that contractors
identify the denominator and numerator using transaction
data or other administrative databases. The denominator
includes all eligible Members.
The Contractor will report a rate based on all Members who
meet the criteria who are found through administrative
data to have received the service identified in the
numerator data.
The hybrid methodology requires that the Contractor
identify the denominator and the numerator through both
administrative and medical record data. The denominator
consists of a systematic sample of Members drawn from the
measure's eligible population.
The Contractor will report a rate based on those Members
in the sample who are found through either administrative
or medical record data to have received the service
identified in the numerator. The Contractor may not report
a measure using the hybrid method when the numerator is
derived solely from administrative data.
5. EXTERNAL QUALITY REVIEW (EQR)
The Contractor agrees to cooperate fully with any external
evaluations and assessments of its performance authorized
by the
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Department under this Agreement. Independent
assessments will include, but not be limited to, any
independent evaluation required or allowed by federal or
state statute or regulation. See Exhibit M(2) of this
Agreement, External Quality Review.
The Contractor agrees to cooperate fully with external
clinical record reviews that assess the Contractor's
quality of care, access to care, and timeliness of care
i.e., any studies as determined by the Department.
The Contractor agrees to assist in the identification and
collection of any data or clinical records to be reviewed
by the independent evaluation team members. In addition,
the Contractor must provide to the External Quality Review
Organization (EQRO) complete medical records in the
timeframe allowed by the EQRO.
The Contractor must ensure that data, clinical records and
workspace located at the Contractor's work site are
available to the independent review team and to the
Department, upon request.
The Contractor must demonstrate how the results of the EQR
are incorporated into the overall Quality and Utilization
Management Programs.
6. QM/UM PROGRAM REPORTING REQUIREMENTS
The Contractor agrees to:
a. Provide the Department with uniform QM, UM, and
Member satisfaction/complaint data, in a format
to be determined by the Department, on a regular
basis;
b. Collaborate with the Department in carrying out
data validation steps;
c. Maintain and make available to the Department,
upon request, studies, reports, protocols,
standards, worksheets, minutes or other such
documentation as may be appropriate; and
d. Submit reports based on the most current version
of HEDIS measures.
The Contractor agrees to comply with all QM and UM program
reporting requirements and time frames outlined in Exhibit
M(1) or this Agreement, Quality Management and Utilization
Management
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Program Requirements. The Department will, on a periodic
basis, review the required reports and make changes to
the information/data and/or formats requested based on
the changing needs of the HealthChoices Program. The
Contractor must comply with all requested changes to the
report information and formats as deemed necessary by
the Department. Copies of current QM and UM reporting
requirements can be found in the HealthChoices
Proposers' Library.
7. COLLABORATION BETWEEN CONTRACTOR QM AND UM DEPARTMENTS AND
SPECIAL NEEDS UNITS
The Contractor must provide evidence of ongoing
collaboration and coordination between its QM and UM
Departments and its SNU regarding quality initiatives,
case management and/or disease management activities
directed toward or involving care of Special Needs
populations. Collaboration must include, but not be
limited to, quality improvement studies; UM referrals;
discharge planning/case management, identification of and
outreach to MA Consumers with Special Needs and Special
Needs populations.
8. DELEGATED QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT
FUNCTIONS
The Contractor must demonstrate that it retains
accountability for all QM and UM programs functions,
including those that are delegated to other entities. The
Contractor must make available to the Department, any
records, documents, and data detailing its oversight of
delegated QM and UM program functions. In addition, the
Contractor must ensure that delegated entities make
available to the Department, any records, documents, and
data detailing the delegated QM and UM program functions
undertaken by the entity of behalf of the Contractor.
9. CONSUMER INVOLVEMENT IN THE QUALITY MANAGEMENT AND
UTILIZATION MANAGEMENT PROGRAMS
The Contractor agrees to participate and cooperate in the
work and review of the Department's formal advisory body
through participation in the Medical Assistance Advisory
Committee (MAAC) and its subcommittees.
10. CONFIDENTIALITY
The Contractor must have written policies and procedures
for maintaining the confidentiality of data that addresses
medical
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records, Member information and Provider information and
is in compliance with the provisions set forth in Section
2131 of the Insurance Company Law of 1921, as amended, 40
P.S. 991.2131 and 55 Pa. Code 105.
The Contractor must ensure that Provider offices/sites
have implemented mechanisms that guard against
unauthorized or inadvertent disclosure of confidential
information to persons outside the Contractor.
All clinical data related to HealthChoices Members is the
property of the Department. Release of data by the
Contractor to third parties, except for the purpose of
individual care and coordination among Providers as
consented to by Members, requires the Department's advance
written approval.
11. DEPARTMENT OVERSIGHT
The Contractor and its subcontractor(s) agree to make
available to the Department upon request, data, clinical
and other records and reports for review of quality of
care, access and utilization issues including but not
limited to EQRO, HEDIS, Encounter Data Validation, and
other related activities.
The Contractor must submit a plan, as determined by the
Department, and within time frames established by the
Department, to resolve any performance or quality of care
deficiencies identified by the Department's ongoing
monitoring activities and any independent assessments or
evaluations requested by the Department.
The Contractor must obtain advance written approval from
the Department before releasing or sharing data,
correspondence and/or improvements from the Department
regarding the Contractor's internal QM and UM programs
with any of the other HealthChoices PH-MCOs or any
external entity.
The Contractor must obtain advance written approval from
the Department before participating in or providing
letters of support for QM or UM data studies and/or any
data related external research projects related to
HealthChoices with any entity.
SECTION VI: PROGRAM OUTCOMES AND DELIVERABLES
All deliverables must receive advance written approval by the Department
prior to the operational date of the Initial Term of the Contract unless
otherwise specified
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by the Department. Deliverables include, but are not limited to:
operational policies and procedures, required materials, letters of
agreement, provider agreements, reimbursement methodology and rates,
coordination agreements, reports, tracking systems, required files,
QM/UM documents (See Exhibit M(3) of this Agreement, Quality
Management/Utilitzation Management Deliverables), and referral systems.
The Department may conduct on-site Readiness Reviews as needed to
document the Contractor's compliance with this Agreement. Upon request
by the Department, as part of the Readiness Review, the Contractor must
provide detailed written descriptions of how the Contractor is complying
with Agreement requirements and standards. The Department retains the
right to continue development of Readiness Review elements, program
standards and forms prior to scheduling the actual on-site Readiness
Review visits.
SECTION VII: FINANCIAL REQUIREMENTS
A. FINANCIAL STANDARDS
1. RISK PROTECTION REINSURANCE FOR HIGH COST CASES
The Contractor must have a risk protection arrangement
during the term of this Agreement. This risk protection
arrangement must include reinsurance that covers, at a
minimum, eighty (80) percent of Inpatient costs incurred
by one (1) Member in one (1) year in excess of $150,000.
The Department may alter or waive the reinsurance
requirement if the Contractor proposes an alternative risk
protection arrangement that the Department determines is
acceptable.
The Contractor may not change or discontinue the risk
protection arrangement without advance written approval
from the Department, which approval shall not be
unreasonably withheld. The Contractor must notify the
Department thirty (30) days prior to any change in the
risk protection arrangement. The Department reserves the
right to review such risk protection arrangements and
require changes based on the Department's assessment of
the Contractor's overall financial condition.
The reinsurance threshold requirement shall be $75,000,
instead of $150,000, if any of the following criteria is
met:
a. The Contractor has been operational (providing
medical benefits to any type of consumer) for less
than three (3) years; or,
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b. The Contractor's Statutory Accounting Principles
(SAP) basis equity is less than 4.2 percent of MA
premiums earned during the most recent calendar
year for which the due date has passed for
submission of the unaudited annual reports filed by
the Contractor with the Insurance Department (DOI);
or,
c. The Contractor did not earn cumulative net surplus
over the previous three (3) years.
2. EQUITY REQUIREMENTS AND INSOLVENCY PROTECTION
The Contractor must meet, during the term of this
Agreement, the equity requirements set forth below. The
Contractor shall comply with all financial requirements
included in this Agreement in addition to those of the
Pennsylvania Departments of Health and Insurance. The
Department reserves the right to review such equity and
financial requirements and require changes based on the
Department's assessment of the Contractor's overall
financial condition.
The Contractor must maintain SAP-basis equity equal to the
highest of the amounts determined by the following "Three
(3) Part Test":
- $1.5 million.
- 4.2% of MA premiums earned during the most recent
four (4) calendar quarters.
- 4.2% of MA premiums earned during the current quarter
multiplied by three (3).
The amount of the requirement for equity for any PH-MCO
that did not provide medical benefits to MA Consumers in
the zone through a HC contract in 2001 shall be phased in
as follows:
-------------------------------------------------------------------------
Equity as of the last day of the 50% of the amount determined by
first contract calendar quarter. the Three (3) Part Test, but not
less than $1.5 million.
-------------------------------------------------------------------------
Equity as of the last day of the 66% of the amount determined by
second contract calendar quarter. the Three (3) Part Test, but not
less than $1.5 million.
-------------------------------------------------------------------------
Equity as of the last day of the 80% of the amount determined by
third contract calendar quarter. the Three (3) Part Test, but not
less than $1.5 million.
104
-------------------------------------------------------------------------
Equity as of the last day of the 100% of the amount determined by
fourth contract calendar quarter. the Three (3) Part Test.
-------------------------------------------------------------------------
MA premiums are defined as all revenue received from the
Commonwealth for any and all Managed Care Medical
Assistance contracts.
For the purpose of this requirement, equity amounts, as of
the last day of each calendar quarter shall be determined
in accordance with statutory accounting principles as
specified or accepted by DOI. The Department shall accept
DOI determinations of equity amounts, and in the absence
of such determination, shall rely on required financial
statements filed by the Contractor with DOI to determine
equity amounts.
The Contractor shall provide the Department with reports
as specified in Section VIII.D of this Agreement,
Financial Reports.
In addition to the Department's general sanction authority
specified in Section VIII.I of this Agreement, Sanctions,
if the Contractor fails to comply with the requirements of
this Section, the Department may take any or all of the
following actions:
- Discuss fiscal plans with the Contractor's management.
- Require the Contractor to submit and implement a
corrective action plan.
- Suspend some or all enrollment of MA Consumers into the
Contractor's plan.
- Terminate this Agreement effective the last day of the
calendar month after the Department notifies the
Contractor of termination.
3. SECONDARY LIABILITY
The Contractor must have in place an acceptable plan to
provide for payment to Providers by a secondary liable
party after default in payment to Providers resulting from
bankruptcy or insolvency. The secondary liability must
ensure payment for all services performed by providers
through the last day for which the Department paid a
capitation premium to the Contractor. The requirements may
be met by submission of one or more of the following
arrangements:
a. Insolvency insurance.
