1
Exhibit 10.3
Texas Department
Of
Human Services
[SEAL]
STAR+PLUS CONTRACT
--------------------------------------------------------------------------------
AMERICAID Texas, Inc.
▇▇▇▇▇▇ SERVICE AREA
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TABLE OF CONTENTS
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT.........1
ARTICLE II DEFINITION............................... 2
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE
REQUIREMENTS.............................14
3.1 ORGANIZATION AND ADMINISTRATION......................14
3.2 NON-PROVIDER SUBCONTRACTS............................15
3.3 MEDICAL DIRECTOR.....................................17
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS....17
3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION...........19
3.6 HMO REVIEW OF TDHS MATERIALS.........................20
3.7 REQUIRMENTS FOR EDUCATION, TRAINING, AND ADVISORY
COMMITTEE ACTIVITIES.................................20
ARTICLE IV FISCAL, FINANCIAL AND SOLVENCY
REQUIREMENTS.............................20
4.1 FISCAL SOLVENCY......................................20
4.2 MINIMUM NET WORTH....................................21
4.3 PERFORMANCE BOND.....................................21
4.4 INSURANCE............................................21
4.5 FRANCHISE TAX........................................22
4.6 AUDIT................................................22
4.7 PENDING OR THREATENED LITIGATION.....................22
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA.......22
4.9 THIRD PARTY RECOVERY.................................23
4.10 CLAIMS PROCESSING REQUIREMENTS.......................24
4.11 INDEMNIFICATION......................................26
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE
REQUIREMENTS.............................26
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS.......26
5.2 PROGRAM INTEGRITY....................................27
5.3 FRAUD AND ABUSE COMPLIANCE PLAN......................27
5.4 SAFEGUARDING INFORMATION.............................29
5.5 NON-DISCRIMINATION...................................30
5.6 HISTORICALLY UNDERUTILIZED BUSINESS (HUBs)...........30
5.7 AFFIRMATIVE ACTION...................................31
5.8 BUY TEXAS............................................31
5.9 CHILD SUPPORT........................................31
5.10 REQUEST FOR PUBLIC INFORMATION.......................32
5.11 NOTICE AND APPEAL....................................32
ARTICLE VI SCOPE OF SERVICES........................33
6.1 SCOPE OF SERVICES....................................33
6.2 PRE-EXISTING CONDITIONS..............................35
6.3 SPAN OF ELIGIBILITY..................................35
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS......36
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6.5 EMERGENCY CARE.......................................36
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS...37
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS..............39
6.8 TEXAS HEALTH STEPS (EPSDT)...........................41
6.9 PERINATAL SERVICES...................................43
6.10 EARLY CHILDHOOD INTERVENTION.........................44
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN
INFANTS, AND CHILDREN (WIC)- SPECIFIC REQUIREMENTS,..45
6.12 TUBERCULOSIS (TB)....................................45
6.13 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS...46
6.14 CARE COORDINATION AND TRANSITION PLANS
FOR LONG TERM CARE SERVICES..........................47
6.15 1915 (C) WAIVER SERVICE(COMMUNITY BBASED
ALTERNATIVES)....................................... 51
ARTICLE VII PROVIDER NETWORK REQUIREMENTS............52
7.1 NETWORK PROVIDER DIRECTORY...........................52
7.2 PROVIDER ACCESSIBILITY...............................53
7.3 PROVIDER CONTRACTS...................................54
7.4 PHYSICIAN INCENTIVE PLANS............................58
7.5 PROVIDER MANUAL AND PROVIDER TRAINING................59
7.6 MEMBER PANEL REPORTS.................................60
7.7 PROVIDER COMPLAINT AND APPEAL PROCEDURES.............60
7.8 PROVIDER QUALIFICATIONS - GENERAL....................61
7.9 PRIMARY CARE PROVIDERS...............................62
7.10 OB/GYN PROVIDERS.....................................66
7.11 SPECIALTY CARE PROVIDERS.............................66
7.12 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES......67
7.13 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY
(LMHA)...............................................67
7.14 SIGNIFICANT TRADITIONAL PROVIDERS (STPS).............69
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND
RURAL HEALTH CLINICS (RHC) ..........................70
ARTICLE VIII MEMBER SERVICES REQUIREMENTS.............70
8.1 MEMBER EDUCATION.....................................70
8.2 MEMBER HANDBOOK......................................71
8.3 ADVANCE DIRECTIVES...................................71
8.4 MEMBER ID CARDS......................................73
8.5 MEMBER HOTLINE.......................................73
8.6 MEMBER COMPLAINT PROCESS.............................73
8.7 MEMBER NOTICES, APPEALS AND FAIR HEARINGS............75
8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES..............77
ARTICLE IX MARKETING AND PROHIBITED PRACTICES.......78
9.1 MARKETING MATERIALS..................................78
9.2 ADHERENCE TO MARKETING GUIDELINES....................78
ARTICLE X MIS SYSTEM REQUIREMENTS..................78
10.1 MODEL MIS REQUIREMENTS...............................78
10.2 SYSTEM WIDE FUNCTIONS................................79
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM.....................80
10.4 PROVIDER SUBSYSTEM...................................81
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM................81
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10.6 FINANCIAL SUBSYSTEM..................................82
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM............83
10.8 REPORT SUBSYSTEM.....................................84
10.9 DATA INTERFACE SUBSYSTEM.............................85
10.10 TPR SUBSYSTEM........................................86
10.11 YEAR 2000 COMPLIANCE.................................87
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT
PROGRAM..................................87
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM.............87
11.2 WRITTEN QIP PLAN.....................................87
11.3 QUI SUBCONTRACTING ..................................87
11.4 BEHAVIORAL HEALTH INTEGRATION INTO QIP...............88
11.5 QIP REPORTING REQUIREMENTS...........................88
ARTICLE XII REPORTING REQUIREMENTS...................88
12.1 FINANCIAL REPORTS....................................88
12.2 STATISTICAL REPORTS..................................89
12.3 ARBITRATION/LITIGATION CLAIMS REPORT.................90
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS................90
12.5 PROVIDER NETWORK REPORTS.............................91
12.6 MEMBER COMPLAINTS....................................91
12.7 FRAUDULENT PRACTICES.................................91
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH...91
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH.....92
12.10 UTILIZATION MANAGEMENT REPORTS - LONG TERM CARE......92
12.11 QUALITY IMPROVEMENT REPORTS..........................92
12.12 HUB QUARTERLY REPORTS................................93
12.13 THSTEPS REPORTS......................................93
ARTICLE XIII PAYMENT PROVISIONS.......................93
13.1 CAPATATION AMOUNTS...................................93
13.2 EXPERIENCE REBATE TO STATE...........................95
13.3 ADJUSTMENTS TO PREMIUM...............................96
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND
DISENROLLMENT............................97
14.1 ELIGIBILITY DETERMINATION............................97
14.2 ENROLLMENT...........................................98
14.3 PLAN CHANGES FROM HMO AND DISENROLLMENT FROM
MANAGED CARE.........................................99
14.4 AUTOMATIC RE-ENROLLMENT.............................100
14.5 ENROLLMENT REPORTS..................................100
ARTICLE XV GENERAL PROVISIONS......................100
15.1 INDEPENDENT CONTRACTOR..............................100
15.2 AMENDMENT...........................................100
15.3 LAW, JURISDICTION AND VENUE.........................101
15.4 NON-WAIVER..........................................101
15.5 SEVERABILITY........................................101
15.6 ASSIGNMENT..........................................101
15.7 MAJOR CHANGE IN CONTRACTING.........................101
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15.8 NON-EXCLUSIVE.......................................102
15.9 DISPUTE RESOLUTION..................................102
15.10 DOCUMENTS CONSTITUTING CONTRACT.....................102
15.11 FORCE MAJEURE.......................................102
15.12 NOTICES.............................................102
15.13 SURVIVAL............................................102
ARTICLE XVI DEFAULT AND REMEDIES....................103
16.1 DEFAULT BY TDHS.....................................103
16.2 REMEDIES AVAILABLE TO HMO FOR TDHS DEFAULT..........103
16.3 DEFAULT BY HMO......................................103
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT...110
ARTICLE XVIII EXPLANATION OF REMEDIES.................111
18.1 TERMINATION.........................................111
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION......113
18.3 SUSPENSION OF NEW ENROLLMENT........................114
18.4 LIQUIDATED MONEY DAMAGES............................114
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT.................116
18.6 TDHS-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS
WITHOUT CAUSE.......................................116
18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN
AGAINST HMO.........................................117
18.8 CIVIL MONETARY PENALTIES............................117
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE
BOND................................................117
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED..........117
ARTICLE XIX TERM....................................118
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ATTACHMENTS
ATTACHMENT A
Value Added Services
ATTACHMENT B
HUB Reporting Requirements and Forms
ATTACHMENT C
Behavioral Health Value-added Services
ATTACHMENT D
Required Critical Elements
ATTACHMENT E
Cost Principles for Administrative Expenses
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1999 CONTRACT FOR SERVICES
BETWEEN
THE TEXAS DEPARTMENT OF HUMAN SERVICES
AND
HMO
This Contract is entered into between the Texas Department of Human Services
("TDHS") and AMERICIAD TEXAS, INC. ("HMO"). The purpose of this Contract is to
set forth the terms and conditions for HMO participation as a managed care
organization in the TDHS STAR+PLUS Program ("STAR+PLUS"). Under the terms of
this Contract HMO will provide comprehensive health care services to qualified
and eligible Medicaid recipients through a managed care delivery system. This is
a risk-based Contract. HMO was selected to provide services under this Contract
pursuant to Human Resources Code Section 22.002(f). The HMO's original selection
for this Contract was based on HMOs Application to TDH/TDHS Request for
Application (RFA). Representation and responses contained in HMO's Application
are incorporated into and are enforceable provisions of this Contract, except
where changed by this Contract.
ARTICLE I PARTIES AND AUTHORITY TO CONTRACT
1.1 The Texas Legislature has designated the Texas Health and Human Services
Commission ("THHSC") as the single state agency to administer the Medicaid
program in the state of Texas. THHSC has delegated the authority to
operate the Medicaid managed care delivery system for the population
covered by this Contract to TDHS. TDHS has authority to contract with HMO
to carry out the duties and functions of the Medicaid managed care program
for the population served by this Contract under the Human Resources Code,
chapter 32.
1.2 HMO is a corporation with authority to conduct business in the State of
Texas and has a certificate of authority from the Texas Department of
Insurance (TDI) to operate as a Health Maintenance Organization (HMO)
under Chapter 20A of the Insurance Code. HMO is in compliance with all TDI
rules and laws that apply to HMOs. HMO has been authorized to enter into
this contract by its Board of Directors or other governing body. HMO is an
authorized vendor with TDHS and has received a Vendor Identification
number from the Texas Comptroller of Public Accounts.
1.3 This contract is subject to the approval and ongoing monitoring of the
federal Health Care Financing Administration (HCFA).
1.4 TDHS is required by Human Resources Code Section 32.043(a) and Government
Code Section 533.007 to conduct readiness review of HMO's performance and
compliance with this contract as a condition for retention and renewal.
1.4.1 Readiness review may include a review of HMO's past performance and
compliance with the requirements of this contract and on-site inspections
of any or all of HMO's systems or processes.
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1.4.2 The State will provide HMO with at least 30 days written notice prior to
conducting an HMO readiness review. A report of the results of the
readiness review findings will be provided to HMO within 10 weeks from the
completion of the readiness review. The readiness review report will
include any deficiencies, which must be corrected, and the timeline within
which the deficiencies must be corrected.
1.4.3 The State reserves the right to conduct on-site inspection of any or all
of HMO's systems and processes as often as necessary to ensure compliance
with contract requirements. TDHS may conduct at least one complete on-site
inspection of all systems and processes every three years.
The State will provide six weeks advance notice to HMO of the three year
on-site inspection, unless the State enters into an MOU with the Texas
Department of Insurance to accept the TDI report in lieu of an on-site
inspection. The State will notify HMO prior to conducting an onsite visit
related to a regularly scheduled review specifically described in this
contract. Even in the case of a regularly scheduled visit, the State
reserves the right to conduct an onsite review without advance notice if
the State believes there may be potentially serious or life-threatening
deficiencies.
1.5 AUTHORITY OF HMO TO ACT ON BEHALF OF THE STATE. HMO is given express,
limited authority to exercise the State's right of recovery, for expenses
incurred related to acute care services, as provided in Article 4.9, and
to enforce provisions of this contract which require providers or
subcontractors to produce records, reports, encounter data, public health
data, and other documents to comply with this contract and which the State
has authority to require under State or federal laws.
The HMO is obligated to pursue recovery for expenses related to long-term
care services or to assist the state in pursuit of recovery as required in
Article 4.9.
ARTICLE II DEFINITIONS
TERMS USED THROUGHOUT THIS CONTRACT HAVE THE FOLLOWING MEANING, UNLESS THE
CONTEXT CLEARLY INDICATES OTHERWISE:
Abuse means provider practices that are inconsistent with sound fiscal,
business, or medical practices, and result in an unnecessary cost to the
Medicaid program, or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health
care. It also includes recipient practices that result in unnecessary cost to
the Medicaid program.
Acute Care means medical care provided under the direction of a physician for a
condition having a relatively short duration.
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Adjudicate means to deny or pay a clean claim.
Adverse action means a denial, termination, suspension, reduction of covered
services, denial of a continued stay in a health facility, a retrospective
denial of a continued service or a denial of prior authorization for covered
services affecting a Member. This term does not include reaching the end of
prior authorized services.
Adverse determination means a determination by a utilization review agent that
the health care services furnished, or proposed to be furnished to a patient,
are not medically necessary or not appropriate.
Affiliate means any individual or entity: owning or holding more than a five
percent (5%) interest in HMO; in which HMO owns or holds more than a five
percent (5%) interest; or, any parent entity; or any subsidiary entity of HMO,
regardless of the organizational structure of the entity.
Allowable Expenses means all expenses related to the Contract for Services
between TDHS and HMO that are incurred during the term of the Contract that are
not reimbursable or recovered from another source.
Allowable Revenue means all Medicaid managed care revenue received by HMO for
the contract period, including retroactive adjustments made by TDHS.
Appeal of adverse determination means the formal process by which a utilization
review agent offers a mechanism to address adverse determinations as defined in
Article 21.58A, Texas Insurance Code.
Behavioral health services means covered services for the treatment of mental or
emotional disorders and treatment of chemical dependency disorders.
Benchmark means a target or standard based on historical data or an
objective/goal.
Capitation means a method of payment in which HMO or a health care provider
receives a fixed amount of money each month for each enrolled Member, regardless
of the amount of covered services used by the enrolled Member.
Care Coordination means a specialized care management service that is performed
by a Care Coordinator and that includes but is not limited to:
(a) Identification of needs, including physical health, mental health
services and long term support services, and development of a Care
Plan (CP) to address those needs;
(b) Assistance to ensure timely and a coordinated access to an array of
providers and services;
(c) Attention to addressing unique needs of Members; and
(d) Coordination of Plan services with social and other services
delivered outside the Plan, as necessary and appropriate.
Care Coordinator means the person with primary responsibility for providing care
coordination/management to members with complex care needs including long term
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care. The Care Coordinator need not be a medical professional. This person is
authorized by HMO to authorize the provision and delivery of long term care
services.
Care Plan (CP) means an individualized plan of care developed with and for
Members who have chronic or complex conditions. A CP includes, but is not
limited to, the following:
(a) A Member's history;
(b) A summary of current medical and social needs and concerns;
(c) Short and long term care needs and goals; and
(d) A list of services required their frequency, and a description of
who will provide the services.
CHIP means Children's Health Insurance Program established by Title XXI of the
Social Security Act to assist state efforts to initiate and expand child health
assistance to uninsured, low-income children.
Chronic or complex condition means a physical, behavioral, or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
Clean claim means a TDHS approved or identified claim format that contains all
data fields required by HMO and TDHS for final adjudication of the claim. The
required data fields must be complete and accurate. Clean claim also includes
HMO-published requirements for adjudication, such as medical records, as
appropriate (see definition of Unclean Claim). The TDHS required data fields are
identified in TDHS "HMO Encounter Data Claims Submission Manual".
CLIA means the federal legislation commonly known as the Clinical Laboratories
Improvement Act of 1988 as found at Section 353 of the federal Public Health
Services Act, and regulations adopted to implement the Act.
Community Based Alternatives (CBA) Waiver is the TDHS waiver program, which
provides home and community-based services to aged and disabled adults as
cost-effective alternatives to institutional care in nursing homes.
Community Management Team (CMT) means interagency groups responsible for
developing and implementing the Texas Children's Mental Health Plan (TCMHP) at
the local level. A CMT consists of local representatives from TXMHMR, the Mental
Health Association of Texas, Texas Commission on Alcohol and Drug Abuse, Texas
Department of Protective and Regulatory Services, Texas Department of Human
Services, Texas Department of Health, Juvenile Probation Commission, Texas Youth
Commission, Texas Rehabilitation Commission, Texas Education Agency, Council on
Early Childhood Intervention and a parent representative. This organizational
structure is also replicated in the State Management Team that sets overall
policy direction for the TCMHP.
Community Resource Coordination Groups (CRCGs) means a statewide system of local
interagency groups, including both public and private providers, which
coordinate services for "multi-problem" children and youth. CRCGs develop
individual service plans for children and adolescents whose needs can be met
only through interagency cooperation. CRCGs address complex needs in a model
that promotes local decision-
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making and ensures that children and adolescents receive the integrated
combination of social, medical and other services needed to address their
individual problems.
Complainant means a Member or a treating provider or other individual designated
to act on behalf of the Member who files the complaint.
Complaint means any dissatisfaction, expressed by a complainant orally or in
writing to the HMO, with any aspect of HMO's operation, including, but not
limited to, dissatisfaction with plan administration; procedures related to
review or appeal of an adverse determination, as that term is defined by Texas
Insurance Code Article 20A.12, with the exception of the Independent Review
Organization requirements; the denial, reduction, or termination of a service
for reasons not related to medical necessity; the way a service is provided; or
disenrollment decisions expressed by a complainant. The term does not include
misinformation that is resolved promptly by supplying the appropriate
information or clearing up the misunderstanding to the satisfaction of the
Member. The term also does not include a provider's or enrollee's oral/written
dissatisfaction or disagreement with an adverse determination or a request for a
Fair Hearing to the State.
Complex Need means a condition or situation that results in a need for
coordination or access to services beyond what a PCP would normally provide, and
which triggers the HMO's determination that a Care Coordinator is required.
Comprehensive Care Program See definition for Texas Health Steps.
Continuity of Care means care provided to a Member by the same primary care
provider, specialty provider or other auxiliary provider to the greatest degree
possible, so that the delivery of care to the Member remains stable, and
services are consistent and unduplicated.
Contract means this Contract between TDHS and HMO and documents included by
reference and any of its written amendments, corrections or modifications.
Contract administrator means an entity contracting with the State to carry out
specific administrative functions under the State Medicaid managed care program.
Contract period means the period of time starting with effective date of the
Contract and ending on the termination date of the Contract.
Court-ordered commitment means a commitment of a STAR+PLUS Member to a
psychiatric facility for treatment that is ordered by the court of law pursuant
to the Texas Health and Safety Code, Title VII Subtitle C.
Covered Services means health care services and health related services the HMO
must provide to Members, including all services required by this Contract and
state and federal law, and all value-added services described by the HMO and
approved by TDHS.
Cultural competency means the ability of individuals and systems to provide
services effectively to people of various cultures, races, ethnic backgrounds,
and religions in a manner that recognizes, values, affirms, and respects the
worth of the individuals and protects and preserves their dignity.
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Day mean calendar day, unless specified otherwise.
Denied claim means a clean claim or a portion of a clean claim for which a
determination is made that the claim cannot be paid.
Disabled Person or Person with Disability means a person under 65 years of age,
including a child, who qualifies for Medicaid services because of a disability.
Disability means a physical or mental impairment that substantially limits one
or more of the major life activities of an individual.
DSM-IV means the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association's official classification
of behavioral health disorders.
ECI means Early Childhood Intervention which is a federally mandated program for
infants and children under the age of three with or at risk for developmental
delays and/or disabilities. The federal ECI regulations are found at 34 C.F.R.
303.1 et seq. The state ECI rules are found at 25 TAC Section 621.21 et seq.
Effective date of the Contract means the day on which all parties are bound by
the terms and conditions of this Contract.
Emergency Behavioral Health Condition means any condition, without regard to the
nature or cause of the condition, which in the opinion of a prudent layperson
possessing an average knowledge of health and medicine requires immediate
intervention and/or medical attention without which Members would present an
immediate danger to themselves or others or which renders Members incapable of
controlling, knowing or understanding the consequences of their actions.
Emergency services means covered inpatient and outpatient services that are
furnished by a provider that is qualified to furnish such services under this
contract and are needed to evaluate or stabilize an emergency medical condition
and/or and emergency behavioral health condition.
Emergency Medical Condition means 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 care could result in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part; or
(d) serious disfigurement; or
(e) in the case of a pregnant woman, serious jeopardy to
the health of the fetus.
Encounter means a covered service or a group of services delivered by a provider
to a Member during a visit between the Member and provider. This also includes
value-added services.
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Encounter data means data elements from fee-for-service claims or capitated
services proxy claims that are submitted to the State by HMO in accordance with
TDHS "HMOs Encounter Data Claims Submission Manual".
Enrollment Broker means an entity contracting with the State to carry out
specific functions related to Member services (i.e., enrollment/disenrollment,
complaints, etc.) under the State's Medicaid managed care program.
Enrollment Report means the list of Medicaid recipients who are enrolled with an
HMO as Members for the month the report was issued.
EPSDT means the federally mandated Early and Periodic Screening, Diagnosis and
Treatment program contained at 42 United States Code 1396d(r). (See definition
for Texas Health Steps.) The name has been changed to Texas Health Steps
(THSteps) in the State of Texas.
Execution Date means the date this Contract is signed by persons with the
authority to contract for TDHS and HMO.
Experience Rebate means excess of allowable HMO STAR+PLUS revenues over
allowable HMO STAR+PLUS expenses.
Fair Hearing means the process adopted and implemented by the Texas Department
of Health, 25 TAC Chapter 1, in compliance with federal regulations and state
rules relating to Medicaid Fair Hearings for Acute Care Services, found at 42
CFR Part 431, Subpart E, and 1 TAC, Chapter 357., or a hearing conducted under
the rules set forth in 40 TAC chapter 79, Subchapters L, M and N for Long Term
Care services.
FQHC means a Federally Qualified Health Center that has been certified by HCFA
to meet the requirements of Section 1861(aa)(3) of the Social Security Act as a
federally qualified health center and is enrolled as provider in the Texas
Medicaid program.
Fraud means an intentional deception or misrepresentation made by a person with
the knowledge that the deception could result in some unauthorized benefit to
himself or some other person. It includes any act that constitutes fraud under
applicable federal or state law.
HCFA means the Federal Health Care Financing Administration.
Health care services means medically necessary physical medicine, behavioral
health care and health-related services which an enrolled population might
reasonably require in order to be maintained in good health, including, as a
minimum, emergency care and impatient and outpatient services.
Implementation Date means the first date that Medicaid managed care services are
delivered to Members in a service area.
Inpatient Stay means at least a 24 hour stay in a facility licensed to provide
hospital care.
JCAHO means Joint Commission on Accreditation of Health Care Organizations.
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Local Health Department means a local health department established pursuant to
Health and Safety Code, Title 2, Local Public Health Reorganization Act Section
121.031.
Local Mental Health Authority (LMHA) means an entity to which the TXMHMR board
delegates its authority or responsibility within a specified region for
planning, policy development, coordination, and resource development and
allocation and for supervising and ensuring the provision of mental health
services to persons with mental illness in one or more local service areas.
Long term care is a continuum of care and assistance ranging from in-home and
community based services for elderly people and people with disabilities who
need help in maintaining their independence, to institutional care for those who
require that level of support, seeking to maintain independence for the
individual while providing the support required. Long term care services are
listed in Appendices KK and LL of the RFA.
Major life activities means functions such as caring for oneself, performing
manual tasks, walking, seeing, hearing, speaking, breathing, learning, and
working.
Major population group means any population which represents at least 10% of the
Medicaid population in any of the counties in the service area served by the
Contractor.
Medical Assistance Only (MAO) means one of the three primary classes of Texas
Medicaid clients. The other two are Public Assistance and SSI. MAO clients
receive no cash assistance but receive "Medical Assistance Only." MAO clients
are related to the financial assistance programs in that, except for some
eligibility criteria, they would be eligible for money payments. This means that
they are in one of the categories of aged, blind, disabled or families with
dependent children.
Medical Home means a primary care provider or specialty care provider who has
accepted the responsibility to act as a PCP for providing accessible,
continuous, comprehensive and coordinated care to Members participating in the
TDHS Medicaid managed care program.
Medically Necessary Behavioral Health Services means those behavioral health
services which:
(a) are reasonable and necessary for the diagnosis or treatment of a
mental health or chemical dependency disorder or to improve or to
maintain or to prevent deterioration of functioning resulting from
such a disorder;
(b) are in accordance with professionally accepted clinical guidelines
and standards of practice in behavioral health care;
(c) are furnished in the most appropriate and least restrictive setting
in which services can be safely provided;
(d) are the most appropriate level of supply or service which can safely
be provided; and
(e) could not be omitted without adversely affecting the Member's mental
and/or physical health or the quality of care rendered.
Medically necessary health services means health services other than behavioral
health services which are:
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(a) reasonable and necessary to prevent illnesses or medical conditions,
or provide early screening, interventions, and/or treatments for
conditions that cause suffering or pain, cause physical deformity or
limitations in function, threaten to cause or worsen a handicap,
cause illness or infirmity of a Member, or endanger life;
(b) provided at appropriate facilities and at the appropriate levels of
care for the treatment of a Member's health conditions;
(c) consistent with health care practice guidelines and standards that
are endorsed by professionally recognized health care organizations
or governmental agencies;
(d) consistent with the diagnoses of the conditions; and
(e) no more intrusive or restrictive than necessary to provide a proper
balance of safety, effectiveness, and efficiency.
Medicare is a health insurance program for people 65 and older and some people
under age 65 who are disabled. It is a federal government program authorized
under Title XVIII of the Social Security Act and is administered by the Health
Care Financing Administration (HCFA). For people with very low incomes, state
Medicaid programs may pay the amounts Medicare does not pay and may pay some
health care expenses not covered by Medicare if the individual is also eligible
for Medicaid.
Member means a person who: is entitled to benefits under Title XIX of the Social
Security Act and the Texas Medical Assistance Program (Medicaid), is in a
Medicaid eligibility category included in the STAR+PLUS Program, and is enrolled
in the STAR+PLUS Program.
Member month means one client enrolled with HMO during any given month. The
total Member months for each month of a year comprise the annual Member months.
Mental health priority population means those individuals served by TXMHMR who
meet the definition of the priority population. The priority population for
mental health services is defined as:
Children and adolescents under the age of 18 who have a diagnosis of
mental illness who exhibit severe emotional or social disabilities which
are life-threatening or require prolonged intervention.
Adults who have severe and persistent mental illnesses such as
schizophrenia, major depression, manic depressive disorder, or other
severely disabling mental disorders which require crisis resolution or
ongoing and long-term support and treatment.
Minimum Data Set for Home Care (MDS-HC) is the screening component of the
Resident Assessment Instrument for Home Care (RAI-HC) that enables a home care
provider to briefly assess multiple key domains of function, health, social
support, and service use. Particular MDS-HC items also identify clients who
could benefit from further evaluation of specific problems and risks for
functional decline. These items, known as "triggers", link the MDS-HC to a
series of problem-oriented Client Assessment Protocols (CAPs). The MDS-HC
instrument is included in Appendix NN of the RFA.
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Minimum Data Set 2.0 for Nursing Facilities (MDS-NF) is a comprehensive
screening component of the Resident Assessment Instrument for long term care
facilities certified to participate in Medicare or Medicaid that is administered
to all residents upon admission to the nursing facility to facilitate
development of a care plan. The items in the MDS-NF standardize communication
about resident problems and conditions within facilities, between facilities,
and between facilities and outside agencies.
MIS means management information system.
Non-provider subcontracts means contracts between HMO and a third party which
performs a function, excluding delivery of health services, that HMO is required
to perform under its contract with TDHS.
Nursing Facility Level of Care is the determination that a Medicaid recipient
requires the services of licensed nurses in an institutional setting to carry
out the physician's planned regimen for total care. In the STAR+PLUS Program
these services can be provided in the home or in community-based programs as a
cost-effective, least restrictive alternative to institutional care in a nursing
home.
Pended claim means a claim submitted for payment which requires additional
information before the claim can be adjudicated as a clean claim.
Premium means the amount paid by the TDHS to a managed care organization on a
monthly basis and is determined by multiplying the Member months times the
capitation amount for each enrolled Member.
Primary care physician or primary care provider (PCP) means a physician or
provider who has agreed with HMO to provide a medical home to Members and who is
responsible for providing initial and primary care to patients, maintaining the
continuity of patient care, and initiating referrals for care (see also Medical
Home).
Provider means an individual or entity and its employees and Subcontractors that
directly provide health care services to HMOs Members under TDHS Medicaid
managed care program.
Provider contract means an agreement entered into by a direct provider of health
services and HMO or an intermediary entity.
Proxy Claim Form means a form submitted by providers to document services
delivered to Medicaid Members under a capitated arrangement. It is not a claim
for payment.
Public Information means information that is collected, assembled, or maintained
under a law or ordinance or in connection with the transaction of official
business by a governmental body or for a governmental body and the governmental
body owns the information or has a right of access.
Qualified Disabled and Working Individual (QDWI) is one whose only Medicaid
benefit is payment of the Medicare Part A premium. The Omnibus Budget
Reconciliation Act of 1989 requires the state to pay the Medicare Part A
premiums for certain disabled and working individuals who are enrolled in
Medicare Part A, who are not otherwise eligible for Medicaid, who have countable
income of no more than 200% of the Federal poverty
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level, and whose countable resources do not exceed twice the resource limit of
the SSI program.
Qualified Medicare Beneficiary (QMB) is an individual who does not receive
Medicaid benefits other than Medicare premiums, deductible, and coinsurance
liabilities. The Medicare Catastrophic Coverage Act of 1988 requires TDHS to pay
Medicare premiums, deductibles, and coinsurance for individuals who are entitled
to Medicare Part A, whose income does not exceed 100% of the federal poverty
level, and whose resources do not exceed twice the resource limit of the SSI
program.
Real Time Captioning (also known as CART, Communication Access Real-Time
Translation) means a process by which a trained individual uses a shorthand
machine, a computer, and real-time translation software to type and
simultaneously translate spoken language into text on a computer screen. Real
Time Captioning is provided for individuals who are deaf, have hearing
impairments, or have unintelligible speech; and it is usually used to interpret
spoken English into text English but may be used to translate other spoken
languages into text.
