SUPPLEMENTAL CONTRACT NO. 2
▇▇▇▇▇▇▇ ▇▇.▇
▇▇▇▇▇
▇▇ ▇▇▇▇▇▇
SUPPLEMENTAL CONTRACT NO.
2
TO CONTRACT DHS-08-MQD-5129
(Insert contract number or other identifying information)
indicated
below, is effective as of December
15 , 2008 , between
the
Department of Human
Services/Med-QUEST
Division
, State of Hawaii
(Insert name of stale department, agency, hoard or
commission)
("STATE"),
by its Director, ▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇ ,
(Insert
title uf stale officer executing contract)
(hereafter
also referred to as the HEAD OF THE PURCHASING AGENCY or designee
("HOPA")),
whose
address is ▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇
▇▇▇▇▇ ,
and
WellCare Health Insurance of
Arizona, Inc. dba 'Ohana Health
Plan, Inc. ("CONTRACTOR"),
a Corporation
(Insert
corporation, partnership, joint venture, sole proprietorship, or other legal
form of the CONTRACTOR)
under the
laws of the State of Hawaii ,
whose business address and federal
|
and
state taxpayer identification numbers are as follows: ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇.,
▇▇▇▇▇, ▇▇ ▇▇▇▇▇
|
|
| GET# Wl 1018973-01 Fed ID# ▇▇-▇▇▇▇▇▇▇ |
RECITALS
|
|
A.
|
WHEREAS,
the STATE and the CONTRACTOR entered into
Contract
|
|
|
DHS-08-MQD-5129
|
(Insert
contract number or other identifying information)
dated
February 4,
2008 , which
was amended by Supplemental Contract No(s). 1
dated
May
15 , 2008 , which was
amended by Supplemental Contract No(s). n/a
dated
_________, which was amended by Supplemental Contract
No(s). __
dated
_________, ____ (hereafter collectively referred to as "Contract") whereby
the
CONTRACTOR
agreed to provide the goods or services, or both, described in the Contract;
and
|
|
B.
|
HEREAS,
the parties now desire to amend the Contract
|
| NOW, THEREFORE, THE STATE and the CONTRACTOR mutually agree to amend the Contract as follows: (Check Applicable box(es)) |
|
x
|
Amend
the SCOPE OF SERVICES according to the terms set forth in Attachment - S1,
which is made a part of the Contract.
|
|
|
¨
|
Amend
the COMPENSATION AND PAYMENT SCHEDULE according to the terms set forth in
Attachment-S2, which is made a part of the
Contract.
|
|
|
¨
|
Amend
the TIME OF PERFORMANCE according to the terms set forth in Attachment-S3,
which is made a part of the Contract.
|
|
|
¨
|
Amend
the SPECIAL CONDITIONS according to the terms set forth in Attachments
SUPPLEMENTAL SPECIAL CONDITIONS, which is made a part of the
contract.
|
|
|
¨
|
Recognize
the CONTRACTOR'S change of name.
|
|
|
FROM:
|
||
AG-005 Rev
04/30/2007
|
TO:
|
||
|
As
set forth in the documents attached hereto as Exhibit ____ , and
incorporated herein.
|
||
|
A
tax clearance certificate from the State of Hawaii o is x is not required
to be submitted
to the STATE prior to commencing any performance under this
|
||
| Supplemental Contract. | ||
| A tax clearance certificate from the Internal Revenue Service Q is x is not required to be submitted to the STATE prior to commencing any performance under this | |
| Supplemental Contract. | |
The entire
Contract, as amended herein, shall remain in full force and
effect.
IN VIEW OF
THE ABOVE, the parties execute this Contract by their signatures, on the dates
below, to be effective as of the date first above written.
|
STATE
/s/ ▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
(Signature)
|
|
|
▇▇▇▇▇▇▇
▇.
