AMENDED AND RESTATED CONTRACT BETWEEN THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH and AMERIGROUP GEORGIA MANAGED CARE COMPANY, INC. for PROVISION OF SERVICES TO GEORGIA FAMILIES

Exhibit 10.4

AMENDED AND RESTATED
CONTRACT BETWEEN

THE GEORGIA DEPARTMENT OF COMMUNITY
HEALTH

and

AMERIGROUP GEORGIA MANAGED CARE
COMPANY, INC.

for

PROVISION OF SERVICES TO

GEORGIA FAMILIES

Contract No.: 0652

Amendment 3

May 1, 2008

TABLE OF CONTENTS

1.0 SCOPE OF SERVICE			1
1.1 BACKGROUND			1
1.2.1 Medicaid			2
1.2.2 PeachCare for Kids			3
1.2.3 Exclusions			3
1.3 SERVICE REGIONS			4
1.4 DEFINITIONS			4
1.5 ACRONYMS			19
2.0 DCH RESPONSIBILITIES			22
2.1 GENERAL PROVISIONS			22
2.2 LEGAL COMPLIANCE			22
2.3 ELIGIBILITY AND ENROLLMENT			22
2.4 DISENROLLMENT			24
2.5 MEMBER SERVICES AND MARKETING			25
2.6 COVERED SERVICES & SPECIAL COVERAGE PROVISIONS			25
2.7 NETWORK			25
2.8 QUALITY MONITORING			26
2.9 COORDINATION WITH CONTRACTOR’S KEY STAFF			27
2.10 FORMAT STANDARDS			27
2.11 FINANCIAL MANAGEMENT			27
2.12 INFORMATION SYSTEMS			27
2.13 READINESS OR ANNUAL REVIEW			28
3.0 GENERAL CONTRACTOR RESPONSIBILITIES			29
4.0 SPECIFIC CONTRACTOR RESPONSIBILITIES			30

4.1 ENROLLMENT			30
4.1.1 Enrollment Procedures			30
4.1.2 Selection of a Primary Care Provider (PCP)			30
4.1.3 Newborn Enrollment			31
4.1.4 Reporting Requirements			32
4.2 DISENROLLMENT			32
4.2.1 Disenrollment Initiated by the Member			32
4.2.2 Disenrollment Initiated by the Contractor			33
4.2.3 Acceptable Reasons for Disenrollment Investigation Requests by Contractor			33
4.2.4 Unacceptable Reasons for Disenrollment Requests by Contractor			34
4.3 MEMBER SERVICES			35
4.3.1 General Provisions			35
4.3.2 Requirements for Written Materials			35
4.3.3 Member Handbook Requirements			36
4.3.4 Member Rights			39
4.3.5 Provider Directory			40
4.3.6 Member Identification (ID) Card			40
4.3.7 Toll-free Member Services Line			41
4.3.8 Internet Presence/Web Site			42
4.3.9 Cultural Competency			43
4.3.10 Translation Services			44
4.3.11 Reporting Requirements			44
4.4 MARKETING			44
4.4.1 Prohibited Activities			44
4.4.2 Allowable Activities			44
4.4.3 State Approval of Materials			45
4.4.4 Provider Marketing Materials			45
4.5 COVERED BENEFITS AND SERVICES			46

4.5.1 Included Services			46
4.5.2 Individuals with Disabilities Education Act (IDEA) Services			48
4.5.3 Enhanced Services			49
4.5.4 Medical Necessity			49
4.5.5 Experimental, Investigational or Cosmetic Procedures			50
4.5.6 Moral or Religious Objections			50
4.6 SPECIAL COVERAGE PROVISIONS			50
4.6.1 Emergency Services			50
4.6.2 Post-Stabilization Services			52
4.6.3 Urgent Care Services			54
4.6.4 Family Planning Services			54
4.6.5 Sterilizations, Hysterectomies and Abortions			55
4.6.6 Pharmacy			56
4.6.7 Immunizations			57
4.6.8 Transportation			57
4.6.9 Perinatal Services			57
4.6.10 Parenting Education			58
4.6.11 Mental Health and Substance Abuse			59
4.6.12 Advance Directives			59
4.6.13 ▇▇▇▇▇▇ Care Forensic Exam			60
4.6.14 Laboratory Services			60
4.6.15 Member Cost-Sharing			60
4.7 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK			60
4.7.1 General Provisions			60
4.7.2 Outreach and Informing			61
4.7.3 Screening			62
4.7.4 Tracking			63

4.7.5 Diagnostic and Treatment Services			64
4.7.6 Reporting Requirements			64
4.8 PROVIDER NETWORK			64
4.8.1 General Provisions			64
4.8.2 Primary Care Providers (PCPs)			66
4.8.3 Direct Access			69
4.8.4 Pharmacies			69
4.8.5 Hospitals			69
4.8.6 Laboratories			70
4.8.7 Mental Health/Substance Abuse			70
4.8.8 Federally Qualified Health Centers (FQHCs)			70
4.8.10 Family Planning Clinics			71
4.8.11 Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)			71
4.8.13 Geographic Access Requirements			72
4.8.14 Waiting Maximums and Appointment Requirements			73
4.8.15 Credentialing			74
4.8.16 Mainstreaming			75
4.8.17 Coordination Requirements			75
4.8.18 Network Changes			75
4.8.19 Out-of-Network Providers			76
4.8.21 Reporting Requirements			77
4.9 PROVIDER SERVICES			78
4.9.1 General Provisions			78
4.9.2 Provider Handbooks			78
4.9.3 Education and Training			79
4.9.4 Provider Relations			80
4.9.5 Toll-free Provider Services Telephone Line			80
4.9.6 Internet Presence/Web Site			81

4.9.7 Provider Complaint System			82
4.9.8 Reporting Requirements			84
4.10 PROVIDER CONTRACTS AND PAYMENTS			85
4.10.1 Provider Contracts			85
4.10.2 Provider Termination			89
4.10.3 Provider Insurance			89
4.10.4 Provider Payment			90
4.10.5 Reporting Requirements			92
4.11 UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES			93
4.11.1 Utilization Management			93
4.11.2 Prior Authorization and Pre-Certification			94
4.11.3 Referral Requirements			95
4.11.4 Transition of Members			96
4.11.5 Court-Ordered Evaluations and Services			98
4.11.6 Second Opinions			98
4.11.7 Care Coordination and Case Management			98
4.11.8 Disease Management			100
4.11.9 Discharge Planning			100
4.11.10 Reporting Requirements			101
4.12 QUALITY IMPROVEMENT			101
4.12.1 General Provisions			101
4.12.2 QUALITY STRATEGIC PLAN REQUIREMENTS			101
4.12.3 REPORTING REQUIREMENTS			102
4.12.4 Quality Assessment Performance Improvement (QAPI) Program			103
4.12.5 Performance Improvement Projects			104
4.12.6 Practice Guidelines			106

4.12.7 Focused Studies			107
4.12.7.1 Focus Studies:			107
4.12.8 Patient Safety Plan			107
4.12.9 Performance Incentives			108
4.12.9.1 Incentive Arrangement			108
4.12.10 External Quality Review			108
4.12.11 Reporting Requirements			108
4.13 FRAUD AND ABUSE			108
4.13.1 Program Integrity			108
4.13.2 Compliance Plan			109
4.13.3 Coordination with DCH and Other Agencies			110
4.13.4 Reporting Requirements			111
4.14 INTERNAL GRIEVANCE SYSTEM			111
4.14.1 General Requirements			111
4.14.2 Grievance Process			113
4.14.3 Proposed Action			114
4.14.4 Administrative Review Process			116
4.14.5 Notice of Adverse Action			117
4.14.7 Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are Pending			119
4.14.8 Reporting Requirements			120
4.15 ADMINISTRATION AND MANAGEMENT			121
4.15.1 General Provisions			121
4.15.2 Place of Business and Hours of Operation			121
4.15.3 Training			121
4.15.4 Data Certification			122
4.15.5 Implementation Plan			122
4.16 CLAIMS MANAGEMENT			122

4.16.1 General Provisions			123
4.16.2 Other Considerations			125
4.16.4 Reporting Requirements			126
4.17 INFORMATION MANAGEMENT AND SYSTEMS			127
4.17.1 General Provisions			127
4.17.2 Global System Architecture and Design Requirements			128
4.17.3 Data and Document Management Requirements by Major Information Type			131
4.17.4 System and Data Integration Requirements			131
4.17.5 System Access Management and Information Accessibility Requirements			131
4.17.6 Systems Availability and Performance Requirements			132
4.17.7 System User and Technical Support Requirements			135
4.17.8 System Change Management Requirements			137
4.17.9 System Security and Information Confidentiality and Privacy Requirements			137
4.17.10 Information Management Process and Information Systems Documentation Requirements			138
4.17.11 Reporting Requirements			139
4.18 REPORTING REQUIREMENTS			139
4.18.1 General Procedures			139
4.18.2 Weekly Reporting			140
4.18.3 Monthly Reporting			140
4.18.4 Quarterly Reporting			143
4.18.5 Annual Reports			147
4.18.6 Ad Hoc Reports			149
4.18.6.5 Contractor Notifications			152
5.0 DELIVERABLES			152
5.1 CONFIDENTIALITY			152
5.2 NOTICE OF DISAPPROVAL			152
5.3 RESUBMISSION WITH CORRECTIONS			152

5.4 NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION			153
5.5 DCH FAILS TO RESPOND			153
5.6 REPRESENTATIONS			153
5.7 CONTRACT DELIVERABLES			153
5.8 CONTRACT REPORTS			156
6.0 TERM OF CONTRACT			158
7.0 PAYMENT FOR SERVICES			158
8.0 FINANCIAL MANAGEMENT			161
8.1 GENERAL PROVISIONS			161
8.2 SOLVENCY AND RESERVES STANDARDS			161
8.3 REINSURANCE			161
8.4 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS			162
8.4.2 Cost Avoidance			162
8.4.3 Compliance			163
8.5 PHYSICIAN INCENTIVE PLAN			163
8.6 REPORTING REQUIREMENTS			164
9.0 PAYMENT OF TAXES			167
10.0 RELATIONSHIP OF PARTIES			167
11.0 INSPECTION OF WORK			168
12.0 STATE PROPERTY			168
13.0 OWNERSHIP AND USE OF DATA/ UPGRADES			168
13.1 OWNERSHIP AND USE OF DATA			168
13.2 SOFTWARE AND OTHER UPGRADES			169
14.0 CONTRACTOR STAFFING			169