105
b. An irrevocable, unconditional, and automatically
renewable letter of credit for the benefit of
the Department which is in place for the entire
term of this Agreement.
c. A guarantee from an entity acceptable to the
Department, with sufficient financial strength and
creditworthiness to assume the payment obligations
of the Contractor in the event of a default in
payment resulting from bankruptcy or insolvency.
d. Other arrangements satisfactory to the Department,
that are sufficient to insure payment to Providers
in the event of default in payment resulting from
bankruptcy or insolvency.
The Department must approve all arrangements for secondary
liability. Such approval shall include approval of the
financial strength of the secondary liable parties and
approval of all legal forms for secondary liability.
4. LIMITATION OF LIABILITY
In accordance with 42 C.F.R. 434.20, the Contractor must
assure that MA Consumers shall not be liable for the
Contractor's debts if the Contractor becomes insolvent.
5. MEDICAL COST ACCRUALS
As part of its accounting and budgeting function, the
Contractor must establish and maintain an actuarially
sound process for estimating and tracking Incurred But Not
Paid (IBNP) amounts. The Contractor must reserve funds by
major categories of service to cover IBNP amounts. As part
of its reserving methodology, the Contractor must conduct
annual reviews to assess its reserving methodology and
make adjustments, as necessary.
6. CLAIMS PROCESSING AND MIS
The Contractor must have a Claims processing system and
MIS sufficient to support the Provider payment and data
reporting requirements specified in Section VIII of this
Agreement, Reporting Requirements. See also Exhibit MM of
this Agreement, Management Information System and System
Performance Review Standards, for MIS and Systems
Performance Review (SPR) standards. The Contractor shall
be prepared to document its ability
106
to expand Claims processing or MIS capacity should
either or both be exceeded through the enrollment of
program Members.
7. DSH/GME PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS (DSH)
/ GRADUATE MEDICAL EDUCATION (GME)
The Department shall make direct payments of DSH/GME to
hospitals. DSH and GME amounts shall not be included in
fee-for-service cost equivalent projections or in
capitation payments paid by the Department to the
Contractor.
8. MEMBER LIABILITY
The Contractor is prohibited from holding the Member
liable for the following:
a. Debts of the Contractor in the event of the
Contractor's insolvency.
b. Services provided to the Member in the event of the
Contractor failing to receive payment from the
Department for such services.
c. Services provided to the Member in the event of a
health care Provider with a contractual, referral
or other arrangement with the Contractor failing to
receive payment from the Department or the
Contractor for such services.
d. Payments to a Provider that furnishes covered
services under a contractual, referral or other
arrangement with the Contractor in excess of the
amount that would be owed by the Member if the
Contractor had directly provided the services.
B. COMMONWEALTH CAPITATION PAYMENTS
1. PAYMENTS FOR IN-PLAN SERVICES
The obligation of the Department to make payments shall be
limited to capitation payments, maternity care payments,
and any other payments provided by this Agreement.
a. CAPITATION PAYMENTS
i. The Contractor shall receive capitated
payments for In-Plan Services as defined in
Section VII.B.1 of this
107
Agreement, Payment for In-Plan Services.
Capitation rates maternity care rates, and
Risk Pool Allocation Amounts (RPAAs),
applicable to the agreement year beginning
January 1, 2002, are set forth in Appendix 3
of this Agreement, Capitated Rates. This
agreement year, for capitation purposes,
begins January 1, 2002, and extends 12
months to December 31, 2002. The contract
period of October 1, 2001 - December 31,
2001 is for Readiness Review and for
pre-operational preparedness. No payment
will be made for this period of time under
this contract.
For the agreement year beginning January 1,
2003, and for each subsequent agreement
year, the Department will provide an initial
schedule of capitation rates, maternity care
rates, and RPAAs, not later than July 1 of
the previous year. The Department will
provide the Contractor with information on
methodology and data used to develop the
initial schedule of rates. The Department
will provide the Contractor with the
opportunity of a meeting, in which the
Department will consider questions from the
Contractor on development of the initial
schedule of rates. The Department will
provide the Contractor with a final schedule
of capitation rates; maternity care rates,
and RPAAs, by September 30 of the year prior
to the effective date of the rates. If the
Contractor does not notify the Department of
its acceptance of the final schedule of
rates by October 15 of the same year, and if
the Contractor has not already provided
notice of its intent to terminate the
Agreement, the Department will, at its sole
discretion, decide on a schedule of rates
for the subsequent agreement year that will
consist of one of the following:
(1) The final schedule of capitation
rates, maternity care rates and
RPAAs, applicable to the subsequent
agreement year, previously provided
by the Department; or
(2) The schedule of capitation rates,
maternity care rates and RPAAs
applicable to the prior agreement
year.
108
ii. The Department shall make a pre-paid
capitation payment, referenced in Section
VII.B.1.a above, for each Member whose
enrollment on the first day of the month is
indicated on the Department's CIS on the
first day of the month. If the Contractor is
responsible to provide benefits to a MA
Consumer who does not appear on CIS on the
first day of the month, the Department shall
initiate a capitation payment on the first
day of the first subsequent month on which
said enrollment appears on CIS. The
Department will compute capitation payments
using per diem rates. The Department will
make a monthly payment to the PH-MCO for
each MA Consumer enrolled in the PH-MCO, for
the first day in the month the MA Consumer
is enrolled in the PH-MCO and for each
subsequent day through, and including the
last day of the month.
iii. The Department shall make each monthly
capitation payment by the fifteenth (15th)
of the month. The Department shall seek to
make arrangements for payment by wire
transfer or electronic funds transfer. If
such arrangements are not in place, payment
shall be made by U.S. Mail.
iv. The Department shall not make a capitation
payment for a Recipient Month if it notifies
the Contractor before the first of the month
that the individual's MA eligibility or
PH-MCO enrollment ends prior to the first of
the month.
v. This Agreement provides for rates for SSI
consumers who have Medicare Part A benefits
that are distinct from rates for SSI
consumers who do not have Medicare Part A
benefits. If the Department's Third Party
Liability (TPL) file is updated to indicate
Medicare Part A coverage within four (4)
months prior to the current month for a MA
Consumer at an SSI Without Medicare rate,
the Department shall adjust the payment to
reflect the rating group appropriate to the
MA Consumer, provided the TPL file indicates
Medicare Part A coverage as of the first day
of coverage by the Contractor for this
MA Consumer during the month for which
payment was made. If the Department's TPL
file is updated to adjust or delete
indication of Medicare Part A coverage
within four (4) months of a payment to the
Contractor for a MA
109
Consumer at an SSI with Medicare or Healthy
Horizons rate, the Department shall adjust
the payment to reflect the rating group
appropriate to the MA Consumer, provided the
TPL file does not indicate Medicare Part A
coverage as of the first day of coverage by
the Contractor for this MA Consumer during
the month for which payment was made. The
Department shall provide information to the
Contractor on this type of payment
adjustment on an electronic file. The
Contractor shall utilize this information to
adjust its payments to Providers and
instruct its Providers to ▇▇▇▇ Medicare.
vi. The Department will recover capitation
payments made for Members who were later
determined to be ineligible for managed care
for up to twelve (12) months after the
service month for which payment was made.
The Department will recover capitation
payments made for deceased recipients for up
to eighteen (18) months after the service
month for which payment was made. See
Exhibit BB of this Agreement, PH-MCO
Recipient Coverage Document.
vii. If a HCFA determination that a PH-MCO has
committed a violation described
in paragraph (a) of 42 C.F.R. Chapter IV
Subsection 434.67 (Sanctions against HMOs
with risk comprehensive contracts) is
affirmed on review of paragraph (d)
(Informal reconsideration), or is not timely
contested by the PH-MCO under paragraph (c)
(Notice of Sanction), HCFA, based upon
this recommendation of the agency, may deny
payment for new enrollees of the PH-MCO
under Section 1903 (m)(5)(B)(ii) of the Act.
Under Subsections 434.22 and 434.42, HCFA's
denial of payment for new enrollees
automatically results in a denial of agency
payments to the PH-MCO for the same
enrollees. A new enrollee is an enrollee
that applies for enrollment after the
effective date in paragraph (f)(1) of 42
C.F.R. Section 434.67.
2. MATERNITY CARE PAYMENT
For each live birth, the Department shall make a one-time
maternity care payment to the Contractor with whom the
mother is enrolled on the date of birth; however, if the
mother is admitted to a hospital and a change in the
PH-MCO coverage occurs during the hospital
110
admission, the PH-MCO responsible for the hospital stay at
the time of birth shall receive the maternity care
payment. The amount of the maternity care payment for the
agreement year beginning January 1, 2002, is shown in
Appendix 3 of this Agreement, Capitated Rates. The payment
is a global fee to cover all maternity expenses, including
prenatal care, delivery fees and post-partum care for the
mother and all services mandated by Act 85 of 1996 ("The
Health Security Act").
If required by the Department, the Contractor must submit
invoices or data files to the Department to receive
maternity care payments, consistent with specifications
determined by the Department.
3. PROGRAM CHANGES
Amendments, revisions, or additions to the State Medicaid
Plan or to state or federal regulations, laws, guidelines,
or policies shall, insofar as they affect the scope or
nature of benefits available to eligible persons, amend
the Contractor's obligations as specified herein, unless
the Department notifies the Contractor otherwise. The
Department shall inform the Contractor of any changes,
amendments, revisions, or additions to the State Medicaid
Plan or changes in the Department's regulations,
guidelines, or policies in a timely manner.
The Department shall adjust rates, as necessary, to
maintain the actuarial soundness of the rates to reflect
the impact on costs of program changes. If the Department
makes an adjustment to the rates, as provided by this
paragraph, the Department will provide information to the
Contractor on the methodology used to determine the amount
of the rate adjustment.
C. HIV/AIDS RISK POOL
The Department shall withhold the portion of each capitation
payment that is designated as a RPAA on each rate schedule. RPAA
funds withheld shall be allocated to an HIV/AIDS Risk Pool and
distributed to PH-MCOs in accordance with Exhibit VV of this
Agreement, HIV/AIDS Risk Pool.
D. CLAIMS PROCESSING STANDARDS, MONTHLY REPORT AND PENALTIES
1. TIMELINESS STANDARDS
The Contractor will adjudicate Provider Claims consistent
with the requirements below. These requirements apply
collectively to
111
Claims processed by the Contractor and any subcontractor.
Subcapitation payments are excluded from these
requirements.