Readiness review means a review process conducted by TDHS or its agent(s) to
assess HMOs capacity and capability to perform the duties and responsibilities
required under the Contract. This process is required by Texas Government Code
Section 533.007.
Representative means a person who can make care-related decisions for a Member
who is not able to make such decisions alone. A representative may, in the
following order of priority, be a person who is:
(a) A court-appointed guardian of the person;
(b) A spouse or other family Member (parent) as designated by the Member
or the State's surrogate decision maker statute; or
(c) Designated as the Member's health care Representative
RFA means the Request for Application issued by TDH/TDHS on January 7, 1997, and
all RFA addenda, appendices, corrections or modifications.
Risk means the potential for loss as a result of expenses and costs of HMO
exceeding payments made by TDHS under this contract.
SED means severe emotional disturbance.
Service area means the counties included in a site selected for the STAR+PLUS
Program, within which a participating HMO must provide services.
Significant Traditional Provider (STP). For acute care services, STP means all
hospitals receiving disproportionate share hospital funds (DSH) in FY'97 and all
other providers in a county that, when listed by provider type in descending
order by the number of recipient encounters, provided the top 80 percent of
recipient encounters for each provider type in FY'97. For Long Term Care
services STP means a provider with whom Medicaid recipients have
well-established or longstanding provider/client relationships, or to whom the
recipients have typically or traditionally gone for health care, emergency care
or family planning advice. A provider falling within this definition shall be
determined by criteria established by the State.
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Special hospital means an establishment that:
(a) offers services, facilities, and beds for use for more than 24 hours
for two or more unrelated individuals who are regularly admitted,
treated, and discharged and who require services more intensive than
room, board, personal services, and general nursing care;
(b) has clinical laboratory facilities, diagnostic X-ray facilities,
treatment facilities, or other definitive medical treatment;
(c) has a medical staff in regular attendance; and
(d) maintains records of the clinical work performed for each patient.
Specified Low-Income Medicare Beneficiary (SLMB) is an individual whose only
Medicaid benefit is payment of the Medicare Part B premium. The Omnibus Budget
Reconciliation Act of 1990 requires the state to pay the Medicare Part B
premiums for individuals who are enrolled in Medicare Part A, whose income is
more than 100% of the federal poverty level (FPL) but less than 120% of the FPL,
and whose resources do not exceed twice the resource limit of the SSI program.
SLMB is considered an extension of QMB.
SPMI means severe and persistent mental illness.
STAR+PLUS is the name of the State of Texas Medicaid managed care program which
provides and coordinates preventive, primary, acute and long term care services
to persons of all ages with disabilities and elderly persons 65 and over who
qualify for Medicaid through SSI/MAO.
State fiscal year means the 12-month period beginning on September 1 and ending
on August 31 of the next year.
Subcontract means any written agreement between HMO and other party to fulfill
the requirements of this Contract. All subcontracts are required to be in
writing.
Subcontractor means any individual or entity which has entered into a
subcontract with HMO.
Supplemental Security Income (SSI) a federal cash assistance program of direct
financial payments to the aged, blind, and disabled. It is federally
administered by the Social Security Administration under Title XVI of the Social
Security Act and funded through general federal tax revenues. All persons who
are certified as eligible for SSI in Texas are eligible for Medicaid. SSI
eligibility determinations are made by local Social Security Administration
(SSA) claims representatives. The transactions are forwarded to SSA in
Baltimore, who then notifies the states through the State Data Exchange (SDX).
Supplemental Security Income (SSI) beneficiary is a person that receives
supplemental security income cash assistance as cited in 42 USCA Section 1320
a-6.
TAC means Texas Administration Code.
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TCADA means Texas Commission on Alcohol and Drug Abuse. State agency responsible
for licensing chemical dependency treatment facilities. TCADA also contracts
with providers to deliver chemical dependency treatment services.
TCMHP stands for Texas Children's Mental Health Plan and means an interagency,
state-funded initiative that plans, coordinates, provides and evaluates service
systems for children and adolescents with behavioral health needs. The Plan is
operated at a state and local level by Community Management Teams representing
the major child-serving state agencies.
TDD means telecommunication device for the deaf. It is interchangeable with the
term teletype machine or TTY.
TDH means the Texas Department of Health
TDHS means the Texas Department of Human Services
TDI means the Texas Department of Insurance.
TDMHMR means the Texas Department of Mental Health and Mental Retardation.
THSteps means Texas Health Steps which is the name adopted by the State of Texas
for the federally mandated Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) program. It includes the state's Comprehensive Care Program
extension to EPSDT, which adds benefits to the federal EPSDT requirements
contained in 42 United States Code Section 1396d(r), and defined and codified at
42 Code of Federal Regulations Section 440.40 and Sections 441.56-62. TDHS rules
are contained in 25 TAC, Chapter 33 (relating to Early and Periodic Screening,
and Diagnosis and Treatment).
Texas Medicaid Provider Procedures Manual means the policy and procedures manual
published by or on behalf of the State which contains policies and procedures
required of all health care providers who participate in the Texas Medicaid
program. The manual is published annually and is updated bi-monthly by the
Medicaid Bulletin.
Texas Medicaid Service Delivery Guide means an attachment to the Texas Medicaid
Provider Procedures Manual.
THHSC means Texas Health & Human Services Commission.
Third Party Liability (TPL) means the legal responsibility of another individual
or entity to pay for all or part of the services provided to Members under this
Contract. (See 25 TAC, Subchapter 28, relating to Third Party Resources).
Third Party Recovery (TPR) means the recovery of payments made on behalf of a
Member by TDHS or HMO from an individual or entity with the legal responsibility
to pay for the services.
TXMHMR means Texas Mental Health and Mental Retardation System which includes
the state agency, TDMHMR, and the Local Mental Health and Mental Retardation
Authorities.
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Unclean claim means a claim that does not contain accurate and complete data in
all claim fields that are required by HMO and TDHS and other HMO-published
requirements for adjudication such as medical records, as appropriate (see
definition of Clean Claim).
Urgent behavioral health situations means conditions which require attention and
assessment within 24 hours but which do not place the Member in immediate danger
to themselves or others and the Member is able to cooperate with treatment.
Urgent condition means a health condition, including an urgent behavioral health
situation, which is not an emergency but is severe or painful enough to cause a
prudent layperson, possessing the average knowledge of medicine, to believe that
his or her condition requires medical treatment evaluation or treatment within
24 hours by the Member's PCP or PCP designee to prevent serious deterioration of
the Member's condition or health.
Value-added services means a service that the state has approved to be included
in this contract for which the HMO does not receive capitation.
ARTICLE III PLAN ADMINISTRATIVE AND HUMAN RESOURCE
REQUIREMENTS
3.1 ORGANIZATION AND ADMINISTRATION
3.1.1 HMO must maintain the organizational and administrative capacity and
capabilities to carry out all duties and responsibilities under this
Contract.
3.1.2 HMO must maintain assigned staff with the capacity and capability to
provide all services to all Members under this Contract.
3.1.3 HMO must maintain an administrative office in the service area (local
office). The local office must comply with the American with
Disabilities Act requirements for public buildings.
3.1.4 HMO will maintain full-time medical and administrative staff with
experience in delivering services to pediatric, geriatric, and
disabled populations.
3.1.5 HMO will ensure that medical, functional, and/or long term care
decisions are based on the assessed needs of the member and that
access to services is not influenced solely by fiscal management
decisions
3.1.6 The HMO must provide upon request a current organizational chart
showing:
- basic functions
- the number of employees for those functions
- a list of key managers in the HMO who are responsible for
the basic functions of the organization
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HMO must also submit a description and organizational chart which
illustrates how behavioral health service administration is integrated
into the overall administrative structure of the HMO, including
individuals assigned to be behavioral health liaisons with the State.
The HMO must notify TDHS within fifteen (15) working days of any
change in key managers or behavioral health subcontractors. This
information must be updated when there is a significant change in
organizational structure or personnel.
3.1.7 Participation in Regional Advisory Committee. HMO must participate on
a Regional Advisory Committee established in the service area in
compliance with the Texas Government Code Section 533.021-533.029.
3.2 NON-PROVIDER SUBCONTRACTS
3.2.1 HMO must enter into written contracts with all Subcontractors and
maintain copies of the subcontracts in HMO's administrative office.
HMO must submit two copies of all non-provider subcontracts to TDHS
for approval no later than 60 days after the effective date of this
contract, unless the contract has already been submitted to and
approved by TDHS. Subcontracts entered into after the effective date
of this contract must be submitted no later than 30 days prior to the
date of execution of the subcontract. HMO must also make non-provider
subcontracts available to TDHS upon request, at the time and location
requested by TDHS.
3.2.1.1 TDHS has 15 working days to review the subcontract and recommend any
suggestions or required changes. If TDHS has not responded to HMO by
the fifteenth day, HMO may execute the subcontract. TDHS reserves the
right to request HMO to modify any subcontract that has been deemed
approved.
3.2.1.2 HMO must notify TDHS not less than 90 days prior to terminating any
Subcontract affecting a major performance function of this contract.
All major Subcontractor terminations or substitutions require TDHS
approval. TDHS may require HMO to provide a transition plan describing
how the subcontracted function will continue to be provided. All
subcontracts are subject to the terms and conditions of this contract
and must contain the provisions of Article V, Statutory and Regulatory
Compliance, and the provisions contained in Article 3.2.4.
3.2.2 Subcontracts which are requested by any agency with authority to
investigate and prosecute fraud and abuse must be produced at the time
and in the manner requested by the requesting Agency. Subcontracts
requested in response to a public information request must be produced
within 3 working days from TDHS' notification to HMO of the request.
All requested records must be provided free of charge.
3.2.3 The form and substance of all Subcontracts including subsequent
amendments are subject to approval by TDHS. TDHS retains the authority
to reject or require changes to any provisions of the subcontract
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that do not comply with the requirements or duties and
responsibilities of this contract or create significant barriers for
TDHS in carrying out its duty to monitor compliance with the contract.
HMO REMAINS RESPONSIBLE FOR PERFORMING ALL DUTIES, RESPONSIBILITIES
AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY,
RESPONSIBILITY OR SERVICE IS SUBCONTRACTED TO ANOTHER.
3.2.4 HMO and all intermediary entities must include the following standard
language in each subcontract and ensure that this language is included
in all subcontracts down to the actual provider of the services. The
following standard language is not the only language which will be
acceptable by TDHS.
3.2.4.1 Contractor understands that services provided under this contract are
funded by state and federal funds under the Texas Medical Assistance
Program (Medicaid). Contractor is subject to all state and federal
laws, rules and regulations that apply to persons or entities
receiving state and federal funds. Contractor understands that any
violation by Contractor of a state or federal law relating to the
delivery of services under this contract, or any violation of the
TDHS/HMO contract could result in liability for contract money
damages, and/or civil and criminal penalties and sanctions under state
and federal law.
3.2.4.2 The Contractor understands and agrees that the HMO has the sole
responsibility for payment of services rendered by the Contractor
under this contract. In the event of HMO insolvency or cessation of
operations, Contractor's sole recourse is against the HMO through the
bankruptcy or receivership estate of the HMO.
3.2.4.3 The Contractor understands and agrees that TDHS is not liable or
responsible for payment for any services provided under this contract.
3.2.4.4 The Contractor agrees that any modification, addition, or deletion of
the provisions of this agreement will become effective no earlier than
30 days after the HMO notifies TDHS of the change. If TDHS does not
provide written approval within 30 days from receipt of notification
from the HMO, changes may be considered provisionally approved.
3.2.4.5 This contract is subject to state and federal fraud and abuse
statutes. The Contractor is subject to state and federal fraud and
abuse statutes. The Contractor will be required to cooperate in the
investigation and prosecution of any suspected fraud or abuse, and
must provide any and all requested originals and copies of records and
information, free of charge on request, to any state or federal agency
with authority to investigate fraud and abuse in the Medicaid program.
3.2.5 The Texas Medicaid Fraud Control Unit must be allowed to conduct
private interviews of HMO personnel, Subcontractors and their
personnel, witnesses, and patients. Requests for information are to be
complied with, in the form and the language requested. HMO employees
and contractors and Subcontractors and their employees and contractors
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must cooperate fully in making themselves available in person for
interviews, consultation, grand jury proceedings, pretrial conference,
hearings, trial and in any other process, including investigations.
Compliance with this Article is at the HMO's and subcontractors' own
expense.
3.3 MEDICAL DIRECTOR
3.3.1 HMO must have the equivalent of a full-time Medical Director licensed
under the Texas State Board of Medical Examiners (M.D. or D.O.). HMO
must have a written job description describing the Medical Director's
authority, duties and responsibilities as follows:
3.3.1.1 Ensure that medical necessity decisions, including prior authorization
protocols, are rendered by qualified medical personnel and are based
on TDHS' definition of medical necessity, and is in compliance with
the Utilization Review Act and 21.58a of the Texas Insurance Code.
3.3.1.2 Oversight responsibility of network providers to ensure that all care
provided complies with the generally accepted health standards of the
community.
3.3.1.3 Oversight of HMO's quality improvement process, including establishing
and actively participating in HMO's quality improvement committee,
monitoring Member health status, HMO utilization review policies and
standards and patient outcome measures.
3.3.1.4 Identify problems and develop and implement corrective actions to
quality improvement process.
3.3.1.5 Develop, implement and maintain responsibility for HMO's medical
policy.
3.3.1.6 Oversight responsibility for medically related complaints.
3.3.1.7 Participate and provide witnesses and testimony on behalf of HMO in
the State Medicaid Fair Hearing process.
3.3.2 The Medical Director must exercise independent medical judgement in
all medical necessity decisions. HMO must ensure that medical
necessity decisions are not adversely influenced by fiscal management
decisions. The State may conduct reviews of medical necessity
decisions by HMO Medical Director at any time.
3.4 PLAN MATERIALS AND DISTRIBUTION OF PLAN MATERIALS
3.4.1 HMO must receive written approval from TDHS for all updated written
materials, produced or authorized by HMO, containing information about
the STAR+PLUS Program prior to distribution to Members, prospective
Members, providers within HMO's network, or potential providers who
HMO intends to recruit as network providers. This includes Member
education materials.
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3.4.2 Member materials must meet cultural and linguistic requirements as
stated in Article VIII. Unless otherwise required, Member materials
must be written at 4th - 6th grade reading comprehension level and
translated into the language of any major population group, except
when the State requires plan to use statutory language (i.e. advanced
directives, medical necessity, etc.).
3.4.3 All materials regarding the STAR+PLUS Program, including Member
education materials, must be submitted to TDHS for approval prior to
distribution. TDHS has 15 working days to review the materials and
recommend any suggestions or required changes. If TDHS has not
responded to the HMO by the fifteenth day, HMO may print and
distribute these materials. TDHS reserves the right to request HMO to
modify plan materials that are deemed approved and have been printed
or distributed. These modifications can be made at the next printing
unless substantial non-compliance exists.
3.4.4 HMO must forward approved English versions of their Member Handbook,
Member Provider Directory, newsletters, individual Member letters, and
any written information that applies to Medicaid-specific services to
TDHS for TDHS to translate into Spanish. TDHS must provide the written
and approved translation into Spanish to HMO no later than 15 working
days after receipt of the English version by TDHS. HMO must
incorporate the approved translation into these materials. If TDHS has
not responded to HMO by the fifteenth day, HMO may print and
distribute these materials. TDHS reserves the right to require
revisions to materials if inaccuracies are discovered or if changes
are required by changes in policy or law. These changes can be made at
the next printing unless substantial non-compliance exists. HMO has
the option of using the TDHS translation unit or their own translators
for health education materials that do not contain Medicaid-specific
information and for other marketing materials such as billboards,
radio spots, and television and newspaper advertisements.
3.4.5 HMO must reproduce all written instructional, educational, and
procedural documents required under this Contract and distribute them
to its providers and Members. HMO must reproduce and distribute
instructions and forms to all network providers who have reporting and
audit requirements under this Contract.
3.4.6 HMO must provide TDHS with at least three paper copies and one
electronic copy in a format approved by TDHS of their Member Handbook,
Provider Manual and Member Provider Directory. If electronic format
not available, five paper copies are required.
3.4.7 Changes to the Required Critical Elements for the Member Handbook,
Provider Manual, and Member Provider Directory may be handled as
inserts until the next printing of these documents.
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3.5 RECORDS REQUIREMENTS AND RECORDS RETENTION
3.5.1 HMO must keep all records required to be created and retained under
this contract. Records related to Members served in this service area
must be made available in HMO s local office when requested by TDHS.
All records must be retained for a period of five (5) years unless
otherwise specified in this contract. Original records must be kept in
the form they were created in the regular course of business for a
minimum of two (2) years following the end of the contract period.
Microfilm, digital or electronic records may be substituted for the
original records after the first two (2) years, if the retention
system is reliable and is supported by a retrieval system which allows
reasonable access to the records. All copies of original records must
be made using guidelines and procedures approved by TDHS, if the
original documents will no longer be available or accessible.
3.5.2 Availability and Accessibility. All records, documents and data
required to be created under this contract are subject to audit,
inspection and production. If an audit, inspection or production is
requested by TDHS, TDHS' designee or TDHS acting on behalf of any
agency with regulatory or statutory authority over Medicaid Managed
Care, the requested records must be made available at the time and at
the place the records are requested. Copies of requested records must
be produced or provided free-of-charge to the requesting agency.
Records requested after the second year following the end of contract
term, which have been stored or archived must be accessible and made
available within 10 calendar days from the date of a request by TDHS
or the requesting agency or at a time and place specified by the
requesting entity.
3.5.3 Accounting Records. HMO must create and keep accurate and complete
accounting records in compliance with to Generally Accepted Accounting
Principles (GAAP). Records must be created and kept for all claims
payments, refunds and adjustment payments to providers, premium or
capitation payments, interest income and payments for administrative
services or functions. Separate records must be maintained for medical
and administrative fees, charges, and payments.
3.5.4 General Business Records. HMO must create and keep complete and
accurate general business records to reflect the performance of duties
and responsibilities, and compliance with the provisions of this
contract.
3.5.5 Medical records. HMO must require, through contractual provisions or
provider manual, providers to create and keep medical records in
compliance with the medical records standards contained in the
Standards for Quality Improvement Programs (pages 76-116 of the
Medicaid Managed Care RFA for the ▇▇▇▇▇▇ Service Area). All medical
records must be kept for at least five (5) years, except for records
of rural health clinics, which must be kept for a period of six (6)
years from the date of service.
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3.5.6 Matters in Litigation. HMO must retain records related to matters in
litigation for five (5) years following the termination or resolution
of the litigation.
3.5.7 On-line Retention of Claims History. HMO must keep automated claims
payment histories for a minimum of 18 months, from date of
adjudication, in an on-line inquiry system. HMO must also keep
sufficient history on-line to ensure all claim/encounter service
information is submitted to and accepted by TDHS for processing.
3.6 HMO REVIEW OF TDHS MATERIALS
TDHS will submit all studies or audits that relate or refer to HMO for
review and comment to HMO 10 working days prior to releasing the
report to the public or to Members.
3.7 REQUIREMENTS FOR EDUCATION, TRAINING, AND ADVISORY COMMITTEE
ACTIVITIES
HMO is required to participate in education and training activities
provided for HMO's staff to educate and train regarding the special
needs populations and services included in the STAR+PLUS Project. HMO
is also required to attend regular meetings with THHSC and TDHS, and
for HMO, CEO staff, the medical director staff, and the care
coordinator staff.
ARTICLE IV FISCAL, FINANCIAL AND SOLVENCY REQUIREMENTS
4.1 FISCAL SOLVENCY
4.1.1 HMO must be and remain in full compliance with all State and federal
solvency requirements for HMOs, including but not limited to all
reserve requirements, net worth standards, debt to equity ratios, or
other debt limitations.
4.1.2 If HMO becomes aware of any impending changes to its financial or
business structure which could adversely impact its compliance with
these requirements or its ability to pay its debts as they come due,
HMO must notify TDHS immediately in writing. In addition, if HMO
becomes aware of a take-over or assignment which would require
approval of TDI or TDHS, HMO must notify TDHS immediately in writing.
4.1.3 HMO must not have been placed under state conservatorship or
receivership or filed for protection under federal bankruptcy laws.
None of HMO s property, plant or equipment must have been subject to
foreclosure or repossession within the preceding 10-year period. HMO
must not have any debt declared in default and accelerated to maturity
within the preceding 10-year period. HMO represents that these
statements are true as of the contract execution date. HMO must inform
TDHS within 24 hours of a change in any of the preceding
representations.
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4.2 MINIMUM NET WORTH
4.2.1 HMO has minimum net worth to the greater of (a) $1,500,000; (b) an
amount equal to the sum of twenty five dollars ($25) times the number
of all enrollees including Medicaid Members; or (c) an amount that
complies with standards adopted by TDI. Minimum net worth means the
excess total admitted assets over total liabilities, excluding
liability for subordinated debt issued in compliance with Article 1.39
of the Insurance Code.
4.2.2 The minimum equity must be maintained during the entire contract
period.
4.3 PERFORMANCE BOND
HMO has furnished TDHS with a performance bond in the form prescribed
by TDHS and approved by TDI, naming TDHS as Obligee, securing HMO's
faithful performance of the terms and conditions of this contract. The
performance bond has been issued in the amount of $100,000 for a two
year period (contract period). If the contract is renewed or extended
under Article XVIII, a separate bond will be required for each
additional term of the contract. The bond has been issued by a surety
licensed by TDI, and specifies cash payment as the sole remedy.
Performance Bond requirements under this Article must comply with
Texas Insurance Code Section 11.1805, relating to Performance and
Fidelity Bonds. The bond must be delivered to TDHS at the same time
the signed HMO contract is delivered to TDHS.
4.4 INSURANCE
4.4.1 HMO must maintain or cause to be maintained general liability
insurance in the amounts of at least $1,000,000 per occurrence and
$5,000,000 in the aggregate.
4.4.2 HMO must maintain or require professional liability insurance on each
of the providers in its network in the amount of $100,000 per
occurrence and $300,000 in the aggregate, or the limits required by
the hospital at which the network provider has admitting privileges.
4.4.3 HMO must maintain an umbrella professional liability insurance policy
for the greater of $3,000,000 or an amount (rounded to the next
$100,000) which represents the number of STAR+PLUS Members enrolled in
HMO in the first month of the contract year multiplied by $150, not to
exceed $10,000,000.
4.4.4 Any exceptions to the requirements of this Article must be approved in
writing by TDHS prior to the effective date of this contract. HMOs and
providers who qualify as either state or federal units of government
are exempt from the insurance requirements of this Article and are not
required to obtain exemptions from these provisions prior to the
effective date of this contract. State and federal units of government
are required to
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comply with and are subject to the provisions of the Texas or Federal
Tort Claims Act.
4.5 FRANCHISE TAX
HMO certifies that its payment of franchise taxes is current or that
it is not subject to the State of Texas franchise tax.
4.6 AUDIT
4.6.1 TDHS, TDI or their designee have the right from time to time to
examine and audit books and records of the HMO or of its
Subcontractors relating to: (1) HMO's capacity to bear the risk of
potential financial losses; (2) services performed or determination of
amounts payable under this contract; (3) detection of fraud and abuse;
and (4) other purposes TDHS deems to be necessary to perform its
regulatory function and/or to enforce the provisions of this contract.
4.6.2 TDHS is required to conduct an audit of HMO at least once every three
years. HMO is responsible for paying the costs of an audit conducted
under this Article. The costs of the audit paid by HMO are allowable
costs under this contract.
4.7 PENDING OR THREATENED LITIGATION
HMO must require disclosure from Subcontractors and network providers
of all pending or potential litigation or administrative actions
against the Subcontractor or network provider and must disclose this
information to TDHS, in writing, prior to the execution of this
contract. HMO must make reasonable investigation and inquiry that
there is not pending or potential litigation or administrative action
against the providers or Subcontractors in HMO s provider network. HMO
must notify TDHS of any litigation which is initiated or threatened
during the contract period within seven days of receiving service or
becoming aware of the threatened litigation.
4.8 MISREPRESENTATION AND FRAUD IN RESPONSE TO RFA
4.8.1 HMO was awarded the original Contract based upon the responses and
representations contained in its application. All responses and
representations upon which scoring was based were considered material
to the decision of whether to award the original Contract to HMO and
are thus incorporated by reference into this Contract. If there is any
difference between HMOs RFA responses and this Contract, the Contract
shall control.
4.8.2 This Contract was awarded in part based upon HMOs representation of
its current equity, deposits and financial ability to bear the risks
under this Contract. TDHS will consider any misrepresentations of
equity at any time, its ability to bear financial risks of this
Contract or otherwise inflating the equity of HMO, solely for the
purpose of being awarded this Contract, a material misrepresentation
and fraud under this Contract.
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4.8.3 Discovery of any material misrepresentation, or fraud on the part of
HMO in HMO s application or in HMO s day-to-day activities and
operations may cause this contract to terminate and may result in
legal action being taken against HMO under this contract, and state
and federal civil and criminal laws.
4.9 THIRD PARTY RECOVERY
FOR ACUTE CARE SERVICES
4.9.1 Third Party Recovery. All Members are required to assign their rights
to any benefits to the State and agree to cooperate with the State in
identifying third parties who may be liable for all or part of the
costs for providing services to the Member, as a condition for
participation in the Medicaid program. HMO is authorized to act as the
State's agent in enforcing the State's rights to third party recovery
under this contract.
4.9.2 Identification. HMO must develop and implement systems and procedures
to identify potential third parties who may be liable for payment of
all or part of the costs for providing medical services to Members
under this contract. Potential third parties must include any of the
sources identified in 42 C.F.R. 433.138, relating to identifying third
parties, except workers' compensation, uninsured and underinsured
motorist insurance, first and third party liability insurance and
tortfeasors. HMO must coordinate with the state to obtain information
from other state and federal agencies and HMO must cooperate with the
State in obtaining information from commercial third party resources.
HMO must require all providers to comply with the provisions of 25 TAC
Section 28, relating to Third Party Recovery in the Medicaid program.
4.9.3 Exchange of identified resources. HMO must forward identified
resources of uninsured and underinsured motorist insurance, first and
third party liability insurance and tortfeasors ("excepted resources")
to the State for the State to pursue collection and recovery from
these resources. The State will forward information on all third party
resources identified by the State to HMO. HMO must coordinate with the
State to obtain information from other state and federal agencies,
including HCFA for Medicare and the Child Support Enforcement Division
of the Office of the Attorney General for medical support. HMO must
cooperate with the State in obtaining and exchanging information from
commercial third party resources.
4.9.4 Recovery. HMO must actively pursue and collect from third party
resources which have been identified, except when the cost of pursuing
recovery reasonably exceeds the amount which may be recovered by HMO.
HMO is not required to, but may pursue recovery and collection from
the excepted resources listed in 4.9.3. HMO must report the identity
of these resources to the State, even if HMO will pursue collection
and recovery from the excepted resources.
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4.9.4.1 HMO must provide third party resource information to network providers
to whom individual Members have been assigned or who provide services
to Members. HMO must require providers to seek recovery from potential
third party resources prior to seeking payment from HMO. If network
providers are paid capitation, HMO must either seek recovery from
third party resources or account to the State for all amounts received
by network providers from third party resources.
4.9.4.2 HMO must prohibit network providers from interfering with or placing
liens upon the State's right or the HMO's right, acting as the State's
agent, to recovery from third party resources. HMO must prohibit
network providers from seeking recovery in excess of the Medicaid
payable amount or otherwise violating state and federal laws.
4.9.5 Retention. HMO may retain as income all amounts recovered from third
party sources as long as recoveries are obtained in compliance with
the contract and state and federal laws.
4.9.6 Accountability. HMO must report all third party recovery efforts and
amounts recovered as required in 12.1.10. If HMO fails to pursue and
recover from third parties no later 180 days after the date of
service, the State may pursue third party recoveries and retain all
amounts recovered without accounting to HMO for the amounts recovered.
Amounts recovered by the State will be added to expected third party
recoveries to reduce future capitation rate, except recoveries from
those excepted third party resources listed in 4.9.3.
FOR LONG-TERM CARE SERVICES
4.9.7 HMO is expected to identify members who have insurance coverage that
should pay for all or part of the expenses related to the long-term
care needs of the client. The use of this process will result in a
cost avoidance to hold down costs to the Medicaid program. The HMO may
retain any amounts recovered, if the HMO must pursue collection of
these benefits after the expenses are incurred.
4.9.8 TDHS retains the right and responsibility to pursue recovery of
amounts from subrogation claims arising out of tort claims and
recovery from OBRA 93 trusts and annuities. HMO must assist TDHS in
these activities by providing information to TDHS related to costs
paid on behalf of the member in these situations.
4.10 CLAIMS PROCESSING REQUIREMENTS
4.10.1 HMO and claims processing Subcontractors must comply with the Texas
Managed Care Claims Manual (Claims Manual), which contains claims
processing requirements. HMO must comply with any changes to Claims
Manual with appropriate notice of changes from the State.
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4.10.2 HMO must not pay any claim submitted by a provider who has been
excluded or suspended from the Medicare or Medicaid programs for fraud
and abuse when the HMO has knowledge of the exclusion or suspension.
4.10.3 All provider clean claims must be adjudicated (finalized as paid or
denied adjudicated) within 30 days from the date the claim is received
by the HMO. HMO must pay providers interest on a clean claim which is
not adjudicated within 30 days from the date the claim is received by
the HMO or becomes clean at a rate of 1.5% per month (18% annual) for
each month the clean claim remains unadjudicated. HMO will be held to
a minimum performance level of 90% of all clean claims paid or denied
within 30 days of receipt and 99% of all clean claims paid or denied
within 90 days of receipt. Failure to meet these performance levels is
a default under this contract and could lead to damages or sanctions
as outlined in Article XVII. The performance levels are subject to
changes if required to comply with federal and state laws or
regulations.
4.10.3.1 All claims and appeals submitted to HMO and claims processing
subcontractors must be paid-adjudicated (clean claims),
denied-adjudicated (clean claims), or denied for additional
information (unclean claims) to providers within 30 days from the date
the claim is received by HMO. Providers must be sent a written notice
for each claim that is denied for additional information (unclean
claims) identifying the claim, all reasons why the claim is being
denied, the date the claim was received by HMO, all information
required from the provider in order for the HMO to adjudicate the
claim, and the date by which the requested information must be
received from the provider.
4.10.3.2 Claims that are suspended (pended internally) must be subsequently
paid-adjudicated, denied-adjudicated, or denied for additional
information (pended externally) within 30 days from date of receipt.
No claim can be suspended for a period exceeding 30 days from date of
receipt of the claim.
4.10.3.3 HMO must identify each data field of each claim form that is required
from the provider in order for the HMO to adjudicate the claim. HMO
must inform all network providers about the required fields no later
than 30 days prior to the effective date of the contract or as a
provision within the HMO/provider contract. Out of network providers
must be informed of all required fields if the claim is denied for
additional information. The required fields must include those
required by the HMO and TDHS.