▇▇▇▇▇▇
(Print
Name)
|
|
|
Director
(Print
Title)
|
|
|
____________________________
(Date)
|
|
CORPORATE
SEAL
(If
available)
|
CONTRACTOR
WellCare
Health Insurance of Arizona, Inc. dba ‘Ohana Health Plan,
Inc.
(Name
of Contractor)
|
|
/s/
▇▇▇▇▇
▇▇▇▇▇▇▇▇▇
(Signature)
|
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|
▇▇▇▇▇
▇▇▇▇▇▇▇▇▇
(Print
Name)
|
|
|
President
and
CEO
(Print
Title)
|
|
|
1-8-09
(Date)
|
APPROVED
AS TO FORM:
/s/
Name
Illegible
Deputy
Attorney General
**Evidence
of authority of the CONTRACTOR'S representative to sign this Contract for the
CONTRACTOR must be attached.
AG-005 Rev
04/30/2007
2
CONTRACT
NO.
DHS-08-MDQ-5129
PROVIDER’S
ACKNOWLEDGMENT
|
STATE
OF
|
FLORIDA
|
)
|
||
| ) | ||||
|
COUNTY
OF
|
HILLSBOROUGH
|
)
ss.
|
||
On this 8th
day of January,
2009, before me
appeared ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ and ______________________, to me known, to be the person(s)
described in and, who, being by me duly sworn, did say that he/she/they is/are
the President
and CEO_________ of Wellcare Health Insurance of
Arizona, Inc. the PROVIDER named in the foregoing instrument, and that
he/she/they is/are authorized to sign said instrument on behalf of the PROVIDER,
and acknowledges that he/she/they executed said instrument as the free act and
deed of the PROVIDER.
|
(Notary
Seal)
|
By /s/ ▇▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
(Signature)
|
||||||
|
Print
Name ▇▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
|
|||||||
|
Date
January 8,
2009
|
|||||||
|
Notary
Public, State of Florida
|
|||||||
|
My
Commission expires 11.30.2012
|
|||||||
|
Doc.
Date:
|
#
Pages: ___________
|
||||||
|
Notary
Name:
|
▇▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
|
________ |
Circuit
|
||||
|
Doc
Description:
|
|||
|
(Notary
Stamp or Seal)
|
|||
|
/s/ ▇▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
Notary
Signature
|
1.8.2009
Date
|
||
|
NOTARY
CERTIFICATION
|
|||
CONTRACT
NO. DHS-08-MQD-5129
PROVIDER'S
STANDARDS
OF CONDUCT DECLAMATION
For the
purposes of this declaration:
|
|
"Agency"
means and includes the State, the legislature and its committees, all
executive departments, boards, commissions, committees, bureaus, offices;
and all independent commissions and other establishments of the state
government but excluding the
courts.
|
|
|
"Controlling
interest" means an interest in a business or other undertaking which is
sufficient in fact to control, whether the interest is greater or less
than fifty per cent (50%).
|
|
|
"Employee"
means any nominated, appointed, or elected officer or employee of the
State, including members of boards, commissions, and committees, and
employees under contract to the State or of the constitutional convention,
but excluding legislators, delegates to the constitutional convention,
justices, and judges. (Section 84-3,
HRS).
|
On behalf
of:
WellCare Health Insurance of Arizona, Inc.,
dba 'Ohana Health Plan, Inc.
(Name of
PROVIDER)
PROVIDER,
the undersigned does declare as follows:
|
|
1.
|
PROVIDER ¨ is* xis not a
legislator or an employee or a business in which a legislator or an
employee has a controlling interest. (Section 84-15(a),
HRS).
|
|
|
2.
|
PROVIDER
has not been represented or assisted personally in the matter by an
individual who has been an employee of the agency awarding this Contract
within the preceding two years and who participated while so employed in
the matter with which the Contract is directly concerned. (Section
84-15(b), HRS).
|
|
|
3.
|
PROVIDER
has not been assisted or represented by a legislator or employee for a fee
or other compensation to obtain this Contract and will not be assisted or
represented by a legislator or employee for a fee or other compensation in
the performance of this Contract, if the legislator or employee had been
involved in the development or award of the Contract. (Section 84-14 (d),
HRS).