The adjudication timeliness standards follow for each of
three (3) categories of Claims:
a. CLAIMS RECEIVED FROM A HOSPITAL FOR INPATIENT
ADMISSIONS ("INPATIENT")
90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
100.0% of all Claims must be adjudicated within
ninety (90) days of receipt.
b. DRUG CLAIMS
90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
100.0% of all Claims must be adjudicated within
ninety (90) days of receipt.
c. ALL CLAIMS OTHER THAN INPATIENT AND DRUG:
90.0% of Clean Claims must be adjudicated within
thirty (30) days of receipt.
100.0% of Clean Claims must be adjudicated within
forty-five (45) days of receipt.
100.0% of all Claims must be adjudicated within
ninety (90) days of receipt.
The adjudication timeliness standards do not apply to
Claims submitted by Providers under investigation for
fraud or abuse from the date of service to the date of
adjudication of the Claims. Providers can be under
investigation by a governmental agency or the Contractor;
however, if under investigation by the Contractor,
112
the Department must have immediate written notification of
the investigation.
Every Claim entered into the Contractor's computer
information system that is not a Rejected Claim must be
adjudicated. The Contractor must maintain an electronic
file of rejected Claims, inclusive of a reason or reason
code for rejection.
The amount of time required to adjudicate a paid Claim is
computed by comparing the date the Claim was received with
the check date or the transmission date of an electronic
payment. The check date is the date printed on the check.
The amount of time required to adjudicate a denied Claim
is computed by comparing the date the Claim was received
with the date the denial notice was created or the
transmission date of an electronic denial notice. For an
amended Claim, the date the Contractor received the
request to adjust the payment from the Provider must be
recorded and counted as the date the Claim was received.
Amended Claims do not include Provider Appeals.
Checks must be mailed not later than three (3) working
days from the check date. The check date is the date
printed on the check.
The Contractor must record, on every Claim processed, the
date the Claim was received. A date of receipt imbedded in
a Claim reference number is acceptable for this purpose.
This date must be carried on Claims records in the Claims
processing computer system. Each hardcopy Claim received
by the Contractor, or the electronic image thereof, must
be date-stamped with the date of receipt no later than the
first work day after the date of receipt. The Contractor
must add a date of receipt to each Claim received in the
form of an electronic record or file within one work day
of receipt.
If responsibility to receive Claims is subcontracted, the
date of initial receipt by the subcontractor determines
the date of receipt applicable to these requirements.
2. SANCTIONS
The Department will utilize the monthly report that is due
on the fifth (5th) calendar day of the fifth (5th)
subsequent month after the Claim is received to determine
Claims processing penalties. For example, the Department
shall utilize the monthly report that is due July 5, 2002,
to determine Claims processing penalties for Claims
received in January 2002. The Department shall utilize the
monthly report that is due August 5, 2002, to determine
Claims processing
113
penalties for Claims received in February 2002. The
Department shall utilize the monthly report that is due
September 5, 2002, to determine Claims received in March
2002, and so on.
All Claims received during the month, for which a penalty
is being computed, that remain unadjudicated at the time
the sanction is being determined, shall be considered a
Clean Claim.
If a Commonwealth audit, or an audit required or paid for
by the Commonwealth, determines Claims processing
timeliness data that are different than data submitted by
the Contractor, or if the Contractor has not submitted
required Claims processing data, the Department shall use
the audit results to determine the penalty amount.
The penalties included in the charts below shall apply
separately to:
a. Inpatient Claims.
b. Claims other than inpatient and drug.
The penalties provided by this Section apply to all Claims
included in each of the two (2) Claim categories specified
above, including Claims processed by any subcontractor.
The Contractor will be considered in compliance with the
requirement for adjudication of 100.0% of all inpatient
Claims if 99.5% of all inpatient Claims are adjudicated
within ninety (90) days of receipt. The Contractor will be
considered in compliance with the requirement of
adjudication of 100.0% of all Claims other than inpatient
or drug if 99.5% of all Claims other than inpatient or
drug are adjudicated within ninety (90) days of receipt.
Penalties in the charts below shall be reduced by
one-third if the Contractor has 25,000-50,000 MA
Consumers. Penalties in the charts below shall be reduced
by two-thirds if the Contractor has less than 25,000 MA
Consumers.
CLAIMS ADJUDICATION MONTHLY PENALTY CHART
This chart is used to compute any applicable penalty for
failure to adjudicate inpatient Claims timely. This chart
is also used to compute any applicable penalty for failure
to adjudicate Claims other than inpatient or drug.
--------------------------------------------------
Percentage of Clean Claims Penalty
--------------------------------------------------
114
--------------------------------------------------
Adjudicated in 30 Days
88.0 - 89.9 $1,000
--------------------------------------------------
80.0 - 87.9 $5,000
--------------------------------------------------
70.0 - 79.9 $10,000
--------------------------------------------------
60.0 - 69.9 $30,000
--------------------------------------------------
50.0 - 59.9 $50,000
--------------------------------------------------
40.0 - 49.9 $70,000
--------------------------------------------------
30.0 - 39.9 $90,000
--------------------------------------------------
Less than 30.0 $100,000
--------------------------------------------------
Percentage of Clean Claims
Adjudicated in 45 Days Penalty
--------------------------------------------------
98.0 - 99.9 $1,000
--------------------------------------------------
90.0 - 97.9 $5,000
--------------------------------------------------
80.0 - 89.9 $10,000
--------------------------------------------------
70.0 - 79.9 $30,000
--------------------------------------------------
60.0 - 69.9 $50,000
--------------------------------------------------
50.0 - 59.9 $70,000
--------------------------------------------------
40.0 - 49.9 $90,000
--------------------------------------------------
Less than 40.0 $100,000
--------------------------------------------------
Percentage of All Claims Penalty
Adjudicated in 90 Days
--------------------------------------------------
98.0 - 99.9 $1,000
--------------------------------------------------
90.0 - 97.9 $5,000
--------------------------------------------------
80.0 - 89.9 $10,000
--------------------------------------------------
70.0 - 79.9 $30,000
--------------------------------------------------
60.0 - 69.9 $50,000
--------------------------------------------------
50.0 - 59.9 $70,000
--------------------------------------------------
40.0 - 49.9 $90,000
--------------------------------------------------
Less than 40.0 $100,000
--------------------------------------------------
3. PHYSICIAN INCENTIVE ARRANGEMENTS
a. Federal financial participation is only available
for payments to Medicaid MCOs that are in
compliance with the Physician Incentive Plan (PIP)
requirements included under 42 C.F.R. 417.479.
b. 42 C.F.R. 417.479(a) permits MCOs to operate PIPs
only if: 1) no specific payment is made directly
or indirectly to a physician or physician group as
an inducement to reduce or limit Medically
Necessary services furnished to an enrollee; and
2) the disclosure, computation of Substantial
Financial Risk, Stop-Loss Protection, and enrollee
survey requirements of this section are met.
115
c. MCOs must provide information specified in the
regulations to the Department and HCFA, upon
request. In addition, MCOs must provide the
information on their physician incentive plans to
any Medicaid client, upon request. MCOs that have
PIPs placing a physician or physician group at
Substantial Financial Risk for the cost of
services the physician or physician group does not
furnish must assure that the physician or
physician group has adequate Stop-Loss Protection.
MCOs that have PIPs placing a physician or
physician group at Substantial Financial Risk for
the cost of service the physician or physician
group does not furnish must also conduct surveys
of enrollees and disenrollees addressing their
satisfaction with the quality of services and
their degree of access to the services.
d. MCOs must provide the following disclosure
information concerning its PIPs to the Department
prior to approval of the contract:
- whether referral services are included in the
PIP plan,
- the type of incentive arrangement used, i.e.
withhold bonus, capitation,
- a determination of the percent of payment under
the contract that is based on the use of
referral services to determine if Substantial
Financial Risk exists,
- panel size, and if patients are pooled, pooling
method used to determine if Substantial
Financial Risk exists,
- assurance that the physician or physician group
has adequate stop-loss protection and the type
of coverage, if this requirement applies.
Where enrollee/disenrollee survey requirements
exist, MCOs must provide the survey results. In
addition, all MCOs must subsequently provide the
above disclosure information annually to the
Department.
e. These PIP regulations apply to all MCOs and any of
their subcontracting arrangements that utilize a
PIP in their payment arrangements with individual
physicians or physician groups. PIP regulations
require that physicians and physician groups be
protected from risk beyond the stop-loss threshold.
116
4. RETROACTIVE ELIGIBILITY PERIOD
The Contractor shall not be responsible for any payments
owed to Providers for services that were rendered prior to
the effective date of a Member's enrollment into the
PH-MCO.
5. IN-NETWORK SERVICES
The Contractor shall be responsible for making timely
payment for Medically Necessary, covered services rendered
by Network Providers when:
a. Services were rendered to treat a medical
emergency;
b. Services were rendered under the terms of the
Contractor's agreement with the Provider;
c. Services were prior authorized; or
d. It is determined by the Department, after a
hearing, that the services should have been
authorized.
The Contractor will not be financially liable for services
rendered to treat a non-emergency condition in a hospital
emergency room (except to the extent required elsewhere by
law), unless the services were prior authorized or
otherwise conformed to the terms of the Contractor's
agreement with the Provider.
6. PAYMENTS FOR OUT-OF-NETWORK PROVIDERS
The Contractor will be responsible for making timely
payments to Out-of-Network Providers for Medically
Necessary, covered services when:
a. Services were rendered to treat a medical
emergency;
b. Services were prior authorized;
c. It is determined by the Department, after a
hearing, that the services should have been
authorized; or
d. A child enrolled in its plan is placed in emergency
substitute care and the county placement agency
cannot identify the child nor verify MA coverage.
See Exhibit O of this Agreement, Description of
Special Services.
117
The Contractor shall not be financially liable for
services rendered to treat a non-emergency condition in a
hospital emergency room (except to the extent required
elsewhere in law), unless the services were prior
authorized.
The Contractor must assume financial responsibility, in
accordance with applicable law, for emergency room
services and urgently needed services as defined in 42
C.F.R. Section 417.401 that are obtained by its Members
from Providers and suppliers outside the Contractor's
Provider Network even in the absence of the Contractor's
prior approval.
7. PAYMENTS TO FQHCS AND RURAL HEALTH CENTERS (RHCS)
The Contractor agrees to negotiate and pay rates to FQHCs
and RHCs comparable to other Providers who provide
comparable services in the Contractor's Provider Network.
The Contractor may require that an FQHC and RHC comply
with case management procedures that apply to other
entities that provide similar benefits or services.
8. LIABILITY DURING AN ACTIVE GRIEVANCE OR APPEAL
The Contractor shall not be liable to pay Claims to
Providers if the validity of the Claim is being challenged
by the Contractor through a Grievance or appeal, unless
the Contractor is obligated to pay the Claim or a portion
of the Claim through its agreement with the Provider.