4.10.4 HMO is subject to the Remedies and Sanctions Article of this contract
for claims that are not processed on a timely basis as required by
this contract and the Claims Manual. Not withstanding the provisions
of Articles 4.10.3, 4.10.3.1 and 4.10.3.2, sanctions will be applied
if at least ninety percent (90%) of all claims are not adjudicated
(paid, denied, or external pended) within thirty (30) days of receipt
and ninety nine percent (99%) with in ninety (90) days of receipt for
the contract year to date.
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4.10.5 HMO agrees that when it receives written notification from TDHS that a
provider's funds be held because the provider has changed ownership,
has an unpaid judgment, sanction, monetary penalty or audit exception,
or has failed to meet some other legal requirement, the HMO will place
the provider's funds on hold until it receives further notification
from TDHS. Upon notification to the HMO, the HMO must either pay the
claim or remit the held funds to TDHS.
4.10.6 HMO must comply with the standards adopted by the U.S. Department of
Health and Human Services under the Health Insurance Portability and
Accountability Act of 1996 submitting and receiving claims information
through electronic data interchange (EDI) that allows for automated
processing and adjudication of claims within two or three years, as
applicable, from the date the rules promulgated under HIPAA are
adopted.
4.11 INDEMNIFICATION
4.11.1 HMO/TDHS: HMO must agree to indemnify TDHS and its agents for any and
all claims, cost, damages and expenses, including court costs and
reasonable attorney fees which are related to or arise out of:
4.11.1.1 Any failure, inability or refusal of HMO or any of its network
providers or other Subcontractors to provide covered services:
4.11.1.2 Claims arising from HMO, HMOs network providers or other
Subcontractors negligent or intentional conduct in not providing
covered services and;
4.11.1.3 Failure, inability or refusal of HMO to pay any of its network
providers or Subcontractors for covered services.
4.11.2 HMO/Provider: HMO is prohibited from requiring any providers to
indemnify HMO for HMOs own acts or omissions which result in damages
or sanctions being assessed against HMO either under this contract or
under State or Federal Law.
ARTICLE V STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS
5.1 COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS
5.1.1 HMO must know, understand and comply with all state and federal laws
and regulations relating to the Texas Medicaid Program which have not
been waived by HCFA. HMO must comply with all rules relating to the
Medicaid Managed Care program adopted by TDHS, TDI, TDH, THHSC, TDMHMR
and any other state agency delegated authority to operate or
administer Medicaid or Medicaid Managed Care Programs.
5.1.2 HMO must require through contract provisions, that all network
providers or Subcontractors comply with all state and federal laws and
regulations
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relating to the Texas Medicaid program and all rules relating to the
Medicaid Managed Care program adopted by TDHS, TDI, TDH, THHSC, TDMHMR
and any other state agency delegated authority to operate Medicaid or
Medicaid Managed Care programs.
5.1.3 HMO must comply with the provisions of the Clean Air Act and the
Federal Water Pollution Control Act, as amended, found at 42 C.F.R.
7401, et. seq. and 33 U.S.C.1251, et. seq., respectively.
5.2 PROGRAM INTEGRITY
5.2.1 HMO has not been excluded, debarred, or suspended from participation
in any program under Title XVIII or Title XIX under any of the
provisions of section 1128(a) or (b) of the Social Security Act (42
USC Section 1320 a-7), or Executive Order 12549. HMO must notify TDHS
within 3 days of the time it receives notice that any action being
taken against HMO or any person defined under the provision of section
1128 (a) or (b) or any Subcontractor, which could result in exclusion,
debarment or suspension of HMO or a Subcontractor from the Medicaid
program, or any program listed in Executive Order 12549.
5.2.2 HMO must Comply with the provisions of and file the certification of
compliance required by the ▇▇▇▇ Anti-Lobbying Amendment, found at 31
USC 1352, relating to use of federal funds for lobbying for or
obtaining federal contracts.
5.3 FRAUD AND ABUSE COMPLIANCE PLAN
5.3.1 This contract is subject to all state and federal laws and regulations
relating to fraud and abuse in health care and the Medicaid program.
HMO must cooperate and assist TDHS and THHSC and any other state or
federal agency charged with the duty of identifying, investigating,
sanctioning or prosecuting suspected fraud and abuse. HMO must provide
originals and/or copies of all records and information requested and
allow access to premises and provide records to TDHS or its authorized
agent(s), THHSC, HCFA, the U.S. Department of Health and Human
Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud
Control Unit. All copies of records must be provided free of charge.
5.3.2 Compliance Plan. HMO must submit to TDHS for approval a written fraud
and abuse compliance plan which is based on the Model Compliance Plan
issued by the U.S. Department of Health and Human Services, the Office
of Inspector General (OIG), no later than 30 days after the effective
date of the contract. HMO must designate an officer or director in its
organization who has the responsibility and authority for carrying out
the provisions of its compliance plan. HMO must submit any updates or
modifications in its compliance plan to TDHS for approval at least 30
days prior to the modifications going into effect. HMO's fraud and
abuse compliance plan must:
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5.3.2.1 ensure that all officers, directors, managers and employees know and
understand the provisions of HMO's fraud and abuse compliance plan.
5.3.2.2 contain procedures designed to prevent and detect potential or
suspected abuse and fraud in the administration and delivery of
services under this contract.
5.3.2.3 contain provisions for the confidential reporting of plan violations
to the designated person in HMO.
5.3.2.4 contain provisions for the investigation and follow-up of any
compliance plan reports.
5.3.2.5 ensure that the identity of individuals reporting violations of the
plan is protected.
5.3.2.6 contain specific and detailed internal procedures for officers,
directors, managers and employees for detecting, reporting, and
investigating fraud and abuse compliance plan violations.
5.3.2.7 require any confirmed or suspected fraud and abuse under state or
federal law be reported to TDHS, the Medicaid Program Integrity
section of the Office of Investigations and Enforcement of the Texas
Health and Human Services Commission, and/or the Medicaid Fraud
Control Unit of the Texas Attorney General.
5.3.2.8 ensure that no individual who reports plan violations or suspected
fraud and abuse is retaliated against.
5.3.3 Training. HMO must designate executive and essential personnel to
attend mandatory training in fraud and abuse detection, prevention and
reporting. The training will be conducted by the Office of
Investigation and Enforcement, Health and Human Services Commission,
and will be provided free of charge. HMO must schedule and complete
training no later than 90 days after the effective date of any updates
or modification of the written Model Compliance Plan.
5.3.3.1 If HMO's personnel have attended OIE training prior to the effective
date of this contract, they are not required to attend additional OIE
training unless new training is required due to changes in federal
and/or state law or regulations. If additional OIE training is
required, TDHS will notify HMO to schedule this additional training.
5.3.3.2 If HMO updates or modifies its written fraud and abuse compliance
plan, HMO must train its executive and essential personnel on these
updates or modifications no later than 90 days after the effective
date of the updates or modifications.
5.3.3.3 If HMO's executive and essential personnel change or if HMO employs
additional executive and essential personnel, the new or additional
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personnel must attend OIE training within 90 days of employment by
HMO.
5.3.4 HMO's failure to report potential or suspected fraud or abuse may
result in sanctions, contract cancellation, or exclusion from
participation in the Medicaid program.
5.3.5 HMO must allow the Texas Medicaid Fraud Control Unit and THHSC's
Office of Investigations and Enforcement, to conduct private
interviews of HMO's employees, subcontractors and their employees,
witnesses, and patients. Requests for information must be complied
with in the form and the language requested. HMO's employees and its
subcontractors and their employees must cooperate fully and be
available in person for interviews, consultation, grand jury
proceedings, pre-trial conference, hearings, trial and in any other
process.
5.3.6 Subcontractors. HMO must submit the documentation described in
Articles 5.3.6.1 through 5.3.6.3, in compliance with Texas Government
Code Section 533.012, regarding any subcontractor providing health
care services under this contract except for those providers who have
re-enrolled as a provider in the Medicaid program as required by
Section 2.07, Chapter 1153, Acts of the 75th Legislature, Regular
Session, 1997, or who modified a contract in compliance with that
section. HMO must submit information in a format as specified by TDHS.
Documentation must be submitted no later than 120 days after the
effective date of this contract. Subcontracts entered into after the
effective date of this contract must be submitted no later than 90
days after the effective date of the subcontract. Documentation
required under this provision is not subject to disclosure under
Chapter 552, Government Code.
5.3.6.1 a description of any financial or other business relationship between
HMO and its subcontractor;
5.3.6.2 a copy of each type of contract between HMO and its subcontractor;
5.3.6.3 a description of the fraud control program used by any subcontractor.
5.4 SAFEGUARDING INFORMATION
5.4.1 All Member information, records and data collected or provided to HMO
by TDHS or another state agency is protected from disclosure by state
and federal law and regulations. HMO may only receive and disclose
information which is directly related to establishing eligibility,
providing services and conducting or assisting in the investigation
and prosecution of civil and criminal proceedings under state or
federal law.
5.4.2 HMO is responsible for informing Members and providers regarding the
provisions of 42 CFR 431, Subpart F, relating to Safeguarding
Information on Applicants and Recipients, and HMO must ensure that
confidential information is protected from disclosure except for
authorized purposes.
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5.4.3 HMO must assist network PCPs in policies for protecting the
confidentiality of AIDS and HIV-related medical information and an
anti-discrimination policy for employees and Members with communicable
diseases. Also see Health and Safety Code, Chapter 85, Subchapter E,
relating to the Duties of State Agencies and State Contractors.
5.4.4 HMO must require that Subcontractors have mechanisms in place to
ensure Member's (including minor's) confidentiality for family
planning services.
5.5 NON-DISCRIMINATION
▇▇▇ agrees to comply with and to include in all subcontracts a
provision that the Subcontractor will comply with each of the
following requirements:
5.5.1 Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, the Americans with Disabilities Act of
1990, and all requirements imposed by the regulations implementing
these acts and all amendments to the laws and regulations. The
regulations provide in part that no person in the United States shall,
on the grounds of race, color, national origin, sex, age, disability,
political beliefs or religion, be excluded from participation in, or
denied, any aid, care, service or other benefits, or be subjected to
any discrimination under any program or activity receiving federal
funds.
5.5.2 Texas Health and Safety Code Section 85.113 (relating to workplace and
confidentiality guidelines regarding AIDS and HIV).
5.5.3 The provisions of Executive Order 11246, as amended by 11375, relating
to Equal Employment Opportunity.
5.6 HISTORICALLY UNDERUTILIZED BUSINESSES (HUBs)
5.6.1 TDHS is committed to providing procurement and contracting
opportunities to historically underutilized businesses (HUBs), under
the provisions of Texas Government Code, Title 10, Subtitle D, Chapter
2161 and 1 TAC Section 111.11(b) and 111.13(c)(7). TDHS requires its
HMOs and Subcontractors to make a good faith effort to assist HUBs in
receiving a portion of the total contract value of this Contract.
5.6.2 The HUB good faith effort goal for this Contract is 18.1%. HMO agrees
to make a good faith effort to meet or exceed this goal. HMO
acknowledges it made certain good faith effort representations and
commitments to TDHS during the HUB good faith effort determination
process. HMO agrees to use its best efforts to abide by these
representations and commitments during the Contract period.
5.6.3 HMO is required to submit to TDHS quarterly reports of its HUB
programs efforts and accomplishments during the Contract period as
required in 12.11 of this Contract. The quarterly reports must include
a narrative
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report describing HMO's HUB efforts and accomplishments and a
financial report reflecting expenditures made with HUBs. Included in
Attachment B of this Contract is the format which must be used for the
quarterly reports.
5.6.4 TDHS will assist HMO in meeting the contracting and reporting
requirements of this section.
5.7 AFFIRMATIVE ACTION
5.7.1 HMO must have in place, to the extent required by federal or state
law, an "Affirmative Action Plan," which is a written document that
details an affirmative action program. Key parts of an affirmative
action plan are:
(a) a policy statement pledging nondiscrimination and
affirmative action in employment;
(b) internal and external dissemination of the policy;
(c) assignment of a key employee as the equal opportunity
officer;
(d) a work force analysis that identifies job classifications
where representation of women, minorities and the disabled
is deficient;
(e) goals and timetables that are specific and measurable, and
that are set to correct deficiencies and to reach a balance
of work force;
(f) revision of all employment practices to ensure that they do
not have discriminatory effects; and
(g) establishment of internal monitoring and reporting systems
to regularly measure progress.
5.8 BUY TEXAS
HMO agrees to Buy Texas products and materials when they are available
at a comparable price and in a comparable period of time, as required
by Section 48 of Article IX of the General Appropriations Act of 1995.
5.9 CHILD SUPPORT
5.9.1 The Texas Family Code Section 231.006 requires the State to withhold
contract payments from any for profit entity or individual who is at
least thirty (30) days delinquent in child support obligations. It is
HMOs responsibility to determine and verify that no owner, partner, or
shareholder who has at least a 25% ownership interest in HMO is
delinquent in child support obligations. HMO must attach a list of the
names and social security numbers of all shareholders, partners or
owners who have at least a 25% ownership interest in HMO.
5.9.2 Under Section 231.006 of the Family Code, contractor certifies that
the contractor is not ineligible to receive the specified grant, loan,
or payment and acknowledges that this Contract may be terminated and
payment may be withheld if this certification is inaccurate. A child
support obligor who is more than thirty (30) days delinquent in paying
child support or a
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business entity in which the obligor is a sole proprietor, partner,
shareholder, or owner with an ownership interest of at least 25
percent is not eligible to receive the specified grant, loan or
payment.
5.9.3 If TDHS is informed and verifies that a child support obligor who is
more than thirty (30) days delinquent is a partner, shareholder, or
owner with at least a 25% ownership interest in HMO, it will withhold
any payments due under this Contract until it has received
satisfactory evidence that the obligation has been satisfied or that
the obligor has entered into a written repayment request.
5.10 REQUEST FOR PUBLIC INFORMATION
5.10.1 This contract and all network provider and Subcontractor contracts are
subject to public disclosure under the Public Information Act (Texas
Government Code, Chapter 552). TDHS may receive Public Information
requests related to this contract, information submitted as part of
the compliance of the contract and the HMO's application upon which
this contract was awarded. TDHS agrees that it will promptly deliver a
copy of any request for public information to the HMO.
5.10.2 TDHS may, in its sole discretion, request a decision from the Office
of the Attorney General (AG opinion) regarding whether the information
requested is excepted from required public disclosure. TDHS may rely
on the HMO's written representations in preparing any AG opinion
request, in accordance with Texas Government Code Section 552.305.
TDHS is not liable for failing to request an AG opinion or for
releasing information which is not deemed confidential by law, if the
HMO fails to provide TDHS with specific reasons why the requested
information is exempt from the required public disclosure. TDHS or the
Office of the Attorney General will notify all interested parties if
an AG opinion is requested.
5.10.3 If the HMO believes that the requested information qualifies as a
trade secret or as commercial or financial information, HMO must
notify TDHS-- within three (3) working days of HMO's receipt of the
request of the specific text, or portion of text, which the HMO claims
is excepted from required public disclosure. The HMO is required to
identify the specific provisions of the Act which the HMO believes are
applicable, and is required to include a detailed written explanation
of how the exceptions apply to the specific information identified by
the HMO as confidential and excepted from required public disclosure.
5.11 NOTICE AND APPEAL
For Acute care services, HMO must comply with the notice requirements
contained in 25 TAC Section 36.21, and the maintaining benefits and
services contained in 25 TAC Section 36.22, whenever the HMO intends
to take an action affecting the Member benefits and services under
this contract. See also the Member appeal requirements contained in
Article 8.7 of this contract.
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For Long Term Care services, HMO must comply with the notice
requirements contained in 40 TAC, Section 79.1204, and the appeal
requirements of 40 TAC ch.79, whenever HMO intends to take an adverse
action affecting Member benefits and services under this Contract. HMO
agrees to provide information regarding fair hearings to TDHS within
fifteen (15) days of the date of appeal and agrees to provide an HMO
staff member to represent HMO at the hearing. See also the Member
appeal requirements containing in paragraph 8.7 of this Contract.
ARTICLE VI SCOPE OF SERVICES
6.1 SCOPE OF SERVICES
HMO is paid capitation for all services included in the State of Texas
Title XIX State Plan and the 1915(b) and 1915(c) waiver applications
for the SDA currently filed and approved by HCFA, except those
services which are specifically excluded and listed in Article 6.1.8
(non-capitated services).
6.1.1 HMO must pay for or reimburse for all covered services provided to
mandatory-enrolled Members for whom HMO is paid capitation.
6.1.2 HMO must provide Acute care covered services described in the 1999
Texas Medicaid Provider Procedures Manual (Provider Procedures
Manual), subsequent editions of the Provider Procedures Manual also in
effect during the contract period, and all Texas Medicaid Bulletins
which update the 1999 Provider Procedures Manual and subsequent
editions of the Provider Procedures Manual published during the
contract period.
6.1.3 Long Term care covered services include attendant care, day activity
and health services, and required services under the 1915 (c) waiver.
6.1.3.1. HMO is responsible for the Medicare co-payment for days
21-100 in a skilled nursing facility.
6.1.4 Covered services are subject to change due to changes in federal law,
changes in Texas Medicaid policy, and/or responses to changes in
Medicine, Clinical protocols, or technology.
6.1.5 The State has obtained a waiver to the State Plan to include three
enhanced benefits to all members. Two of these enhanced benefits
removed restrictions which previously applied to Medicaid eligible
individuals 21 years and older: the three-prescriptions per month
limit for Medicaid only recipients; and, the 30-day spell of illness
limit. One of these expanded the covered benefits to add an annual
adult well check.
6.1.6 Value-added Services. Value-added services that are approved by TDHS
during the contracting process are included in the Scope of Services
under this contract.
6.1.6.1 The approval request must include:
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6.1.6.1.1 A detailed description of the service to be offered;
6.1.6.1.2 Identification of the category or group of Members eligible to receive
the service if it is a type of service that is not appropriate for all
Members.
6.1.6.1.3 Any limits or restrictions which apply to the service; and
6.1.6.1.4 A description of how a Member may obtain or access the service.
6.1.6.2 Value-added services can only be added or removed by written amendment
of this contract. HMO cannot include a value-added service in any
material distributed to Members or prospective Members until this
contract has been amended to include that value-added service.
6.1.6.2.1 If a value-added service is deleted by amendment, HMO must notify each
Member that the service is no longer available through HMO, and HMO
must revise all materials distributed to prospective Members to
reflect the change in covered services.
6.1.6.3 Value-added services must be offered to all eligible HMO Members, as
indicated in Article 6.1.6.1.2, unless the contract is amended or the
contract terminates.
6.1.7 HMO may offer additional benefits that are outside the scope of
services of this contract to individual Members on a case-by-case
basis, based on medical necessity, cost-effectiveness, and
satisfaction and improved health/behavioral health status of the
Member/Member family.
6.1.8 Non-Capitated Services. The following Texas Medicaid program services
have been excluded from the services included in the calculation of
HMO capitation rate:
THSteps Dental (including Orthodontia)
Early Childhood Intervention Case Management/Service Coordination
MHMR Targeted Case Management
Mental Health Rehabilitation
Pregnant Women and Infants Case Management
THSteps Medical Case Management
Texas School Health and Related Services
Texas Commission for the Blind Case Management
Tuberculosis Services Provided by TDH-approved providers (Directly
Observed Therapy and Contact Investigation)
Vendor Drugs (out of office drugs)
Medical Transportation
TDHS Hospice Services
Refer to relevant chapters in the Provider Procedures Manual and the
Texas Medicaid Bulletins for more information.
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Although HMO is not responsible for paying or reimbursing for these
non-capitated services, HMO remains responsible for providing
appropriate referrals for Members to obtain or access these services.
6.1.8.1 HMO is responsible for informing providers that all non-capitated
services must be submitted to the State for payment or reimbursement.
6.2 PRE-EXISTING CONDITIONS
HMO is responsible for providing all covered services to each eligible
Member beginning on the effective date of the Contract or the Member's
date of enrollment under the contract regardless of pre-existing
conditions, prior diagnosis and/or receipt of any prior health care
services.
6.3 SPAN OF ELIGIBILITY
The following outlines the HMO's responsibilities for payment of
hospital and free-standing psychiatric facility (facility) admissions:
6.3.1 Inpatient Admission Prior to Enrollment in HMO. HMO is responsible for
payment of physician and non-hospital/facility charges for the period
for which the HMO is paid a capitation payment for that Member. HMO is
not responsible for hospital/facility charges for Members admitted
prior to the date of enrollment in HMO.
6.3.2 Inpatient Admission after Enrollment in HMO. HMO is responsible for
all charges until the Member is discharged from the hospital facility
or until the Member loses Medicaid eligibility.
6.3.2.1 If a Member regains Medicaid eligibility and the Member was enrolled
in the HMO at the time the Member was admitted to the hospital, the
HMO is responsible for charges as follows:
6.3.2.1.1 Member Re-enrolls into HMO after Regaining Medicaid Eligibility. HMO
is responsible for all charges for the period for which HMO receives a
capitation payment for the Member or until the Member is discharged or
loses Medicaid eligibility.
6.3.2.1.2 Member Re-enrolls in Another Health Plan after Regaining Medicaid
Eligibility. HMO is responsible for hospital/facility charges until
the Member is discharged or loses Medicaid eligibility.
6.3.3 Plan Change. A Member cannot change from one health plan to another
health plan during an inpatient hospital stay.
6.3.4 Hospital/Facility Transfer. Discharge from one acute care
hospital/facility and readmission to another acute care
hospital/facility within 24 hours for continued treatment is not a
discharge under this contract.
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6.3.5 HMO insolvency or receivership. HMO is responsible for payment of all
services provided to a person who was a Member on the date of
insolvency or receivership to the same extent they would otherwise be
responsible under this Article 6.3.
6.4 CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS
6.4.1 HMO must ensure that the care of newly enrolled Members is not
disrupted or interrupted. HMO must take special care to provide
continuity in the care of newly enrolled Members whose health or
behavioral health condition has been treated by specialty care
providers or whose health could be placed in jeopardy if care is
disrupted or interrupted.
6.4.2 Pregnant Members with 12 weeks or less remaining before the expected
delivery date must be allowed to remain under the care of the Member's
current OB/GYN through the Member's postpartum checkup even if the
provider is out-of-network. If Member wants to change her OB/▇▇▇ to
one who is in the plan, she must be allowed to do so if the provider
to whom she wishes to transfer agrees to accept her in the last
trimester.
6.4.3 HMO must pay a Member's existing out-of-network providers for covered
services until the Member's records, clinical information and care can
be transferred to a network provider. Payment must be made within the
time period required for network providers. HMO may pay any
out-of-network provider a reasonable and customary amount determined
by the HMO. This Article does not extend the obligation of HMO to
reimburse the Member's existing out-of-network providers of on-going
care for more than 90 days after Member enrolls in HMO or for more
than nine months in the case of a Member who at the time of enrollment
in HMO has been diagnosed with and receiving treatment for a terminal
illness. The obligation of HMO to reimburse the Member's existing
out-of-network provider for services provided to a pregnant Member
with 12 weeks or less remaining before the expected delivery date
extends through delivery of the child, immediate postpartum care, and
the follow-up checkup within the first six weeks of delivery.
6.4.4 HMO must pay out-of-network providers who provide covered services to
Members who move out of the service area through the end of the period
for which capitation has been paid for the Member.
6.5 EMERGENCY CARE
6.5.1 HMO must pay for the professional, facility, and ancillary services
that are medically necessary to perform the medical screening
examination and stabilization of HMO Member presenting as an emergency
medical condition or an emergency behavioral health condition to the
hospital emergency department, 24 hours a day, 7 days a week, rendered
by either HMO's in-network or out-of-network providers. HMO may elect
to pay any emergency services provider an amount negotiated between
the
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emergency provider and HMO, or a reasonable and customary amount
determined by the HMO.
6.5.2 The HMO must ensure that its network primary care providers (PCPs)
have after-hours telephone availability 24 hours a day, 7 days a week
throughout the service area.
6.5.3 HMO cannot require prior authorization as a condition for payment for
an emergency medical condition, an emergency behavioral health
condition, or labor and delivery.
6.5.4 Medical Screening Examination. A medical screening examination may
range from a relatively simple history, physical examination,
diagnosis, and treatment, to a complex examination, diagnosis, and
treatment that requires substantial use of hospital emergency
department and physician services. HMO must pay for the emergency
medical screening examination required to determine whether an
emergency condition exists, as required by 42 U.S.C. 1395dd. HMOs must
reimburse for both the physician's services and the hospital's
emergency services, including the emergency room and its ancillary
services.
6.5.5 Stabilization services. HMO must pay for emergency services performed
to stabilize the Member as documented by the Emergency physician in
the Member's medical record. HMOs must reimburse for physician's
services and hospital's emergency services including the emergency
room and its ancillary services. With respect to an emergency medical
condition, to stabilize is to provide such medical care as to assure
within reasonable medical probability that no deterioration of the
condition is likely to result from, or occur during discharge,
transfer, or admission of the Member from the emergency room.
6.5.6 Post-stabilization services. Post-stabilization services are services
subsequent to an emergency that a treating physician views as
medically necessary after an emergency medical condition has been
stabilized. They are not "emergency services" and are subject to HMO's
prior authorization process. HMO must be available to authorize or
deny post-stabilization services within one hour after being contacted
by the treating physician.
6.5.7 HMO must provide access to the TDH-designated Level I and Level II
trauma centers within the State or hospitals meeting the equivalent
level of trauma care. HMOs may make out-of-network reimbursement
arrangements with the TDH-designated Level I and Level II trauma
centers to satisfy this access requirement.
6.6 BEHAVIORAL HEALTH SERVICES - SPECIFIC REQUIREMENTS
6.6.1 HMO must provide or arrange to have provided to Members all Behavioral
Health Services included as covered services. These services are
described in detail in the Texas Medicaid Provider Procedures Manual
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(Provider Procedures Manual) and the Texas Medicaid Bulletins, which
is the bi-monthly update to the Provider Procedures Manual. Clinical
information regarding covered services are published by the Texas
Medicaid program in the Texas Medicaid Service Delivery Guide.
6.6.2 HMO must maintain a behavioral health provider network that includes
psychiatrists, psychologists and other behavioral health providers.
HMO must provide or arrange to have provided behavioral health
benefits described as covered services. These services are indicated
in the Provider Procedures Manual and the Texas Medicaid Bulletins,
which is the bi-monthly update to the Provider Procedures Manual.
Clinical information regarding covered services are published by the
Texas Medicaid Program in the Texas Medicaid Service Delivery Guide.
The network must include providers with experience in serving children
and adolescents to ensure accessibility and availability of qualified
providers to all eligible children and adolescents in the service
area. The list of providers including names, addresses and phone
numbers must be available to State upon request.
6.6.3 HMO must maintain a Member education process to help Members know
where and how to obtain behavioral health services.
6.6.4 HMO must implement policies and procedures to ensure that Members who
require routine or regular laboratory and ancillary medical tests or
procedures to monitor behavioral health conditions are provided the
services by the provider ordering the procedure or at a lab located at
or near the provider's office.
6.6.5 When assessing Members for behavioral health services, the HMO and
network behavioral health providers must use the DSM-IV multi-axial
classification and report axes I, II, III, IV, and V to the State. The
State may require use of other assessment instrument/outcome measures
in addition to the DSM-IV. Providers must document DSM-IV and
assessment/outcome information in the Member's medical record.
6.6.6 HMO must permit Members to self refer to any in-network behavioral
health care provider without a referral from the Member's PCP. The HMO
must permit Members to participate in the selection or assignment of
the appropriate behavioral health individual practitioner(s) who will
serve them. HMO previously submitted a written copy of its policies
and procedures for self-referral to the State. Changes or amendments
to those policies and procedures must be submitted to the State for
approval at least 60 days prior to their effective date.
6.6.7 HMO must require, through contract provisions, that PCPs have
screening and evaluation procedures for detection and treatment of, or
referral for, any known or suspected behavioral health problems and
disorders. PCPs may provide any clinically appropriate behavioral
health care services within the scope of their practice. This
requirement must be included in all Provider Manuals.
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6.6.8 HMO must require that behavioral health providers refer Members with
known or suspected physical health problems or disorders to their PCP
for examination and treatment. Behavioral health providers may only
provide physical health services if they are licensed to do so. This
requirement must be included in all Provider Manuals.
6.6.9 HMO must require, that behavioral health providers send initial and
quarterly (or more frequently if clinically indicated) summary reports
of Members' behavioral health status to PCP. This requirement must be
included in all Provider Manuals.
6.6.10 HMO must require, through contract provisions, that all Members
receiving inpatient psychiatric services are scheduled for outpatient
follow-up and/or continuing treatment prior to discharge. The
outpatient treatment must occur within 7 days from the date of
discharge. HMO must ensure that behavioral health providers contact
Members who have missed appointments within 24 hours to reschedule
appointments.
6.6.11 HMO must provide inpatient psychiatric services to Members under the
age of 21 who have been ordered to receive the services by a court of
competent jurisdiction under the provisions of Chapters 573 and 574 of
the Texas Health and Safety Code, relating to court ordered
commitments to psychiatric facilities.
6.6.11.1 HMO cannot deny, reduce or controvert the medical necessity of any
court ordered inpatient psychiatric service for Members under age 21.
Any modification or termination of services must be presented to the
court with jurisdiction over the matter for determination.
6.6.11.2 A Member who has been ordered to receive treatment under the
provisions of Chapter 573 or 574 of the Texas Health and Safety Code
cannot appeal the commitment through the HMO's complaint or appeals
process.
6.6.12 HMO must comply with 28 TAC Sections 3.8001 et seq., regarding
utilization of chemical dependency treatment.
6.7 FAMILY PLANNING - SPECIFIC REQUIREMENTS
6.7.1 Counseling and Education. HMO must require, through contract
provisions, that Members requesting contraceptive services or family
planning services are also provided counseling and education about
family planning and family planning services available to members. HMO
must develop outreach programs to increase community support for
family planning and encourage Members to use available family planning
services. HMO is encouraged to include a representative cross-section
of Members and family planning providers who practice in the community
in developing, planning and implementing family planning outreach
programs.
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6.7.2 Freedom of Choice. HMO must ensure that Members have the right to
choose any Medicaid participating family planning provider, whether
the provider chosen by the Member is in or outside the HMO provider
network. HMO must provide Members access to information about the
providers of family planning services available and the Member's right
to choose any Medicaid family planning provider. HMO must provide
access to confidential family planning services.
6.7.3 Provider Standards and Payment. HMO must require all Subcontractors
who are family planning agencies to deliver family planning services
according to the State Family Planning Service Delivery Standards. HMO
must provide, at minimum, the full scope of services available under
the Texas Medicaid program for family planning services. The HMO will
reimburse family planning agencies and out-of-network family planning
providers the Medicaid fee-for service amounts for family planning
services, including medically necessary medications, contraceptives,
and supplies.