|
|
|
4.
|
PROVIDER
has not been represented on matters related to this Contract, for a fee or
other consideration by an individual who, within the past twelve (12)
months, has been an agency employee, or in the case of the Legislature, a
legislator, and participated while an employee or legislator on matters
related to this Contract. (Sections 84-18(b) and (c),
HRS).
|
PROVIDER
understands that the Contract to which this document is attached is voidable on
behalf of the STATE if this Contract was entered into in violation of any
provision of chapter 84, Hawai'i Revised Statutes, commonly referred to as the
Code of Ethics, including the provisions which are the source of the
declarations above. Additionally, any fee, compensation, gift, or profit
received by any person as a result of a violation of the Code of Ethics may be
recovered by the STATE.
________________________________
*Reminder to agency:
If the "is" block is checked and if the Contract involves goods or services of a
value in excess of $10,000, the Contract may not be awarded unless the agency
posts a notice of its intent to award it and files a copy of the notice with the
State Ethics Commission. (Section 84-15(a), HRS).
AG Form
103F (10/08)
Standards
of Conduct Declaration
Page 1 of
2
CONTRACT
NO. DHS-08-MQD-5129
|
PROVIDER
By
/s/ ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇
(Signature)
|
|
|
Print
Name ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇
|
|
|
Print
Title President
and CEO
|
|
|
___________________
|
|
|
Date
1-8-09
|
AG Form
103F (10/08)
Standards
of Conduct Declaration
Page 2 of 2
CONTRACT
NO. DHS-08-MQD-5129
CERTIFICATE
OF EXEMPTION FROM CIVIL SERVICE
|
1.
|
By
Heads of Departments or Agencies as Delegated by tSie Director of Human
Resources Development1.
|
Pursuant to the delegation of the
authority by the Director of Human Resources Development, I certify that the
services provided under this Contract, and the person(s) providing the services
under this Contract are exempt from the civil service, pursuant to §76-16,
Hawai'i Revised Statutes ("HRS").
|
/s/
▇▇▇▇▇▇▇ ▇.
▇▇▇▇▇▇
(Signature)
|
01/15/09
(Date)
|
|
▇▇▇▇▇▇▇
▇.
▇▇▇▇▇▇
(Print
Name)
|
|
|
Director
of Human Services
(Print
Title)
|
_______________________________________________
1 This
part of the form may be used by all department heads and others to whom the
Director of Human Resources Development (DHRD) has delegated authority to
certify §76-16, HRS, civil service exemptions. The specific paragraph(s) of
§76-16, HRS, upon which an exemption is based should be noted in the contract
file. NOTE: Authority to certify exemptions under §§ 76-16(2), 76-16(12), and
76-16(15), HRS, has not been delegated; only the Director of DHRD may certify
§§76-16(2), 76-16(12), and 76-16(15) exemptions.
2. By
the Director of Human Resources Development, State of
Hawai'i.
I
certify that the services to be provided under this Contract, and the person(s)
providing the services under this Contract are exempt from the civil service,
pursuant to §76-16, HRS.
|
____________________________________
(Signature)
|
________________
(Date)
|
|
____________________________________
(Print
Name)
|
|
|
____________________________________
(Print
Title, if designee of the Director of
DHRD)
|
AG Form
103F (9/08)
Competitive
Page 1
AG Form
103F (9/08) Competitive
STATE
OF HAWAII
SCOPE
OF SERVICES
Revisions to specific provisions in the Request for Proposals, RFP~MQD-2008~006 issued October 10, 2007, as amended, are set forth below. Except for the revised definition of "Medical Necessity," and the amendment to section 40.750.2, all of the following revisions are necessary to comply with conditions imposed by the Centers of Medicare and Medicaid Services (CMS).