14.1 STAFFING ASSIGNMENTS AND CREDENTIALS			169
14.2 STAFFING CHANGES			171
14.3 CONTRACTOR’S FAILURE TO COMPLY			171
15.0 CRIMINAL BACKGROUND CHECKS			172
16.0 SUBCONTRACTS			172
16.1 USE OF SUBCONTRACTORS			172
16.2 COST OR PRICING BY SUBCONTRACTORS			173
17.0 LICENSE, CERTIFICATE, PERMIT REQUIREMENT			173
18.0 RISK OR LOSS AND REPRESENTATIONS			174
19.0 PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES			174
20.0 RECORDS REQUIREMENTS			174
20.1 GENERAL PROVISIONS			174
20.2 RECORDS RETENTION REQUIREMENTS			175
20.3 ACCESS TO RECORDS			175
20.4 MEDICAL RECORD REQUESTS			175
21.0 CONFIDENTIALITY REQUIREMENTS			176
21.1 GENERAL CONFIDENTIALITY REQUIREMENTS			176
21.2 HIPAA COMPLIANCE			176
22.0 TERMINATION OF CONTRACT			176
22.1 GENERAL PROCEDURES			176
22.2 TERMINATION BY DEFAULT			177
22.3 TERMINATION FOR CONVENIENCE			177
22.4 TERMINATION FOR INSOLVENCY OR BANKRUPTCY			177
22.5 TERMINATION FOR INSUFFICIENT FUNDING			178
22.6 TERMINATION PROCEDURES			178

22.7 TERMINATION CLAIMS			180
23.0 LIQUIDATED DAMAGES			181
23.1 GENERAL PROVISIONS			181
23.2 CATEGORY 1			181
23.3 CATEGORY 2			181
23.4 CATEGORY 3			182
23.5 CATEGORY 4			184
23.6 OTHER REMEDIES			186
23.7 NOTICE OF REMEDIES			187
24.0 INDEMNIFICATION			187
25.0 INSURANCE			188
25.1 INSURANCE OF CONTRACTOR			188
27.0 COMPLIANCE WITH ALL LAWS			190
27.1 NON-DISCRIMINATION			190
27.2 DELIVERY OF SERVICE AND OTHER FEDERAL LAWS			190
27.3 COST OF COMPLIANCE WITH APPLICABLE LAWS			191
27.4 GENERAL COMPLIANCE			191
28.0 CONFLICT RESOLUTION			192
29.0 CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE			192
30.0 NOTICE			193
31.0 MISCELLANEOUS			193
31.1 CHOICE OF LAW OR VENUE			193
31.2 ATTORNEY’S FEES			193
31.3 SURVIVABILITY			194
31.4 DRUG-FREE WORKPLACE			194

31.5 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS			194
31.6 WAIVER			194
31.7 FORCE MAJEURE			194
31.8 BINDING			194
31.9 TIME IS OF THE ESSENCE			195
31.10 AUTHORITY			195
31.11 ETHICS IN PUBLIC CONTRACTING			195
31.12 CONTRACT LANGUAGE INTERPRETATION			195
31.13 ASSESSMENT OF FEES			195
31.14 COOPERATION WITH OTHER CONTRACTORS			195
31.15 SECTION TITLES NOT CONTROLLING			196
31.16 LIMITATION OF LIABILITY/EXCEPTIONS			196
31.17 COOPERATION WITH AUDITS			196
31.18 HOMELAND SECURITY CONSIDERATIONS			196
31.19 PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED			197
31.20 OWNERSHIP AND FINANCIAL DISCLOSURE			197
32.0 AMENDMENT IN WRITING			198
33.0 CONTRACT ASSIGNMENT			198
34.0 SEVERABILITY			198
35.0 COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)			198
36.0 ENTIRE AGREEMENT			199
ATTACHMENT A			201
DRUG FREE WORKPLACE CERTIFICATE			201
ATTACHMENT B			203

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS			203
ATTACHMENT C			205
NONPROFIT ORGANIZATION DISCLOSURE FORM			205
ATTACHMENT D			206
CONFIDENTIALITY STATEMENT			206
ATTACHMENT E			207
BUSINESS ASSOCIATE AGREEMENT			207
ATTACHMENT F			212
VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM			212
ATTACHMENT G			214
PAYMENT BOND AND			214
IRREVOCABLE LETTER OF CREDIT			214
ATTACHMENT H			216
CAPITATION PAYMENT			216
NOTICE OF YOUR RIGHT TO A HEARING			218
ATTACHMENT J			219
MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS			219
ATTACHMENT K			220
APPLICABLE CO-PAYMENTS			220
ATTACHMENT L			221
INFORMATION MANAGEMENT AND SYSTEMS			221

     THIS AMENDED AND RESTATED CONTRACT, with an effective date of July 1, 2008 (hereinafter referred to as the “Effective Date”), is made and entered into by and between the Georgia Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and Amerigroup Georgia Managed Care Company, Inc. (hereinafter referred to as the “Contractor”).

     WHEREAS, DCH is responsible for Health Care policy, purchasing, planning and regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-5A-4 et. seq.;

     WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et seq.(the “Medicaid Program”), and is charged with ensuring the appropriate delivery of Health Care services to Medicaid recipients and PeachCare for Kids Members;

     WHEREAS, DCH caused Request for Proposals Number ▇▇▇▇▇-▇▇▇-▇▇▇▇▇▇▇▇▇▇ (hereinafter the “RFP”) to be issued through Department of Administrative Service(s) (DOAS), which is expressly incorporated as if completely restated herein;

     WHEREAS, DCH received from Contractor a proposal in response to the RFP, “Contractor’s Proposal,” which is expressly incorporated as if completely restated herein;

     WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract with Contractor on July 18, 2005, for the provision of various services for the Department; and

     WHEREAS, DCH and Contractor now wish to amend and restate the Contract in its entirety

     NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Department and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

1.0		SCOPE OF SERVICE
1.0.1		The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids programs. These reforms will focus on system-wide improvements in performance and quality, will consolidate fragmented systems of care, and will prevent currently unsustainable trend rates in Medicaid and PeachCare for Kids expenditures. The reforms will be implemented through a management of care approach to achieve the greatest value for the most efficient use of resources.
1.0.2		The Contractor shall assist the State of Georgia in this endeavor through the following tasks, obligations, and responsibilities.
1.1		BACKGROUND
1.1.1		In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid growth and projected that without a change to the system, Medicaid would require

		50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving more than 35 percent of total growth each year. For that reason, DCH decided to employ a management of care approach to organize its fragmented system of care, enhance access, achieve budget predictability, explore possible cost containment opportunities and focus on system-wide performance improvements. Furthermore, DCH believed that managed care could continuously and incrementally improve the quality of healthcare and services provided to patients and improve efficiency by utilizing both human and material resources more effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care program called Georgia Families.
1.1.2		Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed care program through which health care services are delivered to members of Medicaid and PeachCare for Kids™. The intent of this program is to:

	1.		Offer care coordination to members
	2.		Enhance access to health care services
	3.		Achieve budget predictability as well as cost containment
	4.		Create system-wide performance improvements
	5.		Continually and incrementally improve the quality of health care and services provided to members
	6.		Improve efficiency at all levels

1.1.3

The GF program is designed to:

	1.1.3.1		Improve the Health Care status of the Member population;
	1.1.3.2		Establish a “Provider Home” for Members through its use of assigned Primary Care Providers (PCPs);
	1.1.3.3		Establish a climate of contractual accountability among the state, the care management organizations and the health care providers;
	1.1.3.4		Slow the rate of expenditure growth in the Medicaid program; and
	1.1.3.5		Expand and strengthen a sense of Member responsibility that leads to more appropriate utilization of health care services.

1.2

ELIGIBILITY FOR GEORGIA FAMILIES

1.2.1

Medicaid

1.2.1.1

The following Medicaid eligibility categories are required to enroll in GF.

1.2.1.1.1

Low Income Families — Adults and children who meet the standards of the old AFDC (Aid to Families with Dependent Children) program.

	1.2.1.1.2		Transitional Medicaid — Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit.
	1.2.1.1.3		Pregnant Women (Right from the Start Medicaid — RSM) — Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive Medicaid through the RSM program.
	1.2.1.1.4		Children (Right from the Start Medicaid — RSM) — Children less than nineteen (19) years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family.
	1.2.1.1.5		Children (newborn) — A child born to a woman who is eligible for Medicaid on the day the child is born.
	1.2.1.1.6		Women Eligible Due to Breast and Cervical Cancer — Women less than sixty-five (65) years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer.
	1.2.1.1.7		Refugees — Those individuals who have the required INS documentation showing they meet a status in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.

1.2.2

PeachCare for Kids

1.2.2.1

PeachCare for Kids — The State Children’s Health Insurance Program (SCHIP) in Georgia. Children less than nineteen (19) years of age who have family income that is less than two hundred thirty-five percent (235%) of the federal poverty level, who are not eligible for Medicaid or any other health insurance program, and who cannot be covered by the State Health Benefit Plan.

1.2.3

Exclusions

1.2.3.1

The following recipients are excluded from Enrollment in GF, even if the recipient is otherwise eligible for GF per section 1.2.1 and section 1.2.2.

	1.2.3.1.1		Recipients eligible for Medicare;
	1.2.3.1.2		Recipients that are Members of a Federally Recognized Indian Tribe;

	1.2.3.1.3		Recipients that are enrolled in fee-for-service Medicaid through Supplemental Security Income prior to enrollment in GF. Members that are already enrolled in a CMO through GF will remain in that CMO until the disenrollment is completed through the normal monthly process.
	1.2.3.1.4		Children less than twenty-one (21) years of age who are in ▇▇▇▇▇▇ care or other out-of-home placement;
	1.2.3.1.5		Medicaid children enrolled in the Children’s Medical Services program administered by the Georgia Division of Public Health;
	1.2.3.1.6		Children less than twenty-one (21) years of age who are receiving ▇▇▇▇▇▇ care or other adoption assistance under Title IV-E of the Social Security Act (NOTE: ▇▇▇▇▇▇ Children in “Relative” placement remain within the Georgia Families program);
	1.2.3.1.7		Children enrolled in the Georgia Pediatric Program (▇▇▇▇);
	1.2.3.1.8		Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act.
	1.2.3.1.9		Individuals enrolled in a Hospice category of aid.

1.3		SERVICE REGIONS
1.3.1		For the purposes of coordination and planning, DCH has divided the State, by county, into six (6) Service Regions. See Attachment J for a listing of the counties in each Service Region.
1.3.2		Members will choose or will be assigned to a Care Management Organization (CMO) plan that is operating in the Service Region in which they reside.
1.4		DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

Abandoned Call: A call in which the caller elects a valid option and is either not permitted access to that option or disconnects from the system.

Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in 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 Member practices that result in unnecessary cost to the Medicaid program.

Administrative Law Hearing: The appeal process administered by the State in accordance with O.C.G.A. § 49-4-153 and as required by federal law, available to Members and Providers after they exhaust the Contractor’s Grievance System and Complaint Process.

Administrative Review: means the formal reconsideration, as a result of the proper and timely submission of a provider or member’s request, by an Office or Unit of the Division, which has proposed an adverse action.

Administrative Service(s): The contractual obligations of the Contractor that include but may not be limited to utilization management, credentialing providers, network management, quality improvement, marketing, enrollment, member services, claims payment, management information systems, financial management, and reporting.

Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Advance Directives: A written instruction, such as a living will or durable power of attorney for Health Care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of Health Care when the individual is incapacitated.

After-Hours: Provider office/visitation hours that extends beyond the normal business hours of a provider, which are Monday-Friday 9-5:30 and may extend to Saturday hours.

Agent: An entity that contracts with the State of Georgia to perform administrative functions, including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment activities; Systems and technical support; etc.

Appeal: A request for review of an action, as “action” is defined in 438.400.

Assess: Means the process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

At Risk: Any service for which the Provider agrees to accept responsibility to provide, or arrange for, in exchange for the Capitation payment and Obstetrical: Delivery Payments.

Authoritative Host: A system that contains the master or “authoritative” data for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master data files to other systems in real time or in batch mode. Data in an Authoritative Host is expected to be up-to-date and reliable.

Authorized Representative: A person authorized by the Member in writing to make health-related decisions on behalf of a Member, including, but not limited to Enrollment and Disenrollment decisions, filing Appeals and Grievances with the Contractor, and choice of a Primary Care

Physician (PCP). The authorized representative is either the Parent or Legal Guardian for a child. For an adult this person is either the legal guardian (guardianship action), health care or other person that has power of attorney, or another signed HIPAA compliant document indicating who can make decisions on behalf of the member.

Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person, for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new Member to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.

Benefits: The Health Care services set forth in this Contract, for which the Contractor has agreed to provide, arrange, and be held fiscally responsible.

Blocked Call: A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up beyond a defined threshold.

Calendar Days: All seven days of the week.

Capitation: A Contractual agreement through which a Contractor agrees to provide specified Health Care services to Members for a fixed amount per month.

Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor for each Member covered under a Contract for the provision of medical services and assigned to the Contractor. This payment is made regardless of whether the Member receives Covered Services or Benefits during the period covered by the payment.

Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH for each Member assigned to the Contractor to ensure that Covered Services and Benefits under this Contract are provided.

Capitated Service: Any Covered Service for which the Contractor receives an actuarially sound Capitation Payment.

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Coordination is also referred to as Care Management.

Care Management Organization (CMO): an entity organized for the purpose of providing Health Care, has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers, and furnishes Health Care services on a prepaid, capitated basis to Members in a designated Service Region.

Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S. Department of Health and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health Insurance Program.

Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under State law to practice as a nurse-midwife, and has completed a program of study and clinical experience for nurse-midwives or equivalent.

Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder, including chronic illnesses, impairments and disabilities. There is an expected duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive device, etc) and service use or need beyond that which is normally considered routine.

Claim: A ▇▇▇▇ for services, a line item of services, or all services for one recipient within a ▇▇▇▇.

Claims Administrator: The entity engaged by DCH to provide Administrative Service(s) to the CMO Plans in connection with processing and adjudicating risk-based payment, and recording health benefit encounter Claims for Members.

Clean Claim: A claim received by the CMO for adjudication, in a nationally accepted format in compliance with standard coding guidelines, which requires no further information, adjustment, or alteration by the Provider of the services in order to be processed and paid by the CMO. The following exceptions apply to this definition: i. A Claim for payment of expenses incurred during a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and iii. A Claim for which a Third Party Resource should be responsible.

Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a potential Member, for the purposes of marketing.

Completion/Implementation Timeframe: The date or time period projected for a project goal or objective to be met, for progress to be demonstrated or for a proven intervention to be established as the standard of care for the Contractor.

Condition: A disease, illness, injury, disorder, of biological, cognitive, or psychological basis for which evaluation, monitoring and/or treatment are indicated.

Consecutive Enrollment Period: The consecutive twelve (12) month period beginning on the first day of Enrollment or the date the notice is sent, whichever is later. For Members that use their option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment, the twelve-month consecutive Enrollment period will commence when the Member enrolls in the new CMO plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment period.

Contested Claim: A Claim that is denied because the Claim is an ineligible Claim, the Claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount Claimed is in dispute, or the Claim requires special treatment.

Contract: The written agreement between the State and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.

Contract Execution: The date upon which all parties have signed the Contract.

Contractor: The Care Management Organization with a valid Certificate of Authority in Georgia that contracts hereunder with the State for the provision of comprehensive Health Care services to Members on a prepaid, capitated basis.

Contractor’s Representative: The individual legally empowered to bind the Contractor, using his/her signature block, including his/her title. This individual will be considered the Contractor’s Representative during the life of any Contract entered into with the State unless amended in writing.

Co-payment: The part of the cost-sharing requirement for Members in which a fixed monetary amount is paid for certain services/items received from the Contractor’s Providers.

Core Services: Covered services for both the Rural Health Centers (RHC) and Federally Qualified Health Centers (FQHC) programs defined as follows: Physician services, including required physician supervision of Physician Assistants (Pas), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs); Services and supplies furnished as incident to physician professional services; Services of PAs, NPs and CNMs; Services of clinical psychologists and clinical social workers (when providing diagnosis and treatment of mental illness); Services and supplies furnished as incident to professional services provided by PAs, NPs, CNMs, clinical psychologists, and clinical social workers; Visiting nurse services on a part time or intermittent basis to homebound patients (limited to areas in which there is a designated shortage of home health agencies).

Corrective Action Plan: The detailed written plan required by DCH to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.

Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic investigation of discrepancies (failures and/or deviations) in an attempt to prevent their reoccurrence. To ensure that corrective and preventive actions are effective, the systematic investigation of the failure incidence is pivotal in identifying the corrective and preventive actions undertaken.

Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance has been exhausted.

Covered Services: Those Medically Necessary Health Care services provided to Members, the payment or indemnification of which is covered under this Contract.

Credentialing: The Contractor’s determination as to the qualifications and ascribed privileges of a specific Provider to render specific Health Care services.

Critical Access Hospital (CAH): Critical access hospital’ means a hospital that meets the requirements of the federal Centers for Medicare and Medicaid Services to be designated as a critical access hospital and that is recognized by the Department of Community Health as a critical access hospital for purposes of Medicaid.

Cultural Competency: A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among and between groups and the sensitivity to know how these differences influence relationships with Members. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Member needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.

Deliverable: A document, manual or report submitted to DCH by the Contractor to fulfill requirements of this Contract.

Department of Community Health (DCH): The Agency in the State of Georgia responsible for oversight and administration of the Medicaid program, the PeachCare for Kids program, and the State Health Benefits Plan (SHBP).

Department of Insurance (DOI): The Agency in the State of Georgia responsible for licensing, overseeing, regulating, and certifying insuring entities.

Diagnostic Related Group (DRG): Any of the payment categories that are used to classify patients and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred and that are based especially on the principal diagnosis, surgical procedure used, age of patient, and expected length of stay in the hospital.

Diagnostic Services: Any medical procedures or supplies recommended by a physician or other licensed medical practitioner, within the scope of his or her practice under State law, to enable him or her to identify the existence, nature or extent of illness, injury, or other health deviation in a Member.

Discharge: Point at which Member is formally released from hospital, by treating physician, an authorized member of physician’s staff or by the Member after they have indicated, in writing, their decision to leave the hospital contrary to the advice of their treating physician.

Disenrollment: The removal of a Member from participation in the Contractor’s plan, but not necessarily from the Medicaid or PeachCare for Kids program.

Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts may include written correspondence that outlines contracted negotiations between the parties, including rate and contract terms disclosure, as well as documented verbal conversations, to include date and time and parties involved.

Durable Medical Equipment (DME): Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title XIX mandated program that covers screening and Diagnostic Services to determine physical and mental deficiencies in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered.

Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition shall not be defined on the basis of lists of diagnoses or symptoms.

Emergency Services: Covered inpatient and outpatient services furnished by a qualified Provider that are needed to evaluate or stabilize an Emergency Medical Condition that is found to exist using the prudent layperson standard.

Encounter: A distinct set of health care services provided to a Medicaid or PeachCare for Kids Member enrolled with a Contractor on the dates that the services were delivered.

Encounter Data: Health Care Encounter Data include: (i) All data captured during the course of a single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment associated with the Member receiving services during the Encounter; (ii) The identification of the Member receiving and the Provider(s) delivering the Health Care services during the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

Enrollee: See Member.

Enrollment: The process by which an individual eligible for Medicaid or PeachCare for Kids applies (whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and such application is approved by DCH or its Agent.

Enrollment Broker: The entity engaged by DCH to assist in outreach, education and Enrollment activities associated with the GF program.

Enrollment Period: The twelve (12) month period commencing on the effective date of Enrollment.

Evaluate: The process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

External Quality Review (EQR): The analysis and evaluation by an external quality review organization of aggregated information on quality, timeliness, and access to the Health Care services that a CMO or its Subcontractors furnish to Members and to DCH.

External Quality Review Organization (EQRO): An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality review, and other related activities.

Federal Financial Participation (FFP): The funding contribution that the federal government makes to the Georgia Medicaid and PeachCare for Kids programs.

Federally Qualified Health Center (FQHC): An entity that provides outpatient health programs pursuant to Section 1905(l) (2) (B) of the Social Security Act.

Fee-for-Service (FFS): A method of reimbursement based on payment for specific services rendered to a Member.

Financial Relationship: A direct or indirect ownership or investment interest (including and option or non vested interest) in any entity. This direct or indirect interest may be in the form of equity, debt, or other means and includes any indirect ownership or investment interest no matter how many levels removed from a direct interest, or a compensation arrangement with an entity.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable federal or State law.

Grievance: An expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided or aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights.

Grievance System: The overall system that includes Grievances and Appeals at the Contractor level and access to the State Fair Hearing process (the State’s Administrative Law Review).

Georgia Technology Authority (GTA): The state agency that manages the state’s information technology (IT) infrastructure i.e. data center, network and telecommunications services and security, establishes policies, standards and guidelines for state IT, promotes an enterprise approach to state IT, and develops and manages the state portal.