9. FINANCIAL RESPONSIBILITY FOR DUAL ELIGIBLES
The Contractor must pay Medicare deductibles and
coinsurance amounts relating to any Medicare-covered
service for qualified Medicare beneficiaries in accordance
with Section 4714 of the Balanced Budget Act of 1997.
If no contracted PH-MCO rate exists or if the Provider of
the service is an Out-of-Network Provider, the Contractor
must pay deductibles and coinsurance up to the applicable
MA fee schedule for the service.
For Medicare services that are not covered by either MA or
the PH-MCO, the Contractor must pay cost-sharing to the
extent that the payment made under Medicare for the
service and the payment
118
made by the PH-MCO do not exceed eighty percent (80%) of
the Medicare-approved amount.
The Contractor, its subcontractors and Providers are
prohibited from balance billing Members for Medicare
deductibles or coinsurance. The Contractor must ensure
that a Member who is eligible for both Medicaid and
Medicare benefits has the right to access a Medicare
product or service from the Medicare Provider of his/her
choice. The Contractor is responsible to pay any Medicare
coinsurance and deductible amount, whether or not the
Medicare provider is included in the Contractor's Provider
Network and whether or not the Medicare provider has
complied with the authorization requirements of the
Contractor.
10. THIRD PARTY LIABILITY (TPL)
The Contractor must comply with the third party liability
procedures defined by Section 1902(a)(25) of the Social
Security Act, 42 U.S.C.A. 1396(a)(25) and implemented by
the Department. Under this Agreement, the third party
liability responsibilities of the Department will be
allocated between the Department and the Contractor.
a. COST AVOIDANCE ACTIVITIES
i. The Contractor will have primary
responsibility for cost avoidance through
the Coordination of Benefits (COB) relative
to federal and private health insurance-type
resources including, but not limited to,
Medicare, private health insurance,
Employees Retirement Income Security Act of
1974 (ERISA), 29 U.S.C.A. 1396a(a)(25)
plans, and workers compensation. The
Contractor must attempt to avoid initial
payment of Claims, whenever possible, where
federal or private health insurance-type
resources are available. All cost-avoided
funds must be reported to the Commonwealth
via encounter data submissions and financial
report 8A-D. The use of the COB flag,
Medicare fields, and the Other Insurance
Paid (OIP) field shall indicate that TPL has
been pursued and the amount which has been
cost-avoided. The Contractor shall not be
held responsible for any TPL errors in the
Department's Eligibility Verification System
(EVS) or the Department's TPL file.
119
ii. The Contractor agrees to pay, and to require
that its subcontractors pay, all Clean
Claims for prenatal or preventive pediatric
care (including EPSDT services to children),
and services to children having medical
coverage under a Title IV-D child support
order to the extent the Contractor is
notified by the Department of such support
orders or to the extent the Contractor
becomes aware of such orders, and then seek
reimbursement from liable third parties. The
Contractor recognizes that cost avoidance of
these Claims is prohibited with the
exception of hospital delivery Claims, which
may be cost-avoided.
iii. The Contractor may not deny or delay
approval of otherwise covered treatment or
services based upon third party liability
considerations. The Contractor may neither
unreasonably delay payment nor deny payment
of Claims unless the probable existence of
third party liability is established at the
time the Claim is filed.
b. POST-PAYMENT RECOVERIES
i. Post-payment recoveries are categorized by
(a) health-related insurance resources and
(b) other resources. Health-related
insurance resources are ERISA health benefit
plans, Blue Cross/Blue Shield subscriber
contracts, Medicare, private health
insurance, workers compensation, and health
insurance contracts.
ii. The Department's TPL Section retains the
sole and exclusive right to investigate,
pursue, collect, and retain all "Other
Resources" as defined in Section II of this
Agreement, Definitions. Any correspondence
or inquiry forwarded to the Contractor (by
an attorney, provider of service, insurance
carrier, etc.) relating to a personal injury
accident or trauma-related medical service,
or which in any way indicates that there is,
or may be, legal involvement regarding the
MA Consumer and the services which were
provided, must be immediately forwarded to
the Department's TPL Section. The Contractor
may neither unreasonably delay payment nor
deny payment of Claims because they involved
an injury stemming from an accident such as
a motor vehicle accident,
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where the services are otherwise covered.
Those funds recovered by the Commonwealth
under the scope of these "Other Resources"
shall be retained by the Commonwealth.
iii. Due to potential time constraints involving
cases subject to litigation, the Department
must ensure that it identifies these cases
and establishes its Claim before a
settlement has been negotiated. Should the
Department fail to identify and establish a
Claim prior to settlement due to the
Contractor's untimely submission of notice
of legal involvement where the Contractor
has received such notice, the amount of the
Department's actual loss of recovery shall
be assessed against the Contractor. The
Department's actual loss of recovery shall
not include the attorney's fees or other
costs, which would not have been retained by
the Department.
iv. The Contractor has the sole and exclusive
right to pursue, collect and retain all
health-related insurance resources for a
period of nine (9) months from the date of
service or six (6) months after the date of
payment, whichever is later. The
Department's TPL Section may pursue,
collect, and retain recoveries of all
health-related insurance cases which are
outstanding after the earlier of nine (9)
months from the date of service or six (6)
months after the date of payment. However,
in those cases subject to this paragraph
where payment is being pursued by the
Contractor but, for whatever reason, has not
been collected by the earlier of nine (9)
months from the date of service or six (6)
months after the date of payment, the
Contractor shall notify the Department if
action to recover has been initiated by the
Contractor. In such cases, the Contractor
shall retain exclusive responsibility for
the cases while they are being actively
pursued.
v. Should the Department lose recovery rights
to any Claim due to late or untimely filing
of a Claim with the liable third party, and
the untimeliness in billing that specific
Claim is directly related to untimely
submission of encounter data or additional
records under special request, or
inappropriate denial of Claims for accidents
or emergency care in casualty
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related situations. The amount of the
unrecoverable Claim shall be assessed
against the Contractor.
vi. Encounter data that is not submitted to the
Department in accordance with the data
requirements and/or timeframes identified in
this Agreement can possibly result in a loss
of revenue to the Department. Strict
compliance with these requirements and
timeframes shall therefore be enforced by
the Department and could result in the
assessment of sanctions against the
Contractor.
vii. As part of its authority under paragraph iv.
above, the Contractor is responsible for
pursuing, collecting, and retaining
recoveries of health-related insurance
resources where the liable party has
improperly denied payment based upon either
lack of a Medically Necessary determination
or lack of coverage. The Contractor is
encouraged to develop and implement
cost-effective procedures to identify and
pursue cases which are susceptible to
collection through either legal action or
traditional subrogation and collection
procedures.
11. HEALTH INSURANCE PREMIUM PAYMENT (▇▇▇▇) PROGRAM
The ▇▇▇▇ Program pays for employment-related health
insurance for MA Consumers when it is determined to be
cost effective. The cost effectiveness determination
involves the review of group health insurance benefits
offered by employers to their employees to determine if
the anticipated expenditures in MA payments are likely to
be greater than the cost of paying the premiums under a
group plan for those services.
The Department shall not purchase Medigap policies for
equally eligible MA Consumers in the zone.
12. REQUESTS FOR ADDITIONAL DATA
The Contractor must provide, at the Department's request,
such information not included in the encounter data
submissions that may be necessary for the administration
of TPL activity. The Contractor shall use its best efforts
to provide this information within fifteen (15) calendar
days of the Department's request. There are certain urgent
requests involving cases for minors that require
information within forty-eight (48) hours. Such
information may
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include, but is not limited to, individual medical records
for the express purpose of determining TPL for the
services rendered. Confidentiality of the information
shall be maintained as required by federal and state
regulations.
13. ACCESSIBILITY TO TPL DATA
The Department shall provide the Contractor with access to
data maintained on the TPL file.
14. DAMAGE LIABILITY
Liability for damages is identified in Section VII.D.10 of
this Agreement, Third Party Liability, due to the large
dollar value of many Claims which are potentially
recoverable by the Department's TPL Section.
15. ESTATE RECOVERY
Section 1412 of the Public Welfare Code, 62 P.S. 1412,
requires the Department to recover MA costs paid on behalf
of certain deceased individuals. Individuals age
fifty-five (55) and older who were receiving MA benefits
for any of the following services are affected:
a. Public or private Nursing Facility services;
b. Residential care at home or in a community setting;
or
c. Any hospital care and prescription drug services
provided while receiving Nursing Facility services
or residential care at home or in a community
setting.
The applicable MA costs are recovered from the assets of
the individual's probate estate. The Department's TPL
Section is solely responsible for administering the Estate
Recovery Program.
16. AUDITS
The Contractor is responsible to comply with audit
requirements as specified in Exhibit WW of this Agreement,
HealthChoices Audit Clause.
17. RESTITUTION
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The Contractor shall make full and prompt restitution to
the Department, as directed by the Department, for any
payments received in excess of amounts due to the
Contractor under this Agreement whether such overpayment
is discovered by the Contractor, the Department, or other
third party.
SECTION VIII: REPORTING REQUIREMENTS
A. GENERAL
The Contractor must comply with state and federal reporting
requirements that are set forth in this section and throughout
this Agreement.
B. SYSTEMS REPORTS
The Contractor must submit electronic files and data as specified
by the Department. To the extent possible, the Department shall
provide reasonable advance notice of such reports. These reports
include, but are not limited to, the following (Refer to Exhibit
CC of this Agreement, Data Support for PH-MCOs):
1. ENCOUNTER DATA AND SUBCAPITATION DATA REPORTS
The Contractor must record for internal use and submit to
the Department a separate record each time a Member has an
encounter with a Provider. A service rendered under this
Agreement is considered an encounter regardless of whether
or not it has an associated Claim. Every record that is
provided is considered to be an encounter and will require
the Contractor to submit a separate encounter data record
for each service received by a Member. The Provider's MAID
number must be used when submitting required encounter
data.
The Contractor must maintain appropriate systems and
mechanisms to obtain all necessary data from its health
care Providers to ensure its ability to comply with the
encounter data reporting requirements. The failure of a
health care Provider to provide the Contractor with
necessary encounter data shall not excuse the Contractor's
noncompliance with this requirement.
Effective on a date to be determined by the Department,
the Contractor must submit separate subcapitation records
for each advance payment made to a Contractor responsible
for all or part of a Member's medical care. If the payment
is a capitation payment, a separate record is required to
report the amount paid on behalf of each Member. Prior to
the effective date of this requirement, the
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Contractor must provide a periodic report with summary
information on subcapitation payments, consistent with the
content, format and due date requirements specified by the
Department.