20.100 RFP Timeline
Replace the last row on the table with:
|
Commencement
of Services to Members
|
February
1, 2009
|
|
30.200 Definition/Acronyms
Action
(may also be referred to as an adverse action)
Replace the 4th bullet
point with:
The failure to provide services in a
timely manner, as defined in Section 40.230;
Healthcare
Professional
Add the following sentence to the end
of definition of Healthcare Professional:
See Appendix O.
Medical
Necessity
Replace this definition with the
following:
As defined in HRS
§432E-1.4.
30.550 90-Day Grace Period
Replace the first two paragraphs with
the following:
|
|
Provided
the health plan into which the member wants to enroll is not capped, the
DHS will allow members to change health plans without cause for the first
ninety (90) days from the effective date of enrollment in that health
plan. If the member does not change health plans during the ninety (90)
days following the date of initial enrollment in a health plan, the member
will be allowed to change health plans only during the annual plan change
period, as described in Section 30.560, or as outlined in Section
30.600.
|
AG-011 Rev
07/28/2005
1
Attachment – ▇▇
▇▇▇▇▇ ▇▇
▇▇▇▇▇▇
SCOPE
OF SERVICES
|
30.820.4
|
Behavioral Health Services for
Children/Support for Emotional and Behavioral Development (SEBD)
Program
|
Replace this section with the
following:
|
|
The
DOH, through its Child and Adolescent Mental Health Division (CAMHD), will
provide acute inpatient psychiatric and outpatient behavioral health
services, community crisis management and crisis residential services,
intensive family intervention, therapeutic living and therapeutic ▇▇▇▇▇▇
care supports, hospital-based residential treatment, partial
hospitalization, and biopsychosocial rehabilitation to children and
adolescents age three (3) through age twenty (20) who the DOH determines
are in need of intensive mental health services and are determined
eligible for the SEBD Program. Additional information on the SEBD program
is available in Appendix D.
|
40.400 Provider Credentialing,
Recredentialing and Other Certification
Add
the following sentence to the end of the first sentence in the second
paragraph:
See Appendix O.
40.750.1.v Vision
Services
Replace the first sentence of the third
paragraph with the following:
|
|
Visual
aids prescribed by ophthalmologists or optometrists (eyeglasses, contact
lenses and miscellaneous vision supplies) are covered by the health plan,
if medically necessary.
|
40.750.2 Primary and Acute Care Services -
Behavioral Health
Replace this section in its entirety
with the following:
|
40.750.2
|
Primary and Acute Care Services
- Behavioral Health
|
|
|
a.
|
Overview
|
The health plan shall provide all medically necessary behavioral health services
to QExA adults and child members. These services include:
• Twenty-four
(24) hour care for acute psychiatric illnesses including:
|
|
o
|
Room and
board
|
|
|
o
|
Nursing
care
|
AG-011 Rev
07/28/2005
2
Attachment – ▇▇
▇▇▇▇▇ ▇▇
▇▇▇▇▇▇
SCOPE
OF SERVICES
o Medical
supplies and equipment
o Diagnostic
services
o Physician
services
o Other
practitioner services as needed
o Other
medically necessary services;
|
•
|
Ambulatory
services including twenty-four (24) hours, seven (7) days per week crisis
services;
|
|
•
|
Acute
day hospital/partial hospitalization
including:
|
o Medication
management
o Prescribed
drugs
o Medical
supplies
o Diagnostic
tests
|
o
|
Therapeutic
services including individual, family and group therapy and
aftercare
|
o Other
medically necessary services;
|
•
|
Methadone
treatment services which include the provision of methadone or a suitable
alternative (e.g. LAAM), as well as outpatient counseling
services;
|
|
•
|
Prescribed
drugs including medication management and patient
counseling;
|
|
|
•
|
Diagnostic/laboratory
services including:
|
o Psychological
testing
o Screening
for drug and alcohol problems
o Other
medically necessary diagnostic services;
• Psychiatric or
psychological evaluation;
|
|
•
|
Physician
services;
|
|
|
•
|
Rehabilitation
services;
|
| • | Occupational therapy; and | |
| • | Other medically necessary therapeutic services. |
|
|
Individuals
age twenty-one (21) and older are limited to thirty (30) days of
hospitalization per benefit year. No limits exist for outpatient
behavioral health services for individuals. A benefit year is defined as
the period between July 1 through June 30. The health plan may, at its
option, exceed the limits on inpatient behavioral health services.