Health Care: Health Care means care, services, or supplies related to the health of an individual. Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental Condition, or functional status, of an individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

Health Care Professional: A physician or other Health Care Professional, including but not limited to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist,

certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians licensed in the State of Georgia.

Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment program pursuant to Title XIX of the Social Security Act.

Health Insurance Portability and Accountability Act (HIPAA): A law enacted in 1996 by the Congress of the United States. When referenced in this Contract it includes all related rules, regulations and procedures.

Health Maintenance Organization: As used in Section 8.6 a Health Maintenance Organization is an entity, that is organized for the purpose of providing Health Care and has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers and furnishes Health Care services on a prepaid, capitated basis to Members in a designated Service Region.

Historical Provider Relationship: A Provider who has been the main source of Medicaid or PeachCare for Kids services for the Member during the previous year (decided on by the most recent provider on the member’s claim history).

Immediately: Within twenty-four (24) hours.

In-Network Provider: A Provider that has entered into a Provider Contract with the Contractor to provide services.

Incentive Arrangement: Any mechanism under which a Contractor may receive additional funds over and above the Capitation rates, for exceeding targets specified in the Contract.

Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes received but unpaid Claims.

Information: i. Structured Data: Data that adhere to specific properties and Validation criteria that is stored as fields in database records. Structured queries can be created and run against structured data, where specific data can be used as criteria for querying a larger data set; ii. Document: Information that does not meet the definition of structured data includes text, files, spreadsheets, electronic messages and images of forms and pictures.

Information System/Systems: A combination of computing hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e. structured data (which may include digitized audio and video) and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction.

Insolvent: Unable to meet or discharge financial liabilities.

Limited-English-Proficient Population: Individuals with a primary language other than English who must communicate in that language if the individual is to have an equal opportunity to participate effectively in, and benefit from, any aid, service or benefit provided by the health Provider.

Mandatory Enrollment: The process whereby an individual eligible for Medicaid or PeachCare for Kids is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to receive covered Medicaid or PeachCare for Kids services.

Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for Kids eligible individual that can reasonably be interpreted as intended to influence the individual to enroll in that particular CMO plan, or not enroll in or disenroll from another CMO plan.

Marketing Materials: Materials that are produced in any medium, by or on behalf of a CMO, and can reasonably be interpreted as intended to market to any Medicaid or PeachCare for Kids eligible individual.

Measurable: applies to a Contractor objective and means the ability to determine definitively whether, or not the objective has been met, or whether progress has been made toward a positive outcome.

Medicaid: The joint federal/state program of medical assistance established by Title XIX of the Social Security Act, which in Georgia is administered by DCH.

Medicaid Eligible: An individual eligible to receive services under the Medicaid Program but not necessarily enrolled in the Medicaid Program.

Medicaid Management Information System (MMIS): Computerized system used for the processing, collecting, analysis and reporting of Information needed to support Medicaid and SCHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

Medical Director: The licensed physician designated by the Contractor to exercise general supervision over the provision of health service Benefits by the Contractor.

Medical Records: The complete, comprehensive records of a Member including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s participating Primary Care physician or Provider, that document all medical services received by the Member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable DCH rules and regulations, and signed by the medical professional rendering the services.

Medical Screening: An examination: i. provided on hospital property, and provided for that patient for whom it is requested or required, ii. performed within the capabilities of the hospital’s

emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State statutes and regulations and hospital bylaws.

Medically Necessary Services: Those services that meet the definition found in Section 4.5.

Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in a CMO plan.

Methodology: Means the planned process, steps, activities or actions taken by a Contractor to achieve a goal or objective, or to progress toward a positive outcome.

Monitoring: Means the process of observing, evaluating, analyzing and conducting follow-up activities.

National Committee for Quality Assurance (NCQA): An organization that sets standards, and evaluates and accredits health plans and other managed care organizations.

Net Capitation Payment: The Capitation Payment made by DCH to Contractor less any quality assessment fee made by Contractor to DCH. This payment amount also excludes a payment to a Contractor for obstetrical or other medical services that are on a per occurrence basis rather than a per member basis.

Non-Emergency Transportation (NET): A ride, or reimbursement for a ride, provided so that a Member with no other transportation resources can receive services from a medical provider. NET does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.

Non-Institutional Claims: Claims submitted by a medical Provider other than a hospital, nursing facility, or intermediate care facility/mentally retarded (ICF/MR).

Nurse Practitioner Certified (NP-C): A registered professional nurse who is licensed by the State of Georgia and meets the advanced educational and clinical practice requirements beyond the two or four years of basic nursing education required of all registered nurses.

Objective: Means a measurable step, generally in a series of progressive steps, to achieve a goal.

Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a Contractor for each birth of a child to a Member. The Contractor is responsible for all medical services related to the delivery of the Member’s child.

Out-of-Network Provider: A Provider of services that does not have a Provider contract with the Contractor.

PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

Performance Improvement Project (PIP): Means a planned process of data gathering, evaluation and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery.

Pharmacy Benefit Manager (PBM): An entity responsible for the provision and administration of pharmacy benefit management services including but not limited to claims processing and maintenance of associated systems and related processes.

Physician Assistant (PA) — A trained, licensed individual who performs tasks that might otherwise be performed by physicians or under the direction of a supervising physician.

Physician Incentive Plan: Any compensation arrangement between a Contractor and a physician or physician group that may directly have the effect of reducing or limiting services furnished to Members.

Post-Stabilization Services: Covered Services, related to an Emergency Medical Condition that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member’s condition.

Potential Enrollee: See Potential Member.

Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory Enrollment in a care management program but is not yet the Member of a specific CMO plan.

Pre-Certification: Review conducted prior to a Member’s admission, stay or other service or course of treatment in a hospital or other facility.

Prevalent Non-English Language: A language other than English, spoken by a significant number or percentage of potential Members and Members in the State.

Preventive Services: Services provided by a physician or other licensed health practitioner within the scope of his or her practice under State law to: prevent disease, disability, and other health Conditions or their progression; treat potential secondary Conditions before they happen or at an early remediable stage; prolong life; and promote physical and mental health and efficiency.

Primary Care: All Health Care services and laboratory services, including periodic examinations, preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of Referrals to specialty Providers described in this Contract, and for maintaining continuity of patient care. These services are customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse practitioner to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required Primary Care services to Members. A PCP shall include general/family practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these Contract provisions and licensure requirements.

Prior Authorization: (also known as “pre-authorization” or “prior approval”). Authorization granted in advance of the rendering of a service after appropriate medical review.

Proposed Action: The proposal of an action for the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Provider: Any physician, hospital, facility, or other Health Care Professional who is licensed or otherwise authorized to provide Health Care services in the State or jurisdiction in which they are furnished.

Provider Complaint: A written expression by a Provider, which indicates dissatisfaction or dispute with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including a Proposed Action.

Provider Contract: Any written contract between the Contractor and a Provider that requires the Provider to perform specific parts of the Contractor’s obligations for the provision of Health Care services under this Contract.

Quality: The degree to which a CMO increases the likelihood of desired health outcomes of its Members through its structural and operational characteristics, and through the provision of health services that are consistent with current professional knowledge.

Referral: A request by a PCP for a Member to be evaluated and/or treated by a different physician, usually a specialist.

Referral Services: Those Health Care services provided by a health professional other than the Primary Care Provider and which are ordered and approved by the Primary Care Provider or the Contractor.

Reinsurance: An agreement whereby the Contractor transfers risk or liability for losses, in whole or in part, sustained under this Contract. A reinsurance agreement may also exist at the Provider level.

(Claims) Reprocessing: Upon determination of the need to correct the outcome of one or more claims processing transactions, the subsequent attempt to process a single claim or batch of claims.

Remedy: The State’s means to enforce the terms of the Contract through performance guarantees and other actions.

Risk Contract: A Contract under which the Contractor assumes financial risk for the cost of the services covered under the Contract, and may incur a loss if the cost of providing services exceeds the payments made by DCH to the Contractor for services covered under the Contract.

Routine Care: Treatment of a Condition that would have no adverse effects if not treated within twenty-four (24) hours or could be treated in a less acute setting (e.g., physicians office) or by the patient.

Rural Health Clinic (RHC): A clinic certified to receive special Medicare and Medicaid reimbursement. The purpose of the RHC program is improving access to primary care in underserved rural areas. RHCs are required to use a team approach of physicians and midlevel practitioners (nurse practitioners, physician assistants, and certified nurse midwives) to provide services. The clinic must be staffed at least 50% of the time with a midlevel practitioner. RHCs may also provide other health care services, such as mental health or vision services, but reimbursement for those services may not be based on their allowable costs.

Rural Health Services: Medical services provided to rural sparsely populated areas isolated from large metropolitan counties.

Scope of Services: Those specific Health Care services for which a Provider has been credentialed, by the plan, to provide to Members.

Service Authorization: A Member’s request for the provision of a service.

Service Region: A geographic area comprised of those counties where the Contractor is responsible for providing adequate access to services and Providers.

Short Term: A period of thirty (30) Calendar Days or less.

Significant Traditional Providers: Those Providers that provided the top eighty percent (80%) of Medicaid encounters for the GMC-eligible population in the base year of 2004.

Span of Control: Information systems and telecommunications capabilities that the CMO itself operates or for which it is otherwise legally responsible according to the terms and Conditions of this Contract. The CMO span of control also includes Systems and telecommunications capabilities outsourced by the CMO.

Stabilized: With respect to an emergency medical condition; that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or , with respect to a woman in labor, the woman has delivered (including the placenta).

State: The State of Georgia.

State Children’s Health Insurance Program (SCHIP): A joint federal-state Health Care program for targeted, low-income children, established pursuant to Title XXI of the Social Security Act. Georgia’s SCHIP program is called PeachCare for Kids.

State Fair Hearing: See Administrative Law Hearing

Subcontract: Any written contract between the Contractor and a third party, including a Provider, to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor: Any third party who has a written Contract with the Contractor to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor Payments: Any amounts the Contractor pays a Provider or Subcontractor for services they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part) based on use and costs of Referral Services (such as Withhold amounts, bonuses based on Referral levels, and any other compensation to the physician or physician group to influence the use for Referral Services). Bonuses and other compensation that are not based on Referral levels (such as bonuses based solely on quality of care furnished, patient satisfaction, and participation on committees) are not considered payments for purposes of Physician Incentive Plans.

System Access Device: A device used to access System functions; can be any one of the following devices if it and the System are so configured: i. Workstation (stationary or mobile computing device) ii. Network computer/“winterm” device, iii. “Point of Sale” device, iv. Phone, v. Multi-function communication and computing device, e.g. PDA.

System Unavailability: Failure of the system to provide a designated user access based on service level agreements or software/hardware problems within the contractors span of control.