The Contractor will be given a minimum of sixty (60) days
notification of any new edits or changes that DPW intends
to implement regarding encounter data.
a. DATA FORMAT
The Contractor must submit encounter and
subcapitation data electronically over POSNet using
file transfer protocol (FTP). Subcapitation data
reporting currently being submitted via paper
reports will, at a future date, be required to be
transmitted electronically.
Encounter data files must be provided in ASCII text
format using the appropriate format for the five
different record types.
a. TIMING OF DATA SUBMITTAL
Claims must be submitted by Providers to the
Contractor within one hundred eighty (180) days
after the date of service. It is acceptable for the
Contractor to include a requirement for more prompt
submissions of Claims or encounter records in
Provider Agreements. Claims adjudicated by a third
party vendor must be provided to the Contractor by
the end of the month following the month of
adjudication.
An encounter must be submitted and found acceptable
by the Department on or before the last calendar
day of the third month after the encounter's
Contractor payment/adjudication calendar month in
which the Contractor paid/adjudicated the
encounter. References to "accepted by the
Department" refer to encounter records sent to DPW
by the Contractor that have passed all Department
edits; records that fail any Department edits are
returned to the Contractor and must be corrected,
resubmitted to the Department, and pass all edits
before they are accepted by the Department.
One "initial" file and one "correction" file may be
submitted each weekday. If a file is received at
the DPW mainframe computer before 6 p.m. (Eastern
Time), it will be processed
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that weekday. If a file is received at the DPW
mainframe computer after 6 p.m. (Eastern Time), it
will be processed on the next weekday. Files
received at the DPW mainframe computer after 6 p.m.
on Friday are not processed until the following
Monday.
Acceptable subcapitation data must be submitted to
the Department within thirty (30) days after the
end of the month of the subcapitation payment data.
c. DATA COMPLETENESS
The Contractor shall monitor the completeness and
accuracy of the encounter data from all Providers
and shall initiate corrective action, as necessary.
d. FINANCIAL PENALTIES
The Contractor is required to provide complete,
accurate, and timely encounter data to the
Department, and to maintain complete medical
service history data. The Department may withhold a
portion of the monthly capitation payment as
reimbursement for financial penalties assessed.
Financial penalties shall be calculated monthly.
Assessment of financial penalties is based on the
identification of penalty occurrences. Encounter
Data Penalty occurrences/assessments of financial
penalties are outlined in Exhibit XX of this
Agreement, Encounter and Subcapitation Data Penalty
Occurrences.
e. DATA VALIDATION
The Contractor agrees to assist the Department in
its validation of encounter data by making
available medical records and a sample of its
Claims data. The validation may be completed by
Department staff and/or independent, external
review organizations.
f. SECONDARY RELEASE OF ENCOUNTER DATA
All encounter data recorded to document services
rendered to MA Consumers under this Agreement are
the property of the Department. Access to these
data is provided to the Contractor and its agents
for the sole purpose of operating the HealthChoices
Program under this Agreement. The
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Contractor and its agents are prohibited from
releasing any data resulting from this Agreement to
any third party without the advance written
approval of the Department. This prohibition does
not apply to internal quality improvement or
disease management activities undertaken by the
Contractor or its agents in the routine operation
of a managed care plan.
2. FEDERALIZING GA DATA REPORTING
The Contractor shall be required to submit a properly
formatted monthly file to the Department regarding
payments applicable to state-only general assistance (GA)
consumers. The file shall include data on hospital Claims
paid by the Contractor during the reporting month. The
files shall include data for three (3) types of hospital
services that are paid on a capitated basis, as listed
below:
- Admissions to acute care hospitals
- Admissions to rehabilitation hospitals
- Outpatient hospital services, defined by the Department
The following types of information shall be included in
each record on the file:
- Contractor
- Provider
- Consumer
- Claim
- Additional data elements as required.
Failure to comply with this requirement shall result in a
penalty equal to three (3) times the amount that applies
to other reporting requirements.
Additional Federalizing GA Data Reporting requirements can
be found in Exhibit CC of this Agreement, Data Support for
PH-MCOs.
3. THIRD PARTY RESOURCE IDENTIFICATION
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Third party resources identified by the Contractor, which
do not appear on the Department's TPL database, must be
supplied to the Department's TPL Section by the Contractor
on a monthly basis. The method of reporting shall be
electronic submission or hardcopy document, whichever is
deemed most convenient and efficient by the Contractor for
its individual use. For electronic submissions, the
Contractor must follow the required report format, data
elements, and tape specifications supplied by the
Department. For hardcopy submissions, the Contractor must
use an exact replica of the TPL resource referral form
supplied by the Department.
C. OPERATIONS REPORTS
The Contractor is required to submit such reports as specified by
the Department to enable the Department to monitor the
Contractor's internal operations and service delivery. These
reports include, but are not limited to, the following:
1. CONTINUOUS QUALITY IMPROVEMENT
The Contractor agrees to provide the Department with
uniform data on services, QM, UM and Member
satisfaction/complaint data on a regular basis. All
quality reports must be submitted according to
specifications defined by the Department. The Contractor
also agrees to cooperate with the Department in carrying
out data validation steps.
2. FEDERAL WAIVER REPORTING REQUIREMENTS
As a condition of approval of the Waiver for the operation
of HealthChoices in Pennsylvania, the Health Care
Financing Administration has imposed specific reporting
requirements related to the AIDS Home and Community Based
Waiver and Special Needs population, particularly related
to Special Needs services provided to children. The
Contractor must provide the information necessary to meet
these reporting requirements. To the extent possible, the
Department will provide reasonable advance notice of such
reports.
3. COMPLAINT, GRIEVANCE AND DPW FAIR HEARING DATA
The Contractor agrees to requirements governing the
submission of Complaint, Grievance and DPW Fair Hearing
process data found at Section VIII.C.3 of this Agreement,
Complaint, Grievance and DPW Fair Hearing Data.
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The Contractor agrees to submit a quarterly Complaint,
Grievance and DPW Fair Hearing process report no later
than forty-five (45) days from the end of the quarter that
conforms to the Department's and DOH's specifications and
includes at a minimum:
- Total informal Complaints and Member informal Complaint
rate by medical nature of Complaint (quality of care,
days to appointment, specialist referral, request for
interpreter, denial of ER Claim, etc.); and by
non-medical nature of Complaint (PH-MCO office staff,
office waiting time, etc.).
- Total Grievances and Grievance rate using the
indicators in the bullet above.
- Total Provider appeals by nature of Grievance (quality
of care, denial of referral request, denial of Claim,
lack of timely payment, etc.) and resolution.
The Contractor agrees to report its Provider appeal data
and utilization management outcomes to the Department
utilizing the standardized report form specified by the
Department.
4. EPSDT REPORTS
The Contractor must submit EPSDT reports in the time and
manner prescribed by the Department. The Contractor shall
be responsible for maintaining appropriate systems and
mechanisms to obtain all necessary encounter data from its
health care Providers to ensure its ability to comply with
the EPSDT reporting requirements. The failure of a health
care Provider to provide the Contractor with necessary
EPSDT encounter data shall not excuse the Contractor's
compliance with this requirement.
The Contractor must submit reports providing all data
regarding children in substitute care (e.g., the number of
children enrolled in substitute care who have received
comprehensive EPSDT screens, the number who have received
blood level assessments, etc.).
5. HEALTHY BEGINNINGS PLUS REPORTING
The Contractor must report certain Healthy Beginnings Plus
(HBP) statistics to the Department. HBP reporting periods
are January 1 through June 30, and July 1 through December
31. The Contractor must submit a semi-annual report to the
Department within sixty (60) days from the end of the
six-month service period. See Exhibit YY of this
Agreement, MCO Obstetrical Reporting Form.
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6. MEMBER HOTLINE ACTIVITIES REPORT
The Contractor's Member services function shall: provide
reports/analyses of hotline activity in a format and
frequency to be established by the Department.
7. FRAUD AND ABUSE
The Contractor must submit to the Department quarterly and
annual statistical reports which relate to its Fraud and
Abuse detection and sanctioning activities, as well as an
annual update in the aggregate.
8. PROVIDER NETWORK
The Contractor must report the composition of its Provider
Network to the Department and receive advance written
approval from the Department prior to the end of the
Readiness Review. Updates to the Provider file must be
provided to the Department monthly. A list of Network
composition requirements are found in Section V.S.1 of
this Agreement, Network Composition. The file layout for
the provider file can be found in the HealthChoices
Proposers' Library.
9. PROVIDER DISPUTE RESOLUTION SYSTEM
The Contractor must submit to the Department copies of the
completed Provider Dispute Resolution System Quarterly and
Annual Reports relating to Provider specific disputes and
resolutions.
10. REPORTS SUBMISSION SCHEDULE
Reports as defined by the Department must be submitted
according to the following schedule unless the Department
specifies a different due date:
QUARTERLY REPORTS:
Quarter Ending Report Due
March 31 May 15
June 30 August 15
September 30 November 15
December 31 February 15
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ANNUAL REPORTS:
Annual Reports are to be submitted ninety (90) days
after the end of the calendar year.
11. HEDIS INCLUDING CAHPS
The Contractor must submit annual reports based on the
Medicaid HEDIS outcome measures, as outlined in the most
current version of the Medicaid HEDIS applicable to the
reporting year. See Exhibit M(4) of this Agreement, HEDIS.
The Consumer Assessment of Health Plan Satisfaction
(CAHPS) 2.0H surveys (Adult and Child) are part of the
HEDIS required by the Department. Those HEDIS measures
related to behavioral health issues are not the
responsibility of the Contractor. In addition, the
Contractor's voluntary population is not included in these
reports since the HealthChoices Program does not encompass
the voluntary plans.
12. SERB
The Contractor's Quarterly Utilization Report (or similar
type document containing the same information) must be
completed and submitted to the Contracting Officer and the
Bureau of Contract Administration and Business Development
within ten (10) business days at the end of each quarter
the contract is in force. If there was no activity, the
form must also be completed, stating "No activity in this
quarter."
D. FINANCIAL REPORTS
The Contractor agrees to submit such reports as specified by the
Department to assist the Department in assessing the Contractor's
financial viability and to ensure compliance with this Agreement.
The Department shall distribute financial data reporting
requirements to the Contractor. The Contractor will furnish all
financial reports timely and accurately, with content in the
format prescribed by the Department.
E. EQUITY
Not later than May 25, August 25, and November 25 of each
agreement year, the Contractor shall provide the Department with:
- A copy of quarterly reports filed with DOI, for the quarter
ending the last day of the second previous month.
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- A statement that its equity is in compliance with the equity
requirements or is not in compliance with the equity
requirements.
- If equity is not in compliance with the equity requirements,
the Contractor shall supply a report that provides an analysis
of its fiscal health and steps that management plans to take,
if any, to improve fiscal health.
Not later than March 10 of each agreement year, the Contractor
shall provide the Department with:
- A copy of unaudited annual reports filed with DOI.
- A statement that its equity is in compliance with the equity
requirements or is not in compliance with the equity
requirements.
- If equity is not in compliance with the equity requirements,
the Contractor shall supply a report that provides an analysis
of its fiscal health and steps that management plans to take,
if any, to improve fiscal health.
F. CLAIMS PROCESSING REPORTS
The Contractor shall provide the Department with monthly Claims
processing reports with content and in a format specified by DPW.
The reports are due on the fifth (5th) calendar day of the second
subsequent month.
Failure to submit a Claims processing report timely that is
accurate and fully compliant with the reporting requirements
shall result in the following penalties: $200 per day for the
first ten (10) calendar days from the date that the report is due
and $1,000 per day for each calendar day thereafter.
G. PRESENTATION OF FINDINGS
The Contractor must obtain advance written approval from the
Department before publishing or making formal public
presentations of statistical or analytical material based on its
HealthChoices membership.
H. REFERENCE INFORMATION
The Department will make files available to the Contractor on a
routine basis that allow the Contractor to effectively meet its
obligation to provide services and record information consistent
with this Agreement. See
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Exhibit CC of this Agreement, Data Support for PH-MCOs, for
information on the data files the Department will provide to the
Contractor.
I. SANCTIONS
1. The Department may impose sanctions for non-compliance
with the requirements under this Agreement in addition to
any penalties described in Exhibit D of this Agreement,
Standard Contract Terms and Conditions for Services and in
Exhibit E of this Agreement, DPW Addendum to Standard
Contract Terms and Conditions. The sanctions which can be
imposed shall depend on the nature and severity of the
breach, which the Department, in its reasonable
discretion, shall determine as follows:
a. Imposing civil monetary penalties of a minimum of
$1,000.00 per day for non-compliance;
b. Requiring the submission of a corrective action
plan;
c. Limiting enrollment of new MA Consumers;
d. Suspension of payments;
e. Temporary management subject to applicable federal
or state law; and/or
f. Termination of the Agreement.
2. Where this Agreement provides for a specific sanction for
a defined infraction, the Department may, at its
discretion, apply the specific sanction provided for the
non-compliance or apply any of the general sanctions set
forth in Section VIII.I of this Agreement, Sanctions.
Specific sanctions contained in this Agreement include the
following:
a. Claims Processing: Sanctions related to Claims
processing are provided in Section VIII.I of this
Agreement, Sanctions.
b. Report or File, exclusive of Audit Reports: If the
Contractor fails to provide any report or file that
is specified by this Agreement by the applicable due
date, or if the Contractor provides any report or
file specified by this Agreement that does not meet
established criteria, a subsequent payment to the
Contractor may be reduced by the Department. The
reduction shall equal the number of days that elapse
between the due date and the day that the Department
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receives a report or file that meets established
criteria, multiplied by the average
Per-Member-Per-Month capitation rate that applies to
the first month of the agreement year. If the
Contractor provides a report or file on or before
the due date, and if the Department notifies the
Contractor after the 15th calendar day after the due
date that the report or file does not meet
established criteria, no reduction in payment shall
apply to the sixteenth (16th) day after the due date
through the date that the Department notifies the
Contractor.
c. Federalizing GA Data Reporting: The penalty for
failure to comply with the Federalizing GA Data
Reporting requirement is defined in Section VIII.B.2
of this Agreement, Federalizing GA Data Reporting.
d. Encounter Data Reporting: The penalty for late
reporting of encounter data is set forth in Section
VIII.B of this Agreement, Systems Reports, and
Exhibit XX of this Agreement, Encounter and
Subcapitation Data Penalty Occurrences.
e. Marketing: The sanctions for engaging in unapproved
marketing practices are set forth in Section V.F.3
of this Agreement, Contractor Outreach Activities.
f. Access Standard: The sanction for non-compliance
with the access standard is set forth in Section
V.S.14 of this Agreement, Compliance with Access
Standards.
g. Subcontractor Prior Approval: The Contractor's
failure to obtain advance written approval of a
subcontract will result in the application a
penalty of one (1) month's capitation rate for a
categorically needy adult female TANF consumer for
each day that the subcontractor was in effect
without the Department's approval.
J. NON-DUPLICATION OF FINANCIAL PENALTIES
If the Department assesses a financial penalty pursuant to one of
the provisions of Section VIII.I of this Agreement, Sanctions, it
shall not impose a financial sanction pursuant to Section VIII.I
with respect to the same infraction.
SECTION IX: REPRESENTATIONS AND WARRANTIES OF THE CONTRACTOR
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A. ACCURACY OF PROPOSAL
The Contractor represents and warrants that the representations
made to the Department in the Proposal are true and correct. The
Contractor further represents and warrants that all of the
information submitted to the Department in or with the Proposal
is accurate and complete in all material respects. The Contractor
agrees that such representations shall be continuing ones, and
that it is the Contractor's obligation to notify the Department
within ten (10) business days, of any material fact, event, or
condition which arises or is discovered subsequent to the date of
the Contractor's submission of the Proposal, which affects the
truth, accuracy, or completeness of such representations.
B. DISCLOSURE OF INTERESTS
The Contractor must disclose to the Department, in writing, the
name of any person or entity having a direct or indirect
ownership or control interest of five percent (5%) or more in the
Contractor. The Contractor must inform the Department, in
writing, of any change in or addition to the ownership or control
of the Contractor. Such disclosure shall be made within thirty
(30) days of any change or addition. The Contractor acknowledges
and agrees that any failure to comply with this provision in any
material respect, or making of any misrepresentation which would
cause the Contractor's application to be precluded from
participation in the MA Program, shall entitle the Department to
recover all payments made to the Contractor subsequent to the
date of the misrepresentation.
C. DISCLOSURE OF CHANGE IN CIRCUMSTANCES
The Contractor agrees to report to the Department, as well as the
Departments of Health and Insurance, within ten (10) business
days of the Contractor's notice of same, any change in
circumstances that may have a material adverse affect upon
Contractor's or Contractor's parent(s)' financial or operational
conditions. Such reporting shall be triggered by and include, by
way of example and without limitation, the following events, any
of which shall be presumed to be material and adverse:
1. Suspension or debarment of Contractor, Contractor's parent
(s), or any Affiliate or Related Party of either, by any
state or the federal government;
2. The Contractor may not knowingly have a person act as a
director, officer, partner or person with beneficial
ownership of more than five percent (5%) of the
Contractor's equity who has been debarred from
participating in procurement activities under federal
regulations.
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3. Notice of suspension or debarment or notice of an intent
to suspend/debar issued by any state or the federal
government to Contractor, Contractor's parent(s), or any
Affiliate or Related Party of either; and
4. Any new or previously undisclosed lawsuits or
investigations by any federal or state agency involving
Contractor, Contractor's parent(s), or any affiliate or
related party of either, which would have a material
impact upon the Contractor's financial condition or
ability to perform under this Agreement.
D. SERB COMMITMENT
Contractor's SERB commitment as set forth in Appendix 5 of this
Agreement, Contractor SERB Commitment, is hereby incorporated as
a contractual obligation during the term of this Agreement. The
Contractor shall make every reasonable effort to utilize SERB
services. The Contractor shall submit quarterly reports to the
Department outlining SERB utilization.
All contracts containing SERB participation must also include a
provision requiring the Contractor to meet and maintain those
commitments made to SERBs at the time of submittal or contract
negotiation, unless a change in the commitment is approved by the
contracting Commonwealth agency upon recommendation by the Bureau
of Contract Administration and Business Development (BCABD). All
contracts containing SERB participation must include a provision
requiring SERB subcontractors and SERBs in a joint venture to
incur at least fifty percent (50%) of the cost of the subcontract
or SERB portion of the joint venture, not including materials.
Commitments to Minority Business Enterprise (MBE) and Women's
Business Enterprise (WBE) firms made at the time of bidding must
be maintained throughout the term of the contract. Any proposed
change must be submitted to BCABD which will make a
recommendation as to a course of action to the contracting
officer.
If a contract is assigned to another contractor, the new
contractor must maintain the SERB participation of the original
contract.
SECTION X: DURATION OF AGREEMENT AND RENEWAL
A. INITIAL TERM
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This Agreement shall have an initial term of five (5) years and
three (3) months, commencing on October 1, 2001, the "Initial
Term", unless sooner terminated in accordance with Section XI of
this Agreement, Termination and Default; provided that no court
order, administrative decision, or action by any other
instrumentality of the United States Government or the
Commonwealth of Pennsylvania is outstanding which prevents
commencement of this Agreement.
B. RENEWAL
The Department shall have the option to renew this Agreement for
an additional three (3) year period after the expiration of the
Initial Term. The Department shall give written notice to the
Contractor one hundred twenty (120) days prior to the expiration
of the Initial Term as to whether it wishes to renew this
Agreement. If the Department exercises its option to renew this
Agreement, rate discussions shall commence promptly after notice
of the same.
Upon expiration of the Initial Term, the Agreement currently in
effect will continue to be effective for a period of one hundred
and twenty (120) days if the Contractor and the Department agree
to a renewal term, but cannot reach resolution of renewal
contract terms, or if the parties have not proceeded to terminate
the Agreement in accordance with Section XI of this Agreement,
Termination and Default.
SECTION XI: TERMINATION AND DEFAULT
A. TERMINATION BY THE DEPARTMENT
This Agreement may be terminated by the Department upon the
happening of any of the following events and upon compliance with
the notice provisions set forth below:
1. TERMINATION FOR CONVENIENCE UPON NOTICE
The Department may terminate this Agreement at any time
for convenience upon giving one hundred twenty (120) days
advance written notice to the Contractor. The effective
date of the termination shall be the last day of the month
in which the one hundred twentieth (120th) day falls.
2. TERMINATION FOR CAUSE
The Department may terminate this Agreement for cause upon
forty-five (45) days written notice, which notice shall
set forth the grounds for termination and, with the
exception of termination under
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Section XI.A.2.b below, shall provide the Contractor with
forty-five (45) days in which to implement corrective
action and cure the deficiency. If corrective action is
not implemented to the satisfaction of the Department
within the forty-five (45) day cure period, the
termination shall be effective at the expiration of the
forty-five (45) day cure period. "Cause" shall mean the
following for the purposes of termination under this
Agreement:
a. The Contractor defaults in the performance of any
material duties or obligations hereunder or is in
material breach of any provision of this Agreement;
or
b. The Contractor commits an act of theft or Fraud
against the Department, any state agency, or the
Federal Government; or
c. An adverse material change in circumstances as
described in Section IX.C of this Agreement,
Disclosure of Change in Circumstances.
3. TERMINATION DUE TO UNAVAILABILITY OF FUNDS/APPROVALS
The Department may terminate this Agreement immediately
upon the happening of any of the following events:
a. Notification by the United States Department of
Health and Human Services of the withdrawal of
federal financial participation in all or part of
the cost hereof for covered services/contracts; or
b. Notification that there shall be an unavailability
of funds available for the HealthChoices Program;
or
c. Notification that the federal approvals necessary
to operate the HealthChoices Program shall not be
retained; or
d. Notification by the Pennsylvania Insurance
Department or Health Department that the authority
under which the Contractor operates is subject to
suspension or revocation proceedings or sanctions,
has been suspended, limited, or curtailed to any
extent, or has been revoked, or has expired and
shall not be renewed.
B. TERMINATION BY THE CONTRACTOR
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The Contractor may terminate this Agreement at any time upon
giving one hundred twenty (120) days advance written notice to
the Department. The effective date of the termination shall be
the last day of the month in which the one hundred twentieth
(120th)day falls.
C. RESPONSIBILITIES OF THE CONTRACTOR UPON TERMINATION
1. CONTINUING OBLIGATIONS
Termination or expiration of this Agreement shall not
discharge the obligations of the Contractor with respect
to services or items furnished prior to termination,
including retention of records and verification of
overpayments or underpayments. Termination or expiration
shall not discharge the Department's payment obligations
to the Contractor or the Contractor's payment obligations
to its subcontractors.
2. NOTICE TO MEMBERS
In the event that this Agreement is terminated pursuant to
Sections XIII.A or XIII.B above, or expires without a new
contract in place, the Contractor shall notify all Members
of such termination or such expiration at least forty-five
(45) days in advance of the effective date of termination,
if practical. The Contractor shall be responsible for
coordinating the continuation of care for Members who are
undergoing treatment for an acute condition.
3. SUBMISSION OF INVOICES
Upon termination, the Contractor shall submit to the
Department all outstanding invoices for allowable services
rendered prior to the date of termination in the form
stipulated by the Department. Such invoices shall be
submitted promptly but in no event later than forty-five
(45) days from the effective date of termination. Invoices
submitted later than forty-five (45) days from the
effective date of termination shall not be payable.
4. FAILURE TO PERFORM
If the Department terminates a contract due to failure to
perform, the Department may add that PH-MCO's
responsibility to the responsibilities of one (1) or more
different PH-MCOs who are also operating within the
context of the HealthChoices Program in the zone, subject
to consent by the PH-MCO which would gain that
responsibility. The Department will develop a transition
plan should
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it choose to terminate or not extend a contract with one
(1) or more PH-MCOs operating the HealthChoices Program in
the zone.
During the final quarter of this Agreement, the Contractor
will work cooperatively with, and supply program
information to, any subsequent contractors. Both the
program information and the working relationship among the
PH-MCOs will be defined by the Department.
Upon termination or expiration of this Agreement, the
Contractor must:
a. Provide the Department with all information deemed
necessary by the Department within thirty (30) days
of the request;
b. Be financially responsible for MA Claims with dates
of service through the day of termination, except as
provided in c. below, including those submitted
within established time limits after the day of
termination;
c. Be financially responsible for hospitalized patients
through the date of discharge or thirty-one (31)
days after termination or expiration of this
Agreement, whichever is earlier;
d. Be financially responsible for services rendered
through 11:59 p.m. on the day of termination, except
as provided in c. above, for which payment is denied
by the Contractor and subsequently approved upon
appeal by the Provider;
e. Be financially responsible for MA Consumer appeals
of adverse decisions rendered by the Contractor
concerning treatment of services requested prior to
termination which are subsequently overturned at a
DPW Fair Hearing or Grievance proceeding; and
f. Arrange for the orderly transfer of patient care
and patient records to those Providers who will be
assuming care for the Member. For those Members in a
course of treatment for which a change of providers
could be harmful, the Contractor must continue to
provide services on a FFS basis until that treatment
is concluded or appropriate transfer of care can be
arranged.
D. TRANSITION AT EXPIRATION AND/OR TERMINATION OF AGREEMENT
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A transition period shall begin prior to the last day the
Contractor awarded this Agreement is responsible for operating
under this Agreement, if no new contract is in place. During the
transition period, the Contractor shall work cooperatively with
any subsequent contractor and the Department. Both the program
information and the working relationship between the two
contractors shall be defined by the Department. The length of the
transition period shall be no less than three (3) months and no
more than six (6) months in duration.
All costs relating to the transfer of materials and
responsibilities will be paid by the Contractor as a normal part
of doing business with the Department.
The Contractor shall be responsible for the provision of
necessary information to the new contractor and/or the Department
during the transition period to ensure a smooth transition of
responsibility. The Department shall define the information
required during this period and time frames for submission, and
may solicit input from the PH-MCOs involved.
SECTION XII: RECORDS
A. FINANCIAL RECORDS RETENTION
1. The Contractor shall maintain and shall cause its
subcontractors to maintain all books, records, and other
evidence pertaining to revenues, expenditures, and other
financial activity pursuant to this Agreement in
accordance with the standards and procedures specified in
Section V.O.5 of this Agreement, Records Retention.
2. The Contractor agrees to submit to the Department or to
the Secretary of Health and Human Services or their
designees, within thirty-five (35) days of a request,
information related to the Contractor's business
transactions which are related to the provision of
services for the HealthChoices Program pursuant to this
Agreement which shall include full and complete
information regarding:
a. The Contractor's ownership of any subcontractor with
whom the Contractor has had business transactions
totaling more than $25,000 during the twelve (12)
month period ending on the date of the request; and
b. Any significant business transactions between the
Contractor and any wholly-owned supplier or between
the
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Contractor and any subcontractor during the five (5)
year period ending on the date of the request.
3. The Contractor agrees to include the requirements set
forth in Section XIII in this Agreement, Subcontractual
Relationships, in all contracts it enters with
subcontractors under the HealthChoices Program, and to
ensure that all persons and/or entities with whom it so
contracts agree to comply with said provisions.
B. OPERATIONAL DATA REPORTS
The Contractor shall maintain and shall cause its subcontractors
to maintain all source records for data reports in accordance
with the procedures specified in Section V.O.5 of this Agreement,
Records Retention.
C. MEDICAL RECORDS RETENTION
The Contractor shall maintain and shall cause its subcontractors
to maintain all medical records in accordance with the procedures
outlined in Section V.O.5 of this Agreement, Records Retention.
The Contractor must provide MA Consumers medical records to the
Department or its contractor(s) within fifteen (15) business days
of the Department's request.
D. REVIEW OF RECORDS
1. The Contractor shall make all records relating to the
HealthChoices Program, including but not limited to, the
records referenced in this Section, available for audit,
review, or evaluation by the Department, or federal
agencies. Such records shall be made available on site at
the Contractor's chosen location, subject to the
Department's approval, during normal business hours or
through the mail. The Department shall, to the extent
required by law, maintain as confidential any confidential
information provided by the Contractor.
2. In the event that the Department, or federal agencies
request access to records after the expiration or
termination of this Agreement or at such time that the
records no longer are required by the terms of this
Agreement to be maintained at the Contractor's location,
but in any case, before the expiration of the period for
which the Contractor is required to retain such records,
the Contractor, at its own expense, shall send copies of
the requested
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records to the requesting entity within thirty (30) days
of such request.
SECTION XIII: SUBCONTRACTUAL RELATIONSHIPS
A. COMPLIANCE WITH PROGRAM STANDARDS
As part of its contracting or subcontracting, with the exception
of Provider Agreements which are outlined in Section V.S.2 of
this Agreement, Provider Agreements, the Contractor agrees that
it shall comply with the procedures set forth in Section V.O.3 of
this Agreement, Contracts and Subcontracts.
The written information that must be provided to the Department
prior to the awarding of any contract or Subcontract must provide
disclosure of ownership interests of five percent (5%) or more in
any entity or subcontractor.
All contracts and Subcontracts must be in writing and must
contain all items set forth in this Agreement and Exhibit AAA,
Internal Operations Contract Monitoring Guidelines.
The Contractor shall require its subcontractors to provide
written notification of a denial, partial approval, reduction, or
termination of service or coverage, or a change in the level of
care, using the standard form notice outlined in Exhibit M(1) of
this Agreement, Quality Management and Utilization Management
Program Requirements.
In addition, all contracts or Subcontracts that cover the
provision of medical services to the Contractor's Members must
include the following provisions:
1. A requirement for cooperation for the submission of all
encounter data for all services provided within the
timeframes required in Section VIII of this Agreement,
Reporting Requirements, no matter whether reimbursement
for these services is made by the Contractor either
directly or indirectly through capitation.
2. Language which ensures compliance with all applicable
federal and state laws.
3. Language which prohibits gag clauses which would limit the
subcontractor from disclosure of Medically Necessary or
appropriate health care information or alternative
therapies to Members, other health care professionals, or
to the Department.
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4. A requirement that ensures that the Department has ready
access to any and all documents and records of
transactions pertaining to the provision of services to MA
Consumers.
5. The definition of Medically Necessary as outlined in
Section II of this Agreement, Definitions and Acronyms.
6. The Contractor must ensure, if applicable, that its
Subcontracts adhere to the standards for Network
composition and adequacy.
7. Should the Contractor use a subcontracted utilization
review entity, the Contractor must ensure that its
subcontractors process each request for benefits in
accordance with Section V.B.1 of this Agreement, General
Prior Authorization Requirements.
8. Should the Contractor subcontract with an entity to
provide any information systems services, the Subcontract
must include provisions for a transition plan in the event
that the Contractor terminates the Subcontract or enters
into a Subcontract with a different entity. This
transition plan must include information on how the data
shall be converted and made available to the new
subcontractor. The data must include all historical Claims
and service data.
The Contractor must make all necessary revisions to its contracts
and Subcontracts to be in compliance with the requirements set
forth in Section XIII.A of this Agreement, Compliance with
Program Standards. Revisions may be completed as contracts and
Subcontracts become due for renewal provided that all contracts
and Subcontracts are amended within one (1) year of execution of
this Agreement with the exception of the encounter data
requirements, which must be amended immediately, if necessary, to
ensure that all subcontractors are submitting encounter data to
the Contractor within the timeframes specified in Section VIII.B
of this Agreement, Systems Reports.
B. CONSISTENCY WITH POLICY STATEMENTS
The Contractor agrees that its agreements with all Providers
shall be consistent, as may be applicable, with the policy
statements governing HMO Contracting with Integrated Delivery
Systems issued by the Pennsylvania Department of Health on April
6, 1996 and those issued by the Pennsylvania Department of
Insurance on April 6, 1996. (26 Pa. Bulletin 1629, et seq.
[04/06/96]).
SECTION XIV: CONFIDENTIALITY
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A. The Contractor shall comply with all applicable federal and state
laws regarding the confidentiality of medical records. The
Contractor shall also cause each of its subcontractors to comply
with all applicable federal and state laws regarding the
confidentiality of medical records. The Contractor shall comply
with Exhibit M(1) of this Agreement, Quality Management and
Utilization Management Program Requirements, regarding
maintaining confidentiality of data. The federal and state laws
with regard to confidentiality of medical records include, but
are not limited to: Mental Health Procedures Act, 50 P.S. 7101
et seq.; Confidentiality of HIV-Related Information Act, 35 P.S.
7601 et seq.; and the Pennsylvania Drug and Alcohol Abuse
Contract Act, 71 P.S. 1690.101 et seq., 42 U.S.C. 1396a(a)(7);
62 P.S. 404(a); 55 Pa. Code 105.1 et seq.; and 42 C.F.R.
431.300.
B. The Contractor shall be liable for any state or federal fines,
financial penalties, or damages levied upon the Department for a
breach of confidentiality due to the negligent or intentional
conduct of the Contractor in relation to the Contractor's
systems, staff, or other area of responsibility.
C. The Contractor agrees to return all data and material obtained in
connection with this Agreement and the implementation thereof,
including confidential data and material, at the Department's
request. No material can be used by the Contractor for any
purpose after the expiration or termination of this Agreement.
The Contractor also agrees to transfer all such information to a
subsequent contractor at the direction of the Department.
D. The Contractor considers its financial reports and information,
marketing plans, provider rates, trade secrets, information or
materials relating to the Contractor's software, databases or
technology, and information or materials licensed from, or
otherwise subject to contractual nondisclosure rights of third
parties, which would be harmful to the Contractor's competitive
position to be confidential information. This information shall
not be disclosed by the Department to other parties except as
required by law or except as may be determined by the Department
to be related to the administration and operation of the
HealthChoices Program. The Department will notify the Contractor
when it determines that disclosure of information is necessary
for the administration of the HC Program. The Contractor will be
given the opportunity to respond to such a determination prior
to the disclosure of the information.
E. The Contractor is entitled to receive all information relating to
the health status of its Members in accordance with applicable
confidentiality laws.
SECTION XV: INDEMNIFICATION AND INSURANCE
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A. INDEMNIFICATION
1. The Contractor shall indemnify and hold the Department and
the Commonwealth of Pennsylvania, their respective
employees, agents, and representatives free and harmless
against any and all liabilities, losses, settlements,
Claims, demands, and expenses of any kind (including, but
not limited to, attorneys' fees) which may result or arise
out of any dispute of any kind by and between the
Contractor and its subcontractors with Members, agents,
clients, or any defamation, malpractice, fraud,
negligence, or intentional misconduct caused or alleged to
have been caused by the Contractor or its agents,
subcontractors, employees, or representatives in the
performance or omission of any act or responsibility
assumed by the Contractor pursuant to this Agreement.
2. The Contractor shall indemnify and hold harmless the
Department and the Commonwealth of Pennsylvania from any
audit disallowance imposed by the federal government
resulting from the Contractor's failure to follow state or
federal rules, regulations, or procedures unless prior
authorization was given by the Department. The Department
shall provide timely notice of any disallowance to the
Contractor and allow the Contractor an opportunity to
participate in the disallowance appeal process and any
subsequent judicial review to the extent permitted by law.
Any payment required under this provision shall be due
from the Contractor upon notice from the Department. The
indemnification provision hereunder shall not extend to
disallowances which result from a determination by the
federal government that the terms of this Agreement are
not in accordance with federal law. The obligations under
this paragraph shall survive any termination or
cancellation of this Agreement.
B. INSURANCE
The Contractor shall maintain for itself, each of its employees,
agents, and representatives, general liability and all other
types of insurance in such amounts as reasonably required by the
Department and all applicable laws. In addition, the Contractor
shall require that each of the health care professionals with
which the Contractor contracts maintains professional malpractice
and all other types of insurance in such amounts as required by
all applicable laws. The Contractor shall provide to the
Department, upon the Department's request, certificates
evidencing such insurance coverage.
SECTION XVI: DISPUTES
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A. In the event that a dispute arises between the parties relating
to any matter regarding this Agreement, the Contractor shall
send written notice of an initial level dispute to the
Contracting Officer for this Agreement, who shall make a
determination in writing of his/her interpretation and shall
send the same to the Contractor within thirty (30) days of the
Contractor's written request for same. That interpretation shall
be final, conclusive, and binding on the Contractor, and
unreviewable in all respects unless the Contractor within twenty
(20) days of its receipt of said interpretation, delivers a
written appeal to the Secretary of Public Welfare. Unless the
Contractor consents to extend the time for disposition by the
Secretary, the decision of the Secretary shall be released
within thirty (30) days of the Contractor's written appeal and
shall be final, conclusive, and binding, and the Contractor
shall thereafter with good faith and diligence, render such
performance in compliance with the Secretary's determination;
subject to the provisions of Section XVIII.B below. Notice of
initial level dispute shall be sent to:
▇▇. ▇▇▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇
Director, Bureau of Managed Care Operations
▇.▇. ▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
B. All Claims against the Department relating to any matter
regarding this Agreement may be filed by the Contractor in the
Board of Claims pursuant to 72 P.S. 4651-1 et seq., but only
after first complying with Section XVI.A above. Resolution of
disputes under this provision must occur prior to any final
payment of a disputed amount to the Contractor.
SECTION XVII: FORCE MAJEURE
In the event of a major disaster or epidemic as declared by the
Governor of the Commonwealth of Pennsylvania or an act of any
military or civil authority, outage of communications, power, or
other utility, the Contractor shall cause its employees and all
Providers to render all services provided for in the RFP and
herein as is practical within the limits of Providers' facilities
and available staff. The Contractor, however, shall not be liable
nor deemed to be in default for any Provider's failure to provide
services or for any delay in the provision of services when such
a failure or delay is the direct or proximate result of the
depletion of staff or facilities by the major disaster or
epidemic, or act of any military or civil authority, outage of
communications, power, or other utility; provided, however, in
the event that the provision of services is substantially
interrupted, the Department shall have the right to terminate
this Agreement upon ten (10) days written notice to the
Contractor.
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SECTION XVIII: GENERAL
A. SUSPENSION FROM OTHER PROGRAMS
In the event that the Contractor learns that a Health Care
Professional with whom the Contractor contracts is suspended or
terminated from participation in the MA Program of another state
or from the Medicare Program, the Contractor shall promptly
notify the Department, in writing, of such suspension or
termination.
No payment shall be made to any Health Care Professional for any
services rendered by a health care practitioner during the period
the Contractor knew, or should have known, such practitioner was
suspended or terminated from the Medical Assistance Program of
this or another state, or the Medicare Program.
B. RIGHTS OF THE DEPARTMENT AND THE CONTRACTOR
The rights and remedies of the Department provided herein shall
not be exclusive and are in addition to any rights and remedies
provided by law.
Except as otherwise stated in Section XVI of this Agreement,
Disputes, the rights and remedies of the Contractor provided
herein shall not be exclusive and are in addition to any rights
and remedies provided by law.
C. WAIVER
No waiver by either party of a breach or default of this
Agreement shall be considered as a waiver of any other or
subsequent breach or default.
D. INVALID PROVISIONS
Any provision of this Agreement which is in violation of any
state or federal law or regulation shall be deemed amended to
conform with such law or regulation, pursuant to the terms of
this Agreement, except that if such change would materially and
substantially alter the obligations of the parties under this
Agreement, any such provision shall be renegotiated by the
parties. The invalidity or unenforceability of any terms or
provisions hereof shall in no way affect the validity or
enforceability of any other terms or provisions hereof.
E. GOVERNING LAW
This Agreement shall be governed by and construed in accordance
with the laws of the Commonwealth of Pennsylvania.
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F. EXPANSION OF THE ZONE
The Department reserves the right to expand the required
geographic coverage area of the zone to include additional
counties under this Agreement. Expansion of the zone will be
solely at the discretion of the Department.
G. NOTICE
Any notice, request, demand, or other communication required or
permitted hereunder, with the exception of initial level disputes
submitted to the Contracting Officer pursuant to Section XVI of
this Agreement, Disputes, shall be given in writing by certified
mail, communication charges prepaid, to the party to be notified.
All communications shall be deemed given and received upon
delivery or attempted delivery to the address specified herein,
as from time to time amended. The addresses for the parties for
the purposes of such communication are:
To the Department:
Department of Public Welfare
Office of Medical Assistance Programs
Director, Bureau of Managed Care Operations
Box ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇
With a Copy to:
Department of Public Welfare
Office of Legal Counsel
3rd Floor West, Health and Welfare Building
▇▇▇▇▇▇▇ and ▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇
Attention: Chief Counsel
To the Contractor - See Appendix 4 of this Agreement, Contractor
Information, for name and address.
H. COUNTERPARTS
This Agreement may be executed in counterparts, each of which
shall be deemed an original for all purposes, and all of which,
when taken together shall constitute but one and the same
instrument.
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I. HEADINGS
The section headings used herein are for reference and
convenience only, and shall not enter into the interpretation of
this Agreement.
J. ASSIGNMENT
Neither this Agreement nor any of the parties' rights hereunder
shall be assignable by either party hereto without the advance
written approval of the other party hereto, which approval shall
not be unreasonably withheld.
K. NO THIRD PARTY BENEFICIARIES
This Agreement does not, nor is it intended to, create any
rights, benefits, or interest to any third party, person, or
organization.
L. NEWS RELEASES
News releases pertaining to the HealthChoices Program may not be
made without advance written approval by the Department, and then
only in conjunction with the Issuing Office.
M. ENTIRE AGREEMENT: MODIFICATION
This Agreement constitutes the entire understanding of the
parties hereto and supersedes any and all written or oral
agreements, representations, or understandings. No modifications,
discharges, amendments, or alterations shall be effective unless
evidenced by an instrument in writing signed by both parties.
Furthermore, neither this Agreement nor any modifications,
discharges, amendments or alterations thereof shall be considered
executed by or binding upon the Department or the Commonwealth of
Pennsylvania unless and until signed by a duly authorized officer
of the Department or Commonwealth of Pennsylvania.
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