Individuals under age twenty-one (21) are not subject to the inpatient
behavioral health limits.
|
|
|
The
health plan may utilize a full array of effective interventions and
qualified professionals such as psychiatrists, psychologists, counselors,
social workers, registered nurses and others. Substance abuse counselors
shall comply with the State Department of Health Alcohol and Drug Abuse
Division (ADAD) certification
requirements.
|
AG-01I Rev
07/28/2005
3
Attachment –▇▇
▇▇▇▇▇
▇▇ ▇▇▇▇▇▇
SCOPE
OF SERVICES
|
|
The
health plan is encouraged to utilize currently existing publicly funded
community-based substance abuse treatment programs, which have received
ADAD oversight, through accreditation and monitoring. Methadone/LAAM
services are covered for acute opiate detoxification as well as
maintenance. The health plan may develop its own payment methodologies for
Methadone/LAAM services.
|
|
|
The
health plan shall be responsible for providing behavioral health services
to persons who have been involuntarily committed for evaluation and
treatment under the provisions of Chapter 334, HRS to the extent that
these services are deemed medically necessary by the health plan's
utilization review procedures and are within the established
limits.
|
|
|
The
health plans are responsible for training residential care facilities on
how to care for members who require behavioral health
services.
|
|
|
The
health plan is not obligated to provide behavioral health services to
those members:
|
|
|
•
|
Whose
diagnostic, treatment or rehabilitative services are determined not to be
medically necessary by the health plan;
or
|
|
|
•
|
Who
have been determined eligible for and have been transferred to the
behavioral health managed care (BHMC) plan, as described below;
or
|
|
|
•
|
Who
have been determined eligible for and have been transferred to the DOH's
Child and Adolescent Mental Health Division (CAMHD) for services, as
described in below; or
|
|
|
•
|
Who
have been criminally committed for evaluation or treatment in an inpatient
setting under the provisions of Chapter 706, HRS. These individuals will
be disenrolled from the programs and will become the clinical and
financial responsibility of the appropriate State agency. The psychiatric
evaluation and treatment of members who have been criminally committed to
ambulatory mental healthcare settings will be the clinical and financial
responsibility of the appropriate State agency. The health plan shall
remain responsible for providing medical services to these
members.
|
|
|
Room
and board in special treatment facilities for adolescents is not covered
but therapy/treatment provided in the facility for this population is the
responsibility of the health plan.
|
AG-011 Rev
07/28/2005
4
Attachment
– ▇▇
▇▇▇▇▇
▇▇ ▇▇▇▇▇▇
SCOPE
OF SERVICES
b.
Health Plan Responsibilities for SMI
Adults
Certain
specialized mental health services for adults diagnosed with SMI will be carved
out of QExA as provided in this subsection. The health plan shall continue to be
responsible for all other Medicaid services (primary, acute and long-term care
services) for the member who is receiving behavioral health services through
another entity. Adult members with SMI may receive services through the Adult
Mental Health Division (AMHD) or the BHMC program.
Health
plans will coordinate with the AMHD regarding behavioral health services for
adult members with SMI who are receiving services through AMHD. The cost of AMHD
services will not be included in the capitation rate paid to the health plans.
The AMHD will continue to ▇▇▇▇ the DHS on a FFS basis for the services it
provides to these members. All other behavioral health services will be provided
by the health plans.