System Function Response Time: Based on the specific sub function being performed,

Record Search Time-the time elapsed after the search command is entered until the list of matching records begins to appear on the monitor.

Record Retrieval Time-the time elapsed after the retrieve command is entered until the record data begin to appear on the monitor.

Print Initiation Time- the elapsed time from the command to print a screen or report until it appears in the appropriate queue.

On-line Claims Adjudication Response Time- the elapsed time from the receipt of the transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off a response to the Provider and/or switch vendor.

Systems: See Information Systems.

Telecommunication Device for the Deaf (TDD): Special telephony devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.

Third Party Resource: Any person, institution, corporation, insurance company, public, private or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance.

Urgent Care: Medically Necessary treatment for an injury, illness, or another type of Condition (usually not life threatening) which should be treated within twenty-four (24) hours.

Utilization: The rate patterns of service usage or types of service occurring within a specified time.

Utilization Management (UM): A service performed by the Contractor which seeks to assure that Covered Services provided to Members are in accordance with, and appropriate under, the standards and requirements established by the Contractor, or a similar program developed, established or administered by DCH.

Utilization Review (UR): Evaluation of the clinical necessity, appropriateness, efficacy, or efficiency of Health Care services, procedures or settings, and ambulatory review, prospective review, concurrent review, second opinions, care management, discharge planning, or retrospective review.

Validation: The review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias and in accord with standards for data collection and analysis.

Week: The traditional seven-day week, Sunday through Saturday.

Withhold: A percentage of payments or set dollar amounts that a Contractor deducts from a practitioner’s service fee, Capitation, or salary payment, and that may or may not be returned to the physician, depending on specific predetermined factors.

Working Days: Monday through Friday but shall not include Saturdays, Sundays, or State and Federal Holidays.

Work Week: The traditional work week, Monday through Friday.

1.5

ACRONYMS

AFDC — Aid to Families with Dependent Children

AICPA — American Institute of Certified Public Accountants

CAH — Critical Access Hospital

CAP — Corrective Action Plan

CAPA — Corrective Action Preventive Action

CDC — Centers for Disease Control

CFR — Code of Federal Regulations

CMO — Care Management Organization

CMS — Centers for Medicare & Medicaid Services

CNM — Certified Nurse Midwives

CSB — Community Service Boards

DCH — Department of Community Health

DME — Durable Medical Equipment

DOI — Department of Insurance

EB — Enrollment Broker

EPSDT — Early and Periodic Screening, Diagnostic, and Treatment

EQR — External Quality Review

EQRO — External Quality Review Organization

EVS — Eligibility Verification System

FFS — Fee-for-Service

FQHC — Federally Qualified Health Center

GF — Georgia Families

GTA — Georgia Technology Authority

HHS — US Department of Health and Human Services

HIPAA — Health Insurance Portability and Accountability Act

HMO — Health Management Organization

IBNR — Incurred-But-Not-Reported

INS — U.S. Immigration and Naturalization Services

LIM — Low-Income Medicaid

MMIS — Medicaid Management Information System

NAIC — National Association of Insurance Commissioners

NCQA — National Committee for Quality Assurance

NET — Non-Emergency Transportation

NP-C — Certified Nurse Practitioners

NPI — National Provider Identifier

PA — Physician Assistant

PBM — Pharmacy Benefit Manager

PCP — Primary Care Provider

PPS — Prospective Payment System

QAPI — Quality Assessment Performance Improvement

RHC — Rural Health Clinic

RSM — Right from the Start Medicaid

SCHIP — State Children’s Health Insurance Program

SSA — Social Security Act

TANF — Temporary Assistance for Needy Families

TDD — Telecommunication Device for the Deaf

UM — Utilization Management

UPIN — Unique Physician Identifier Number

UR — Utilization Review

2.0		DCH RESPONSIBILITIES
2.1		GENERAL PROVISIONS
2.1.1		DCH is responsible for administering the GF program. The agency will administer Contracts, monitor Contractor performance, and provide oversight in all aspects of the Contractor operations.
2.2		LEGAL COMPLIANCE
2.2.1		DCH will comply with, and will monitor the Contractor’s compliance with, all applicable State and federal laws and regulations.
2.3		ELIGIBILITY AND ENROLLMENT

2.3.1		The State of Georgia has the sole authority for determining eligibility for the Medicaid program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its Agent will determine eligibility for PeachCare for Kids and will collect applicable premiums. DCH or its agent will continue responsibility for the electronic eligibility verification system (EVS).
2.3.2		DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all Members who are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a monthly notice of all Enrollments to the CMO plan.
2.3.3		If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the following algorithm:

	2.3.3.1		If an immediate family member(s) of the Member is already enrolled in one CMO plan, the Member will be Auto-Assigned to that plan;
	2.3.3.2		If there are no immediate family members already enrolled and the Member has a Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to the CMO plan where the Provider is contracted;

2.3.3.3

If the Member does not have a Historical Provider Relationship with a Provider in any CMO plan, or the Provider contracts with all plans, the Member will be Auto-Assigned to the CMO plan that has the lowest capitated rates in the Service Region.

2.3.4		Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first (1st) Calendar Day of the month following the Member selection or Auto-Assignment, for those Members assigned on or between the first (1st) and twenty-fourth (24th) Calendar Day of the month. For those Members assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the second (2nd) month after assignment.
2.3.5		In the future, at a date to be determined by DCH, DCH or its Agent may include quality measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to those plans that have higher scores on quality measures to be defined by DCH. This factor will be applied after determining that there are no Historical Provider Relationships, but prior to utilizing the lowest Capitation rates criteria.
2.3.6		In the ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ will limit enrollment in a single plan to no more than forty percent (40%) of total GF eligible lives in the Service Region. Members will not be Auto-Assigned to a CMO plan unless a family member is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Atlanta Service Region. DCH may, at its sole discretion, elect to modify this threshold for reasons it deems necessary and proper.
2.3.7		In the five (5) Service Regions other than Atlanta DCH will limit Enrollment in a single plan to no more than sixty-five percent (65%) of total GF eligible lives in the Service Region. Members will not be Auto-Assigned to a CMO plan unless a family member is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Service Region. Enrollment limits will be figured once per quarter at the beginning of each quarter.
2.3.8		DCH or its Agent will have five (5) Business Days to notify Members and the CMO plan of the Auto-Assignment. Notice to the Member will be made in writing and sent via surface mail. Notice to the CMO plan will be made via file transfer.
2.3.9		DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment functions.
2.3.10		Conditioned on continued eligibility, all Members will be enrolled in a CMO plan for a period of twelve (12) consecutive months. This consecutive Enrollment period will commence on the first (1st) day of Enrollment or upon the date the notice is sent, whichever is later. If a Member disenrolls from one CMO plan and enrolls in a

		different CMO plan, consecutive Enrollment period will begin on the effective date of Enrollment in the second (2nd) CMO plan.
2.3.11		DCH or its Agent will automatically enroll a Member into the CMO plan in which he or she was most recently enrolled if the Member has a temporary loss of eligibility, defined as less than sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will continue as though there has been no break in eligibility, keeping the original twelve (12) month period.
2.3.12		DCH or its Agent will notify Members at least once every twelve (12) months, and at least sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends (the annual Enrollment opportunity), that they have the opportunity to switch CMO plans. Members who do not make a choice will be deemed to have chosen to remain with their current CMO plan.
2.3.13		In the event a temporary loss of eligibility has caused the Member to miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan in which he or she was enrolled prior to the loss of eligibility. The member will receive a new 60-calendar day notification period beginning the first day of the next month.
2.3.14		In accordance with current operations, the State will issue a Medicaid number to a newborn upon notification from the hospital, or other authorized Medicaid provider.
2.3.15		Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant mother. This packet shall include information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her newborn to choose a different CMO plan.
2.4		DISENROLLMENT
2.4.1		DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due to non-payment of the PeachCare for Kids premiums, loss of eligibility for GF due to other reasons, and all Disenrollment requests Members or CMO plans submit via telephone, surface mail, internet, facsimile, and in person.
2.4.2		DCH or its Agent will make final determinations about granting Disenrollment requests and will notify the CMO plan via file transfer and the Member via surface mail of any Disenrollment decision within five (5) Calendar Days of making the final determination
2.4.3		Whether requested by the Member or the Contractor the following are the Disenrollment timeframes:

	2.4.3.1		If the Disenrollment request is received by DCH or its agent on or before the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the month following the month in which the request was filed; and
	2.4.3.2		If the Disenrollment request is received by DCH or its agent after the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the second (2nd) month following the month in which the request was filed.
	2.4.3.3		If a Member is hospitalized in an inpatient facility on the first day of the month their Disenrollment is to be effective, the Member will remain enrolled until the month following their discharge from the inpatient facility.

2.4.4		When Disenrollment is necessary due to a change in eligibility category, or eligibility for GF, the Member will be disenrolled according to the timeframes identified in Section 2.4.3.
2.4.5		When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids eligibility (for example, he or she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.
2.5		MEMBER SERVICES AND MARKETING
2.5.1		DCH will provide to the Contractor its methodology for identifying the prevalent non-English languages spoken. For the purposes of this Section, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible individuals in the State.
2.5.2		DCH will review and prior approve all marketing materials.
2.6		COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
2.6.1		DCH will use submitted Encounter Data, and other data sources, to determine Contractor compliance with federal requirements that eligible Members under the age of twenty-one (21) receive periodic screens and preventive/well child visits in accordance with the specified periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416 methodology for measuring the Contractor’s performance.
2.7		NETWORK

2.7.1		DCH will provide to the Contractor up-to-date changes to the State’s list of excluded Providers, as well as any additional information that will affect the Contractor’s Provider network.
2.7.2		DCH will consider all Contractors’ requests to waive network geographic access requirements in rural areas. All such requests shall be submitted in writing.
2.7.3		DCH will provide the State’s Provider Credentialing policies to the Contractor upon execution of this Contract.
2.8		QUALITY MONITORING
2.8.1		DCH will have a written strategy that the contractor fully cooperates with DCH’s Quality Monitoring reviews by providing at a minimum information for review that supports it’s compliance with the items being monitored. In accordance with 42 CFR 438.204, this strategy will, at a minimum, monitor:

	2.8.1.1		The availability of services;
	2.8.1.2		The adequacy of the Contractor’s capacity and services;
	2.8.1.3		The Contractor’s coordination and continuity of care for Members;
	2.8.1.4		The coverage and authorization of services;
	2.8.1.5		The Contractor’s policies and procedures for selection and retention of Providers;
	2.8.1.6		The Contractor’s compliance with Member information requirements in accordance with 42 CFR 438.10;
	2.8.1.7		The Contractor’s compliance with State and federal privacy laws and regulations relative to Member’s confidentiality;
	2.8.1.8		The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;
	2.8.1.9		The Contractor’s Grievance System;
	2.8.1.10		The Contractor’s oversight of all Subcontractor relationships and delegations;
	2.8.1.11		The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Providers’ application of them;
	2.8.1.12		The Contractor’s quality assessment and performance improvement program; and

	2.8.1.13		The Contractor’s health information systems.
	2.8.1.14		The Contractor shall respond to requests for information within stipulated time frame.