6.7.4 HMO must provide medically-approved methods of contraception to
Members. Contraceptive methods must be accompanied by verbal and
written instructions on their correct use. HMO must establish
mechanisms to ensure all medically approved methods of contraception
are made available to the Member, either directly or by referral to a
Subcontractor. The following initial Member education content may vary
according to the educator's assessment of the Member's current
knowledge:
6.7.4.1 general benefits of family planning services and contraception;
6.7.4.2 information on male and female basic reproductive anatomy and
physiology;
6.7.4.3 information regarding particular benefits and potential side effects
and complications of all available contraceptive methods;
6.7.4.4 information concerning all of the health care provider's available
services, the purpose and sequence of health care provider procedures,
and the routine schedule of return visits;
6.7.4.5 information regarding medical emergencies and where to obtain
emergency care on a 24-hour basis;
6.7.4.6 breast self-examination rationales and instructions unless provided
during physical exam (for females); and
6.7.4.7 information on HIV/STD infection and prevention and safer sex
discussion.
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6.7.5 HMO must require, through contractual provisions, that subcontractors
have mechanisms in place to ensure Member's (including minor's)
confidentiality for family planning services.
6.7.6 HMO must develop, implement, monitor, and maintain standards, policies
and procedures for providing information regarding family planning to
providers and Members, specifically regarding State and federal laws
governing Member confidentiality (including minors). Providers and
family planning agencies cannot require parental consent for minors to
receive family planning services.
6.7.7 HMO must report encounter data on family planning services in
accordance with Article 12.2.
6.8 TEXAS HEALTH STEPS (EPSDT)
6.8.1 THSteps Services. HMO must develop methods to ensure that children
under the age of 21 receive THSteps services when due and according to
the recommendations established by the American Academy of Pediatrics
and the THSteps periodicity schedule for children. HMO must arrange
for THSteps services to be provided to all eligible Members except
when a Member knowingly and voluntarily declines or refuses services
after the Member has been provided information upon which to make an
informed decision.
6.8.2 Member education and information. HMO must ensure that Members are
provided information and educational materials about the services
available through the THSteps program, and how and when they can
obtain the services. The information should tell the Member how they
can obtain dental benefits, transportation services through the TDHS
Medicaid Transportation programs and advocacy assistance from HMO.
6.8.3 Provider education and training. HMO must provide appropriate training
to all network providers and provider staff in the providers area of
practice regarding the scope of benefits available and the Texas
Health Steps program. Training must include THSteps benefits, the
periodicity schedule for THSteps check-ups and immunizations, and
Comprehensive Care Program (CCP) services that are available under the
THSteps program to member under age 21 years. Providers must also be
educated and trained regarding the requirements imposed upon the
department and contracting HMOs under the Consent Decree entered in
▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇, et. al., Civil Action No. 3:93CV65, in the United
States District Court for the Eastern District of Texas, Paris
Division. Providers should be educated and trained to treat each
THSteps visit as an opportunity for a comprehensive assessment of the
Member.
6.8.4 Member Outreach. HMO must provide an outreach unit that works with
Members to ensure they receive prompt services and are effectively
informed about available THSteps services. Each month the HMO must
retrieve from the Enrollment Broker BBS a list of members who are due
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and overdue THSteps services. Using these lists and their own
internally generated lists, HMOs will contact members and encourage
members who are periodically due or overdue a THSteps service to
obtain the service as soon as possible. HMO outreach staff must
coordinate with TDH THSteps outreach staff to ensure that Members have
access to the Medical Transportation Program, and that any
coordination with other agencies is maintained.
6.8.5 Initial Checkups upon enrollment. HMO must have mechanisms in place to
ensure that all newly enrolled Members receive a THSteps checkup
within 90 days from enrollment, if one is due according to the
American Academy of Pediatrics periodicity schedule, or if there is
uncertainty regarding whether one is due. HMO should make THSteps
checkups a priority to all newly enrolled Members.
6.8.6 Accelerated Services to Migrant Populations. HMO must cooperate and
coordinate with the department, outreach programs and THSteps regional
program staff and agents to ensure prompt delivery of services to
children of migrant farm workers and other migrant populations who may
transition into and out of HMO s program more rapidly and/or
unpredictably than the general population.
6.8.7 Coordination and Cooperation. HMO must make an effort to coordinate
and cooperate with existing community and school-based health and
education programs that offer services to school-aged children in a
location that is both familiar and convenient to the Members. HMO must
make a good faith effort to comply with Head Start requirement that
members participating in Head Start receive their THSteps checkup no
later than 45 days after enrolling into either program.
6.8.8 Immunizations. HMO must educate providers of the Immunization standard
requirements set forth in Chapter 161, Health and Safety Code,
standard in the ACIP Immunization Schedule and AAP Periodicity
Schedule.
6.8.8.1 ImmTrac Compliance. HMO must educate providers about and require
providers to comply with the requirements of Chapter 161, Health and
Safety Code, relating to the Texas Immunization Registry (ImmTrac), to
include parental consent on the Vaccine Information Statement.
6.8.9 Claim forms. HMO must require all THSteps providers to submit claims
for services paid (either on a capitated or fee-for-service basis) on
the HCFA 1500 claim form and use the unique procedure coding required
by TDHS.
6.8.10 Compliance with THSteps performance benchmarks. The State will
establish performance benchmarks against which HMO s full compliance
with the THSteps periodicity schedule will be measured. The
performance benchmarks will establish minimum compliance measures
which will increase over time. HMO must meet all performance
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benchmarks required for THSteps services. HMO must submit all THSteps
reports and encounters as required under this contract. Failure to
meet or exceed the performance benchmarks may result in: removal of
THSteps component of the capitation amounts paid to HMO; or any of the
Remedies contained in Article XVIII. Repeated non-compliance with the
THSteps performance benchmarks is a major breach of the terms of this
contract and could result in termination of the contract, or non-
renewal of the contract, in addition to all money damages and
sanctions assessed against HMO for non-compliance with reporting
administrative requirements.
6.8.11 Validation of Encounter Data. Encounter data will be validated by
chart review of a random sample of THSteps eligible enrollees against
monthly encounter data reported by HMO. Chart reviews will be
conducted by the State to validate that all screens are performed when
due and as reported and that reported data is accurate and timely.
Substantial deviation between reported and charted encounter data
could result in HMO and/or network providers being investigated for
potential fraud and abuse without notice to the HMO or the provider.
6.9 PERINATAL SERVICES
6.9.1 HMO's perinatal health care services must ensure appropriate care is
provided to women who are Members of HMO. The HMO's perinatal health
care system must comply with the requirements of Health & Safety Code,
Chapter 32 Maternal and Infant Health Improvement Act and 25 TAC
Section 37.233 et. seq.
6.9.2 HMO shall have a perinatal health care system in place that, at a
minimum, provides the following services:
6.9.2.1 pregnancy planning and perinatal health promotion and education for
reproductive age women;
6.9.2.2 perinatal risk assessment of nonpregnant women, pregnant and
postpartum women;
6.9.2.3 access to appropriate levels of care based on risk assessment,
including emergency care;
6.9.2.4 transfer and care of pregnant women to tertiary care facilities when
necessary;
6.9.2.5 availability and accessibility of obstetrician/gynecologists;
anesthesiologists, and neonatologists capable of dealing with
complicated perinatal problems;
6.9.2.6 availability and accessibility of appropriate outpatient and inpatient
facilities capable of dealing with complicated perinatal problems; and
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6.9.2.7 compiles, analyzes and reports process and outcome data of Members to
the State.
6.9.3 HMO must provide inpatient care for its pregnant/delivering Members in
a health care facility, if requested by the mother or is determined to
be medically necessary by the Member's PCP, for a minimum of:
6.9.3.1 48 hours following an uncomplicated vaginal delivery and,
6.9.3.2 96 hours for an uncomplicated caesarian delivery.
6.9.4 HMO must establish mechanisms to ensure that medically necessary
inpatient care is provided to the Member for complications following
the birth of newborn using the HMO's prior authorization procedures
for a medically necessary hospitalization.
6.10 EARLY CHILDHOOD INTERVENTION
6.10.1 ECI Services. HMO must provide all federally mandated services
contained at 34 C.F.R. 303.1 et. seq., and 25 TAC Section 621.21 et.
seq., relating to identification, referral and delivery of health care
services contained in the Member's Individual Family Service Plan
(IFSP). An IFSP is the written plan which identifies a Member's
disability or chronic or complex conditions(s) or developmental delay,
and describes the course of action developed to meet those needs, and
identifies the person or persons responsible for each action in the
plan. The plan is a mutual agreement of the Member's Primary Care
Physician (PCP), Case Manager, and the Member/family, and is part of
the Member's medical record.
6.10.2 ECI Providers. HMO must contract with qualified providers to provide
ECI services to Members under age 3 with developmental delays. HMO may
contract with local ECI programs or non-ECI providers who meet
qualifications for participation by the Texas Interagency Council on
Early Childhood Intervention to provide ECI services.
6.10.3 Identification and Referral. HMO must ensure that network providers
are educated regarding the identification of Members under age 3 who
have or are at risk for having disabilities and/or developmental
delays. HMO must use written education material developed or approved
by the Texas Interagency Council on Early Childhood Intervention. HMO
must ensure that all providers refer identified Members to ECI service
providers within two working days from the day the Member is
identified. Eligibility for ECI services is determined by the local
ECI program using the criteria contained in 25 TAC Section 621.21 et.
seq.
6.10.4 Coordination. HMO must coordinate and cooperate with local ECI
programs which perform assessment in the development of the Individual
Family Service Plan (IFSP), including ongoing case management and
other non-capitated services required by the Member's IFSP.
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Cooperation includes conducting medical diagnostic procedures and
providing medical records required to perform developmental
assessments and develop the IFSP within the time lines established at
34 C.F.R. 303.1 et. seq. ECI case management is not an HMO capitated
service.
6.10.5 Intervention. HMO must require, through contract provisions, that all
medically necessary health and behavioral health services contained in
the Member's IFSP are provided to the Member in amount, duration and
scope established by the IFSP. Medical necessity for health and
behavioral health services is determined by the interdisciplinary team
as approved by the Member's PCP. HMO cannot modify the plan of care or
alter the amount, duration and scope of services required by the
Member's IFSP. HMO cannot create unnecessary barriers for the Member
to obtain IFSP services, including requiring prior authorization for
the ECI assessment and insufficient authorization periods for prior
authorized services.
6.11 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND
CHILDREN (WIC) - SPECIFIC REQUIREMENTS
6.11.1 HMO must coordinate with WIC to provide certain medical information,
which is necessary to determine WIC eligibility, such as height,
weight, hematocrit or hemoglobin.
6.11.2 HMO must direct all eligible Members to the WIC program (Medicaid
recipients are automatically income-eligible for WIC).
6.11.3 HMO must coordinate with existing WIC providers to ensure Members have
access to the special supplemental nutrition program for women,
infants and children (WIC), or HMO must provide these services.
6.11.4 The HMO may use the nutrition education provided by WIC to satisfy
health education requirements described in this contract.
6.12 TUBERCULOSIS (TB)
6.12.1 Education, screening, diagnosis and treatment. HMO must provide
Members and providers with education on the prevention, detection and
effective treatment of tuberculosis (TB). HMO must establish
mechanisms to ensure all procedures required to screen at-risk Members
and to form the basis for a diagnosis and proper prophylaxis and
management of TB are available to all Members, except services
referenced in Article 6.1.8 as non-capitated services. HMO must
develop policies and procedures to ensure that Members who may be or
are at risk for exposure to TB are screened for TB. An at-risk Member
refers to a person who is susceptible to TB because of the association
with certain risk factors, behaviors, drug resistance, or
environmental conditions. HMO must consult with the local TB control
program to ensure that all services and treatments provided by HMO are
in compliance with the
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guidelines recommended by the American Thoracic Society (ATS), the
Centers for Disease Control and Prevention (CDC), and TDH policies and
standards.
6.12.2 Reporting and referral. HMO must implement policies and procedures
requiring providers to report all confirmed or suspected cases of TB
to the local TB control program within one working day of
identification of a suspected case, using the forms and procedures for
reporting TB adopted by TDHS (25 TAC Chapter 97). HMO must require
that in-state or out-of-state labs report mycobacteriology culture
results positive for M. Tuberculosis and M. Tuberculosis antibiotic
susceptibility to TDH as required for in-state labs by 25 TAC Section
97.5(a). Referral to state-operated hospitals specializing in the
treatment of tuberculosis should only be made for TB-related
treatment.
6.12.3 Medical records. HMO must provide access to Member medical records to
TDHS and the local TB control program for all confirmed and suspected
TB cases upon request.
6.12.4 Coordination and cooperation with the local TB control program. HMO
must coordinate with the local TB control program to ensure that all
Members with confirmed or suspected TB have a contact investigation
and receive directly observed therapy (DOT). HMO must require, through
contract provisions, that providers report any Member who is
non-compliant, drug resistant, or who is or may be posing a public
health threat to TDHS or the local TB control program. HMO must
cooperate with the local TB control program in enforcing the control
measures and quarantine procedures contained in Chapter 81 of the
Texas Health and Safety Code.
6.12.4.1 HMO must have a mechanism for coordinating a post-discharge plan for
follow-up DOT with the local TB program.
6.12.4.2 HMO must coordinate with the TDHS South Texas Hospital and Texas
Center for Infectious Disease for voluntary and court-ordered
admission, discharge plans, treatment objectives and projected length
of stay for Members with multi-drug resistant TB.
6.12.4.3 HMO may contract with the local TB control programs to perform any of
the capitated services required in this Article.
6.13 HEALTH EDUCATION AND WELLNESS AND PREVENTION PLANS
6.13.1 Health Education Plan. HMO must develop and implement a Health
Education plan. The health education plan must tell Members how HMO
system operates, how to obtain services, including emergency care and
out-of-plan services. The plan must emphasize the value of screening
and preventive care and must contain disease-specific information and
educational materials.
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6.13.2 Wellness Promotion Programs. HMO must conduct wellness promotion
programs to improve the health status of its Members. HMO may
cooperatively conduct Health Education classes for all enrolled
STAR+PLUS members with one or more HMOs also contracting with TDHS in
the service area to provide services to Medicaid recipients in all
counties of the service area. Providers and HMO staff must integrate
health education, wellness and prevention training into the care of
each Member. HMO must provide a range of health promotion and wellness
information and activities for Members in formats that meet the needs
of all Members. HMO must:
(1) develop, maintain and distribute health education services
standards, policies and procedures to providers;
(2) monitor provider performance to ensure the standards for
health education services are complied with;
(3) inform providers in writing about any non-compliance with
the plan standards, policies or procedures;
(4) establish systems and procedures that ensure that provider's
medical instruction and education on preventive services
provided to the Member are documented in the Member's
medical record; and
(5) establish mechanisms for promoting preventive care services
to Members who do not access care, e.g. newsletters,
reminder cards, and mail-outs.
6.13.3 Health Education Activities Report. HMO must submit, upon request, a
Health Education Activities Schedule to the State or its designee
listing the time and location of classes, health fairs or other events
conducted during the time period of the request.
6.14 CARE COORDINATION AND TRANSITION PLANS FOR LONG TERM CARE SERVICES
6.14.1 For STAR+PLUS Members that are receiving all preventive, primary,
acute, and long term care services from the same HMO (this includes
Members that are eligible for Medicaid only and Members that are
Medicare eligible who select the STAR+PLUS HMO to also provide
Medicare covered services), HMO shall ensure that each Member has a
qualified PCP who is responsible for overall clinical direction and
serves as a central point of integration and coordination of covered
primary, acute, and long term care services. HMO will furnish a Care
Coordinator to all Members who request one, or when HMO has determined
through an assessment of the Member's health and support needs, that a
Care Coordinator is required. The Care Coordinator shall be
responsible for working with the Member or his representative and
service providers to develop a seamless package of care in which
primary, acute, and long
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term care service needs are met through a single, understandable,
rational plan. Each Member's plan must also be well coordinated with
the Member's family and community support systems. The Care
Coordinator shall work as a team with the PCP, and coordinate all
STAR+PLUS services with the PCP. HMO must identify and train certain
Members or their families to coordinate their own care, to the extent
of the Member's capability. HMO must empower its Care Coordinators to
authorize and refer Members for all long term care services.
6.14.2 For dually eligible Members who obtain their Medicare services outside
the STAR+PLUS HMO's Medicare network, HMO is responsible for meeting
the Member's long term care service needs. HMO's Care Coordinator
shall be responsible for providing a seamless package of long term
care services for each Member, and for coordinating preventive,
primary, and acute care services provided elsewhere into an
integrated, single, understandable, rational plan. Each Member's plan
must also be coordinated with the Member's family and community
support systems. In integrating each Member's care, the Care
Coordinator shall work with the Members physician as a team in
furnishing and coordinating a comprehensive long term care package.
HMO must empower its Care Coordinators to authorize and refer Members
for all long term care services. In order to integrate the Members
acute and primary care, and stay abreast of the Members needs and
condition, the Care Coordinator shall also actively involve and
coordinate with the Members primary and specialty care providers and
work cooperatively together.
6.14.3 HMO shall provide information about and referral to community
organizations that may not be providing STAR+PLUS covered services,
but are otherwise important to the health and well-being of Members.
These organizations include, but are not limited to:
1) State/Federal agencies (e.g., those agencies with
jurisdiction over children's services, aging, protective
services, public health, substance abuse, mental
health/retardation, rehabilitation, developmental
disabilities, income support, nutritional assistance, school
districts, family support agencies, etc.);
2) Social Service agencies (e.g., Area Agencies on Aging,
residential support agencies, independent living centers,
supported employment agencies, etc.) and ECI providers;
3) City and County agencies (e.g., welfare departments, Women,
Infants, and Children (WIC), housing programs, etc.);
4) Civic and religious organizations; and
5) Consumer groups, advocates, and councils (e.g., legal aid
offices, consumer/family support groups, permanency
planning, etc.).
6.14.4 HMO must have a protocol for quickly assessing the needs of Members
who are discharged from a hospital or other care or treatment
facility. HMO must ensure that social workers and discharge planners
in hospitals and hospital care coordinators are knowledgeable about
the mandatory requirement for Medicaid Members to receive their long
term care
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services under managed care. HMO Care Coordinator must work with the
Members PCP (whether or not the PCP is in HMOs network), the hospital
discharge planner(s), the Member, and the Members family to assess and
plan for the Members discharge. When long term care is needed, HMO
must ensure that the Members discharge plan includes arrangements for
receiving community-based care whenever possible. HMO must ensure that
the Member, the Members family, and the Members PCP are all
well-informed of all service options that are available to meet the
Members needs in the community.
6.14.5 Within thirty (30) days of receiving the Member's enrollment package,
HMO must review the screening information and any existing care plan,
and develop a transition plan for that Member Until such time as HMO
contacts the Member and coordinates modifications to the Members
current treatment/long term care services plan, HMO must ensure that
the current services continue and that there are no breaks in
services/treatment.
6.14.6 HMO must have assessment instruments. For infants and children, HMO
must have an instrument appropriate for the assessment of children.
The instrument(s) must be used to identify Members with significant
health problems, requiring immediate attention, and which can be used
to identify Members who need or are at risk of needing long term care
services. The appropriate Minimum Data Set (MDS) instrument must be
completed for every Member receiving long term care services, either
in the community or in a facility, in addition to any assessment
instrument HMO might use with the exception that for children under 21
do not have to be assessed using the MDS-HC. The instrument may be
completed by HMO Subcontractor, or service provider, but HMO remains
responsible for the data recorded. As specialized MDS instruments are
developed for other living arrangements (e.g., assisted living), TDHS
will notify HMO of the availability of the instrument and the date by
which data collection for using the instrument would be required.
6.14.7 For Members residing in nursing facilities, HMO must ensure that the
NF provider uses the MDS version required by HCFA regulations for
assessment and care planning and submits the MDS data electronically
to TDHS
6.14.8 All Members who qualify for nursing facility level of care must be
given the freedom to choose their setting of care, i.e., nursing
facility, within HMO's network. HMO shall ensure that the Member or
his representative is aware of all available options.
6.14.9 HMO must ensure that Members needing home and community based long
term care services are identified and referred to services in a timely
manner.
No individual under 21 should be admitted to a nursing facility
without completion of the following:
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1) Information about all available community-based long-term
care services appropriate to the individual's needs provided
to the individual and parent/guardian; and
2) A CRCG (Community Resource Coordination Group) meeting has
been held in which all other available options have been
considered and rejected.
6.14.10 When a need for nursing facility level of care is indicated, HMO must
refer the Member to TDHS for determination of Members eligibility.
HMO, at its discretion, may provide this level of care to Members not
determined eligible by TDHS.
6.14.11 HMO must develop a system to have a centralized record for each Member
reflecting current service plan and showing all services received by
the Member from providers within HMO network and from providers
external to the network. The centralized record will ensure that all
Plan providers, including specialty and long term care service
providers, make appropriate and timely entries regarding care
provided, diagnosis, medications prescribed, and treatment plans
developed. The PCP, or when applicable, the Care Coordinator, shall
determine the appropriate physical location of the Member record. In
most cases, the most appropriate location will be with the PCP or the
Care Coordinator. However, the location may vary depending on
residence (e.g., nursing homes or group homes) and particular care
needs of the Member. The HMO shall ensure that the organization of and
documentation included in the centralized Member record shall meet all
applicable professional standards ensuring confidentiality of Member
records, referrals, and documentation of information.
HMO must have a systematic process for generating or receiving
referrals and sharing confidential medical, treatment, and planning
information across providers.
6.14.12 HMO must assure that the Member is involved in the assessment process
and fully informed about options, is included in the development of
the service plan and is in agreement with the plan of care that is
developed.
6.14.13 HMO must provide a transition plan for Members currently receiving
Medicaid services. TDHS and/or previous health plan will provide
current HMO with detailed service plans, names of current providers,
etc. for Members receiving long term care services at the time of
enrollment. The transition planning process includes, but is not
limited to, the following:
(a) Review of existing TDHS care plans;
(b) Preparation of a transition plan that ensures continuous
care under the Member's current care plan during the
transfer into HMOs network while HMO conducts an appropriate
assessment and development of a new plan if needed; and
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(c) If Durable Medical Equipment had been ordered prior to
enrollment but not received by the time of enrollment,
coordination and follow through to ensure that the Member
receives other necessary supportive equipment and supplies
without undue delay.
6.14.14 HMO will hire as Care Coordinators persons experienced in meeting
the needs of vulnerable populations who have chronic or complex
conditions. These include, but are not limited to, persons with an
undergraduate and/or graduate degree in either social work or
nursing with relevant work experience. HMO may subcontract the Care
Coordination function to other entities or agencies, as long as the
Subcontractor's Care Coordinators meet these requirements.
6.15 1915 (c) WAIVER SERVICE (COMMUNITY BASED ALTERNATIVES)
6.15.1 The HMO must provide to members the array of services allowable
through the HCFA approved 1915 (c) waiver.
6.15.1.1 1915 (c) Waiver services must be available to all members who meet
CBA eligibility requirements based on their assessment and medical
necessity.
6.15.1.2 1915 (c) Waiver services may be made available to members who do not
meet the CBA eligibility requirements based on assessment and
medical necessity as a value added service.
6.15.2 Waiver Service eligibility for members of the HMO
6.15.2.1 The HMO must notify the TDHS when CBA eligibility testing is
initiated on a member of the HMO.
6.15.2.2 The HMO must apply risk criteria, complete the 3652 for medical
necessity determination, complete the assessment documentation and
prepare a CBA Individual Service Plan (ISP) for each member
requesting CBA services or for members identified as needing CBA
services.
6.15.2.3 The HMO must provide TDHS the results of the assessment activities.
6.15.2.4 TDHS will notify the member and the HMO of the results of their
eligibility determination based on the information provider by the
HMO.
6.15.2.4.1 If the member is eligible, the member will be notified of the
effective date of eligibility. A copy of the notice will be sent to
the HMO.
6.15.2.4.2 If the member is not eligible, the notification will provide
information on the member's right to appeal the adverse
determination. A copy of the notice will be sent to the HMO.
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6.15.3 Waiver Service eligibility for Medical Assistance Only non-member
applicants.
6.15.3.1 TDHS will inform the applicant that services are provided through
an HMO and allow the applicant to select the HMO.
6.15.3.2 TDHS will notify the selected HMO to initiate pre-enrollment
assessment services required under the waiver for the non-member.
6.15.3.3 The HMO must complete the 3652 for medical necessity determination,
complete the assessment documentation and prepare a CBA Individual
Service Plan (ISP) for each applicant referred by TDHS.
6.15.3.4 The HMO must provide information to TDHS reflecting the results of
the assessment activities.
6.15.3.5 The HMO will be authorized payment for the assessment activities in
accordance with the fee-for-services schedule in effect at the time
of the assessment regardless of final determination of applicant
eligibility.
6.15.3.6 TDHS will notify the client and the HMO of the results of their
eligibility determination.
6.15.3.6.1 If the applicant is eligible,
6.15.3.6.1.1 The HMO will be notified of their eligibility and the effective
date of eligibility will be the first day of the month following
the determination of eligibility.
6.15.3.6.1.2 The HMO will be notified of client eligibility and the client will
be enrolled in the HMO on the date that eligibility is effective.
The HMO will initiate the ISP on the date of enrollment.
6.15.3.6.2 If the applicant is not eligible, the notification will provide
information on the applicant's right to appeal the adverse
determination. No notification will be sent to the HMO if the
client is not eligible for CBA services.
6.15.4 Annual Reassessment
Prior to the end date of the annual ISP, the HMO must initiate the
annual reassessment to determine and validate continued eligibility
for CBA services for each CBA client. The HMO will be expected to
complete the same activities and submit the same documentation to
TDHS for the annual reassessment as required for the initial
determination of eligibility. The HMO is responsible for assessment
activities for members and no additional compensation will be paid
for the annual reassessment for members.
ARTICLE VII PROVIDER NETWORK REQUIREMENTS
7.1 NETWORK PROVIDER DIRECTORY
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7.1.1 HMO must submit a provider directory to TDHS prior to the effective
date of this contract unless already approved. HMO must provide the
provider directory to the Enrollment Broker for prospective members.
The directory must contain all critical elements specified in
Attachment D, Required Critical Elements.
7.1.2 If HMO contracts with limited provider networks, the provider
directory must comply with the requirements of 28 TAC 11.1600(b)(11),
relating to the disclosure and notice of limited provider networks.
7.1.3 Updates to the provider directory must be provided to the Enrollment
Broker at the beginning of each State fiscal year quarter. This
includes the months of September, December, March and June. HMO is
responsible for submitting draft updates to TDHS only if changes other
than PCP information are incorporated. HMO is responsible for sending
three final paper copies and one electronic copy of the updated
provider directory to TDHS each quarter. If an electronic format is
not available, five paper copies must be sent. TDHS will forward two
updated provider directories, along with its approval notice, to the
Enrollment Broker to facilitate the distribution of the directories.
7.2 PROVIDER ACCESSIBILITY
7.2.1 HMO must enter into written contracts with properly credentialed
health care service providers. The names of all providers must be
submitted to TDHS as part of HMO subcontracting process. HMO must have
its own credentialing process to review, approve and periodically
recertify the credentials of all participating providers in compliance
with 28 TAC Section 11.1902, relating to credentialing of providers in
HMOs.
7.2.2 HMO must require tax I.D. numbers from all providers. HMO is required
to do backup withholding from all payments to providers who fail to
give tax I.D. numbers, or who give incorrect numbers.
7.2.3 Timeframes for Access Requirements. HMO must have sufficient network
providers and establish procedures to ensure Members have access to
routine, urgent, and emergency services; telephone appointments;
advice and Member service lines. These services must be accessible to
Members within the following timeframes:
7.2.3.1 Urgent Care within 24 hours of request;
7.2.3.2 Routine care within 2 weeks of request;
7.2.3.3 Physical/Wellness Exams for adults must be provided within 10 weeks of
the request;
7.2.3.4 HMO must establish policies and procedures to ensure that THSteps
Checkups be provided within 90 days of new enrollment, except newborn
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Members should be seen within 2 weeks of enrollment, and in all cases
for all Members be consistent with the American Academy of Pediatrics
and THSteps periodicity schedule which is based on the American
Academy of Pediatrics schedule and delineated in the Texas Medicaid
Provider Procedures Manual and the Medicaid bi-monthly bulletins (see
also Article 6.1, Scope of Services). If the Member does not request a
checkup, HMO must establish a procedure for contacting the Member to
schedule the checkup.
7.2.4 HMO is prohibited from requiring a provider or provider group to enter
into an exclusive contracting arrangement with HMO as a condition for
participation in its provider network.
7.3 PROVIDER CONTRACTS
7.3.1 All providers must have a written contract, either with an
intermediary entity or an HMO, to participate in the Medicaid program
(provider contract). HMO must make all contracts available to TDHS
upon request, at the time and location requested by TDHS. All standard
formats of provider contracts must be submitted to TDHS for approval
no later than 60 days after the execution date of this contract,
unless previously filed with TDHS. HMO must submit 1 paper copy and 1
electronic copy in a form specified by TDHS. Any change to the
standard format must be submitted to TDHS for approval no later than
30 days prior to the implementation of the new standard format. All
provider contracts are subject to the terms and conditions of this
contract and must contain the provisions of Article V, Statutory and
Regulatory Compliance, and the provisions contained in Article 3.2.4.
7.3.1.1 TDHS has 15 working days to review the materials and recommend any
suggestions or required changes. If TDHS has not responded to the HMO
by the fifteenth day, HMO may execute the contract. TDHS reserves the
right to request HMO to modify any contract that has been deemed
approved.
7.3.2 Primary Care Provider (PCP) contracts and specialty care contracts
must contain provisions relating to the requirements of the provider
types found in this contract. For example, PCP contracts must contain
the requirements of Article 7.9 relating to Primary Care Providers.
7.3.3 Provider contracts that are requested by any agency with authority to
investigate and prosecute fraud and abuse must be produced at the time
and place required by TDHS or the requesting agency. Provider
contracts requested in response to a Public Information request must
be produced within 48 hours of the request. Requested contracts and
all related records must be provided free-of-charge to the requesting
agency.
7.3.4 The form and substance of all provider contracts are subject to
approval by TDHS. TDHS retains the authority to reject or require
changes to any contract that do not comply with the requirements or
duties and
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responsibilities of this contract. HMO REMAINS RESPONSIBLE FOR
PERFORMING AND FOR ANY FAILURE TO PERFORM ALL DUTIES, RESPONSIBILITIES
AND SERVICES UNDER THIS CONTRACT REGARDLESS OF WHETHER THE DUTY,
RESPONSIBILITY OR SERVICE IS CONTRACTED TO ANOTHER FOR ACTUAL
PERFORMANCE.