The
health plan is responsible for making the initial determination of whether or
not an adult member has SMI (using the definition in Appendix D). Once the
health plan has made this determination, the health plan shall refer the adult
member to the DOH AMHD for an evaluation to confirm the initial diagnosis and
coverage AMHD services. During the referral process, the health plan shall
continue to coordinate the member's care and provide any medically necessary
services. AMHD services shall include:
|
•
|
Crisis
Management
|
|
o
|
24-hour crisis telephone
consultation
|
|
o
|
Mobile outreach
services
|
|
o
|
Crisis intervention/stabilization
services
|
| • | Crisis Residential Services |
| • | Intensive Outpatient Hospital Services |
| • | Therapeutic Living Supports |
|
o
|
Community-based
Specialized Residential
|
|
o
|
Mental
Health Respite Home
|
|
o
|
Therapeutic
Group Home
|
•
Biopsychosocial Rehabilitative Services
•
Intensive Case Management/Community Based Case Management
If AMHD
denies the SMI designation the health plan shall refer the member to the DHS for
determination as to whether he or she is eligible for the BHMC program.
Appendices D.2 and D.3 provide additional information on this
process.
AG-011 Rev
07/28/2005
5
Attachment
▇▇
▇▇▇▇▇
▇▇ ▇▇▇▇▇▇
SCOPE
OF SERVICES
|
|
If
a member's SMI designation is denied by the DHS, the DHS or its designee
must provide written denial and notification of appeal rights. The health
plan may, with approval of the affected member, appeal any denial of SMI
determination to the DHS on behalf of the
member.
|
40.750.3.g Counseling
and Training
Add the following sentence to the end
of the last paragraph:
Training should occur by qualified
health professionals as defined in Appendix 0.
50.100 Health
Plan Enrollment Responsibilities
50.110 General
Overview
Add as the final bullet point to the
bulleted list in the section:
|
|
•
|
A
provider directory that includes the names, location, telephone numbers
of, and non-English languages spoken by contracted providers in the
member's service area including identification of providers that are not
accepting new patients.
|
50.350 Member
Rights
|
|
The
bullets from "Have direct access to a women's health specialist within the
network" to "Receive a description of cost sharing responsibilities, if
any" are moved out one level to below the bullet "Freely exercise his or
her rights..."
|
AG-0II Rev
07/28/2005
6
Attachment
– ▇▇
▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇
SCOPE
OF SERVICES
Appendix
O
State
Requirements for Health Care Professionals, including Mental Health
Providers
|
Specialty
|
Hawaii
Revised Statutes (HRS)1
|
Hawaii
Administrative Rules (HAR)2
|
|
Advanced
Practice Registered Nurse
|
457-8.5
|
Title
16-89C
|
|
Audiologist
|
468E
|
Title
16-100
|
|
Chiropractor
|
442
|
Title
16-76
|
|
Community
Mental Health Center
|
Title
11-179
|
|
|
Dentist
|
448
|
Title
16-79
|
|
Licensed
Practical Nurse
|
457-8
|
Title
16-89
|
|
Marriage
and Family Therapist
|
451J
|
|
|
Mental
Health and Substance Abuse Systems
|
Title
11-175
|
|
|
Mental
Health Counselor
|
453D
|
|
|
Occupational
Therapist
|
457G
|
|
|
Optometrist
|
459
|
Title
16-92
|
|
Physician/Psychiatrist
|
453
|
|
|
Physical
Therapist
|
461J
|
Title
16-110
|
|
Physician
Assistant
|
453-5.3
|
|
|
Podiatrist
|
463E
|
|
|
Psychologist
|
465
|
|
|
Registered
Dietitian
|
448-B
|
Title
11-79
|
|
Registered
Nurse
|
457-7
|
Title
16-89
|
|
Speech-Language
Pathologist
|
468E
|
Title
16-100
|
|
Social
Worker
|
467E
|
|
|
Special
Treatment Facility
|
Title
11-98
|
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2
|
HAR
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HAR Title 16: ▇▇▇▇://▇▇▇▇▇▇.▇▇▇/▇▇▇▇/▇▇▇▇/▇▇▇
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AG-OII Rev
07/28/2005
7