2.9		COORDINATION WITH CONTRACTOR’S KEY STAFF
2.9.1		DCH will make diligent good faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of GF operations.
2.9.2		Specifically, DCH will designate individuals within the department who will serve as a liaison to the corresponding individual on the Contractor’s staff, including:

	2.9.2.1		A program integrity staff Member;
	2.9.2.2		A quality oversight staff Member;
	2.9.2.3		A Grievance System staff Member who will also ensure that the State Administrative Law Hearing process is consistent with the Rules of the Office of the State Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation, or procedure whether State or federal;
	2.9.2.4		An information systems coordinator; and
	2.9.2.5		A vendor management staff Member.

2.10		FORMAT STANDARDS
2.10.1		DCH will provide to the Contractor its standards for formatting all Reports requested of the Contractor. DCH will require that all Reports be submitted electronically.
2.11		FINANCIAL MANAGEMENT
2.11.1		In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure that primary payments from the liable third party are identified and collected to offset medical expenses; DCH will include information about known Third Party Resources on the electronic Enrollment data given to the Contractor.
2.11.2		DCH will monitor Contractor compliance with federal and State physician incentive plan rules and regulations.
2.12		INFORMATION SYSTEMS
2.12.1		DCH will supply the following information to the Contractor:

	2.12.1.1		Application and database design and development requirements (standards) that are specific to the State of Georgia.
	2.12.1.2		Networking and data communications requirements (standards) that are specific to the State of Georgia.
	2.12.1.3		Specific information for integrity controls and audit trail requirements.
	2.12.1.4		State web portal (▇▇▇▇▇▇▇.▇▇▇) integration standards and design guidelines.
	2.12.1.5		Specifications for data files to be transmitted by the Contractor to DCH and/or its agents.
	2.12.1.6		Specifications for point-to-point, uni-directional or bi-directional interfaces between Contractor and DCH systems.

2.13		READINESS OR ANNUAL REVIEW
2.13.1		DCH will conduct a readiness review of each new CMO at least 30 days prior to Enrollment of Medicaid and/or PeachCare for Kids™ recipients in the CMO plan and an annual review of each existing CMO plan. The readiness and financial review will include, one (1) or more as needed as determined by DCH on-site review. DCH will conduct the reviews to provide assurances that the Contractor is able and prepared to perform all administrative functions and is providing for high quality of services to Members.
2.13.2		Specifically, DCH’s review will document the status of the Contractor with respect to meeting program standards set forth in this Contract, as well as any goals established by the Contractor. A multidisciplinary team appointed by DCH will conduct the readiness and annual review. The scope of the reviews will include, but not be limited to, review and/or verification of:

	2.13.2.1		Network Provider composition and access;
	2.13.2.2		Staff;
	2.13.2.3		Marketing materials;
	2.13.2.4		Content of Provider agreements;
	2.13.2.5		EPSDT plan;
	2.13.2.6		Member services capability;

	2.13.2.7		Comprehensiveness of quality and Utilization Management strategies;
	2.13.2.8		Policies and procedures for the Grievance System and Complaint System;
	2.13.2.9		Financial solvency;
	2.13.2.10		Contractor litigation history, current litigation, audits and other government investigations both in Georgia and in other states; and
	2.13.2.11		Information systems’ Claims payment system performance and interfacing capabilities.

2.13.3		The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.
2.13.4		Members may not be enrolled in a CMO plan until DCH has determined that the Contractor is capable of meeting these standards. A Contractor’s failure to pass the readiness review 30 days prior to the beginning of service delivery may result in immediate Contract termination. Contractor’s failure to pass the annual review may result in corrective action and pending contract termination.
2.13.5		DCH will provide the Contractor with a summary of the findings as well as areas requiring remedial action.
3.0		GENERAL CONTRACTOR RESPONSIBILITIES
3.1		The Contractor shall immediately notify DCH of any of the following:
3.1.1		Change in business address, telephone number, facsimile number, and e-mail address;
3.1.2		Change in corporate status or nature;
3.1.3		Change in business location;
3.1.4		Change in solvency;
3.1.5		Change in corporate officers, executive employees, or corporate structure;
3.1.6		Change in ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address;
3.1.7		Change in incorporation status; or
3.1.8		Change in federal employee identification number or federal tax identification number.

3.1.9		Change in CMO litigation history, current litigation, audits and other government investigations both in Georgia and in other states.
3.2		The Contractor shall not make any changes to any of the requirements herein, without explicit written approval from Commissioner of DCH, or his or her designee.
4.0		SPECIFIC CONTRACTOR RESPONSIBILITIES
		The Contractor shall complete the following actions, tasks, obligations, and responsibilities:
4.1		ENROLLMENT
4.1.1		Enrollment Procedures

	4.1.1.1		DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO plan; Disenrollment; education; and outreach activities. The Contractor shall coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment functions.
	4.1.1.2		DCH or its Agent will make every effort to ensure that recipients ineligible for Enrollment in GF are not enrolled in GF. However, to ensure that such recipients are not enrolled in GF, the Contractor shall assist DCH or its Agent in the identification of recipients that are ineligible for Enrollment in GF, as discussed in Section 1.2.3, should such recipients inadvertently become enrolled in GF.
	4.1.1.3		The Contractor shall assist DCH or its Agent in the identification of recipients that become ineligible for Medicaid (for example, those who have died, been incarcerated, or moved out-of-state).
	4.1.1.4		The Contractor shall accept all individuals for enrollment without restrictions. The Contractor shall not discriminate against individuals on the basis of religion, gender, race, color, or national origin, and will not use any policy or practice that has the effect of discriminating on the basis of religion, gender, race, color, or national origin or on the basis of health, health status, pre-existing Condition, or need for Health Care services.

4.1.2

Selection of a Primary Care Provider (PCP)

4.1.2.1

At the time of plan selection, Members, with counseling and assistance from DCH or its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members to a PCP based on the following algorithm:

	4.1.2.1.1		Assignment shall be made to a Provider with whom, based on FFS Claims history, the Member has a Historical Provider Relationship, provided that the geographic access requirements in 4.8.13 are met;
	4.1.2.1.2		If there is no Historical Provider Relationship the Member shall be Auto-Assigned to a Provider who is the assigned PCP for an immediate family member enrolled in the CMO plan, if the Provider is an appropriate Provider based on the age and gender of the Member;
	4.1.2.1.3		If other immediate family members do not have an assigned PCP, Auto-Assignment shall be made to a Provider with whom a family member has a Historical Provider Relationship; if the Provider is an appropriate Provider based on the age and gender of the Member;
	4.1.2.1.4		If there is no Member or immediate family member historical usage Members shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on the age and sex of the Member, and geographic proximity.

	4.1.2.2		PCP assignment shall be effective immediately. The Contractor shall notify the Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
	4.1.2.3		The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.

4.1.3

Newborn Enrollment

	4.1.3.1		All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.
	4.1.3.2		The Contractor shall be responsible for notifying DCH or its Agent of any Members who are expectant mothers at least sixty (60) Calendar Days prior to the expected date of delivery. The Contractor shall be responsible for notifying DCH or its Agent of newborns born to enrolled members that do not appear on a monthly roster within 60 days of birth.
	4.1.3.3		The Contractor shall provide assistance to any expectant mother who contacts them wishing to make a PCP selection for her newborn and record that selection.
	4.1.3.4		Within twenty-four (24) hours of the birth, the Contractor shall ensure the submission of a newborn notification form to DCH or its agent. If the mother has made a PCP selection, this information shall be included in the newborn

notification form. If the mother has not made a PCP selection, the Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of the birth. Auto-Assignment shall be made using the algorithm described in Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother within twenty-four (24) hours.

4.1.4

Reporting Requirements

	4.1.4.1		The Contractor shall submit to DCH weekly Member Information Reports as described in Section 4.18.2.1.
	4.1.4.2		The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation Reports as described in Section 4.18.3.2.

4.2		DISENROLLMENT
4.2.1		Disenrollment Initiated by the Member

	4.2.1.1		A Member may request Disenrollment from a CMO plan without cause during the ninety (90) Calendar Days following the date of the Member’s initial Enrollment with the CMO plan or the date DCH or its Agent sends the Member notice of the Enrollment, whichever is later. A Member may request Disenrollment without cause every twelve (12) months thereafter.
	4.2.1.2		A Member may request Disenrollment from a CMO plan for cause at any time. The following constitutes cause for Disenrollment by the Member:
	4.2.1.2.1		The Member moves out of the CMO plan’s Service Region;
	4.2.1.2.2		The CMO plan does not, because of moral or religious objections, provide the Covered Service the Member seeks;
	4.2.1.2.3		The Member needs related services to be performed at the same time and not all related services are available within the network. The Member’s Provider or another Provider have determined that receiving service separately would subject the Member to unnecessary risk;
	4.2.1.2.4		The Member requests to be assigned to the same CMO plan as family members; and
	4.2.1.2.5		The Member’s Medicaid eligibility category changes to a category ineligible for GF, and/or the Member otherwise becomes ineligible to participate in GF.
	4.2.1.2.6		Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the

Contract, or lack of Providers experienced in dealing with the Member’s Health Care needs. (DCH or its Agent shall make determination of these reasons.)

4.2.1.3

The Contractor shall provide assistance to Members seeking to disenroll. This assistance shall consist of providing the forms to the Member and referring the Member to DCH or its Agent who will make Disenrollment determinations.

4.2.2

Disenrollment Initiated by the Contractor

	4.2.2.1		The Contractor shall complete all Disenrollment paperwork for Members it is seeking to disenroll.
	4.2.2.2		The Contractor shall notify DCH or its Agent upon identification of a Member who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.1.
	4.2.2.3		Prior to requesting Disenrollment of a Member for reasons described in Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s action.
	4.2.2.4		If the Member has demonstrated abusive or threatening behavior as defined by DCH, only one (1) written attempt to resolve the difficulty is required.
	4.2.2.5		The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member.
	4.2.2.6		The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.