7.3.5 TDHS reserves the right and retains the authority to make reasonable
inquiry and conduct investigations into patterns of provider and
Member complaints against HMO or any intermediary entity with whom HMO
contracts to deliver health services under this contract. TDHS may
impose appropriate sanctions and contract remedies to ensure HMO
compliance with the provisions of this contract.
7.3.6 HMO must not restrict a provider's ability to provide opinions or
counsel to a Member with respect to benefits, treatment options, and
provider's change in network status.
7.3.7 To the extent feasible within HMO's existing claims processing
systems, HMO should have a single or central address to which
providers must submit claims. If a central processing center is not
possible within the HMO's existing claims processing system, HMO must
provide each network provider a complete list of all entities to whom
the providers must submit claims for processing and/or adjudication.
The list must include the name of the entity, the address to which
claims must be sent, explanation for determination of the correct
claims payer based on services rendered, and a phone number the
provider may call to make claims inquiries. HMO must notify providers
in writing of any changes in the claims filing list at least 30 days
prior to effective date of change. If HMO is unable to provide 30 days
notice, providers must be given a 30-day extension on their claims
filing deadline to ensure claims are routed to correct processing
center.
7.3.8 HMO, all IPAs, and other intermediary entities must include contract
language which substantially complies with the following standard
contract provisions in each Medicaid provider contract. This language
must be included in each contract with an actual provider of services,
whether through a direct contract or through intermediary provider
contracts:
7.3.8.1 [Provider] is being contracted to deliver Medicaid managed care under
the TDHS STAR+PLUS program. HMO must provide copies of the TDHS/HMO
Contract to the [Provider] upon request. [Provider] understands that
services provided under this contract are funded by State and federal
funds under the Medicaid program. [Provider] is subject to all state
and federal laws, rules and regulations that apply to all persons or
entities receiving state and federal funds. [Provider] understands
that any violation by a provider of a State or federal law relating to
the delivery of services by the provider under this HMO/Provider
contract, or any violation of the TDHS/HMO contract could
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result in liability for money damages, and/or civil or criminal
penalties and sanctions under state and/or federal law.
7.3.8.2 [Provider] understands and agrees that HMO has the sole responsibility
for payment of covered services rendered by the provider under
HMO/Provider contract. In the event of HMO insolvency or cessation of
operations, [Provider's] sole recourse is against HMO through the
bankruptcy, conservatorship, or receivership estate of HMO.
7.3.8.3 [Provider] understands and agrees TDHS is not liable or responsible
for payment for any Medicaid covered services provided to mandatory
Members under HMO/Provider contract. Federal and State laws provide
severe penalties for any provider who attempts to collect any payment
from or bill a Medicaid recipient for a covered service.
7.3.8.4 [Provider] agrees that any modification, addition, or deletion of the
provisions of this contract will become effective no earlier than 30
days after HMO notifies TDHS of the change in writing. If TDHS does
not provide written approval within 30 days from receipt of
notification from HMO, changes can be considered provisionally
approved, and will become effective. Modifications, additions or
deletions which are required by TDHS or by changes in state or federal
law are effective immediately.
7.3.8.5 This contract is subject to all state and federal laws and regulations
relating to fraud and abuse in health care and the Medicaid program.
[Provider] must cooperate and assist TDHS and any state or federal
agency that is charged with the duty of identifying, investigating,
sanctioning or prosecuting suspected fraud and abuse. [Provider] must
provide originals and/or copies of any and all information, allow
access to premises and provide records to TDHS or its authorized
agent(s), THHSC, HCFA, the U.S. Department of Health and Human
Services, FBI, TDI, and the Texas Attorney General's Medicaid Fraud
Control Unit, upon request, and free-of-charge. [Provider] must report
any suspected fraud or abuse including any suspected fraud and abuse
committed by HMO or a Medicaid recipient to TDHS for referral to
THHSC.
7.3.8.6 [Provider] is required to submit proxy claims forms to HMO for
services provided to all STAR+PLUS Members that are capitated by HMO
in accordance with the encounter data submissions requirements
established by HMO and TDHS.
7.3.8.7 HMO is prohibited from imposing restrictions upon the [Provider's]
free communication with Members about a Member's medical conditions,
treatment options, HMO referral policies, and other HMO policies,
including financial incentives or arrangements and all STAR+PLUS
managed care plans with whom [Provider] contracts.
7.3.8.8 The Texas Medicaid Fraud Control Unit must be allowed to conduct
private interviews of [Providers] and the [Providers'] employees,
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contractors, and patients. Requests for information must be complied
with, in the form and language requested. [Providers] and their
employees and contractors must cooperate fully in making themselves
available in person for interviews, consultation, grand jury
proceedings, pre-trial conference, hearings, trial and in any other
process, including investigations. Compliance with this Article is
at HMO's and [Provider's] own expense.
7.3.8.9 HMO must include the method of payment and payment amounts in all
provider contracts.
7.3.8.10 All provider clean claims must be adjudicated within 30 days. HMO must
pay provider interest on all clean claims that are not paid within 30
days at a rate of 1.5% per month (18% annual) for each month the claim
remains unadjudicated.
7.3.8.11 HMO must prohibit network providers from interfering with or placing
liens upon the state's right or HMO's right, acting as the state's
agent, to recovery from third party resources. HMO must prohibit
network providers from seeking recovery in excess of the Medicaid
payable amount or otherwise violating state and federal laws.
7.3.9 HMO must follow the procedures outlined in Article 20A.18A of the
Texas Insurance Code if terminating a contract with a provider,
including an STP. At least 30 days before the effective date of the
proposed termination of the provider's contract the HMO must provide a
written explanation to the provider of the reasons for termination.
HMO may immediately terminate a provider contract if the provider
presents imminent harm to patient health, actions against a license or
practice, or fraud.
7.3.9.1 Within 60 days of the termination notice date, a provider may request
a review of the HMO's proposed termination by an advisory review
panel, except in a case in which there is imminent harm to patient
health, an action against a private license, or fraud. The advisory
review panel must be composed of physicians and providers, as those
terms are defined in Article 20A.02(r) and (t), including at least one
representative in the provider's specialty or a similar specialty, if
available, appointed to serve on the standing quality assurance
committee or utilization review committee of the HMO. The decision of
the advisory review panel must be considered by the HMO but is not
binding on the HMO. The HMO must provide to the affected provider, on
request, a copy of the recommendation of the advisory review panel and
the HMO's determination.
7.3.9.2 A provider who is terminated is entitled to an expedited review
process by the HMO on request by the provider. The HMO must provide
notification of the provider's termination to the HMO's Members
receiving care from the terminated provider at least 30 days before
the effective date of the
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termination. If a provider is terminated for reasons related to
imminent harm to patient health, HMO may notify its Members
immediately.
7.3.10 HMO must notify TDHS no later than 90 days prior to terminating any
subcontract affecting a major performance function of this contract.
If the HMO seeks to terminate a provider's contract for imminent harm
to patient health, actions against a license or practice, or fraud,
contract termination may be immediate. TDHS will require assurances
that any contract termination will not result in an interruption of an
essential service or major contract function.
7.3.11 HMO must include a complaint and appeals process which complies with
the requirements of Article 20A.12 of the Texas Insurance Code
relating to Complaint System in all subcontracts. HMO's complaint and
appeals process must be the same for all Contractors.
7.4 PHYSICIAN INCENTIVE PLANS
7.4.1 HMO may operate a physician incentive plan only if 1) no specific
payment may be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to reduce or
limit medically necessary services furnished to a Member, and 2) the
stop-loss protection, enrollee surveys and disclosure requirements of
this article are met.
7.4.2 HMO must disclose to TDHS information required by federal regulations
found at 42 C.F.R. Section 417.479. The information must be disclosed
in sufficient detail to determine whether the incentive plan complies
with the requirements at 42 C.F.R. Section 417.479. The disclosure
must contain the following information:
7.4.2.1 Whether services not furnished by a physician group (referral
services) are covered by the incentive plan. If only services
furnished by the physician or physician group are covered by the
incentive plan, disclosure of other aspects of the incentive plan are
not required to be disclosed.
7.4.2.2 The type of incentive arrangement (e.g. withhold, bonus, capitation).
7.4.2.3 The percent of the withhold or bonus, if the incentive plan involves a
withhold bonus.
7.4.2.4 Whether the physician or physician group has evidence of a stop-loss
protection, including the amount and type of stop-loss protection.
7.4.2.5 The panel size and the method used for pooling patients, if patients
are pooled.
7.4.2.6 The results of Member and disenrollee surveys, if HMO is required
under 42 C.F.R. Section 417.479 to conduct Member and disenrollee
surveys.
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7.4.3 HMO must submit the information required in 7.4.2.1 - 7.4.2.5 to TDHS
by the effective date of this contract and each anniversary date of
the contract.
7.4.4 HMO must submit the information required in 7.4.2.6 one year after
effective date of initial contract or effective date of renewal
contract, and annually each subsequent year under the contract. ▇▇▇'s
who put physicians or physician groups at substantial financial risk
must conduct a survey of all Members who have voluntarily disenrolled
in the previous year. A list of voluntary disenrollees may be obtained
from the Enrollment Broker.
7.4.5 HMO must provide Members with information regarding Physician
Incentive Plans upon request. The information must include the
following:
7.4.5.1 whether the HMO uses physician incentive plan that covers referral
services;
7.4.5.2 the type of incentive arrangement (i.e., withhold, bonus, capitation);
7.4.5.3 whether stop-loss protection is provided; and,
7.4.5.4 results of enrollee and disenrollee surveys, if required under 42
C.F.R. Section 417.479.
7.4.5.5 HMO must ensure that IPAs and ANHCs with whom HMO contracts comply
with the above requirements. HMO is required to meet above
requirements for all levels of subcontracting.
7.5 PROVIDER MANUAL AND PROVIDER TRAINING
7.5.1 HMO must prepare and issue a Provider Manual(s) including any
necessary specialty manuals (e.g. behavioral health) to the providers
in HMO network and to newly contracted providers in the HMO network
within five (5) working days from inclusion of the provider into the
network. The Provider Manual must contain sections relating to special
requirements of the STAR+PLUS Program as required under this Contract.
See Attachment D, Required Critical Elements, for specific details
regarding content requirements. The HMO Provider Manual containing the
new required critical elements must be distributed no later than March
1, 2000. HMO must submit a Provider Manual to TDHS for approval prior
to use. See Article 3.4.1 regarding the process for plan materials
review.
7.5.2 HMO must provide training to all network providers and their staff
regarding the requirements of the contract and special needs of
STAR+PLUS Members.
7.5.2.1 HMO training for all providers must be completed within 30 days of
placing a newly contracted provider on active status. HMO must provide
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on-going training to new and existing providers as required by HMO or
TDHS to comply with this contract.
7.5.2.2 HMO must provide training to PCPs on screening for and identifying
behavioral health disorders, HMOs referral process for behavioral
health services and clinical coordination requirements for behavioral
health. HMO must provide training to behavioral health providers to
identify physical health disorders, HMOs referral process to primary
care and clinical coordination requirements between physical medicine
and behavioral health providers. HMO must include topics on
coordination and quality of care such as behavioral health screening
techniques for PCPs and new models of behavioral health interventions.
7.5.3 HMO must provide primary care and behavioral health providers with
screening instruments approved by TDHS.
7.5.4 HMO must maintain and make available upon request enrollment or
attendance rosters dated and signed by each attendee or other written
evidence of training of each network provider and their staff.
7.5.5 HMO must have its written policies and procedures for the screening,
assessment and referral processes between behavioral health providers
and physical medicine providers available for TDHS review upon
request.
7.6 MEMBER PANEL REPORTS
HMO must furnish each PCP with a current list of enrolled Members
enrolled or assigned to that Provider no later than 5 days after HMO
receives the Enrollment File from the Enrollment Broker each month. If
the 5th day falls on a weekend or state holiday, the file must be
provided by the following working day.
7.7 PROVIDER COMPLAINT AND APPEAL PROCEDURES
7.7.1 HMO must develop, implement and maintain a provider complaint system.
The complaint and appeal procedure must be in compliance with all
applicable State and federal law or regulations. Modifications and
amendments to the complaint system must be submitted to TDHS no later
than 30 days prior to the implementation of the modification or
amendment.
7.7.2 HMO must include the provider complaint and appeal procedure in all
network provider contracts or in the provider manual.
7.7.3 HMO s complaint and appeal process cannot contain provisions referring
the complaint or appeal to TDHS for resolution. HMO providers and
other subcontractors are not "contractors" for purposes of 40 TAC Sec.
79.1601.
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7.7.4 HMO must establish mechanisms to ensure that network providers have
access to a person who can assist providers in resolving issues
relating to claims payment, plan administration, education and
training, and complaint procedures.
7.8 PROVIDER QUALIFICATIONS - GENERAL
The providers in HMO network must meet the following qualifications:
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FQHC A Federally Qualified Health Center meets the
standards established by federal rules and
procedures. The FQHC must also be an eligible
provider enrolled in the Medicaid.
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Physician An individual who is licensed to practice medicine
as an MD or a DO in the State of Texas either as a
primary care provider or in the area of
specialization under which they will provide
medical services under contract with HMO; who is a
provider enrolled in the Medicaid program; and who
has a valid Drug Enforcement Agency registration
number and a Texas Controlled Substance
Certificate, if either is required in their
practice.
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Hospital An institution licensed as a general or
special hospital by the State of Texas
under Chapter 241 of the Health and
Safety Code and Private Psychiatric
hospitals under Chapter 577 of the
Health and Safety Code (or is a provider
which is a component part of a State or
local government entity which does not
require a license under the laws of the
State of Texas), which is enrolled as a
provider in the Texas Medicaid Program.
HMO will require that all facilities in
the network used for acute inpatient
specialty care for people under age 21
with disabilities or chronic or complex
conditions will have a designated
pediatric unit; 24-hour laboratory and
blood bank availability; pediatric
radiological capability; meet JCAHO
standards; and have discharge planning
and social service units.
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Non-Physician An individual holding a license issued by the
Practitioner applicable licensing agency of the State of
Provider Texas who is enrolled in the Texas Medicaid
Program or an individual properly trained to
provide behavioral health support services who
practices under the direct supervision of an
appropriately licensed professional.
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Clinical An entity having a current certificate issued
Laboratory under the Federal Clinical Laboratory
Improvement Act (CLIA), and is enrolled in the
Texas Medicaid Program.
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Rural An institution which meets all of the criteria
Health for designation as a rural health clinic and
Clinic (RHC) is enrolled in the Texas Medicaid Program.
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Local A local health department established pursuant
Health to Health and Safety Code, Title 2, Local
Department Public Health Reorganization Act Section
121.031ff.
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Local Under Section 531.002(8) of the Health and
Mental Safety Code, the local component of the TXMHMR
Health system designated by TDMHMR to carry out the
Authority legislative mandate for planning, policy
(LMHA) development, coordination, and resource
development/allocation and for supervising and
ensuring the provision of mental health
services to persons with mental illness in one
or more local service areas.
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Non-Hospital A provider of health care services which is
Facility licensed and credentialed to provide services
Provider and is enrolled in the Texas Medicaid Program.
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School Clinics located at school campuses that
Based provide on site primary and preventive care to
Health children and adolescents.
Clinic
(SBHC)
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Home and A provider licensed by the Texas Department of
Community Health as a Home and Community Support
Support services Agency. The level of licensure
Service required depends on the type of service
Agency delivered. NOTE: For Primary Home Care and
Client Managed Attendant Care, the agency may
have only the Personal Assistance Services
level of licensure.
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Nursing A provider licensed and Medicaid
Home certified by the Texas Department of Human
Services, Long Term Care Regulatory Division.
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Personal A provider licensed by the Texas Department of
Care Home Human Services, Long Term Care Regulatory
Division. The type of licensure determines
what services may be provided. NOTE: Adult
▇▇▇▇▇▇ Homes providing care for 4 individuals
must be licensed as a Type C Personal Care
Home.
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Adult Day A provider licensed by the Texas Department of
Care Human Services, Long Term Care Regulatory
Facility Division as an adult day care provider. To
provide Day Activity and Health Services, the
provider must provide the range of services
required for DAHS.
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Emergency A provider licensed by the Texas Board of
Response Private Investigators and Private Security
Service Agencies unless specifically exempt from such
Provider licensure.
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Respiratory A provider certified by the Texas Department
Care of Health as a certified Respiratory Care
Practitioner Practitioner.
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Adult A Provider serving 3 or less clients, must be
▇▇▇▇▇▇ Home certified by the Applicant/HMO using
guidelines from the Texas Department of Human
Services.
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7.9 PRIMARY CARE PROVIDERS
7.9.1 HMO must have a system for monitoring Member enrollment into its plan
to allow HMO to effectively plan for future needs and recruit network
providers as necessary to ensure adequate access to primary care and
specialty care. The Member enrollment monitoring system must include
evaluating the length of time required for Members to access care
within the network. The monitoring system must also include a means
for routinely monitoring after-hours availability and accessibility of
PCPs.
7.9.2 HMO must maintain a primary care provider network in sufficient
numbers and geographic distribution to serve a minimum of forty-five
percent (45%) of the mandatory STAR+PLUS eligibles in each county of
the service area. HMO is required to increase the capacity of the
network as
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necessary to accommodate enrollment growth beyond the forty-fifth
percentile (45%).
7.9.3 HMO must maintain a provider network that includes pediatricians and
physicians with pediatric experience in sufficient numbers and
geographic distribution to serve eligible children and adolescents in
the service area and provide timely access to the full scope of
benefits, especially THSteps checkups and immunizations.
7.9.4 HMO must comply with the access requirements as established by the
Texas Department of Insurance for all HMOs doing business in Texas,
except as otherwise required by this contract.
7.9.5 HMO must have physicians with board eligibility/board certification in
pediatrics to be available for referral for Members under the age of
21.
7.9.5.1 Individual PCPs may serve more than 2,000 Members. However, if TDHS
determines that a PCP's Member enrollment exceeds the PCP's ability to
provide accessible, quality care, TDHS may prohibit the PCP from
receiving further enrollments. TDHS may direct HMOs to assign or
reassign Members to another PCP's panel.
7.9.6 HMO must have PCPs available throughout the service area to ensure
that no Member must travel more than 30 miles, or 45 minutes which
ever is less, to access the PCP, unless an exception to this distance
requirement is made by TDHS.
7.9.7 HMO's primary care provider network may include providers from any of
the following practice areas: General Practitioners; Family
Practitioners; Internists; Pediatricians; Obstetricians/Gynecologists
(OB/GYN); Pediatric and Family Advanced Practice Nurses (APNs) and
Certified Nurse Midwives Women Health (CNMs) practicing under the
supervision of a physician; Physician Assistants (PAs) practicing
under the supervision of a physician specializing in Family Practice,
Internal Medicine, Pediatrics or Obstetrics/Gynecology who also
qualifies as a PCP under this contract; or Federally Qualified Health
Centers (FQHCs), Rural Health Clinics (RHCs) and similar community
clinics; and specialists who are willing to provide medical homes to
selected Members with special needs and conditions.
7.9.8 The PCP for a Member with disabilities or chronic or complex
conditions may be a specialist who agrees to provide PCP services to
the Member. The specialty provider must agree to perform all PCP
duties required in the contract and PCP duties must be within the
scope of the specialist s license. HMO, specialty providers, for the
member or his representative may initiate the request for a specialist
to serve as a PCP for a Member with disabilities or chronic or complex
conditions.
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7.9.9 PCPs must either have admitting privileges at a hospital, which is
part of HMO network of providers, or make referral arrangements with
an HMO provider who has admitting privileges to a network hospital.
7.9.10 HMO must require that PCPs are accessible to Members 24 hours a day, 7
days a week. The following are acceptable and unacceptable phone
arrangements for contacting PCPs after normal business hours.
Acceptable:
(1) Office phone is answered after hours by an answering service
which meets language requirements of the major population
groups and which can contact the PCP or another designated
medical practitioner. All calls answered by an answering
service must be returned within 30 minutes.
(2) Office phone is answered after normal business hours by a
recording in the language of each of the major population
groups served directing the patient to call another number
to reach the PCP or another provider designated by the PCP.
Someone must be available to answer the designated provider
s phone. Another recording is not acceptable.
(3) Office phone is transferred after office hours to another
location where someone will answer the phone and be able to
contact the PCP or another designated medical practitioner,
who can return the call within 30 minutes.
Unacceptable:
(1) Office phone is only answered during office hours.
(2) Office phone is answered after hours by a recording which
tells patients to leave a message.
(3) Office phone is answered after hours by a recording which
directs patients to go to an Emergency Room for any services
needed.
(4) Returning after-hour calls outside of 30 minutes.
7.9.11 HMO must require PCPs, through contract provisions or provider manual,
to provide primary care services and continuity of care to Members who
are enrolled with or assigned to the PCP. Primary care services are
all services required by a Member for the prevention, detection,
treatment and cure of illness, trauma, disease or disorder, which are
covered and/or required services under this contract. All services
must be provided in compliance with generally accepted medical and
behavioral health standards for the community in which services are
rendered. HMO must require PCPs, through contract provisions or
provider manual, to provide children under the age of 21 services in
accordance with the American Academy of Pediatric recommendations and
the THSteps periodicity schedule and provide adults services in
accordance with the U.S. Preventive Services Task Force s publication
Put Prevention Into Practice.
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7.9.11.1 HMO must require PCPs, through contract provisions or provider manual,
to assess the medical needs of Members for referral to specialty care
providers and provide referrals as needed. PCP must coordinate care
with specialty care providers after referral.
7.9.11.2 HMO must require PCPs, through contract provisions or provider manual,
to make necessary arrangements with home and community support
services to integrate the Member s needs. This integration may be
delivered by coordinating the care of Members with other programs,
public health agencies and community resources which provide medical,
nutritional, behavioral, educational and outreach services available
to Members.
7.9.11.3 HMO must require, through contract provisions or provider manual, that
the Member s PCP or HMO provider through whom PCP has made
arrangements, be the admitting or attending physician for inpatient
hospital care, except for emergency medical or behavioral health
conditions or when the admission is made by a specialist to whom the
Member has been referred by the PCP. HMO must require, through
contract provisions or provider manual, that PCP assess the
advisability and availability of outpatient treatment alternatives to
inpatient admissions. HMO must require, through contract provisions or
provider manual, that PCP provide or arrange for pre-admission
planning for non-emergency inpatient admissions, and discharge
planning for Members. PCP must call the emergency room with relevant
information about the Member. PCP must provide or arrange for
follow-up care after emergency or inpatient care.
7.9.11.4 HMO must require PCPs for children under the age of 21 to provide or
arrange to have provided all services required under Article 6.8
relating to Texas Health Steps, Article 6.9 relating to Perinatal
Services, Article 6.10 relating to Early Childhood Intervention,
Article 6.11 relating to WIC, Article 6.13 relating to Health
Education and Wellness and Prevention Plans. PCP must cooperate and
coordinate with HMO to provide Member and the Member s family with
knowledge of and access to available services.
7.9.12 PCP selection, OB/GYN selection, and PCP default
7.9.12.1 Medicaid only recipients
Members who are not covered by Medicare have the right to select the
PCP and HMO to whom they will be assigned. Female members also have
the right to select an OB/GYN in addition to a PCP. An HMO may limit a
Members request to change PCP or OB/GYN to no more than four changes
in any 12-month period. If a PCP or OB/GYN who has been selected by or
assigned to a Member is not longer in HMOs provider network, HMO must
contact the member and provide them an opportunity to reselect. If the
Member does not want to change the PCP or OB/GYN to another network
provider the Member must be directed to the
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enrollment broker to select an alternative plan. If a PCP or OB/GYN
who has been selected by or assigned to a member is no longer in an
IPA's provider network but continues to participate in HMO network,
HMO or IPA may not change the members PCP or OB/GYN.
7.9.12.2 Dual eligible Members
Members covered by Medicare have the right to select the HMO to whom
they will be assigned. Failure to select an HMO will result in the
clients be defaulted to an HMO. Because the STAR+PLUS HMO is not
responsible for primary and acute care services for dual eligible
members, requirements related to PCP and OB/GYN selection and default
are not applicable.
7.10 OB/GYN PROVIDERS
HMO must allow a female Member to select an OB/GYN within its provider
network or within a limited provider network in addition to a PCP, to
provide health care services within the scope of the professional
specialty practice of a properly credentialed OB/GYN. See Article
21.53D of the Texas Insurance Code and 28 TAC Sections 11.506, 11.1600
and 11.1608. A Member who selects an OB/▇▇▇ must be allowed direct
access to the health care services of the OB/GYN without a referral by
the woman's PCP or a prior authorization or precertification from HMO.
HMO must allow Members to change OB/GYNs up to four times per year.
Health care services must include, but not be limited to:
7.10.1 One well-woman examination per year;
7.10.2 Care related to pregnancy;
7.10.3 Care for all active gynecological conditions; and
7.10.4 Diagnosis, treatment, and referral for any disease or condition within
the scope of the professional practice of a properly credentialed
obstetrician or gynecologist.
7.10.5 HMOs which allow its Members to directly access any OB/GYN provider
within its network, must ensure that the provisions of Articles 7.9.1
through 7.9.4 continue to be met.
7.10.6 OB/GYN providers must comply with HMO's procedures contained in HMO's
provider manual or provider contract for OB/GYN providers, including
but not limited to prior authorization procedures.
7.11 SPECIALTY CARE PROVIDERS
7.11.1 HMO must maintain specialty providers and facilities in sufficient
numbers and areas of practice to meet the needs of all Members
requiring specialty care or services.
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7.11.2 HMO must require, through contract provisions or provider manual, that
specialty providers send a record of consultation and recommendations
to a Member s PCP for inclusion in Member s medical record and report
encounters to the PCP and/or HMO.
7.11.3 HMO must ensure availability and accessibility to appropriate
specialists.
7.11.4 HMO must ensure that no Member is required to travel in excess of 75
miles to secure initial contact with referral specialists; special
hospitals, psychiatric hospitals; diagnostic and therapeutic services;
and single service health care physicians, dentists or providers.
Exceptions to this requirement may be allowed when an HMO has
established, through utilization data provided to TDHS, that a normal
pattern for securing health care services within an area exists or HMO
is providing care of a higher skill level or specialty than the level
which is available within the service area such as, but not limited
to, treatment of cancer, ▇▇▇▇▇, and cardiac diseases.
7.12 SPECIAL HOSPITALS AND SPECIALTY CARE FACILITIES
7.12.1 HMO must include all medically necessary specialty services through
its network specialists, subspecialists and specialty care facilities
(e.g., children's hospitals, and tertiary care hospitals).
7.12.2 HMO must include requirements for pre-admission and discharge planning
in its contracts with network hospitals. Discharge plans for a Member
must be provided by the HMO or the hospital to the Member/family, the
PCP and specialty care physicians.
7.12.3 The HMO must have appropriate multidisciplinary teams for people with
disabilities or chronic or complex medical conditions. These teams
must include the PCP and any individuals or providers involved in the
day-to-day or ongoing care of the Member.
7.12.4 The HMO must include in its provider network a TDHS-designated
perinatal care facility, as established by Section 32.042, Texas
Health and Safety Code, once the designated system is finalized and
perinatal care facilities have been approved for the service area. See
also Article 6.9.1 of this contract.
7.13 BEHAVIORAL HEALTH - LOCAL MENTAL HEALTH AUTHORITY (LMHA)
7.13.1 Assessment to determine eligibility for rehabilitative and targeted
MHMR case management services is a function of the LMHA. HMO must
provide all covered services described in detail in the Texas Medicaid
Provider Procedures Manual (Provider Procedures Manual) and the Texas
Medicaid Bulletins which is the bi-monthly update to the Provider
Procedures Manual. Clinical information regarding covered services are
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published by the Texas Medicaid program in the Texas Medicaid Service
Delivery Guide. Covered services must be provided to Members with SPMI
and SED, when medically necessary, whether or not they are also
receiving targeted case management or rehabilitation services through
the LMHA.
7.13.2 HMO will coordinate with the LMHA and state psychiatric facility
regarding admission and discharge planning, treatment objectives and
projected length of stay for Members committed by a court of law to
the state psychiatric facility.
7.13.3 HMO must enter into written agreement with all LMHAs in the service
area which describes the process(es) which the HMO and LMHA will use
to coordinate services for STAR+PLUS Members with SPMI or SED. The
agreement will contain the following provisions:
7.13.3.1 Describe the behavioral health covered services indicated in detail in
the Provider Procedures Manual and the Texas Medicaid Bulletins which
is the bi-monthly update to the Provider Procedures Manual. Clinical
information regarding covered services are published by the Texas
Medicaid program in the Texas Medicaid Service Delivery Guide. Also
include the amount, duration, and scope of basic and value-added
services, and HMO's responsibility to provide these services;
7.13.3.2 Describe criteria, protocols, procedures and instrumentation for
referral of STAR+PLUS Members from and to the HMO and LMHA;
7.13.3.3 Describe processes and procedures for referring Members with SPMI or
SED to LMHA for assessment and determination of eligibility for
rehabilitation or targeted case management services;
7.13.3.4 Describe how the LMHA and HMO will coordinate providing behavioral
health services to Members with SPMI or SED;
7.13.3.5 Establish clinical consultation procedures between the HMO and LMHA
including consultation to effect referrals and on-going consultation
regarding the Member's progress;
7.13.3.6 Establish procedures to authorize release and exchange of clinical
treatment records;
7.13.3.7 Establish procedures for coordination of assessment, intake/triage,
utilization review/utilization management and care for persons with
SPMI or SED;
7.13.3.8 Establish procedures for coordination of inpatient psychiatric
services (including court ordered commitment of Members under 21) in
state psychiatric facilities within the LMHA's catchment area;
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7.13.3.9 Establish procedures for coordination of emergency and urgent services
to Members;
7.13.3.10 Establish procedures for coordination of care and transition of care
for new HMO Members who are receiving treatment through the LMHA.
7.13.4 The HMO must offer licensed practitioners of the healing arts, who are
part of the Member's treatment team for rehabilitation services, the
opportunity to participate in the HMO's network. The practitioner must
agree to accept the standard provider reimbursement rate, meet the
credentialing requirements, comply with all the terms and conditions
of the standard provider contract of the HMO.
7.13.5 Members receiving rehabilitation services must be allowed to choose
the licensed practitioners of the healing arts who are currently a
part of the Member's treatment team for rehabilitation services. If
the Member chooses to receive these services from licensed
practitioners of the healing arts who are part of the Member's
rehabilitation services treatment team, the HMO must reimburse the
LMHA at current Medicaid fee-for-service amounts.
7.14 SIGNIFICANT TRADITIONAL PROVIDERS (STPS)
HMO must seek participation in its provider network from:
7.14.1 Each health care provider in the service area who has traditionally
provided care to Medicaid recipients;
7.14.2 Each hospital in the service area that has been designated as a
disproportionate share hospital under Medicaid; and
7.14.3 Each specialized pediatric laboratory in the service area, including
those laboratories located in children's hospitals.
7.14.4 HMO must include significant traditional providers as designated by
TDHS in its provider network to provide primary care and specialty
care services. HMO must include STPs in its provider network for at
least three (3) years following the Implementation Date in the service
area.
7.14.5 STPs must agree to the contract requirements contained in Article 7.2,
unless exempted from a requirement by law or rule. STPs must also
agree to the following contract requirements:
7.14.5.1 STP must agree to accept the standard reimbursement rate offered by
HMO to other providers for the same or similar services.
7.14.5.2 STP must meet the credentialing requirements of the HMO. HMO must not
require STPs to meet a different or higher credentialing standard than
is required of other providers providing the same or similar services.
HMO must not require STPs to contract with a subcontractor which
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requires a different or higher credentialing standard than the HMO's
if the application of the higher standard results in a
disproportionate number of STPs being excluded from the Subcontractor.
7.15 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINICS
(RHC)
7.15.1 HMO must make reasonable efforts to include FQHCs and RHCs
(Freestanding and hospital-based) in its provider network.
7.15.2 FQHCs or RHCs will receive a cost settlement from TDHS and must agree
to accept initial payments from the HMO in an amount that is equal to
or greater than the HMO's payment terms for other providers providing
the same or similar services.
7.15.2.1 HMO must submit monthly FQHC and RHC encounter and payment reports to
all contracted FQHCs and RHCs and FQHCs and RHCs with whom there have
been encounters, not later than 21 days from the end of the month for
which the report is submitted. The format will be developed by TDHS.
The FQHC and RHC must validate the encounter and payment information
contained in the report(s). HMO and the FQHC/RHC must both sign the
report(s) after each party agrees that it accurately reflects
encounters and payments for the month reported. The HMO must submit
the signed FQHC and RHC encounter and payment reports to TDHS not
later than 45 days from the end of the month for which the report is
submitted.
7.15.2.2 For FQHCs, TDHS will determine the amount of the interim settlement
based on the difference between: an amount equal to the number of
Medicaid allowable encounters multiplied by the rate per encounter
from the latest settled FQHC fiscal year cost report, and the amount
paid by HMO to FQHC for the quarter. For RHCs, TDHS will determine the
amount of the interim settlement based on the difference between a
reasonable cost amount methodology provided by TDHS and the amount
paid by HMO to the RHC for the quarter. TDHS will pay the FQHC or the
RHC the amount of the interim settlement, if any, as determined by
TDHS or collect and retain the quarterly recoupment amount, if any.
7.15.2.3 TDHS will cost settle with each FQHC and RHC annually, based on the
FQHC or RHC state fiscal year cost report and the methodology
described in Article 7.15.2.2. TDHS will make additional payments or
recoup payments from the FQHC or the RHC based on reasonable costs
less prior interim payment settlements.
7.15.2.4 Cost settlements for RHCs, and HMO's obligation to provide RHC
reporting described in Article 7.15, are retroactive to October 1,
1997.
ARTICLE VIII MEMBER SERVICES REQUIREMENTS
8.1 MEMBER EDUCATION
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HMO must provide the Member education requirements as contained in
Article VI at 6.5, 6.6, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14
and this Article of the contract.
8.2 MEMBER HANDBOOK
8.2.1 HMO must mail each newly enrolled Member a Member Handbook no later
than five (5) days after HMO receives the Enrollment File. If the 5th
day falls on a weekend or state holiday, the Member Handbook must be
mailed by the following working day. The Member Handbook must be
written at a 4th - 6th grade reading comprehension level. The Member
Handbook must contain all critical elements specified by TDHS. See
Attachment D, Required Critical Elements, for specific details
regarding content requirements. HMO must submit a Member Handbook to
TDHS for approval prior to the effective date of the contract unless
previously approved (see Article 3.4.1 regarding the process for plan
materials review).
8.2.2 Member Handbook Updates. HMO must provide updates to the Handbook to
all Members as changes are made to the Required Critical Elements in
Attachment D. HMO must make the Member Handbook available in the
languages of the major populations and the visually impaired served by
HMO.
8.2.3 THE MEMBER HANDBOOK AND ANY REVISIONS OR CHANGES MUST BE APPROVED BY
TDHS PRIOR TO PUBLICATION AND DISTRIBUTION TO MEMBERS (See Article
3.4.1 regarding the process for plan materials review).
8.3 ADVANCE DIRECTIVES
8.3.1 Federal and state law require HMOs and providers to maintain written
policies and procedures for informing and providing written
information to all adult Members 18 years of age and older about their
rights under state and federal law, in advance of their receiving care
(Social Security Act Section 1902(a)(57) and Section 1903(m)(1)(A)).
The written policies and procedures must contain procedures for
providing written information regarding the Member's right to refuse,
withhold or withdraw medical treatment advance directives. HMO's
policies and procedures must comply with provisions contained in 42
CFR Section 434.28 and 42 CFR Section 489, Sub Part I, relating to
advance directives for all hospitals, critical access hospitals,
skilled nursing facilities, home health agencies, providers of home
health care, providers of personal care services and hospices, as well
as the following state laws and rules:
8.3.1.1 the Member's right to self-determination in making health care
decisions;
8.3.1.2 the Advance Directives includes:
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8.3.1.2.1 a Member's right to execute an advance written directive to physicians
and family or surrogates, or to make a non-written directive to
administer, withhold or withdraw life-sustaining treatment in the
event of a terminal or irreversible condition;
8.3.1.2.2 a Member's right to make written and non-written Out-of-Hospital
Do-Not-Resuscitate Orders; and
8.3.1.2.3 a Member's right to execute a Medical Power of to appoint an agent to
make health care decisions on the Member's behalf if the Member
becomes incompetent.
8.3.2 HMO must maintain written policies for implementing a Member's advance
directive. Those policies must include a clear and precise statement
of limitation if HMO or a participating provider cannot or will not
implement a Member's advance directive.
8.3.2.1 A statement of limitation on implementing a Member's advance directive
should include at least the following information:
8.3.2.1.1 a clarification of any differences between HMO's conscience objections
and those which may be raised by the Member's PCP or other providers;
8.3.2.1.2 identification of the state legal authority permitting HMO's
conscience objections to carrying out an advance directive; and
8.3.2.1.3 a description of the range of medical conditions or procedures
affected by the conscience objection.
8.3.3 HMO cannot require a Member to execute or issue an advance directive
as a condition for receiving health care services.
8.3.4 HMO cannot discriminate against a Member based on whether or not the
Member has executed or issued an advance directive.
8.3.5 HMO's policies and procedures must require HMO and Subcontractor to
comply with the requirements of state and federal law relating to
advance directives. HMO must provide education and training to
employees, Members, and the community on issues concerning advance
directives.
8.3.6 All materials provided to Members regarding advance directives must be
written at a 7th - 8th grade reading comprehension level, except where
a provision is required by state or federal law, and the provision
cannot be reduced or modified to a 7th- 8th grade reading level
because it is a reference to the law or is required to be included "as
written" in the state or federal law. HMO must submit to TDHS any
revisions to existing approved advance directive materials.
8.3.7 HMO must notify Members of any changes in state or federal laws
relating to advance directives within 90 days from the effective date
of the
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change, unless the law or regulation contains a specific time
requirement for notification.
8.4 MEMBER ID CARDS
8.4.1 A Medicaid Identification Form (Form 3087) is issued monthly by the
TDHS. The form includes the "STAR+PLUS" Program logo and the name and
toll free number of the Member's health plan. A Member may have a
temporary Medicaid Identification (Form 1027-A) which will include a
STAR+PLUS indicator.
8.4.2 HMO must issue a Member Identification Card (ID) to the Member within
five (5) days from receiving the Enrollment File from the Enrollment
Broker. If the 5th day falls on a weekend or state holiday, the ID
Card must be issued by the following working day. The ID Card must
include, at a minimum, the following: Member's name; Member's Medicaid
number; either the issue date of the card or effective date of the PCP
assignment; PCP's name, address, and telephone number; name of HMO;
name of IPA to which the Member's PCP belongs, if applicable; the
24-hour, seven (7) day a week toll-free telephone number operated by
HMO; the toll-free number for behavioral health care services; and
directions for what to do in an emergency. The ID Card must be
reissued if the Member reports a lost card, there is a Member name
change, if Member requests a new PCP, or for any other reason which
results in a change to the information disclosed on the ID Card.
8.5 MEMBER HOTLINE
8.5.1 HMO must maintain a toll-free Member telephone hotline 24 hours a day,
seven days a week for Members to obtain assistance in accessing
services under this contract.
8.6 MEMBER COMPLAINT PROCESS
8.6.1 HMO must develop, implement and maintain a Member complaint system
that complies with the requirements of Article 20A.12 of the Texas
Insurance Code, relating to the Complaint System, except where
otherwise provided in this contract and in applicable federal law. The
complaint and appeals procedure must be the same for all Members and
must comply with Texas Insurance Code, Article 20A.12 or applicable
federal law. Modifications and changes must be submitted to TDHS at
least 30 days prior to the implementation of the modification or
changes.
8.6.2 HMO must have written policies and procedures for taking, tracking,
reviewing, and reporting and resolving of member complaints. Any
changes to the procedures must be submitted to TDHS for approval
thirty (30) days prior to the effective date of the change.
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8.6.3 HMO must designate an officer of HMO who has primary responsibility
for ensuring that complaints are resolved in compliance with written
policy and within the time required. An officer of HMO means the
president, a vice president, the secretary, the treasurer, or the
chairperson of the board for a corporation, the sole proprietor, the
managing general partner of a partnership, or a person having similar
executive authority in the organization.
8.6.4 HMO must have a routine process to detect patterns of complaints and
plan changes and involve management and supervisory staff to develop
policy and procedural improvements to address the complaints. HMO must
cooperate with the state and its contractors in resolving Member
complaints.
8.6.5 HMOs complaint procedures must be provided to Members in writing and
in alternative communications formats. A written description of HMOs
complaint procedures must be in appropriate languages and easy for
Members to understand. HMO must include a written description of the
complaint procedures in the Member Handbook. HMO must maintain at
least one local or toll-free telephone number for making complaints.
8.6.6 HMOs process must require that every complaint received in person, by
telephone or in writing, is recorded in a written record and is logged
with the following details: date, identification of the individual
filing the complaint, identification of the individual recording the
complaint, nature of the complaint, disposition of the complaint,
corrective action required, and date resolved.
8.6.7 HMOs process must include a requirement that the governing body of the
HMO reviews the written record (logs) for complaints and appeals.
8.6.8 HMO is prohibited from discriminating against a Member because that
Member is making or has made a complaint.
8.6.9 HMO cannot process requests for disenrollments through the HMO's
complaint procedures. Requests for disenrollments must be referred to
TDHS within five (5) business days after the Member makes a
disenrollment request.
8.6.10 HMO must develop, implement and maintain an appeal of adverse
determination procedure that complies with the requirements of Article
21.58A of the Texas Insurance Code, relating to the utilization
review, except where otherwise provided in this contract and in
applicable federal law. The appeal of an adverse determination
procedure must be the same for all Members and must comply with Texas
Insurance Code, Article 21.58A or applicable federal law.
Modifications and amendments must be submitted to TDHS no less than 30
days prior to the implementation of the modification or amendment.
When an enrollee, a person acting on behalf of an enrollee, or an
enrollee's provider of record expresses orally or in writing any
dissatisfaction or disagreement with an
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adverse determination, HMO or UR agent must regard the expression of
dissatisfaction as a request to appeal an adverse determination.
8.6.11 If a complaint or appeal of an adverse determination relates to the
denial, delay, reduction, termination or suspension of covered
services by either HMO or a utilization review agent contracted to
perform utilization review by HMO, HMO must inform Members they have
the right to access the States Fair Hearing process at any time in
lieu of the internal complaint system provided by HMO. HMO is required
to comply with the requirements contained in 1 TAC Chapter 357,
relating to notice and Fair Hearings in the Medicaid program, whenever
an action is taken to deny, delay, reduce, terminate or suspend a
covered service.
8.6.12 If Members utilize HMO's internal complaint or appeal of adverse
determination system and the complaint relates to the denial, delay,
reduction, termination or suspension of covered services by either HMO
or a utilization review agent contracted to perform utilization review
by HMO, HMO must inform the Member that they continue to have a right
to appeal the decision through the States Medicaid Fair Hearing
process.
8.6.13 The provisions of Article 21.58A, Texas Insurance Code, relating to a
Member s right to appeal an adverse determination made by HMO or a
utilization review agent by an independent review organization, do not
apply to a Medicaid recipient. Federal fair hearing regulations
(Social Security Act Section 1902a(3), codified at 42 C.F.R. 431.200
et seq.) require the agency to make a final decision after a Fair
Hearing, which conflicts with the State requirement that the IRO make
a final decision. Therefore, the State requirement is pre-empted by
the federal requirement and the IRO requirement is not applicable to
this contract.
8.6.14 HMO will cooperate with the Enrollment Broker and TDHS or its designee
to resolve all Member complaints.
8.6.15 HMO must have policies and procedures in place outlining the role of
HMO s Medical Director in the Member Complaint System and appeal of an
adverse determination. The Medical Director must have a significant
role in monitoring, investigating and hearing complaints.
8.6.16 HMO must assist Members in understanding and using HMO s complaint
system.
8.6.17 HMO s must assist Members in writing or filing a complaint and
monitoring the complaint through the Contractor s complaint process
until the issue is resolved.
8.7 MEMBER NOTICES, APPEALS AND FAIR HEARINGS
8.7.1 HMO must send a Member notice whenever the HMO takes an adverse action
to deny, delay, reduce or terminate covered services to a Member.
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Upon request, HMO will make available to the State a copy of all
adverse action notices.
For acute care services the notice must be mailed to the Member no
less than 10 days before HMO intends to take an action. If an
emergency exists, or if the time within which the service must be
provided makes giving 10 days notice impractical or impossible, notice
must be provided by the most expedient means reasonably calculated to
provide actual notice to the Member, including by phone or through the
provider's office.
For long term care services the notice must be mailed to the Member no
less than 30 days before the HMO intends to take an action.
8.7.2 The notice must contain the following information:
8.7.2.1 the Members right to immediately access the State Medicaid Fair
Hearing process including where written requests may be sent and the
toll free number the member can call for a fair hearing;
8.7.2.2 a statement of the action HMO will take;
8.7.2.3 the date the action will be taken;
8.7.2.4 an explanation of the reasons HMO will take the action;
8.7.2.5 a reference to the state and/or federal regulation or HMO criteria or
guidelines which support HMOs action;
8.7.2.6 an address where written requests may be sent and a toll-free number
Member can call to: request the assistance of a Member representative,
or file a complaint, or request a State Medicaid Fair Hearing;
8.7.2.7 a procedure by which Member may appeal HMO's action through either
HMO's complaint process or the State Fair Hearing process;
8.7.2.8 an explanation that the Member may represent himself or herself, or be
represented by a representative, a third party ombudsman, a friend, a
relative, legal counsel or another spokesperson;
8.7.2.9 an explanation of whether and under what circumstances services may be
continued if a State Medicaid Fair Hearing is requested;
8.7.2.10 a statement that if the Member wants a State Medicaid Fair Hearing on
the action, Member must make the request for a Fair Hearing within 90
days of the date on the notice or the right to request a hearing is
waived;
8.7.2.11 an explanation that the Member may request that the State Medicaid
Fair Hearing be conducted based on written information without the
necessity of taking oral testimony; and
8.7.2.12 a statement explaining that HMO must make its decision within 30 days
from the date the complaint is received by HMO; and
8.7.2.13 a statement explaining that a final decision must be made by the State
within ninety (90) days from the date a State Medicaid Fair Hearing is
requested.
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8.8 MEMBER CULTURAL AND LINGUISTIC SERVICES
8.8.1 HMO must have a written plan describing how HMO will meet the
linguistic and cultural needs of Members. The Cultural Competency Plan
must describe how the individuals and systems within HMO will
effectively provide services to people of all cultures, races, ethnic
backgrounds, and religions in a manner that recognizes, values,
affirms, and respects the worth of the individuals and protects and
preserves the dignity of each. The plan must also be made available to
HMOs network of providers.
8.8.2 HMO must provide interpreter services to members as necessary to
ensure availability of effective communication regarding treatment,
medical history, or health education. HMO must provide 24 hour access
to interpreter services for members to access emergency medical
services within HMOs network, either through telephone language
services or interpreters. HMO must include individuals who can
translate Spanish and American Sign Language and additional languages
of major population groups. HMO must include individuals skilled in
communication and services for the cognitively impaired. In addition,
HMO must have capabilities to provide TDD access.
8.8.3 Experienced professional interpreters must be used when technical,
medical, or treatment information is to be discussed, or where use of
a family member or friend as interpreter is inappropriate. Family
members, especially children, should not be used as interpreters in
assessments, therapy and other situations where impartiality is
critical unless specifically requested by the Member. A family member
or friend may be used as an interpreter if they can be relied upon to
provide a complete and accurate translation of the information being
provided to the Member; the Member is advised that a free interpreter
is available; and, the Member expresses a preference to rely on the
family member or friend.
8.8.3.1 HMO must adhere to and provide to Members the Member Bill of Rights
and Responsibilities as adopted by the Texas Health and Human Services
Commission and contained at 1 Texas Administrative Code (TAC) Sections
353.202--353.203.
8.8.3.2 HMO must have policies and procedures in place that outline how
Members can access face-to-face interpreter services in a provider's
office if necessary to ensure the availability of effective
communication regarding treatment, medical history or health education
for a Member.
8.8.4 HMO must maintain a current list of interpreters who maintain
"on-call" status to provide interpreter services to members.
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8.8.5 Orientation presentations or education classes must be presented in
the languages of the major population groups, as specified by TDHS,
in the proposed service area(s) as the identified need arises.
ARTICLE IX MARKETING AND PROHIBITED PRACTICES
9.1 MARKETING MATERIALS
HMOs may present their marketing materials to eligible Medicaid
recipients through any method or media determined to be acceptable
by TDHS. The media may include but are not limited to: written
materials, such as brochures, posters, or fliers which can be mailed
directly to the client or left at Texas Department of Human Services
eligibility offices; TDHS sponsored community enrollment events; and
paid or public service announcements on radio. All marketing
materials must be approved by TDHS prior to distribution (see
Article 3.4).
9.2 ADHERANCE TO MARKETING GUIDELINES
9.2.1 HMO must abide by Texas Medicaid Marketing Guidelines as provided by
the State.
ARTICLE X MIS SYSTEM REQUIREMENTS
10.1 MODEL MIS REQUIREMENTS
10.1.1 HMO must maintain an MIS that will provide support for all functions
of HMOs processes and procedures related to the flow and use of data
within HMO. The MIS must enable HMO to meet the requirements of this
Contract. The MIS must have the capacity and capability of capturing
and utilizing various data elements to develop information for HMO
administration.
10.1.2 HMO must maintain a claim retrieval service processing system that
can identify date of receipt, action taken on all provider claims or
encounters (i.e., paid, denied, etc.), and when any action was taken
in real time.
10.1.3 HMO must have a system that can be adapted to changes in Business
Practices/Policies within a short period of time.
10.1.4 HMO is required to submit and receive data as specified in this
contract and HMO Encounter Data Submissions Manual. The MIS must
provide complete acute and long term care encounter data of all
capitated services within the scope of services of the contract
between HMO and TDHS. Encounter data must follow the format, data
elements and method of transmission specified in the contract and
HMO Encounter Data Submissions Manual. HMO must submit encounter
data, including adjustments to encounter data. The Encounter
transmission will include all encounter data and encounter data
adjustments processed by HMO
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for the previous month. Data quality validation will incorporate
assessment standards developed jointly by HMO and TDHS. Original
records will be made available for inspection by TDHS for validation
purposes. Data which do not meet quality standards must be corrected
and returned within a time period specified by TDHS.
10.1.5 HMO must use the procedure codes, diagnosis codes, and other codes
used for reporting encounters and fee-for-service claims in the most
recent edition of the Medicaid Provider Procedures Manual or as
otherwise provided by the State. Any exceptions will be considered on
a code-by-code basis after TDHS receives written notice from HMO
requesting an exception. HMO must also use the provider numbers as
directed by the State for both encounter and fee-for-service claims
submission.
10.1.6 HMO must have hardware, software, network and communications system
with the capability and capacity to handle and operate all MIS
subsystems as specified in 10.1.8.1.
10.1.7 HMO must provide upon request an organizational chart and description
of responsibilities of HMO's MIS department dedicated to or supporting
this Contract. Any updates to the organizational chart and the
description of responsibilities must be provided to TDHS within 15
days of the effective date of the change. Official points of contact
must be provided to TDHS on an ongoing basis. An Internet e-mail
address must be provided for each point of contact.
10.1.8 HMO must operate and maintain an MIS that meets or exceeds the
requirements outlined in the Model MIS Guidelines that follow:
10.1.8.1 The contractor's system must be able to meet all eight MIS Model
Guidelines as listed below. The eight subsystems are used in the Model
MIS Requirements to identify specific functions or features required
by HMOs MIS. The HMO systems must use file format, edit validation
techniques as specified by TDHS or its designee. These subsystems
focus on the individual systems functions or capabilities to support
the following operational and administrative areas:
(1) Enrollment/Eligibility Subsystem
(2) Provider Subsystem
(3) Encounter/Claims Processing Subsystem
(4) Financial Subsystem
(5) Utilization/Quality Improvement Subsystem
(6) Reporting Subsystem
(7) Interface Subsystem
(8) TPR Subsystem
10.2 SYSTEM WIDE FUNCTIONS
HMO MIS system must include functions and/or features which must
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apply across all subsystems as follows:
(1) Able to update and edit data.
(2) Maintain a history of changes and adjustments and audit
trails for current and retroactive data. Audit trails will
capture date, time, and reasons for the change, as well as
who made the change.
(3) Allow input mechanisms through manual and electronic
transmissions.
(4) Have procedures and processes for accumulating, archiving,
and restoring data in the event of a system or subsystem
failure.
(5) Maintain automated or manual linkages between and among all
MIS subsystems and interfaces.
(6) Able to relate Member and provider data with utilization,
service, accounting data, and reporting functions.
(7) Able to relate and extract data elements into summary and
reporting formats as required by TDHS.
(8) Have written process and procedures manuals which document
and describe all manual and automated system procedures and
processes for all the above functions and features, and the
various subsystem components.
(9) Maintain and cross reference all Member-related information
with the most current Medicaid number.
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM
The Enrollment/Eligibility Subsystem is the central processing point
for the entire MIS. It must be constructed and programmed to secure
all functions which require membership data. It must have function
and/or features which support requirements as follows:
(1) Identify other health coverage available or third party
liability (TPL), including type of coverage and effective
dates.
(2) Maintain historical data (files) as required by the State.
(3) Maintain data on enrollment/disenrollments and complaint
activities. This data must include reason or type of
disenrollment, complaint and resolution by incidence.
(4) Receive, translate, edit and update files in accordance with
TDHS requirements prior to inclusion in HMOs MIS. Updates
will be received from the TDHS agent and processed within
two business days of receipt.
(5) Provide error reports and a reconciliation process between
new data and data existing in MIS.
(6) Identify enrollee changes in PCP and the reason(s) for those
changes and effective dates.
(7) Monitor PCP capacity and limitations prior to connecting the
enrollee to PCP in the system, and provide an exception
report when capacity and limitations are exceeded.
(8) Verify enrollee eligibility for medical services rendered or
for other enrollee inquires.
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(9) Generate and track referrals, e.g.,
Hospitals/Specialists/Long Term Care Providers.
(10) Search records by a variety of fields (e.g., name, unique
identification numbers, date of birth, SSN, etc.) for
eligibility verification.
(11) Send PCP assignment updates to TDHS or its agent in the
format as specified by TDHS
10.4 PROVIDER SUBSYSTEM
The provider subsystem must accept, process, store and retrieve
current and historical data on providers, including services, payment
methodology, license information, service capacity, and facility
linkages.
Functions and Features:
(1) Identify specialty(s), admission privileges, enrollee
linkage, capacity, facility linkages, emergency arrangements
or contact, and other limitations, affiliations, or
restrictions.
(2) Maintain provider history files to include audit trails and
effective dates of information.
(3) Maintain provider fee schedules/remuneration agreements to
permit accurate payment for services based on the financial
agreement in effect on the date of service.
(4) Support HMO credentialing, re-credentialing, and credential
tracking processes; incorporate or links information to
provider record.
(5) Support monitoring activity for physician to enrollee ratios
(actual to maximum) and total provider enrollment to
physician and HMO capacity.
(6) Flag and identify providers with restrictive conditions
(e.g., limits to capacity, type of patient, and other
services if approved out of network, to include age
restrictions).
(7) Support national provider number format (UPIN, NPIN, CLIA,
TPI, etc. as required by TDHS).
(8) Provide updated provider network files monthly. Format will
be provided by TDHS to contracted entities.
(9) Support the national CLIA certification numbers for clinical
laboratories.
(10) Exclude providers from participation that have been
identified by TDHS as ineligible or excluded. Files must be
updated to reflect period and reason for exclusion.
10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM
The encounter/claims processing subsystem collects, processes, and
stores data on all health services delivered for which HMO is
responsible. The functions of these subsystems are claims/encounter
processing and capturing health service utilization data. The
subsystem captures all health related services, including medical
supplies, using standard codes
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(e.g. CPT-4, HCPCS, ICD9-CM, UB92 Revenue Codes, State Specific Code),
rendered by health care providers to an eligible enrollee regardless
of payment arrangement (e.g. capitation or fee-for-service). This
subsystem captures long term care and value added services using codes
provided by TDHS. It approves and prepares claims for payment, or
denies claims submitted. This subsystem may integrate manual and
automated systems to validate and adjudicate claims and encounters.
HMO must use encounter data validation methodologies prescribed by the
State.
Functions and Features:
(1) Accommodate multiple input methods - electronic submission,
tape, claim document, and media.
(2) Support entry and capture of a minimum of all required data
elements specified in the Encounter Data Submission Manual.
(3) Edit and audit to ensure allowed services are provided by
eligible providers for eligible members.
(4) Interface with Member and provider subsystems.
(5) Capture and report TPL potential, reimbursement or denial.
(6) Edit for utilization and service criteria, medical policy,
fee schedules, multiple contracts, contract periods,
conditions, etc.
(7) Submit data to TDHS or its designee through electronic
transmission using specified formats.
(8) Support multiple fee schedule benefit packages and
capitation rates for all contract periods for individual
providers, groups, services, etc. A claim encounter must be
initially adjudicated and all adjustments must use the fee
applicable to the date of service.
(9) Provide timely, accurate, and complete data for monitoring
claims processing performance.
(10) Provide timely, accurate, and complete data for reporting
medical service utilization.
(11) Maintain and apply prepayment edits to verify accuracy and
validity of claims data for proper adjudication.
(12) Maintain and apply edits and audits to verify timely,
accurate, and complete encounter data reporting.
(13) Submit reimbursement to non-contracted providers for
emergency care rendered to enrollees in a timely and
accurate fashion.
(14) Validate approval and denials of precertification and prior
authorization requests during adjudication of
claims/encounters.
(15) Track and report the exact date a service was performed. Use
of date ranges must have TDHS approval.
(16) Receive and capture claim and encounter data from TDHS or
its designee.
(17) Receive and capture value-added services codes, (18)
Capability of identifying adjustments and linking them to
the original claims/encounters.
10.6 FINANCIAL SUBSYSTEM
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The financial subsystem must provide the necessary data for all
accounting functions including cost accounting, inventory, fixed
assets, payroll, general ledger, accounts receivable and payable, and
financial statement presentation. The financial subsystem must provide
management with information that can demonstrate that HMO is meeting,
exceeding, or falling short of fiscal goals. The information must also
provide management with the necessary data to spot the early signs of
fiscal distress, far enough in advance to allow management to take
corrective action where appropriate.
Functions and Features:
(1) Provide information on HMO's economic resources, assets, and
liabilities and present accurate historical data and
projections based on historical performance and current
assets and liabilities.
(2) Produce financial statements in conformity with Generally
Accepted Accounting Principles and in the format prescribed
by TDHS.
(3) Provide information on potential third party payers;
information specific to the client; claims made against
third party payers; collection amounts and dates; denials,
and reasons for denials.
(4) Track and report savings by category as a result of cost
avoidance activities.
(5) Track payments per Member made to network providers compared
to utilization of the provider's services.
(6) Generate Remittance and Status Reports.
(7) Make claim and capitation payments to providers or groups.
(8) Reduce/Increase accounts payable/receivable based on
adjustments to claims or recoveries of Third Party Recovery.
10.7 UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM
The quality management/quality improvement/utilization review
subsystem combines data from other subsystems, and/or external
systems, to produce reports for analysis which focus on the review and
assessment of quality of care given, detection of over and under
utilization, and the development of user defined reporting criteria
and standards. This system profiles utilization of providers and
enrollees and compares them against experience and norms for
comparable individuals. This subsystem also supports the quality
assessment function.
The subsystem tracks utilization control function(s) and monitoring
inpatient admissions, emergency room use, ancillary, Long Term Care
and out-of-area services. It provides provider profiles, occurrence
reporting, monitoring and evaluation studies. The subsystem may
integrate HMO's manual and automated processes or incorporate other
software reporting and/or analysis programs.
The subsystem incorporates and summarizes information from enrollee
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surveys, provider and enrollee complaints, and appeal processes.
Functions and Features:
(1) Support provider credentialing and recredentialing
activities.
(2) Support HMO processes to monitor and identify deviations in
patterns of treatment from established standards or norms.
Provides feedback information for monitoring progress toward
goals, identifying optimal practices, and promoting
continuous improvement.
(3) Support development of cost and utilization data by provider
and service.
(4) Provide aggregate performance and outcome measures using
standardized quality indicators similar to HEDIS or as
specified by TDHS.
(5) Supports focused quality of care studies.
(6) Support the management of referral/utilization control
processes and procedures, including prior authorization and
precertifications and denials of services.
(7) Monitor PCP referral patterns.
(8) Support functions of reviewing access, use and coordination
of services (i.e. actions of Peer Review and alert/flag for
review and/or follow-up; laboratory, x-ray, Long Term Care,
and other ancillary service utilization per visit).
(9) Store and report patient satisfaction data through use of
enrollee surveys.
(10) provides fraud and abuse detection, monitoring and
reporting.
(11) Meet minimum reporting/data collection/analysis functions of
Section 7.5 of the RFA.
(12) Monitor and track provider and enrollee complaints and
appeals from receipt to disposition or resolution by
provider.
(13) TDHS will provide to HMO Social Security applied income
information for any Member residing in a Nursing Facility.
It is HMOs responsibility to manage applied income
appropriately with the nursing facility.
(14) HMO will ensure the accuracy of and electronically transmit
MDS-HC information on any Member living in the community and
receiving long term care services.
(15) HMO will ensure that the appropriate document, as specified
by TDHS, to determine medical necessity for nursing facility
level of care is transmitted to TDHS or its designee.
10.8 REPORT SUBSYSTEM
The reporting subsystem supports reporting requirements of all HMO
operations to HMO management and TDHS. It allows HMO to develop
various reports to enable HMO management and TDHS to make decisions
regarding HMO activity.
Functions and Capabilities:
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(1) Produces standard, TDHS-required reports and ad hoc reports
from the data available in all MIS subsystems. All reports
will be submitted on hard copy or electronically in a format
approved by TDHS.
(2) Have system flexibility to permit the development of reports
at irregular periods as needed.
(3) Generate reports which provide unduplicated counts of
enrollees, providers, payments and units of service unless
otherwise specified.
(4) Generate an alphabetic Member listing.
(5) Generate a numeric Member listing.
(6) Generate a client eligibility listing by PCP (panel report).
(7) Report on PCP change by reason code.
(8) Report on TPL (COB) information to TDHS.
(9) Report on provider capacity and assignment from date of
service to date received.
(10) Generate an aged outstanding liability report.
(11) Produce a Member ID Card .
(12) Produce client/provider mailing labels.
10.9 DATA INTERFACE SUBSYSTEM
10.9.1 The interface subsystem supports incoming and outgoing data from and
to other organizations. It allows HMO to maintain enrollee, benefit
package, eligibility, disenrollment/enrollment status, and medical
services received outside of capitated services and associated cost.
All interfaces must follow the specifications frequencies and formats
provided by the state and as amended.
10.9.2 HMO must obtain access to the TexMedNet BBS or other site. Some file
transfers and E-mail will be handled through this mechanism.
10.9.3 Provider Network File - The provider file shall supply Network
Provider data between HMO and TDHS and its designee. This process
shall accomplish the following:
(1) Provide identifying information for all managed care
providers (e.g. name, address, etc...)
(2) Maintain history on provider enrollment/disenrollment
(3) Identify any restrictions (e.g, age, sex, etc.)
(4) Identify PCP capacity
(5) Identify number and types of specialty providers available
to Members.
10.9.4 Eligibility/Enrollment Interface - The enrollment interface must
provide eligibility data between TDHS or its designee and HMO.
(1) Provides benefit package data to HMO in accordance with
capitated services.
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(2) Provides PCP assignments.
(3) Provides Member eligibility status data.
(4) Provides Member demographics data.
(5) Provides HMO with cross reference data to identify
duplicate Members.
10.9.5 Encounter/ClaimData Interface - The encounter/claim interface must
transfer paid fee-for-service claims data to HMO and capitated
services/encounters from HMO, including adjustments. This file will
include all service types, such as, inpatient, outpatient, long term
care services and medical services. The State or its designee will
process claims for non-capitated services.
10.9.6 Capitation interface - The capitation interface must transfer premium
and Member information to HMO. This interface's basic purpose is to
balance HMO's Members and premium amount.
10.9.7 TPR Interface - TDHS will provide a data file that contains
information on enrollees that have other insurance. Because Medicaid
is the payor of last resort, all services and encounters should be
billed to the other insurance companies for recovery. TDHS will also
provide an insurance company data file which contains the name and
address of each insurance company.
10.9.8 The State will provide a diagnosis file which will give the code and
description of each diagnosis permitted by the State or its designee.
10.9.9 The State or its designee will provide a procedure file which contains
the procedures which must be used on all claims and encounters. This
file contains HCPCS, revenue, and ICD9-CM surgical procedure codes and
codes specified by the state.
10.9.10 The State or its designee will provide a provider file which will
contain the Medicaid provider numbers, name, and address of each
Medicaid provider. The Medicaid number authorized by the State or its
designee will be submitted on all claims, encounters, and network
provider submissions.
10.10 TPR SUBSYSTEM
HMO's third party recovery system must have the following capabilities
and capacities:
(1) Identify, store, and use other health coverage available to
eligible Members or third party liability (TPL) including
type of coverage and effective dates.
(2) Provide changes in information to TDHS as specified by TDHS.
(3) Receive TPL data from TDHS to be used in claim and
encounter processing.
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10.11 YEAR 2000 COMPLIANCE
10.11.1 HMO must take all appropriate measures to make all software which will
record, store, and process and present calendar dates falling on or
after January 1, 2000, perform in the same manner and with the same
functionality, data integrity and performance, as dates falling on or
before December 31, 1999, at no added cost to TDHS. HMO must take all
appropriate measures to ensure that the software will not lose, alter
or destroy records containing dates falling on or after January 1,
2000. HMO will ensure that all software will interface and operate
with all TDHS, or its agent s, data systems which exchange data,
including but not limited to historical and archived data. In
addition, HMO guarantees that the year 2000 leap year calculations
will be accommodated and will not result in software, firmware or
hardware failures.
10.11.2 TDHS and all subcontracted entities are required by state and federal
law to meet Y2K compliance standards. Failure of TDHS or TDHS
contractor other than an HMO to meet Y2K compliance standards which
results in an HMOs failure to meet the Y2K requirements of this
contract is a defense against a declaration of default under this
contract.
ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM
11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM
HMO must develop, maintain, and operate a Quality Improvement Program
(QIP) system which complies with federal regulations relating to
Quality Assurance systems, found at 42 C.F.R. Section 434.34. The
system must meet the Standards for Quality Improvement Programs
contained in the Medicaid Managed Care (RFA) for ▇▇▇▇▇▇ Service Area
(pages 79-116 and 270-276).
11.2 WRITTEN QIP PLAN
HMO must have ON FILE WITH TDHS an approved plan describing its
Quality Improvement Plan (QIP), including how HMO will accomplish the
activities pertaining to each Standard (I-XVI) in the Medicaid Managed
Care (RFA) for ▇▇▇▇▇▇ Service Area (pages 79-116 and 270-276).
MODIFICATIONS AND AMENDMENTS MUST BE SUBMITTED TO TDHS NO LATER THAN
60 DAYS PRIOR TO THE IMPLEMENTATION OF THE MODIFICATION OR AMENDMENT.
11.3 QIP SUBCONTRACTING
If HMO subcontracts any of the essential functions or reporting
requirements of QIP to another entity, HMO must MAINTAIN A FILE of the
Subcontractors and a description of how the Subcontractor will meet
the standards and reporting requirements of this contract. THE LIST
MUST BE AVAILABLE FOR REVIEW BY TDHS OR ITS DESIGNEE UPON REQUEST. HMO
must notify TDHS no later than
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90 days prior to terminating any subcontract affecting a major
performance function of this contract (see Article 3.2.1.2).
11.4 BEHAVIORAL HEALTH INTEGRATION INTO QIP
HMO must integrate behavioral health into its QIP system and include a
systematic and on-going process for monitoring, evaluating, and
improving the quality and appropriateness of behavioral health
services provided to Members. HMO's QIP must enable HMO to collect
data, monitor and evaluate for improvements to physical health
outcomes resulting from behavioral health integration into the overall
care of the Member.
11.5 QIP REPORTING REQUIREMENTS
The HMO must meet all of the QIP Reporting Requirements contained in
Article XII.
ARTICLE XII REPORTING REQUIREMENTS
12.1 FINANCIAL REPORTS
12.1.1 HMO must file the Managed Care Financial Statistical Report on a
quarterly basis using the format prescribed by the State. The report
must be submitted to the State 30 days after the end of each State
Fiscal Quarter and must include complete financial and statistical
information for each month.
12.1.2 HMO must file two annual Managed Care Financial Statistical Reports.
The reports must be in the format prescribed by the State. The first
annual report must reflect expenses incurred through the ninetieth
(90th) day after the end of the contract year and must be filed on or
before the one hundred and twentieth (120th) day after the end of the
contract year. The second annual report must reflect data completed
through the 334th day after the end of the contract year and must be
filled on or before the 365th day following the end of the Contract
year.
12.1.3 Administrative expenses must be reported in accordance with Attachment
E, Cost Principles for Administrative Expenses. Indirect
administrative expenses must be based on an allocation methodology for
Medicaid managed care activities and services that is developed or
approved by the State.
12.1.4 HMO must file a duplicate of HMO Annual Statement and Supplemental
Exhibits required by the Texas Department of Insurance (TDI) within
thirty (30) days after the TDI filing deadline.
12.1.5 On or before June 30 of each year, HMOs shall submit to the State a
copy of the annual audited financial report filed with TDI.
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12.1.6 HMO must file an updated Form HCFA-1513 regarding control, ownership,
or affiliation of HMO thirty (30) days prior to the end of the
contract year. An updated Form HCFA must also be filed within thirty
(30) days of any change in control, ownership, or affiliation of HMO.
12.1.7 HMO must file an updated HCFA Public Health Service ("PHS") "Section
1318 Financial Disclosure Report" within thirty (30) days of entering
into, renewing, or terminating a relationship with an affiliated
party.
12.1.8 TDI Examination Report. HMO must furnish a copy of any TDI Examination
Report no later than 10 days after receipt of the final report from
TDI.
12.1.9 IBNR Plan. HMO must furnish a written ▇▇▇▇ ▇▇▇▇ to manage
incurred-but-not-reported (IBNR) expenses, and a description of the
method of insuring against insolvency, including information on all
existing or proposed insurance policies. The plan must include the
methodology for estimating ▇▇▇▇. The plan and description must be
submitted to the State no later than 60 days after the effective date
of the contract unless previously submitted to the State. Changes to
the IBNR plan and description must be submitted to the State no later
than 30 days before changes to the plan are implemented by HMO.
12.1.10 HMO must file quarterly third party recovery (TPR) reports in
accordance with a format developed by the State. TPR reports must
include total dollars recovered from third party payers for services
to HMOs Members for each month and the total dollars recovered through
coordination of benefits, subrogation, and workers compensation.
12.1.11 Each report required under this section must be mailed to:
Texas Department of Human Services (TDHS)
Managed Care Section
▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇
P.O. Box 149030, Mail Code W516
Austin, Texas
78714-9030
12.2 STATISTICAL REPORTS
12.2.1 HMO must electronically file the following monthly reports: (1)
encounter; (2) encounter detail; (3) institutional; (4) institutional
detail; and (5) claims detail for cost-reimbursed services filed, if
any, with HMO. Encounter data must include the data elements, follow
the format, and use the transmission method specified by the state in
the Encounter Data Submission Manual. Encounters must be submitted by
HMO to the State no later than 45 days after the date of adjudication
(finalization) of the claims.
12.2.2 Monthly reports must include current months encounter data and
encounter data adjustments to the previous months data.
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12.2.3 Data quality standards will be developed jointly by HMO and the State.
Encounter data must meet or exceed data quality standards. Data which
does not meet quality standards must be corrected and returned within
the period specified by the State. Original records must be made
available to validate all encounter data.
12.2.4 HMO must require providers to submit claims and encounter data to HMO
within ninety-five (95) days from the date services are provided.
12.2.5 HMO must use the procedure codes, diagnosis codes and other codes
contained in the most recent edition of the Medicaid Provider
Procedures Manual (and as otherwise provided by the State.) Exceptions
or additional codes must be submitted for approval before HMO uses the
codes.
12.2.6 HMO must use its State specified identification numbers on all
encounter data submissions. Please refer to the Encounter Data
Submission Manual for further specifications.
12.2.7 All Claims Summary Report. HMO must submit the "All Claims Summary
Report identified in the Texas Managed Care Claims Manual as a
contract year-to-date report. The report must be submitted quarterly
by the last day of the month following the reporting period. The
report must be submitted to TDHS in a format specified by TDHS.
12.2.8 HMO must validate all encounter data using the encounter data
methodology prescribed by the State prior to submission of encounter
data to the State.
12.2.9 HMO must file preliminary and final Medicaid Disproportionate Share
Hospital (DSH) Reports, required by the State to identify and
reimburse hospitals which qualify for Medicaid disproportionate share
funds. The preliminary and final DSH reports must include the data
elements and be submitted in the form and format specified by the
State. The preliminary DSH reports are due on or before June 1 of the
year following the State fiscal year for which data is being reported.
The final DSH reports are due on or before August 15 of the year
following the state fiscal year for which data is being reported.
12.3 ARBITRATION/LITIGATION CLAIMS REPORT
HMO must submit an Arbitation/Litigation Claims Report in a format
provided by the State identifying all provider or HMO request for
arbitration or matters in Litigation. The report must be submitted:
within 30 days from the date the matter is referred to arbitration; or
suit is filed; or whenever there is a change of status in a matter
referred to arbitration or litigation.
12.4 SUMMARY REPORT OF PROVIDER COMPLAINTS
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HMO must submit a Summary Report of Provider Complaints. HMO must also
report complaints submitted to its subcontracted risk groups (e.g.,
IPAs). The complaint report must be submitted in two paper copies and
one electronic copy on or before the 45 days following the end of the
state fiscal quarter using a form specified by TDHS.
12.5 PROVIDER NETWORK REPORTS
12.5.1 Provider Network Report. HMO must submit to the Enrollment Broker an
electronic file summarizing changes in HMO's provider network
including PCPs, specialists, ancillary providers and hospitals. The
file must indicate if the PCPs and specialists participate in a closed
network and the name of the delegated network. The electronic file
must be submitted in the format specified by the State and can be
submitted as often as daily but must be submitted at least weekly.
12.5.2 Provider Termination Report. HMO must submit a monthly report which
identifies any providers who cease to participate in HMO's provider
network, either voluntarily or involuntarily. The report must be
submitted to the State in the format specified by the State. HMO will
submit the report no later than thirty (30) days after the end of the
reporting month. The information must include the provider's name,
Medicaid number, the reason for the provider's termination, and
whether the termination was voluntary or involuntary.
12.6 MEMBER COMPLAINTS
HMO must submit a quarterly summary report of Member complaints. HMO
must also report complaints submitted to its subcontracted risk groups
(e.g., IPAs). The complaint report format must be submitted to TDHS as
two paper copies and one electronic copy on or before 45 days
following the end of the state fiscal quarter using a form specified
by TDHS.
12.7 FRAUDULENT PRACTICES
HMO must report to TDHS all fraud and abuse enforcement actions or
investigations taken against HMO and/or any of its Subcontractors or
providers by any state or federal agency for fraud or abuse under
Title XVIII or Title XIX of the Social Security Act or any state law
or regulation and any basis upon which an action for fraud or abuse
may be brought by a state or federal agency as soon as such
information comes to the attention of HMO.
12.8 UTILIZATION MANAGEMENT REPORTS - BEHAVIORAL HEALTH
HMO must submit Behavioral Health (BH) utilization management (UM)
reports to TDHS or its designee semi-annually using a format and
instructions provided by TDHS. HMO's UM data file (raw data) is due in
a file format specified by TDHS quarterly (TDHS prefers and encourages
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monthly submission of the data file to BBS). The semi-annual BH UM
reports and quarterly data submission are due no later than 150 days
following the reporting as specified by TDHS.
12.9 UTILIZATION MANAGEMENT REPORTS - PHYSICAL HEALTH
Physical health (PH) utilization management reports are required on a
semi-annual basis with submission of data files that are, at a
minimum, due to TDHS or its designee on a quarterly basis no later
than 150 days following the end of the period. The State will provide
the standardized reporting format for each report and detailed
instructions for obtaining specific data required in the report and
for data file submission specifications. The PH Utilization Management
Report and data file submission instructions may periodically be
updated by TDHS to facilitate clear communication to the health plan.
12.10 UTILIZATION MANAGEMENT REPORTS - LONG TERM CARE
Long Term Care (LTC) utilization management reports are required on a
semi-annual basis with submission of data files that are, at a
minimum, due to TDHS or its designee on a quarterly basis no later
than 150 days following the end of the period. The State will provide
the standardized reporting format for each report and detailed
instructions for obtaining specific data required in the report and
for data file submission specifications. The LTC Utilization
Management Report and data file submission instructions may
periodically be updated by TDHS to facilitate clear communication to
the health plan.
12.11 QUALITY IMPROVEMENT REPORTS
12.11.1 The HMO must conduct at a minimum, three focused studies. One study
will be specified by TDHS, the second will be selected by the HMO and
approved by TDHS, and the third study will be a behavioral study
specified by TDHS. These studies shall be conducted and data collected
using criteria, methods and reporting format developed by the state.
12.11.2 Focused study reports must be submitted to the state according to due
dates established by the State.
12.11.3 Annual QIP Summary Report. An annual QIP summary report must be
conducted yearly. The annual QIP summary report must be submitted
within 30 days after approved by HMO QIP committee. This report must
provide summary information on HMOs QIP system and include the
following:
(1) Executive summary of QIP-include results of all QI reports
and interventions.
(2) Activities pertaining to each standard in the Standards for
Quality Improvement Programs (pages 79-116 and pages
270-276) of the
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Medicaid Managed Care Request for Application (RFA) for the
▇▇▇▇▇▇ Service Area.
(3) Methodologies for collecting, assessing data and measuring
outcomes.
(4) Tracking and monitoring quality of care.
(5) Role of health professionals in QIP review.
(6) Methodology for collection data and providing feedback to
providers and staff.
(7) Outcomes and/or action plan.
12.11.4 Provider Medical Record Audit and Report. HMO is required to conform
to commonly accepted medical record standards such as those used by,
NCQA, JCAHO, or those used for credentialing review such as the Texas
Environment of Care Assessment Program (TECAP), and have documentation
on file at HMO for review by the State or its designee during an
on-site review.
12.12 HUB QUARTERLY REPORTS
HMO must submit quarterly reports documenting HMOs HUB program efforts
and accomplishments. The report must include a narrative description
of HMOs program efforts and a financial report reflecting payments
made to HUB. HMO must use the format included in Attachment B of this
Contract for HUB quarterly reports.
12.13 THSTEPS REPORTS
Minimum reporting requirements. HMO must submit, at a minimum, 80% of
all THSteps checkups on HCFA 1500 claim forms as part of the encounter
file submission to the State's Claims Administrator no later than
thirty (30) days after the date of final adjudication (finalization)
of the claims. Failure to comply with these minimum reporting
requirements will result in Article XVIII sanctions and money damages.
ARTICLE XIII PAYMENT PROVISIONS
13.1 CAPITATION AMOUNTS
13.1.1 TDHS will pay HMO monthly premiums calculated by multiplying the
number of Member months by the Member risk group times the monthly
capitation amount by Member risk group. HMO and network providers are
prohibited from billing or collecting any amount from a Member except
for costs for health care services or long term care services not
covered by this Contract, in which case the Member must be informed of
such costs prior to providing non-covered services.
13.1.2. The capitation amount by Member risk group has been calculated to be
less than the amount payable for providing the same services for an
actuarially equivalent population in the regular Medicaid
fee-for-service
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program. The following capitation payments will be effective for the
first year of this Contract. The monthly capitation amounts for the
▇▇▇▇▇▇ County Service Area are as follows:
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FY 2000
Member Risk Groups Monthly Capitation
Amounts
9/1/1999 - 8/31/2000
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CBA Waiver Clients-Dual Eligible $1523.62
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CBA Waiver Clients-Medicaid Only $3012.60
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Other Community Clients-Dual Eligible $96.13
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Other Community Clients-Medicaid only $597.34
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Nursing Facility Clients-Dual Eligible $1819.89
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Nursing Facility Clients-Medicaid Only $3327.78
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13.1.3 The monthly premium payments will be made to HMO not later than the
tenth (10) state working day of the month for which premiums are made.
HMO must accept payment for premiums by direct deposit into HMOs
account.
13.1.4 Payment of monthly capitation amounts is subject to availability of
appropriations. If appropriations are not available to pay the full
monthly capitation amounts, TDHS will equitably adjust capitation
amounts, for all participating HMOs, and reduce scope of service
requirements as appropriate.
13.1.5 TDHS will re-examine the capitation rates paid to HMO under this
contract during the first year of the contract period and will provide
HMO with capitation rates for the second year of the contract period
no later than 30 days before the date of the one-year anniversary of
the contract's effective date. Capitation rates for state fiscal year
2001 will be re-examined based on the most recent available
traditional Medicaid cost data for the contracted risk groups in the
service area, trended forward and discounted.
13.1.5.1 Once HMO has received their capitation rates established by TDHS for
the second year of this contract, HMO may terminate this contract as
provided in Article 18.1.6 of this contract.
13.1.6 For HMO members who upgrade to a higher risk group, the adjustment to
the higher risk group will be delayed by 120 days as an incentive for
the
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HMO to maintain members at the least restrictive setting that meets
the client's health and safety needs.
13.1.7 For SSI members that upgrade to CBA eligibility by for whom the
annualized cost of the plan of care is less than $ 9,000, the risk
group will remain at the Other Community Care level.
13.1.8 HMO renewal rates reflect program increases appropriated by the 76
legislature for physician (to include THSteps providers) and
outpatient facility services. HMO must report to TDHS any change in
rates for participating physicians (to include THSteps providers) and
outpatient facilities resulting from this increase. The report must be
submitted to TDHS at the end of the first quarter of the FY2000 and
FY2001 contract years according to the deliverables matrix scheduled
set for HMO.
13.2 EXPERIENCE REBATE TO STATE
13.2.1 The HMO must pay to TDHS an experience rebate calculated in accordance
with the tiered rebate method listed below based on the excess of
allowable HMO STAR+PLUS revenues over allowable HMO STAR+PLUS expenses
as measured by any positive amount on Line 8 of "Part 1: Financial
Summary, All Coverage Groups Combined" of the final (Contract period)
Managed Care Financial-Statistical Report as reviewed and confirmed by
the State.
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Graduated Rebate Method
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Experience Rebate HMO Share State Share
as a Percentage of Revenues
------------------------------------------------------------------------------------------
0% - 3% 100% 0%
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Over 3% - 7% 75% 25%
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Over 7% - 10% 50% 50%
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Over 10% - 15% 25% 75%
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Over 15% 0% 100%
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13.2.2 Allowable start-up costs (pre-implementation costs) are costs incurred
between the contract effective date and the implementation date as
defined in the "Cost Principles for Administrative Expenses"
(Attachment E).
13.2.3 Carry Forward of Prior Contract Period Losses: Losses incurred for one
contract period can only be carried forward to the next contract
period.
13.2.4 Experience rebate will be based on a pre-tax basis.
13.2.5 There will be two settlements for payment of the experience rebate.
The first settlement shall equal 100 percent of the experience rebate
as derived from Line 7 of Part 1 (Net Income Before Taxes) of the
contract period Managed Care Financial Statistical (MCFS) Report and
shall be paid on the same day the first contract period MCFS Report is
submitted to TDHS. The second settlement shall be an adjustment to the
first
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settlement and shall be paid to TDHS on the same day that the second
contract period MCFS Report is submitted to TDHS if the adjustment is
a payment from HMO to TDHS. TDHS or its agent may audit or review the
MCFS reports. If TDHS determines that corrections to the MCFS reports
are required, based on a TDHS audit/review or other documentation
acceptable to TDHS, to determine an adjustment to the amount of the
second settlement, then final adjustment shall be made within two
years from the date that the HMO submits the second contract period
MCFS report. HMO must pay the first and second settlements on the due
dates for the first and second MCFS reports respectively as identified
in Article 12.1.3. TDHS may adjust the experience rebate if TDHS
determines HMO has paid affiliates amounts for goods or services that
are higher than the fair market value of the goods and services in the
service area. Fair market value may be based on the amount HMO pays a
non-affiliate(s) or the amount another HMO pays for the same or
similar service in the service area. TDHS will have final authority in
assessing the amount of the experience rebate.
13.3 ADJUSTMENTS TO PREMIUM
13.3.1 TDHS may recoup premiums paid to HMO in error. Error may be either
human or machine error on the part of TDHS or an agent or contractor
of TDHS. TDHS may recoup premiums paid to HMO if a Member is enrolled
into HMO in error, and HMO provided no covered services to Member for
the period of time for which premium was paid. If services were
provided to Member as a result of the error, recoupment will not be
made.
13.3.2 TDHS may recoup premium paid to HMO if a Member for whom premium is
paid moves outside the United States, and the HMO has not provided
covered services to the Member for the period of time for which
premium has been paid. TDHS will not recoup premium if HMO has
provided covered services to the Member during the period of time for
which premium has been paid.
13.3.3 TDHS may recoup premium paid to HMO if a Member for whom premium is
paid dies before the first day of the month for which premium is paid.
13.3.4 TDHS may recoup or adjust premium paid to HMO for a Member if the
Members eligibility status or program type is changed, corrected as a
result of error, or is retroactively adjusted.
13.3.5 Recoupment or adjustment of premium under 13.3.1 through 13.3.4 may be
appealed using the TDHS dispute resolution process.
13.3.6 TDHS may adjust premiums for all Members within an eligibility status
or program type if adjustment is required by reductions in
appropriations or if a benefit or category of benefits is excluded or
included as a covered service. Adjustment must be made by amendment as
required by 15.2.2
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Adjustment to premium under this subsection may not be appealed using
the TDHS dispute process.
ARTICLE XIV ELIGIBILITY, ENROLLMENT, AND DISENROLLMENT
14.1 ELIGIBILITY DETERMINATION
14.1.1 DHS will identify Medicaid recipients who are eligible for
participation in the STAR+PLUS program using the eligibility status
described below.
14.1.2 MANDATORY - Individuals in the following must enroll in one of the
STAR+PLUS HMOs providing services in the Service Area:
SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS 21 AND OLDER SSI
Eligible clients 21 and older living in the community, except for
those individuals listed as "voluntary" or "non-participant."
CLIENTS IN SOCIAL SECURITY (RSDI) EXCLUSIONS PROGRAMS Clients denied
SSI because of specified increases (e.g., cost-of-living adjustments,
etc.) in Social Security (RSDI or Title II) benefits.
CLIENTS ENTERING TITLE-XIX NURSING FACILITIES (NFs)
Clients entering Title-XIX NFs who qualify for nursing facility level
of care, as determined by DHS after the date of implementation.
COMMUNITY-BASED ALTERNATIVES (CBA) WAIVER CLIENTS Clients who qualify
for nursing facility level of care, as determined by DHS, but who
elect to receive services in the community.
SPEND DOWN CLIENTS
Adult Clients in nursing facilities who spend down to Medicaid
eligibility (SSI/MAO) in less than twelve (12) months after date of
implementation and qualify for nursing facility level of care as
determined by DHS.
14.1.3 VOLUNTARY - The following individuals are not required to enroll in a
STAR+PLUS HMO, but have the option to enroll in an HMO. HMO will be
required to accept enrollment of any clients in these groups who elect
to enroll:
SSI ELIGIBLE CHILDREN
SSI eligible children under age 21 may choose two types of managed
care models (HMO or PCCM).
SSI ELIGIBLE CLIENTS WITH SEVERE AND PERSISTENT MENTAL ILLNESS AND
CHILDREN/ADOLESCENTS WITH SERIOUS EMOTIONAL DISTURBANCE (SED)
SSI eligible clients with severe and persistent mental illness and
children/adolescents with SEA who are receiving Medicaid- funded
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rehabilitation services through the local mental health authority may
choose two types of Managed Care models (HMO or PCCM).
MEDICAID RECIPIENTS IN NURSING FACILITIES (NFs) ON DATE OF
IMPLEMENTATION
Individuals eligible for SSI/MAO and residing in NFs on
date of implementation.
SPEND DOWN NF RESIDENTS WHO SPEND DOWN RESOURCES AFTER TWELVE (12)
MONTHS IN NF
Individuals residing in NFs who spend down to MAO after twelve
(12) months or more in the NF.
14.1.4 NON-PARTICIPANTS - The following individuals are not affected by
STAR+PLUS and will not be included in the project:
COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) WAIVER
CLIENTS
Individuals receiving CLASS waiver services.
MEDICALLY DEPENDENT CHILDREN'S WAIVER PROGRAM (MDCP) CLIENTS
Individuals receiving MDCP waiver services.
HOME AND COMMUNITY SERVICES (HAS and HAS-O) WAIVER CLIENTS
Individuals receiving HAS services.
DEAF-BLIND MULTIPLE DISABLED (DBMD) WAIVER CLIENTS
Individuals receiving DBMD services.
HOSPICE - Individuals who exercise their option to participate in a
Hospice program.
14.2 ENROLLMENT
14.2.1 TDHS has the right and responsibility to enroll and disenroll eligible
individuals into the STAR+PLUS program. HMO must accept all persons
who chose to enroll as Members in HMO, without regard to the Members
health status or any other factor.
14.2.2 All enrollments are subject to the accessibility and availability
limitations and restrictions contained in the Section 1915(b) Waiver
obtained by TDHS. TDHS has the authority to limit enrollment into HMO
if the number and distance limitations are exceeded.
14.2.3 TDHS makes no guarantees or representations to HMO regarding the
number of eligible Medicaid recipients who will ultimately be enrolled
as STAR+PLUS Members of HMO.
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14.2.4 HMO must cooperate and participate in all TDHS sponsored and announced
enrollment activities. HMO must have a representative at all TDHS
enrollment activities unless an exception is given by TDHS. HMOs
representative must comply with HMOs cultural and linguistic
competency plan (see Cultural and Linguistic in section 8.8 of this
Contract). HMO must provide marketing materials, HMO pamphlets, Member
handbooks, a list of network providers, HMOs linguistic and cultural
capabilities and other information requested or required by TDHS or
its Contract administrator to assist potential Members in making
informed choices.
14.2.5 TDHS will provide HMO with at least ten (10) days written notice of
all TDHS planned activities. Failure to participate in, or send a HMO
representative to a TDHS sponsored enrollment activity is a default of
the terms of the Contract. Default may be excused if HMO can show that
TDHS failed to provided the required notice, or if HMOs absence is
excused by TDHS.
14.3 PLAN CHANGES FROM HMO AND DISENROLLMENT FROM MANAGED CARE
14.3.1 Members have a right to change HMOs at any time.
14.3.2 TDHS is responsible for disenrolling the Member from HMO. If a
disenrollment request is received before the 15th of the month,
disenrollment is effective on the first day of the next month. If a
disenrollment request is received after the fifteenth (15) of the
month, disenrollment will be effective the 1st day of the month
following the next month.
14.3.3 HMO has a limited right to request a Member be disenrolled from HMO
without the Members consent. Disenrollment of a Member may be
permitted under the following circumstances:
(1) disruptive behavior at HMOs facility or a network providers
office, unrelated to a physical or behavioral health
condition;
(2) loaning or allowing another person to use HMOs Membership
card; or
(3) other circumstances approved by TDHS justifying
disenrollment.
14.3.4 HMO must take reasonable measures to work with the Member to
ameliorate the situation prior to requesting disenrollment. Reasonable
measures may include providing education and counseling regarding the
offensive acts or behaviors.
14.3.5 HMO must notify the Member of HMOs decision to disenroll the Member if
all reasonable measures have failed to remedy the problem.
14.3.6 If the Member disagrees with HMOs decision, HMO must notify the Member
of the availability of the complaint procedure and the TDHS Fair
Hearing process.
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14.3.7 HMO CANNOT REQUEST A DISENROLLMENT BASED ON ADVERSE CHANGE IN THE
MEMBER[ ]S HEALTH STATUS OR UTILIZATION OF SERVICES WHICH ARE
MEDICALLY NECESSARY FOR TREATMENT OF A MEMBER[ ]S CONDITION.
14.3.8 Members may not be disenrolled solely because of a disability or
chronic or complex condition.
14.4 AUTOMATIC RE-ENROLLMENT
14.4.1 Members who are disenrolled because they are temporarily ineligible
for Medicaid will be automatically re-enrolled into the same health
plan. Temporary loss of eligibility is defined as a period of 6 months
or less.
14.4.2 HMO must inform its Members of the automatic re-enrollment procedure.
Automatic re-enrollment must be included in the Member Handbook (See
Article 8.2.1).
14.5. ENROLLMENT REPORTS
14.5.1 TDHS will provide monthly HMO Enrollment Reports to HMO on or before
the first of the month.
ARTICLE XV GENERAL PROVISIONS
15.1 INDEPENDENT CONTRACTOR
HMO, its agents, employees, network providers, and Subcontractors are
independent contractors and do not perform services under this
contract as employees or agents of TDHS. HMO is given express, limited
authority to exercise the State's right of recovery as provided in
Article 4.9.
15.2 AMENDMENT
15.2.1 This contract must be amended by TDHS if amendment is required to
comply with changes in state or federal laws, rules, or regulations.
15.2.2 TDHS and HMO may amend this contract if reductions in funding or
appropriations make full performance by either party impracticable or
impossible, and amendment could provide a reasonable alternative to
termination. If HMO does not agree to the amendment, contract may be
terminated under Article XVIII.
15.2.3 This contract must be amended if either party discovers a material
omission of a negotiated or required term, which is essential to the
successful performance or maintaining compliance with the terms of the
contract. The party discovering the omission must notify the other
party of the omission in writing as soon as possible after discovery.
If there is a
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disagreement regarding whether the omission was intended to be a term
of the contract, the parties must submit the dispute to dispute
resolution under Article 15.8 of this contract.
15.2.4 This contract may be amended by mutual agreement at any time.
15.2.5 All amendments to this contract must be in writing and signed by both
parties.
15.2.6 No agreement shall be used to amend this contract unless it is made a
part of this contract by specific reference, and is numbered
sequentially by order of its adoption.
15.3 LAW, JURISDICTION AND VENUE
Venue and jurisdiction shall be in the state and federal district
courts of ▇▇▇▇▇▇ County, Texas. The laws of the State of Texas shall
be applied in all matters of state law.
15.4 NON-WAIVER
Failure to enforce any provision or breach shall not be taken by
either party as a waiver of the right to enforce the provision or
breach in the future.
15.5 SEVERABILITY
Any part of this contract which is found to be unenforceable, invalid,
void, or illegal shall be severed from the contract. The remainder of
the contract shall be effective.
15.6 ASSIGNMENT
This contract was awarded to HMO based on HMO s qualifications to
perform personal and professional services. HMO cannot assign this
contract without the written consent of TDI and TDHS. This provision
does not prevent HMO from subcontracting duties and responsibilities
to qualified Subcontractors. If TDI and TDHS consent to an assignment
of this contract, a transition period of 90 days will run from the
date the assignment is approved by TDI and TDHS so that Members'
services are not interrupted and, if necessary, the notice provided
for in Section 15.7 can be sent to Members. The assigning HMO must
also submit a transition plan, as set out in Section 18.2.1, subject
to TDHS approval.
15.7 MAJOR CHANGE IN CONTRACTING
TDHS may send notice to Members when a major change affecting HMO
occurs. A "major change" includes, but is not limited to, a
substantial change of subcontractors and assignment of this contract.
The notice
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letter to Members may permit the Members to re-select their plan and
PCP. TDHS will bear the cost of preparing and sending the notice
letter.
15.8 NON-EXCLUSIVE
This contract is a non-exclusive agreement. Either party may contract
with other entities for similar services in the same service area.
15.9 DISPUTE RESOLUTION
All disputes arising under this contract shall be resolved through
TDHS' dispute resolution procedures, except where a remedy is provided
for through TDHS' administrative rules or processes. All
administrative remedies must be exhausted prior to other methods of
dispute resolution.
15.10 DOCUMENTS CONSTITUTING CONTRACT
This contract includes this document and all amendments and appendices
to this document, the Request for Application, the Application
submitted in response to the Request for Application, the Texas
Medicaid Provider Procedures Manual and Texas Medicaid Bulletins
addressed to HMOs, contract interpretation memoranda issued by TDHS
for this contract, and the federal waiver granting TDHS authority to
contract with HMO. If any conflict in provisions between these
documents occurs, the terms of this contract and any amendments shall
prevail. The documents listed above constitute the entire contract
between the parties.
15.11 FORCE MAJEURE
TDHS and HMO are excused from performing the duties and obligations
under this contract for any period that they are prevented from
performing their services as a result of a catastrophic occurrence, or
natural disaster, clearly beyond the control of either party,
including but not limited to an act of war, but excluding labor
disputes.
15.12 NOTICES
Notice may be given by any means which provides for verification of
receipt. All notices to TDHS shall be addressed to Bureau Chief, Texas
Department of Health, Bureau of Managed Care, ▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇▇▇,
▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇, with a copy to the Contract Administrator.
Notices to HMO shall be addressed to President/CEO,
▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇, ▇▇.
▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
15.13 SURVIVAL
The provisions of this contract which relate to the obligations of HMO
to maintain records and reports shall survive the expiration or
earlier
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termination of this contract for a period not to exceed six (6) years
unless another period may be required by record retention policies of
the State of Texas or HCFA.
ARTICLE XVI DEFAULT AND REMEDIES
16.1 DEFAULT BY TDHS
16.1.1 FAILURE TO MAKE CAPITATION PAYMENTS
Failure by TDHS to make capitation payments when due is a default
under this contract.
16.1.2 FAILURE TO PERFORM DUTIES AND RESPONSIBILITIES
Failure by TDHS to perform a material duty or responsibility as set
out in this contract is a default under this contract.
16.2 REMEDIES AVAILABLE TO HMO FOR TDHS DEFAULT
HMO may terminate this contract as set out in Article 18.1.5 of this
contract if TDHS commits either of the events of default set out in
Article 16.1.
16.3 DEFAULT BY HMO
16.3.1 FAILURE TO PERFORM AN ADMINISTRATIVE FUNCTION
Failure of HMO to perform an administrative function is a default
under this contract. Administrative functions are any requirements
under this contract that are not direct delivery of health care
services, including claims payment; encounter data submission; filing
any report when due; cooperating in good faith with TDHS, an entity
acting on behalf of TDHS, or an agency authorized by statute or law to
require the cooperation of HMO in carrying out an administrative,
investigative, or prosecutorial function of the Medicaid program;
providing or producing records upon request; or entering into
contracts or implementing procedures necessary to carry out contract
obligations.
16.3.1.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to perform an administrative function under this
contract, TDHS may:
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- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article 18.4;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.2 ADVERSE ACTION AGAINST HMO BY TDI
Termination or suspension of HMO's TDI Certificate of Authority or any
adverse action taken by TDI that TDHS determines will affect the
ability of HMO to provide health care services to Members is a default
under this contract.
16.3.2.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For an adverse action against HMO by TDI, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.3 INSOLVENCY
Failure of HMO to comply with state and federal solvency standards or
incapacity of HMO to meet its financial obligations as they come due
is a default under this contract.
16.1.1.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's insolvency, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
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16.3.4 FAILURE TO COMPLY WITH FEDERAL LAWS AND REGULATIONS
Failure of HMO to comply with the federal requirements for Medicaid,
including, but not limited to, federal law regarding
misrepresentation, fraud, or abuse; and, by incorporation, Medicare
standards, requirements, or prohibitions, is a default under this
contract.
The following events are defaults under this contract pursuant to 42
U.S.C. "1396b(m)(5), 1396u-2(e)(1)(A):
16.3.4.1 HMO's substantial failure to provide medically necessary items and
services that are required under this contract to be provided to
Members;
16.3.4.2 HMO's imposition of premiums or charges on Members in excess of the
premiums or charge permitted by federal law;
16.3.4.3 HMO's acting to discriminate among Members on the basis of their
health status or requirements for health care services, including
expulsion or refusal to enroll an individual, except as permitted by
federal law, or engaging in any practice that would reasonably be
expected to have the effect of denying or discouraging enrollment with
HMO by eligible individuals whose medical condition or history
indicates a need for substantial future medical services;
16.3.4.4 HMO's misrepresentation or falsification of information that is
furnished to HCFA, TDHS, a Member, a potential Member, or a health
care provider;
16.3.4.5 HMO's failure to comply with the physician incentive requirements
under 42 U.S.C. '1396b(m)(2)(A)(x); or
16.3.4.6 HMO's distribution, either directly or through any agent or
independent contractor, of marketing materials that contain false or
misleading information, excluding materials prior approved by TDHS.
16.3.5 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. If HMO repeatedly fails to
meet the requirements of Articles 16.3.4.1 through and including
16.3.4.6, TDHS must, regardless of what other sanctions are provided,
appoint temporary management and permit Members to disenroll without
cause. Exercise of any remedy in whole or in part does not limit TDHS
in exercising all or part of any remaining remedies.
For HMO's failure to comply with federal laws and regulations, TDHS
may:
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- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Appoint temporary management as set out in Article 18.5;
- Initiate disenrollment of a Member of Members without cause
as set out in Article 18.6;
- Suspend or default all enrollment of individuals;
- Suspend payment to HMO;
- Recommend to HCFA that sanctions be taken against HMO as set
out in Article 18.7;
- Assess civil monetary penalties as set out in Article 18.8;
and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.6 FAILURE TO COMPLY WITH APPLICABLE STATE LAW
HMO's failure to comply with Texas law applicable to Medicaid,
including, but not limited to, Article 32.039 of the Texas Human
Resources Code and state law regarding misrepresentation, fraud, or
abuse, is a default under this contract.
16.3.6.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to comply with applicable state law, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess administrative penalties as set out in Article
32.039, Government Code, with the opportunity for notice and
appeal as required by Article 32.039; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.7 MISREPRESENTATION OR FRAUD UNDER ARTICLE 4.8
HMO's misrepresentation or fraud under Article 4.8 of this contract is
a default under this contract.
16.3.7.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
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For HMO's misrepresentation or fraud under Article 4.8, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- P Suspend new enrollment as set out in Article 18.3; and/or
- P Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.8 EXCLUSION FROM PARTICIPATION IN MEDICARE OR MEDICAID
16.3.8.1 Exclusion of HMO or any of the managing employees or persons with an
ownership interest whose disclosure is required by '1124(a) of the
Social Security Act (the Act) from the Medicaid or Medicare program
under the provisions of '1128(a) and/or (b) of the Act is a default
under this contract.
16.3.8.2 Exclusion of any provider or subcontractor or any of the managing
employees or persons with an ownership interest of the provider or
subcontractor whose disclosure is required by '1124(a) of the Social
Security Act (the Act) from the Medicaid or Medicare program under the
provisions of '1128(a) and/or (b) of the Act is a default under this
contract if the exclusion will materially affect HMO's performance
under this contract.
16.3.8.3 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's exclusion from Medicare or Medicaid, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.9 FAILURE TO MAKE PAYMENTS TO NETWORK PROVIDERS AND SUBCONTRACTORS
HMO's failure to make timely and appropriate payments to network
providers and subcontractors is a default under this contract.
Withholding or recouping capitation payments as allowed or required
under other articles of this contract is not a default under this
contract.
16.3.9.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
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All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to make timely and appropriate payments to network
providers and subcontractors, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.10 FAILURE TO TIMELY ADJUDICATE CLAIMS
Failure of HMO to adjudicate (paid, denied, or external pended) at
least ninety (90%) of all claims within thirty (30) days of receipt
and ninety-nine percent (99%) of all claims within ninety days of
receipt for the contract year is a default under this contract.
16.3.10.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consequently. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to timely adjudicate claims, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.11 FAILURE TO DEMONSTRATE THE ABILITY TO PERFORM CONTRACT FUNCTIONS
Failure to pass any of the mandatory system or delivery functions of
the Readiness Review required in Article I of this contract is a
default under the contract.
16.3.11.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised
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concurrently or consecutively. Exercise of any remedy in whole or in
part does not limit TDHS in exercising all or part of any remaining
remedies.
For HMO's failure to demonstrate the ability to perform contract
functions, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.12 FAILURE TO MONITOR AND/OR SUPERVISE ACTIVITIES OF CONTRACTORS OR
NETWORK PROVIDERS
16.3.12.1 Failure of HMO to audit, monitor, supervise, or enforce functions
delegated by contract to another entity that results in a default
under this contract or constitutes a violation of state or federal
laws, rules, or regulations is a default under this contract.
16.3.12.2 Failure of HMO to properly credential its providers, conduct
reasonable utilization review, or conduct quality monitoring is a
default under this contract.
16.3.12.3 Failure of HMO to require providers and contractors to provide timely
and accurate encounter, financial, statistical, and utilization data
is a default under this contract.
16.3.12.4 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to monitor and/or supervise activities of
contractors or network providers, TDHS may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.13 PLACING THE HEALTH AND SAFETY OF MEMBERS IN JEOPARDY
HMO's placing the health and safety of the Members in jeopardy is a
default under this contract.
16.3.13.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
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All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's placing the health and safety of Members in jeopardy, TDHS
may:
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
16.3.14 FAILURE TO MEET ESTABLISHED BENCHMARK
Failure of HMO to meet any benchmark established by TDHS under this
contract is a default under this contract.
16.3.14.1 REMEDIES AVAILABLE TO TDHS FOR THIS HMO DEFAULT
All of the listed remedies are in addition to all other remedies
available to TDHS by law or in equity, are joint and several, and may
be exercised concurrently or consecutively. Exercise of any remedy in
whole or in part does not limit TDHS in exercising all or part of any
remaining remedies.
For HMO's failure to meet any benchmark established by TDHS under this
contract, TDHS may:
- Remove the THSteps component from the capitation paid to HMO
if the benchmark(s) missed is for THSteps;
- Terminate the contract if the applicable conditions set out
in Article 18.1.1 are met;
- Suspend new enrollment as set out in Article 18.3;
- Assess liquidated money damages as set out in Article
18.4; and/or
- Require forfeiture of all or part of the TDI performance
bond as set out in Article 18.9.
ARTICLE XVII NOTICE OF DEFAULT AND CURE OF DEFAULT
17.1 TDHS will provide HMO with written notice of default (Notice of
Default) under this contract. The Notice of Default may be given by
any means that provides verification of receipt. The Notice of Default
must contain the following information:
17.1.1 A clear and concise statement of the circumstances or conditions that
constitute a default under this contract;
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17.1.2 The contract provision(s) under which default is being declared;
17.1.3 A clear and concise statement of how and/or whether the default may be
cured;
17.1.4 A clear and concise statement of the time period during which the HMO
may cure the default if HMO is allowed to cure;
17.1.5 The remedy or remedies TDHS is electing to pursue and when the remedy
or remedies will take effect;
17.1.6 If TDHS is electing to impose money damages and/or civil monetary
penalties, the amount that TDHS intends to withhold or impose and the
factual basis on which TDHS is imposing the chosen remedy or remedies;
17.1.7 Whether any part of money damages or civil monetary penalties, if TDHS
elects to pursue one or both of those remedies, may be passed through
to an individual or entity who is or may be responsible for the act or
omission for which default is declared;
17.1.8 Whether failure to cure the default within the given time period, if
any, will result in TDHS pursuing an additional remedy or remedies,
including, but not limited to, additional damages or sanctions,
referral for investigation or action by another agency, and/or
termination of the contract
ARTICLE XVIII EXPLANATION OF REMEDIES
18.1 TERMINATION
18.1.1 TERMINATION BY TDHS
18.1.1 TDHS may terminate this contract if:
18.1.1.1 HMO substantially fails or refuses to provide medically necessary
services and items that are required under this contract to be
provided to Members after notice and opportunity to cure;
18.1.1.2 HMO substantially fails or refuses to perform administrative functions
under this contract after notice and opportunity to cure;
18.1.1.3 HMO materially defaults under any of the provisions of Article XVI;
18.1.1.4 Federal or state funds for the Medicaid program are no longer
available; or
18.1.1.5 TDHS has a reasonable belief that HMO has placed the health or welfare
of Members in jeopardy.
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18.1.2 TDHS must give HMO 90 days written notice of intent to terminate this
contract if termination is the result of HMO's substantial failure or
refusal to perform administrative functions or a material default
under any of the provisions of Article XVI. TDHS must give HMO
reasonable notice under the circumstances if termination is the result
of federal or state funds for the Medicaid program no longer being
available. TDHS must give the notice required under TDHS formal
hearing procedures set out in Section 1.21 in Title 25 of the Texas
Administrative Code if termination is the result of HMO's substantial
failure or refusal to provide medically necessary services and items
that are required under the contract to be provided to Members or
TDHS' reasonable belief that HMO has placed the health or welfare of
Members in jeopardy.
18.1.2.1 Notice may be given by any means that gives verification of receipt.
18.1.2.2 Unless termination is the result of HMO's substantial failure or
refusal to provide medically necessary services and items that are
required under this contract to be provided to Members or is the
result of TDHS' reasonable belief that HMO has placed the health or
welfare of Members in jeopardy, the termination date is 90 days
following the date that HMO receives the notice of intent to
terminate. For HMO's substantial failure or refusal to provide
services and items, HMO is entitled to request a pre-termination
hearing under TDHS' formal hearing procedures set out in Section 1.21
of Title 25, Texas Administrative Code.
18.1.3 TDHS may, for termination for HMO's substantial failure or refusal to
provide medically necessary services and items, notify HMO's Members
of any hearing requested by HMO and permit Members to disenroll
immediately without cause. Additionally, if TDHS terminates for this
reason, TDHS may enroll HMO's Members with another HMO or permit the
HMO's Members to receive Medicaid-covered services other than from an
HMO.
18.1.4 HMO must continue to perform services under the transition plan
described in Article 18.2.1 until the last day of the month following
90 days from the date of receipt of notice if the termination is for
any reason other than TDHS' reasonable belief that HMO is placing the
health and safety of the Members in jeopardy. If termination is due to
this reason, TDHS may prohibit HMO's further performance of services
under the contract.
18.1.5 If the state terminates this contract, HMO may appeal the termination
under 32.034, Texas Human Resources Code.
18.1.6 TERMINATION BY HMO
HMO may terminate this contract if TDHS fails to pay HMO as required
under Article XIII of this contract or otherwise materially defaults
in its duties and responsibilities under this contract, or by giving
notice no later than 30 days after receiving the capitation rates for
the second contract year. Retaining premium, recoupment, sanctions, or
penalties that are allowed under this contract or that result from
HMO's failure to perform or
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HMO's default under the terms of this contract is not cause for
termination.
18.7.1 HMO must give TDHS 90 days written notice of intent to terminate this
contract. Notice may be given by any means that gives verification of
receipt. The termination date will be calculated as the last day of
the month following 90 days from the date the notice of intent to
terminate is received by TDHS.
18.1.8 TDHS must be given 30 days from the date TDHS receives HMO's written
notice of intent to terminate for failure to pay HMO to pay all
amounts due. If TDHS pays all amounts then due within this 30-day
period, HMO cannot terminate the contract under this article for that
reason.
18.1.9 TERMINATION BY MUTUAL CONSENT
This contract may be terminated at any time by mutual consent of both
HMO and TDHS.
18.2 DUTIES OF CONTRACTING PARTIES UPON TERMINATION
When termination of the contract occurs, TDHS and HMO must meet the
following obligations:
18.2.1 TDHS and HMO must prepare a transition plan, which is acceptable to
and approved by TDHS, to ensure that Members are reassigned to other
health plans without interruption of services. That transition plan
will be implemented during the 90-day period between receipt of notice
and the termination date unless termination is the result of TDHS'
reasonable belief that HMO is placing the health or welfare of Members
in jeopardy.
18.2.2 If the contract is terminated by TDHS for any reason other than
federal or state funds for the Medicaid program no longer being
available or if HMO terminates the contract based on lower capitation
rates for the second contract year as set out in Article 13.1.2:
18.2.2.1 TDHS is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract services;
18.2.2.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.2.3 HMO is responsible for all expenses incurred by TDHS in implementing
the transition plan.
18.2.3 If the contract is terminated by HMO for any reason other than based
on lower capitation rates for the second contract year as set out in
Article 13.1.2:
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18.2.3.1 TDHS is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract services;
18.2.3.2 TDHS is responsible for all expenses related to giving notice to
Members; and
18.2.3.3 TDHS is responsible for all expenses it incurs in implementing the
transition plan.
18.2.4 If the contract is terminated by mutual consent:
18.2.4.1 TDHS is responsible for notifying all Members of the date of
termination and how Members can continue to receive contract services;
18.2.4.2 HMO is responsible for all expenses related to giving notice to
Members; and
18.2.4.3 TDHS is responsible for all expenses it incurs in implementing the
transition plan.
18.3 SUSPENSION OF NEW ENROLLMENT
18.3.1 TDHS must give HMO 30 days notice of intent to suspend new enrollment
in the Notice of Default other than for default for fraud and abuse or
imminent danger to the health or safety of Members. The suspension
date will be calculated as 30 days following the date that HMO
receives the Notice of Default.
18.3.2 TDHS may immediately suspend new enrollment into HMO for a default
declared as a result of fraud and abuse or imminent danger to the
health and safety of Members.
18.3.3 The suspension of new enrollment may be for any duration, up to the
termination date of the contract. TDHS will base the duration of the
suspension upon the type and severity of the default and HMO's
ability, if any, to cure the default.
18.4. LIQUIDATED MONEY DAMAGES
18.4.1 The measure of damages in the event that HMO fails to perform its
obligations under this contract may be difficult or impossible to
calculate or quantify. Therefore, should HMO fail to perform in
accordance with the terms and conditions of this contract, TDHS may
require HMO to pay sums as specified below as liquidated damages. The
liquidated damages set out in this Article are not intended to be in
the nature of a penalty but are intended to be reasonable estimates of
TDHS' financial loss and damage resulting from HMO's non-performance.
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18.4.2 TDHS imposes money damages, TDHS may collect those damages by reducing
the amount of any monthly premium payments otherwise due to HMO by the
amount of the damages. Money damages that are withheld from monthly
premium payments are forfeited and will not be subsequently paid to
HMO upon compliance or cure of default unless a determination is made
after appeal that the damages should not have been imposed.
18.4.3 Failure to file or filing incomplete or inaccurate annual, semi-annual
or quarterly reports may result in money damages of not more than
$11,000.00 for every month from the month the report is due until
submitted in the form and format required by TDHS. These money damages
apply separately to each report.
18.4.4 Failure to produce or provide records and information requested by
TDHS, an entity acting on behalf of TDHS, or an agency authorized by
statute or law to require production of records at the time and place
the records were required or requested may result in money damages of
not more than $5,000.00 per day for each day the records are not
produced as required by the requesting entity or agency if the
requesting entity or agency is conducting an investigation or audit
relating to fraud or abuse, and not more than $1,000.00 per day for
each day records are not produced if the requesting entity or agency
is conducting routine audits or monitoring activities.
18.4.5 Failure to file or filing incomplete or inaccurate encounter data may
result in money damages of not more than $25,000 for each month HMO
fails to submit encounter data in the form and format required by
TDHS. TDHS will use the encounter data validation methodology
established by TDHS to determine the number of encounter data and the
number of months for which damages will be assessed.
18.4.6 Failing or refusing to cooperate with TDHS, an entity acting on behalf
of TDHS, or an agency authorized by statute or law to require the
cooperation of HMO in carrying out an administrative, investigative,
or prosecutorial function of the Medicaid program may result in money
damages of not more than $8,000.00 per day for each day HMO fails to
cooperate.
18.4.7 Failure to enter into a required or mandatory contract or failure to
contract for or arrange to have all services required under this
contract provided may result in money damages of not more than
$1,000.00 per day that HMO either fails to negotiate in good faith to
enter into the required contract or fails to arrange to have required
services delivered.
18.4.8 Failure to meet the benchmark for benchmarked services under this
contract may result in money damages of not more than $25,000 for each
month that HMO fails to meet the established benchmark.
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18.4.9 TDHS may also impose money damages for a default under Article
16.3.11, Failure to Make Payments to Network Providers and
Subcontractors, of this contract. These money damages are in addition
to the interest HMO is required to pay to providers under the
provisions of Article 7.3.8.10 of this contract.
18.4.9.1 If TDHS determines that HMO has failed to pay a provider for a claim
or claims for which the provider should have been paid, TDHS may
impose money damages of $2 per day for each day the claim is not paid
from the date the claim should have been paid (calculated as 30 days
from the date a clean claim was received by HMO) until the claim is
paid by HMO.
18.4.9.2 If TDHS determines that HMO has failed to pay a capitation amount to a
provider who has contracted with HMO to provide services on a
capitated basis, TDHS may impose money damages of $10 per day, per
Member for whom the capitation is not paid, from the date on which the
payment was due until the capitation amount is paid.
18.5 APPOINTMENT OF TEMPORARY MANAGEMENT
18.5.1 TDHS may appoint temporary management to oversee the operation of the
HMO upon a finding that there is continued egregious behavior by the
HMO or there is a substantial risk to the health of the Members.
18.5.2 TDHS may appoint temporary management to assure the health of the
HMO's Members if there is a need for temporary management while
18.5.2.1 there is an orderly termination or reorganization of the HMO, or
18.5.2.2 are made to remedy violations found under Article 16.3.4.
18.5.3 Temporary management will not be terminated until TDHS has determined
that HMO has the capability to ensure that the violations that
triggered appointment of temporary management will not recur.
18.5.4 TDHS is not required to appoint temporary management before
terminating this contract.
18.5.5 No pre-termination hearing is required before appointing temporary
management.
18.6 TDHS-INITIATED DISENROLLMENT OF A MEMBER OR MEMBERS WITHOUT CAUSE
TDHS must give HMO 30 days notice of intent to initiate disenrollment
of a Member or Members in the Notice of Default. The TDHS-initiated
disenrollment date will be calculated as 30 days following the date
that HMO receives the Notice of Default.
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18.7 RECOMMENDATION TO HCFA THAT SANCTIONS BE TAKEN AGAINST HMO
18.7.1 If HCFA determines that HMO has violated federal law or regulations
and that federal payments will be withheld, TDHS will deny and
withhold payments for new enrollees of HMO.
18.7.2 HMO must be given notice and opportunity to appeal a decision of TDHS
and HCFA pursuant to 42 CFR '434.67.
18.8 CIVIL MONETARY PENALTIES
18.8.1 For a default under Article 16.3.4.1, TDHS may assess not more than
$25,000 for each default;
18.8.2 For a default under Article 16.3.4.2, TDHS may assess double the
excess amount charged in violation of the federal requirements for
each default. The excess amount shall be deducted from the penalty and
returned to the Member concerned.
18.8.3 For a default under Article 16.3.4.3, TDHS may assess not more than
$100,000 for each default, including $15,000 for each individual not
enrolled as a result of the practice described in Article 16.3.4.3.
18.8.4 For a default under Article 16.3.4.4, TDHS may assess not more than
$100,000 for each default if the material was provided to HCFA or TDHS
and not more than $25,000 for each default if the material was
provided to a Member, a potential Member, or a health care provider.
18.8.5 For a default under Article 16.3.4.5, TDHS may assess not more than
$25,000 for each default.
18.8.6 For a default under Article 16.3.4.6, TDHS may assess not more than
$25,000 for each default.
18.8.7 HMO may be subject to civil money penalties under the provisions of 42
CFR 1003 in addition to or in place of withholding payments for a
default under Article 16.3.4.
18.9 FORFEITURE OF ALL OR A PART OF THE TDI PERFORMANCE BOND
TDHS may require forfeiture of all or a portion of the face amount of
the TDI performance bond if TDHS determines that an event of default
has occurred. Partial payment of the face amount shall reduce the
total bond amount available pro rata.
18.10 REVIEW OF REMEDY OR REMEDIES TO BE IMPOSED
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18.10.1 HMO may dispute the imposition of any sanction under this contract.
HMO notifies HMO of its dispute by filing a written response to the
Notice of Default, clearly stating the reason HMO disputes the
proposed sanction. With the written response, HMO must submit to TDHS
any documentation that supports HMO's position. HMO must file the
review within 15 days from HMO's receipt of the Notice of Default.
Filing a dispute in a written response to the Notice of Default
suspends imposition of the proposed sanction.
18.10.2 HMO and TDHS must attempt to informally resolve the dispute. If HMO
and TDHS are unable to informally resolve the dispute, HMO must notify
the Bureau Chief of Managed Care that HMO and TDHS cannot agree. The
Bureau Chief will refer the dispute to the Associate Commissioner for
Health Care Financing who will appoint a committee to review the
dispute under TDHS' dispute resolution procedures. The decision of the
dispute resolution committee will be TDHS' final administrative
decision.
ARTICLE XIX TERM
19.1 The effective date of this contract is September 1, 1999. This
contract will terminate on August 31, 2001, unless terminated earlier
as provided for elsewhere in this contract.
19.2 The contract will not automatically renew beyond the contract period.
19.3 If either party does not intend to renew the contract beyond its
initial term, the party intending not to renew must submit a written
notice of its intent not to renew to the other party no later than 90
days before the termination date set out in Article 19.1.
19.4 If either party does not intend to renew the contract beyond its
initial term and sends the notice required in Article 19.3, a
transition period of 90 days will run from the date the notice of
intent not to renew is received by the other party. By signing this
contract, the parties agree that the terms of this contract shall
automatically continue during any transition period.
19.5 The party that does not intend to renew the contract beyond its
initial term and sends the notice required by Article 19.3 is
responsible for sending notices to all Members on how the Member can
continue to receive covered services. The expense of sending the
notices will be paid by the non-renewing party. If TDHS does not
intend to renew and sends the required notice, TDHS is responsible for
any costs it incurs in ensuring that Members are reassigned to other
plans without interruption of services. If HMO does not intend to
renew and sends the required notice, HMO is responsible for any costs
TDHS incurs in ensuring that Members are reassigned to other plans
without interruption of services. If both parties do not intend to
renew the contract beyond its initial term, TDHS will send the notices
to Members and the parties will share equally in the cost of sending
the notices and of implementing the transition plan.
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19.6 Non-renewal of this contract is not a contract termination for
purposes of appeal rights under the Human Resources Code Section
32.034.
TEXAS DEPARTMENT OF AMERICAID TEXAS, INC.
HUMAN SERVICES
BY: BY:
---------------------- -------------------------
▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇ JR.
COMMISSIONER PRESIDENT AND CEO
DATE SIGNED: 9/1/99 DATE SIGNED: 8/24/99
------------ ---------------
APPROVED AS TO FORM:
------------------------
Office of General Counsel
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ATTACHMENTS
Copies of attachments A - E will be available in the Regulatory Department upon
request.
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