4.2.3

Acceptable Reasons for Disenrollment Investigation Requests by Contractor

4.2.3.1

The Contractor may request Disenrollment if:

4.2.3.1.1

The Member demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness;

	4.2.3.1.2		The Member’s Utilization of services is Fraudulent or abusive;
	4.2.3.1.3		The Member has moved out of the Service Region;
	4.2.3.1.4		The Member is placed in a long-term care nursing facility, State institution, or intermediate care facility for the mentally retarded;
	4.2.3.1.5		The Member’s Medicaid eligibility category changes to a category ineligible for GF, and/or the Member otherwise becomes ineligible to participate in GF. Disenrollments due to Member eligibility will follow the normal monthly process as described in Section 2.4.3. Disenrollments will be processed as of the date that the member eligibility category actually changes and will not be made retroactive, regardless of the effective date of the new eligibility category. Note exception when SSI members are hospitalized.
	4.2.3.1.6		The Member has any other condition as so defined by DCH; or
	4.2.3.1.7		The Member has died, been incarcerated, or moved out of State, thereby making them ineligible for Medicaid.

4.2.4

Unacceptable Reasons for Disenrollment Requests by Contractor

4.2.4.1

The Contractor shall not request Disenrollment of a Member for discriminating reasons, including:

	4.2.4.1.1		Adverse changes in a Member’s health status;
	4.2.4.1.2		Missed appointments;
	4.2.4.1.3		Utilization of medical services;
	4.2.4.1.4		Diminished mental capacity;
	4.2.4.1.5		Pre-existing medical condition;
	4.2.4.1.6		Uncooperative or disruptive behavior resulting from his or her special needs; or
	4.2.4.1.7		Lack of compliance with the treating physician’s plan of care.

4.2.4.2

The Contractor shall not request Disenrollment because of the Member’s attempt to exercise his or her rights under the Grievance System.

4.2.4.3

The request of one PCP to have a Member assigned to a different Provider shall not be sufficient cause for the Contractor to request that the Member be disenrolled from the plan. Rather, the Contractor shall utilize its PCP assignment process to assign the Member to a different and available PCP.

4.3		MEMBER SERVICES
4.3.1		General Provisions

4.3.1.1

The Contractor shall ensure that Members are aware of their rights and responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or urgent medical situation, how to request a Grievance, Appeal, or Administrative Law Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications that allow the Members to submit questions and receive responses from the Contractor.

4.3.2

Requirements for Written Materials

	4.3.2.1		The Contractor shall make all written materials available in alternative formats and in a manner that takes into consideration the Member’s special needs, including those who are visually impaired or have limited reading proficiency. The Contractor shall notify all Members and Potential Members that information is available in alternative formats and how to access those formats.
	4.3.2.2		The Contractor shall make all written information available in English, Spanish and all other prevalent non-English languages, as defined by DCH. For the purposes of this Contract, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible individuals in the State.
	4.3.2.3		All written materials distributed to Members shall include a language block, printed in Spanish and all other prevalent non-English languages, that informs the Member that the document contains important information and directs the Member to call the Contractor to request the document in an alternative language or to have it orally translated.
	4.3.2.4		All written materials shall be worded such that they are understandable to a person who reads at the fifth (5th) grade level. Suggested reference materials to determine whether this requirement is being met are:

4.3.2.4.1

Fry Readability Index;

	4.3.2.4.2		PROSE The Readability Analyst (software developed by Education Activities, Inc.);
	4.3.2.4.3		Gunning FOG Index;
	4.3.2.4.4		▇▇▇▇▇▇▇▇▇▇ SMOG Index;
	4.3.2.4.5		The ▇▇▇▇▇▇-▇▇▇▇▇▇▇ Index; or
	4.3.2.4.6		Other word processing software approved by DCH.

	4.3.2.5		The Contractor shall provide written notice to DCH of any changes to any written materials provided to the Members. Written notice shall be provided at least thirty (30) Calendar Days before the effective date of the change.
	4.3.2.6		All written materials, including information for the Web site, must be submitted to DCH for approval before being distributed.

4.3.3

Member Handbook Requirements

	4.3.3.1		The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter.
	4.3.3.2		Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:

	4.3.3.2.1		A table of contents;
	4.3.3.2.2		Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
	4.3.3.2.3		Information about the role of the PCP;
	4.3.3.2.4		Information about choosing a PCP;
	4.3.3.2.5		Information about what to do when family size changes;
	4.3.3.2.6		Appointment procedures;
	4.3.3.2.7		Information on Benefits and services, including a description of all available GF Benefits and services;

	4.3.3.2.8		Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
	4.3.3.2.9		An explanation of any service limitations or exclusions from coverage;
	4.3.3.2.10		A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
	4.3.3.2.11		Information on where and how Members may access Benefits not available from or not covered by the Contractor;
	4.3.3.2.12		The Medical Necessity definition used in determining whether services will be covered;
	4.3.3.2.13		A description of all pre-certification, prior authorization or other requirements for treatments and services;
	4.3.3.2.14		The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;
	4.3.3.2.15		Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
	4.3.3.2.16		Cost-sharing;
	4.3.3.2.17		The geographic boundaries of the Service Regions;
	4.3.3.2.18		Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;
	4.3.3.2.19		A description of Utilization Review policies and procedures used by the Contractor;
	4.3.3.2.20		A description of Member rights and responsibilities as described in Section 4.3.4;
	4.3.3.2.21		The policies and procedures for Disenrollment;
	4.3.3.2.22		Information on Advance Directives;
	4.3.3.2.23		A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;

4.3.3.2.24

Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:

	i.		What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
	ii.		The fact that Prior Authorization is not required for Emergency Services;
	iii.		The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
	iv.		The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
	v.		The fact that a Member has a right to use any hospital or other setting for Emergency Services;

4.3.3.2.25

Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:

	i.		The right to file a Grievance and Appeal with the Contractor;
	ii.		The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
	iii.		The availability of assistance in filing a Grievance or Appeal with the Contractor;
	iv.		The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
	v.		The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
	vi.		Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and

vii.

Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.

4.3.3.3

The Contractor shall submit to DCH for review and approval any changes and edits to the Member Handbook at least thirty (30) Calendar Days before the effective date of change.

4.3.4

Member Rights

4.3.4.1

The Contractor shall have written policies and procedures regarding the rights of Members and shall comply with any applicable federal and State laws and regulations that pertain to Member rights. These rights shall be included in the Member Handbook. At a minimum, said policies and procedures shall specify the Member’s right to:

	4.3.4.1.1		Receive information pursuant to 42 CFR 438.10;
	4.3.4.1.2		Be treated with respect and with due consideration for the Member’s dignity and privacy;
	4.3.4.1.3		Have all records and medical and personal information remain confidential;
	4.3.4.1.4		Receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s Condition and ability to understand;
	4.3.4.1.5		Participate in decisions regarding his or her Health Care, including the right to refuse treatment;
	4.3.4.1.6		Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion;
	4.3.4.1.7		Request and receive a copy of his or her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
	4.3.4.1.8		Be furnished Health Care services in accordance with 42 CFR 438.206 through 438.210;
	4.3.4.1.9		Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the Member is treated;

	4.3.4.1.10		Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Member for which DCH does not pay the Contractor; not be held liable for Covered Services provided to the Member for which DCH or the CMO plan does not pay the Health Care Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of amount the Member would owe if the Contractor provided the services directly; and
	4.3.4.1.11		Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.

4.3.5

Provider Directory

	4.3.5.1		The Contractor shall mail via surface mail a Provider Directory to all new Members within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the State’s Agent.
	4.3.5.2		The Provider Directory shall include names, locations, office hours, telephone numbers of, and non-English languages spoken by, current Contracted Providers. This includes, at a minimum, information on PCPs, specialists, dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse Providers, and hospitals. The Provider Directory shall also identify Providers that are not accepting new patients.
	4.3.5.3		The Contractor shall submit the Provider Directory to DCH for review and prior approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	4.3.5.4		The Contractor shall up-date and amend the Provider Directory on its Web site within five (5) Business Days of any changes, produce and distribute quarterly up-dates to all Members, and re-print the Provider Directory and distribute to all Members at least once per year.
	4.3.5.5		At least once per month, the Contractor shall submit to DCH and its Agent any changes and edits to the Provider Directory. Such changes shall be submitted electronically in a format to be determined by DCH.
	4.3.5.6		The Contractor shall post on its website a searchable list of all providers with which the care management organization has contracted. At a minimum, this list shall be searchable by provider name, specialty, and location.

4.3.6

Member Identification (ID) Card

4.3.6.1

The Contractor shall mail via surface mail a Member ID Card to all new Members according to the following timeframes:

	4.3.6.1.1		Within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the Agent for Members who have selected a CMO plan and a PCP;
	4.3.6.1.2		Within ten (10) Calendar Days of PCP assignment or selection for Members that are Auto-Assigned to the CMO plan.

4.3.6.2

The Member ID Card must, at a minimum, include the following information:

	4.3.6.2.1		The Member’s name;
	4.3.6.2.2		The Member’s Medicaid or PeachCare for Kids identification number;
	4.3.6.2.3		The PCP’s name, address, and telephone numbers (including after-hours number if different from business hours number);
	4.3.6.2.4		The name and telephone number(s) of the Contractor;
	4.3.6.2.5		The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free Member services telephone number;
	4.3.6.2.6		Instructions for emergencies; and
	4.3.6.2.7		Includes minimum or instructions to facilitate the submission of a claim by a provider.

	4.3.6.3		The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of notice if a Member reports a lost card, there is a Member name change, the PCP changes, or for any other reason that results in a change to the information disclosed on the Member ID Card.
	4.3.6.4		The Contractor shall submit a front and back sample Member ID Card to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.

4.3.7

Toll-free Member Services Line

	4.3.7.1		The Contractor shall operate a toll-free telephone line to respond to Member questions, comments and inquiries.
	4.3.7.2		The Contractor shall develop Telephone Line Policies and Procedures that address staffing, personnel, hours of operation, access and response standards,

			monitoring of calls via recording or other means, and compliance with standards.
	4.3.7.3		The Contractor shall submit these Telephone Line Policies and Procedures, including performance standards pursuant to Section 4.3.7.7, to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	4.3.7.4		The telephone line shall handle calls from non-English speaking callers, as well as calls from Members who are hearing impaired.
	4.3.7.5		The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.
	4.3.7.6		The telephone line shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State holidays. The telephone line staff shall be trained to accurately respond to Member questions in all areas, including, but not limited to, Covered Services, the provider network, and non-emergency transportation (NET).
	4.3.7.7		The Contractor shall develop performance standards and monitor Telephone Line performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).
	4.3.7.8		The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays. This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Contractor’s Representative shall return messages on the next Business Day.
	4.3.7.9		The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval within sixty (60) Calendar Days of Contract Award and annually with updates thereafter.

4.3.8

Internet Presence/Web Site

	4.3.8.1		The Contractor shall provide general and up-to-date information about the CMO plan’s program, its Provider network, its customer services, and its Grievance and Appeals Systems on its Web site.
	4.3.8.2		The Contractor shall maintain a Member portal that allows Members to access a searchable Provider Directory that shall be updated within five (5) Business Days upon changes to the Provider network.
	4.3.8.3		The Web site must have the capability for Members to submit questions and comments to the Contractor and for members to receive responses.
	4.3.8.4		The Web site must comply with the marketing policies and procedures and with requirements for written materials described in this Contract and must be consistent with applicable State and federal laws.
	4.3.8.5		In addition to the specific requirements outlined above, the Contractor’s Web site shall be functionally equivalent, with respect to functions described in this Contract, to the Web site maintained by the State’s Medicaid fiscal agent (▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇).
	4.3.8.6		The Contractor shall submit Web site screenshots to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.

4.3.9

Cultural Competency

	4.3.9.1		In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency Plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Members, including those with limited English proficiency. The Cultural Competency Plan must describe how the Providers, individuals and systems within the CMO plan 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 individual Members and protects and preserves the dignity of each.
	4.3.9.2		The Contractor shall submit the Cultural Competency Plan to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	4.3.9.3		The Contractor may distribute a summary of the Cultural Competency Plan to the In-Network Providers if the summary includes information on how the Provider may access the full Cultural Competency Plan on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.

4.3.10

Translation Services

4.3.10.1

The Contractor is required to provide oral translation services of information to any Member who speaks any non-English language regardless of whether a Member speaks a language that meets the threshold of a Prevalent Non-English Language. The Contractor is required to notify its Members of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to the Member for translation services.

4.3.11

Reporting Requirements

4.3.11.1

The Contractor shall submit monthly Telephone and Internet Activity Reports to DCH as described in Section 4.18.3.1.

4.4

MARKETING

4.4.1

Prohibited Activities

4.4.1.1

The Contractor is prohibited from engaging in the following activities:

	4.4.1.1.1		Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call Marketing activities to Potential Members;
	4.4.1.1.2		Offering any favors, inducements or gifts, promotions, and/or other insurance products that are designed to induce Enrollment in the Contractor’s plan, and that are not health related and/or worth more than $10.00 cash;
	4.4.1.1.3		Distributing information, plans and materials that contain statements that DCH determines are inaccurate, false, or misleading. Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the recipient must enroll in the Contractor’s plan in order to obtain Benefits or in order to not lose Benefits or that the Contractor’s plan is endorsed by the federal or State government, or similar entity; and
	4.4.1.1.4		Distributing information or materials that, according to DCH, mislead or falsely describe the Contractor’s Provider network, the participation or availability of network Providers, the qualifications and skills of network Providers (including their bilingual skills); or the hours and location of network services.

4.4.2

Allowable Activities

4.4.2.1

The Contractor shall be permitted to perform the following marketing activities:

	4.4.2.1.1		Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);
	4.4.2.1.2		Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor;
	4.4.2.1.3		Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in which the Provider participates have an equal opportunity to be represented; and
	4.4.2.1.4		Attend activities that benefit the entire community such as health fairs or other health education and promotion activities.

	4.4.2.2		If the Contractor performs an allowable activity, the Contractor shall conduct these activities in the entire Service Region as defined by this Contract.
	4.4.2.3		All materials shall comply with the information requirements in 42 CFR 438.10 and detailed in Section 4.3.2 of this Contract.

4.4.3

State Approval of Materials

			The Contractor shall submit a detailed description of its Marketing Plan and copies of all Marketing Materials (written and oral) it or its Subcontractors plan to distribute to DCH for review and approval within sixty (60) Calendar Days of Contract Award and as updated thereafter.
	4.4.3.1		This requirement includes, but is not limited to posters, brochures, Web sites, and any materials that contain statements regarding the benefit package and Provider network-related materials. Neither the Contractor nor its Subcontractors shall distribute any marketing materials without prior, written approval from DCH.
	4.4.3.2		The Contractor shall submit any changes to previously approved marketing materials and receive approval from DCH of the changes before distribution.

4.4.4

Provider Marketing Materials

4.4.4.1

The Contractor shall collect from its Providers any Marketing Materials they intend to distribute and submit these to DCH for review and approval prior to distribution.

4.5		COVERED BENEFITS AND SERVICES
4.5.1		Included Services

	4.5.1.1		The Contractor shall at a minimum provide Medically Necessary services and Benefits as outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manual. Such Medically Necessary services shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under Fee-for-Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or Condition.
	4.5.1.2

SERVICE		COVERAGE LIMITATIONS
Ambulatory Surgical Services
Audiology Services		Not covered for Members age 21 and older. Available under EPSDT as part of a written service plan.
Childbirth Education Services
Dental Services		Preventive, diagnostic and treatment services provided to Members under age 21. Emergency Services only for Members age 21 and older.
Durable Medical Equipment
Early and Periodic Screening, Diagnostic, and Treatment Services
Emergency Transportation Services
Emergency Services
Family Planning Services and Supplies
Federally Qualified Health Center Services		Ambulatory services such as dental services are subject to any limitations applicable to the specific ambulatory service.
Home Health Services		Not covered: social services, chore services, meals on wheels, audiology services.
Hospice Services		Available to Members certified as

SERVICE		COVERAGE LIMITATIONS
		being terminally ill and having a medical prognosis of life expectancy of six (6) months or less.
Inpatient Hospital Services		Psychiatric hospitalizations are covered for a maximum of 30 days per treatment episode
Laboratory and Radiological Services		Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent laboratory or X-ray facility; services or procedures referred to another testing facility; services furnished by a State or public laboratory; services or procedures performed by a facility not certified to perform them.
Mental Health Services		Community Mental Health Rehabilitation services are only available as part of a written service plan.
Nurse Midwife Services
Nurse Practitioner Services
Nursing Facility Services		Not covered: Long-term nursing facility (over 30 Consecutive Days)
Obstetrical Services
Occupational Therapy Services		These services are covered for children under age 21 as medically necessary. Services for adults 21 and older are covered when medically necessary for short term rehabilitation.
Optometric Services		Not covered for Members age 21 and older: routine refractive services and optical devices.
Orthotic and Prosthetic Services		Not covered for Members age 21 and older: orthopedic shoes and supportive devices for the feet which are not an integral part of a leg brace; hearing aids and accessories.
Oral Surgery
Outpatient Hospital Services

SERVICE		COVERAGE LIMITATIONS
Pharmacy Services		Not covered: certain outpatient drugs pursuant to Section 1927(d) of the Social Security Act. Additionally, certain over the counter (OTC) drugs must be included, pursuant to the Georgia State Policies and Procedures Manual.
Physical Therapy Services		These services are covered for children under age 21 as medically necessary. Services for adults 21 and older are covered when medically necessary for short term rehabilitation.
Physician Services
Podiatric Services		Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections.
Pregnancy-Related Services
Private Duty Nursing Services
Rural Health Clinic Services
Speech Therapy Services		These services are covered for children under age 21 as medically necessary. Services for adults 21 and older are covered when medically necessary for short term rehabilitation.
Substance Abuse Treatment Services (Inpatient)		Substance abuse treatment, inpatient and rehabilitative, are covered as part of a written service plan.
Swing Bed Services
Targeted Case Management		Covered for pregnant women under age 21 and other pregnant women at risk for adverse outcomes; infants and toddlers with established risk for developmental delay.
Transplants		Not covered for Members age 21 and older: heart, lung and heart/lung transplants.

4.5.2

Individuals with Disabilities Education Act (IDEA) Services

	4.5.2.1		For Members up to and including age three (3), the Contractor shall be responsible for Medically Necessary IDEA services provided pursuant to an Individualized Family Service Plan (IFSP) or Individualized Service Plan (IEP).
	4.5.2.2		For Members age four (4) and older, the Contractor shall not be responsible for Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services shall remain in FFS Medicaid.

4.5.2.2.1

The Contractor shall be responsible for all other Medically Necessary covered services.

4.5.3

Enhanced Services

4.5.3.1

In addition to the Covered Services provided above, the Contractor shall do the following:

	4.5.3.1.1		Place strong emphasis on programs to enhance the general health and well-being of Members;
	4.5.3.1.2		Make health promotion materials available to Members;
	4.5.3.1.3		Participate in community-sponsored health fairs; and
	4.5.3.1.4		Provide education to Members, families and other Health Care Providers about early intervention and management strategies for various illnesses.

4.5.3.2

The Contractor shall not charge a Member for participating in health education services that are defined as either enhanced or Covered Services.

4.5.4

Medical Necessity

4.5.4.1

Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are:

	4.5.4.1.1		Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition;
	4.5.4.1.2		Compatible with the standards of acceptable medical practice in the community;
	4.5.4.1.3		Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;

	4.5.4.1.4		Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and
	4.5.4.1.5		Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.

	4.5.4.2		There must be no other effective and more conservative or substantially less costly treatment, service and setting available.
	4.5.4.3		For children under 21, the Contractor is required to provide medically necessary services to correct or ameliorate physical and behavioral health disorders, a defect, or a condition identified in as EPSDT (Health Check) screening, regardless whether those services are included in the State Plan, but are otherwise allowed pursuant to 1905 (a) of the Social Security Act. See Diagnostic and Treatment, Section 4.7.5.2.

4.5.5

Experimental, Investigational or Cosmetic Procedures

4.5.5.1

Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid Policies and Procedures Manual, in no instance shall the Contractor cover experimental, investigational or cosmetic procedures.

4.5.6

Moral or Religious Objections

4.5.6.1

The Contractor is required to provide and reimburse for all Covered Services. If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor elects not to provide, reimburse for, or provide coverage of a counseling or Referral service because of an objection on moral or religious grounds, the Contractor shall notify:

	4.5.6.1.1		DCH within one hundred and twenty (120) Calendar Days prior to adopting the policy with respect to any service;
	4.5.6.1.2		Members within ninety (90) Calendar Days after adopting the policy with respect to any service; and
	4.5.6.1.3		Members and Potential Members before and during Enrollment.

4.5.6.2.

The Contractor acknowledges that such objection will be grounds for recalculation of rates paid to the Contractor.

4.6

SPECIAL COVERAGE PROVISIONS

4.6.1

Emergency Services

	4.6.1.1		Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a week to treat an Emergency Medical Condition.
	4.6.1.2		An Emergency Medical Condition shall not be defined or limited based on a list of diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following: