STATE OF FLORIDA DEPARTMENT OF ELDER AFFAIRS STANDARD CONTRACT LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT
Exhibit
10.1
STATE
OF FLORIDA
DEPARTMENT
OF ELDER AFFAIRS
LONG-TERM
CARE COMMUNITY DIVERSION PILOT PROJECT
THIS
CONTRACT is entered into between the State of Florida, Department of
Elder Affairs, hereinafter referred to as the "department", and Wellcare,
hereinafter referred to as the "contractor".
I.THE
Contractor AGREES:
▇.▇▇
provide services according to the conditions specified in Attachment(s)
I.
B.Federal
Laws and Regulations
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1.If
this contract contains federal funds, the contractor shall comply
with the
provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other
applicable regulations as specified in Attachment
I.
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2.
If this contract contains federal funding in excess of $100,000,
the contractor shall comply with all applicable standards, orders,
or
regulations issued under Section 306 of the Clean Air Act, as amended
(42
U.S.C. 1857(h) et seq.), Section 508 of the Clean Water Act, as amended
(33 U.S.C. 1368 et seq.), Executive Order 11738, and Environmental
Protection Agency regulations (40 CFR Part 15). The contractor
shall report any violations of the above to the department within
ten (10)
days of the discovery of any such
violation.
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3.If
this contract contains federal funding the contractor must, prior
to
contract execution, complete the Certification Regarding Lobbying
form,
Attachment II. If a Disclosure of Lobbying Activities form,
Standard Form LLL, is required, it may be obtained from the contract
manager. All disclosure forms as required by the Certification
Regarding Lobbying form must be completed and returned to the contract
manager no more than 10 days after contract
execution.
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4.The
contractor shall comply with the provisions of the U.S. Department
of
Labor, Occupational Safety and Health Administration (OSHA) code,
29 CFR,
Part 1910.1030.
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5.If
this contract contains federal funding in excess of $100,000, the
contractor or vendor must, prior to contract execution, complete
the
Debarment, Suspension, Ineligibility and Voluntary Exclusion Certification
form, Attachment III.
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▇.▇▇▇▇▇▇
Insurance Portability and Accountability Act of 1996 (HIPAA) Compliance:
If the recipient will receive consumer’s protected health
information as a result of this agreement, then the department recognizes
that the department and recipient are "Business Associates" of each
other
under the terms of HIPAA and, as such, the department and recipient
will
enter into a Business Associate agreement separate from this
agreement.
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C.Civil
Rights Certification
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1.The
contractor gives this assurance in consideration of and for the purpose
of
obtaining federal grants, loans, contracts (except contracts of insurance
or guaranty), property, discounts, or other federal financial assistance
to programs or activities receiving or benefiting from
federal
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financial
assistance. The contractor agrees to complete the Civil Rights
Compliance Questionnaire, DOEA Form 101 A and B, if services are
provided
to consumers and if fifteen (15) or more persons are employed. For
contractors employing less than 15 persons, the department requests
completion of the Civil Rights Compliance Questionnaire, in accordance
with the Governor's One Florida Initiative, Executive Order
99-281.
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2.The
contractor assures that it will comply
with:
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a.Title
VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
seq., which prohibits discrimination on the basis of race, color,
or
national origin in programs and activities receiving or benefiting
from
federal financial assistance.
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b.Section
504 of the Rehabilitation Act of 1973, as amended,
29 U.S.C. 794, which prohibits discrimination on the basis of
handicap in programs and activities receiving or benefiting from
federal
financial assistance.
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c.Title
IX of the Education Amendments of 1972, as amended,
20 U.S.C. 1681 et seq., which prohibits discrimination on the
basis of sex in education programs and activities receiving or benefiting
from federal financial assistance.
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d.The
Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
which
prohibits discrimination on the basis of age in programs or activities
receiving or benefiting from federal financial
assistance.
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e.Section
654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
42 U.S.C. 9849, which prohibits discrimination on the basis of
race, creed, color, national origin, sex, handicap, political affiliation
or beliefs in programs and activities receiving or benefiting from
federal
financial assistance.
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f.The
Americans with Disabilities Act of 1990, 42 USC 12101, et seq., which
prohibits discrimination against, and provides equal opportunities
for
individuals with disabilities, in employment, public services,
and public accommodations.
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g.All
regulations, guidelines, and standards as are now or may be lawfully
adopted under the above statutes.
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3.The
contractor shall establish procedures to handle complaints of
discrimination involving services or benefits through this
contract. The contractor shall advise consumers, employees, and
participants of the right to file a complaint, the right to appeal
a
denial or exclusion from the services or benefits from this contract,
and
their right to a fair hearing. Complaints of discrimination
involving services or benefits through this contract may also be
filed
with the Secretary of the department or the appropriate federal or
state
agency.
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4.The
contractor agrees that compliance with this assurance is a condition
of
continued receipt of or benefit from federal financial assistance,
and
that it is binding upon the contractor, its successors, transferees,
and
assignees for the period during which such assistance is provided.
The
contractor further assures that all contractors, subcontractors,
subgrantees, or others with whom it arranges to provide services
or
benefits to participants or employees in connection with any of its
programs and activities are not discriminating against those participants
or employees in violation of the above statutes, regulations, guidelines,
and standards. In the event of failure to comply, the
contractor understands that the department may, at its discretion,
seek a
court order requiring compliance with the terms of this assurance
or seek
other appropriate judicial or administrative relief, including but
not
limited to, termination of and denial of further
assistance.
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D.Requirements
of Chapter 287, Florida Statutes
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▇.▇▇
provide all reports set forth in Attachment I to be received and
accepted
by the contract manager.
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▇.▇▇
comply with the criteria and final date by which such criteria must
be met
for completion of this contract as specified in Section I,
Paragraph V, of this contract.
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▇.▇▇
allow public access to all documents, papers, letters, or other materials
subject to the provisions of Chapter 119, Florida Statutes, and made
or received by the contractor in conjunction with this contract.
It is
expressly understood that substantial evidence of the contractor's
refusal
to comply with this provision shall constitute a breach of
contract.
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▇.▇▇
develop procurement procedures for all services purchased pursuant
to this
contract and subcontracts subject to this agreement in accordance
with
state and federal regulations that encourages competition and promotes
a
diversity of contractors for services for the elder
consumers.
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E.Withholdings
and Other Benefits
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1.The
contractor is responsible for Social Security and Income Tax withholdings
of its employees.
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2.The
contractor is not entitled to state retirement or leave benefits
except
where the contractor is a state
agency.
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3.Unless
justified by the contractor and agreed to by the department in Attachment
I, the department will not furnish services of support (e.g., office
space, office supplies, telephone service, secretarial, or clerical
support) normally available to career service
employees.
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F.Indemnification
If
the
contractor is a state or local governmental entity, pursuant to subsection
768.28(18) Florida Statutes, the provisions of this section do not
apply.
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1.Contractor
and all subcontractors agree to indemnify, defend, and hold harmless
the
department and all of the department's officers, agents, and employees
from any claim, loss, damage, cost, charge, or expense arising out
of any
acts, actions, neglect or omission, action in bad faith, or violation
of
federal or state law by the contractor, its agents, employees, or
subcontractors during the performance of this agreement and all contracts
incorporating this agreement by reference, whether direct or indirect,
and
whether to any person or property to which the department or said
parties
may be subject, except neither contractor nor any of its subcontractors
will be liable under this section for damages arising out of injury
or
damage to persons or property directly caused or resulting from the
sole
negligence of the department or any of its officers, agents, or
employees.
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2.Contractor's
and subcontractor’s obligation to indemnify, defend, and pay for the
defense or, at the department's option, to participate and associate
with
the department in the defense and trial of any claim and any related
settlement negotiations, shall be triggered by the department's notice
of
claim for indemnification to contractor. Contractor's and
subcontractor’s inability to evaluate liability or its evaluation of
liability shall not excuse contractor's or subcontractor’s duty to defend
and indemnify the department, upon notice by the
department. Notice shall be given by registered or certified
mail, return receipt requested. Only an adjudication or
judgment after the highest appeal is exhausted specifically finding
the
department solely negligent shall excuse performance of this provision
by
contractors and subcontractors. The contractor shall pay all costs
and
fees related to this obligation and its enforcement by the
department. The department's failure to notify contractor of a
claim shall not release contractor of the above duty to
defend.
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▇.▇▇
is the intent and understanding of the parties that the contractor
is
NOT an agent of the department for purposes of
application of Chapter 768.28, F.S., and is NOT entitled
or subject to any of the benefits and limitations
therein. Contractor expressly agrees to and does hereby waive
any and all claims or entitlement to any and all application of Chapter
768.28, F.S., contractor may have or may hereafter acquire by reason
of
this agreement or by any interpretation of this agreement and applicable
law by any court of law equity, or by or through any other dispute
resolution method or forum, regarding any and all claims that may
directly
or indirectly arise from or otherwise involve contractor’s direct or
indirect involvement, obligations, or benefits under this
agreement. Not withstanding the foregoing provisions, nothing
in this agreement shall serve as a waiver of sovereign immunity,
or any
other defense, by the department. Neither the contractor nor
any of its subcontractors are employees of the department and shall
not
hold themselves out as employees or agents of the department without
specific authorization from the department. It is the further
intent and understanding of the parties that the department does
not
control the employment practices of the contractor and shall not
be liable
for any wage and hour, employment discrimination, or other labor
and
employment claims, which arise against the
contractor.
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▇.▇▇▇▇▇▇▇▇▇
and Bonding
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provide adequate liability insurance coverage on a comprehensive
basis and
to hold such liability insurance at all times during the existence
of this
contract. The contractor accepts full responsibility for identifying
and
determining the type(s) and extent of liability insurance necessary
to
provide reasonable financial protections for the contractor and the
consumers to be served under this contract. Upon the execution
of this contract, the contractor shall furnish the department written
verification supporting both the determination and existence of such
insurance coverage. Such coverage may be provided by a
self-insurance program established and operating under the laws of
the
State of Florida. The department reserves the right to require
additional insurance where
appropriate.
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furnish an insurance bond from a responsible commercial insurance
company
covering all officers, directors, employees and agents of the contractor
authorized to handle funds received or disbursed under this contract
in an
amount commensurate with the funds handled, the degree of risk as
determined by the insurance company and consistent with good business
practices.
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3.If
the contractor is a state agency or subdivision as defined by
Chapter 768.28, Florida Statutes, the contractor shall furnish the
department, upon request, written verification of liability protection
in
accordance with Chapter 768.28, Florida Statutes. Nothing
herein shall be construed to extend any party's liability beyond
that
provided in Chapter 768.28, Florida Statutes. (See also Paragraph
F
above.)
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H.Abuse,
Neglect and Exploitation Reporting
In
compliance with Chapter 415, Florida Statutes, an employee of the contractor
who
knows, or has reasonable cause to suspect, that a child, aged person or disabled
adult is or has been abused, neglected, or
exploited, shall immediately report such knowledge or suspicion to the State
of
Florida central abuse registry and tracking system on the statewide toll-free
telephone number (1-800-96ABUSE).
I.Transportation
Disadvantaged
If
consumers are to be transported under this contract, the contractor will comply
with the provisions of Chapter 427, Florida Statutes, and Rule Chapter 41-2,
Florida Administrative Code.
J.Purchasing
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1.PRIDE
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It
is
expressly understood and agreed that any articles which are the subject of,
or
are required to carry out this contract shall be purchased from Prison
Rehabilitative Industries and Diversified Enterprises, Inc. (PRIDE) identified
under Chapter 946, Florida Statutes, in the same manner and under the procedures
set forth in subsections 946.515(2) and (4), Florida Statutes. For purposes
of
this contract, the person, firm, or other business entity carrying out the
provisions of this contract shall be deemed to be substituted for the department
insofar as dealings with PRIDE. This clause is not applicable to any
subcontractors, unless otherwise required by law. An abbreviated list of
products/services available from PRIDE may be obtained by contacting PRIDE'S
Tallahassee branch office at (▇▇▇) ▇▇▇-▇▇▇▇ or SunCom 277-3774.
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2.Procurement
of Products or Materials with Recycled
Content
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Additionally,
it is expressly understood and agreed that any products or materials which
are
the subject of, or are required to carry out this contract shall be procured
in
accordance with the provisions of Chapter 403.7065 and 287.045, Florida
Statutes.
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3.Equity
in Contracting
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Pursuant
to Chapter 287.09451, F.S., the department is committed to embracing diversity
in the provision of services to Florida’s elders and in providing fair and equal
opportunities for all qualified minority businesses in Florida. The
contractor shall report information to the department on utilization of
certified, and non-certified minority contractors and vendors for all
subcontractors and vendors receiving funds pursuant to all contracts covered
by
this contract. This report shall be submitted quarterly to the
department.
K.Publication
or Statement of State Sponsorship
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required by Chapter 286.25, Florida Statutes, if the contractor or
subcontractor is a nongovernmental organization which sponsors a
program
financed wholly or in part by state funds, including any funds obtained
through contracts executed in accordance with this agreement, it
shall in
publicizing, advertising or describing the sponsorship of the program,
state: "Sponsored by Wellcare, and the State of
Florida, Department of Elder Affairs". If the sponsorship
reference is in written material the words "State of Florida, Department
of Elder Affairs" shall appear in the same size letters and type
as the
name of the organization.
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2.If
the contractor is a governmental entity or political subdivision
of the
state, the department requests compliance with the conditions specified
above.
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3.The
contractor shall not use the words “The State of Florida, Department of
Elder Affairs” to indicate sponsorship of a program otherwise financed
unless specific authorization has been obtained by the department
prior to
use.
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L.Use
of Funds for Lobbying Prohibited
To
comply
with the provisions of Chapter 216.347, Florida Statutes, which prohibit the
expenditure of contract funds for the purpose of lobbying the Legislature,
a
judicial branch or a state agency.
M.Public
Entity Crime; Denial or revocation of the right to transact business with public
entities.
It
is the
intent of the legislature to place the following restrictions on the ability
of
persons convicted of public entity crimes to transact business with the
department per Chapter 287.133, Florida Statutes:
A
person
or affiliate who has been placed on the convicted vendor list following a
conviction for a public entity crime may not submit a bid on a contract to
provide any goods or services to a public entity, may not submit a bid on a
contract with a public entity for the construction or repair of a public
building or public work, may not submit bids on leases of real property to
a
public entity, may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public entity, and may
not transact business with any public entity in excess of the threshold amount
provided in s. 287.017 for CATEGORY TWO for a period of 36 months from the
date
of being placed on the convicted vendor list. The contractor agrees
that compliance with this statute is a condition of receipt or benefit from
state or federal funds and it is binding upon the contractor, and it’s
successors during the period of this agreement. The contractor
further assures that the contractor, it’s officers, directors, senior
management, partners, employees, or agents, have not been convicted of any
public entity crimes within the last 36 months. If the contractor or any of
its
officers or directors are convicted, pursuant to the definition set forth in
s.287.133 (1)(b), of a public entity crime during the period of this agreement,
the contractor shall notify the department immediately. Non-compliance with
this
statute shall constitute a breach of contract.
N.Employment
If
the
contractor is a non-governmental organization, it is expressly understood and
agreed that the contractor will not knowingly employ unauthorized alien
workers. Such employment constitutes a violation of the employment
provisions as determined pursuant to section 274A(e) of the Immigration
Nationality Act (INA), 8 U.S.C. s.1324 a (e) (section 274A(e). Violation of
the
employment provisions as determined pursuant to section 274A(e) shall be grounds
for unilateral cancellation of this contract.
O.Audits
and Records
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maintain books, records, and documents (including electronic storage
media) in accordance with generally accepted accounting procedures
and
practices which sufficiently and properly reflect all revenues and
expenditures of funds provided by the department under this
contract. Contractors and subcontractors agree to maintain
records including paid invoices, payroll registers, travel vouchers,
copy
logs, postage logs, time sheets, etc., as supporting documentation
for
service cost reports and for administrative expenses itemized for
reimbursement. This documentation will be made available upon
request for monitoring and auditing
purposes.
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assure that these records shall be subject at all reasonable times
to
inspection, review, or audit by state personnel and other personnel
duly
authorized by the department, as well as by federal
personnel.
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maintain and file with the department such progress, fiscal and inventory
reports as specified in Attachment I, and other reports as the department
may require within the period of this contract. Such reporting
requirements must be reasonable given the scope and purpose of this
contract.
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provide a financial and compliance audit to the department as specified
in
Attachment I and to ensure that all related party transactions are
disclosed to the auditor. Additional audit requirements are
specified in Attachment I.
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▇.▇▇
include these aforementioned audit and record keeping requirements
in all
approved subcontracts and
assignments.
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6.The
contractor agrees to respond to requests for consumer information
and
statistical data for research and evaluative purposes when requested
by
the department.
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provide to the department all fiscal information regarding services
contracted to subcontractors pursuant to this agreement using the
application or format required by the
department.
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P.Retention
of Records
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1.Unless
otherwise expressly set forth in Attachment I of this contract, the
contractor agrees to retain all consumer records, financial records,
supporting documents, statistical records, and any other documents
(including electronic storage media) pertinent to this contract for
a
period of five (5) years after termination of this contract, or if
an
audit has been initiated and audit findings have not been resolved,
the
records shall be retained until resolution of the audit
findings. Any special provisions regarding retention of records
must be in accord with applicable state or federal law or
regulation.
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2.Persons
duly authorized by the department and federal auditors, pursuant
to 45
CFR, Part 74.53(e), and 92.42(e) (1) and (2) shall have full access
to and
the right to examine or duplicate any of said records and documents
during
said retention period.
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Q.Incident
Reporting
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1.The
contractor will provide reports as specified in Attachment I. These
reports will be used for monitoring progress or performance of the
contractual services as specified in Attachment
I.
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2.The
contractor will permit persons duly authorized by the department
to
inspect any records, papers, documents, facilities, goods and services
of
the contractor and subcontractor which are relevant to this agreement
or
the mission and statutory authority of the department, and/or interview
any consumers and employees of the contractor and subcontractor to
be
assured of satisfactory performance of the terms and conditions of
this
contract. Following such inspection the department will deliver
to the contractor a list of its concerns with regard to the manner
in
which said goods or services are being provided. The contractor
will rectify all noted deficiencies provided by the department within
the
time set forth by the department, or provide the department with
a
reasonable and acceptable justification for the contractor's failure
to
correct the noted deficiencies. The department shall determine
whether such failure is reasonable and acceptable. The
contractor's failure to correct or justify within a reasonable time
as
specified by the department may result in the department taking any
of the
actions identified in the Suspension section, or the department deeming
the contractor’s failure to be a breach of
contract.
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3.The
contractor will notify the department within 48 hours of conditions
related to subcontractor performance that could impair continued
service
delivery. Reportable conditions may
include:
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proposed
consumer terminations
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contractor
or subcontractor financial
concerns/difficulties
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service
documentation problems
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contract
non-compliance
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service
quality and consumer complaint
trends
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Contractors
will provide the department with a brief summary of the problem(s) and proposed
corrective action plans and time frames for implementation.
R.Safeguarding
Information
Not
to
use or disclose any information concerning a contractor of services under this
contract for any purpose not in conformity with applicable state and federal
regulations, except upon written consent of the contractor, or the custodial
parent or legal guardian of the contractor, as authorized by law.
S.Consumer
Information
To
submit
management, program, and consumer identifiable data, as specified by the
department in Attachment I.
T.Assignments
and Subcontracts
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1.Except
as otherwise allowed in Attachment I, to neither assign the responsibility
of this contract to another party nor subcontract for any of the
work
contemplated under this contract without prior written approval of
the
department. No such approval by the department of any
assignment or subcontract shall be deemed in any event or in any
manner to
obligate the department beyond the total dollar amount agreed upon
in this
contract. All such assignments or subcontracts shall be subject
to the conditions of this contract (except Section I, Paragraph J.1.,
Section II, Paragraph B. and Section I, Paragraph M., [unless the
subcontractor is a political subdivision of the state]) and to any
conditions of approval that the department shall deem
necessary.
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2.Unless
otherwise stated in the contract between the contractor and subcontractor,
payments made by the contractor to the subcontractor must be in accordance
with Attachment I and other applicable state and federal
regulations.
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▇.▇▇▇▇▇▇▇▇▇
Reports
To
provide financial reports to the department as specified in
Attachment I.
▇.▇▇▇▇▇
Invoice
Any
payment that may become due under the terms of this contract may be withheld
until all reports and documentation due from the contractor, and necessary
adjustments thereto, have been approved by the department.
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W.Return
of Funds
The
contractor shall return any overpayment to the agency after either discovery
by
the contractor, or notification by the agency, of the overpayment. In
the event that the contractor or its independent auditor discovers an
overpayment has been made, the contractor shall repay said overpayment without
prior notification from the agency. In the event that the agency
first discovers an overpayment has been made, the agency will notify the
contractor by letter of such a finding. Such repayment shall be made
pursuant to all applicable state and federal regulations.
▇.▇▇▇▇
Integrity
Pursuant
to the accounting and reporting requirements for federal grants management
in
OMB Circulars A-102 and A-110, which require certification of Data Integrity
for
any procurement document, the contractor must, prior to execution of this
agreement, complete the Data Integrity Certification form, Attachment
VI.
In
the
event a data integrity issue results in a delay of service, the contractor
agrees to execute their agency disaster plan to ensure the delivery of
service(s) continues.
Y.Conflict
of Interest
The
contractor hereby agrees that it will ensure that its employees, board members,
management and subcontractors, will avoid any conflict of interest or the
appearance of a conflict of interest when disbursing or using the funds
described in this agreement or when contracting with another entity which will
be paid by the funds described in this agreement. A conflict of
interest includes but is not limited to receiving, or agreeing to receive,
a
direct or indirect benefit, or anything of value from a contractor, consumer,
subcontractor, or any person wishing to benefit from the use or disbursement
of
these funds. To avoid a conflict of interest a contractor must ensure
that all individuals make a disclosure to the department of any relationship
which may be, or may be perceived to be, as a conflict of interest within thirty
(30) days of an individual’s original appointment or placement on a board, or if
the individual is serving as an incumbent, within thirty (30) days of the
commencement of the contract.
Z.Successors
and Transferees
This
contract and its attachments are binding on the contractor and its successors
and transferees.
Intentionally
Left Blank
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II.THE
DEPARTMENT AGREES:
A.Contract
Amount
To
pay
for contracted services according to the conditions of Attachment I in
an amount not to exceed $60 million, subject to the
availability of funds. The funds awarded to the contractor pursuant to this
contract consists of the following:
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Program
Title
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Year
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Funding
Source
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CFDA/CSFA#
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Fund
Amounts
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Long
Term Community Diversion Pilot Project
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2007-2008
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General
revenue-match
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93.777
& 93.778
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$60
Million
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The
State
of Florida's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the Legislature. The costs of services paid
under any other contract or from any other source are not eligible for
reimbursement under this contract.
B.Contract
Payment
Payment
will be made pursuant to the terms and conditions of Attachment I and any
applicable state and federal regulations.
C.Vendor
Ombudsman
A
Vendor
Ombudsman has been established within the Department of Financial
Services. The duties of this individual include acting as an advocate
for vendors who may be experiencing problems in obtaining timely payment(s)
from
a state agency. The Vendor Ombudsman may be contacted at (▇▇▇)
▇▇▇-▇▇▇▇ or by calling the Department of Financial Services Consumer Hotline
at
▇(▇▇▇) ▇▇▇-▇▇▇▇.
III.The
Contractor Agrees to the following special provisions:
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A.Grievance
and Appeal Procedures
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If
this
contract contains funds for services to elder consumers, the contractor will
abide by the grievance section in Attachment I and any applicable state and
federal regulations.
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B.Investigation
of Allegations
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Any
report that implies criminal intent on the part of this contractor or any
subcontractor and is referred to a governmental or investigatory agency must
be
sent to the department. The contractor must investigate allegations regarding
falsification of client information, service records, payment requests, and
other related information. If the contractor has reason to believe that the
allegations will be referred to the State Attorney, a law enforcement agency,
the United States Attorney’s Office, or other governmental agency, the
contractor shall notify the Inspector General at the department immediately.
A
copy of all documents, reports, notes or other written material concerning
the
investigation, whether in the possession of the contractor or subcontractor,
must be sent to the department’s Inspector General with a summary of the
investigation and allegations.
C.Disaster
In
preparation for the threat of an emergency event as defined in the State of
Florida Comprehensive Emergency Management Plan, the Department of Elder Affairs
may exercise authority over a service provider to implement preparedness
activities to improve the safety of the elderly in the threatened area
and
to
secure service provider facilities to minimize the potential impact of the
event. These actions will be within the existing roles and
responsibilities of the service providers.
10
In
the
event the President of the United States or Governor of the State of Florida
declares a disaster or state of emergency, the Department of Elder Affairs
may
exercise authority over the service provider to implement emergency relief
measures and/or activities.
In
either
of these cases, only the Secretary, Deputy Secretary or his/her designee of
the
Department of Elder Affairs shall have such authority to order the
implementation of such measures. All actions directed by the
department under this section shall be for the purpose of ensuring the health,
safety and welfare of the elderly in the potential or actual disaster
area.
▇.▇▇▇▇▇▇▇▇
System Backup and Recovery
Each
contractor, among other requirements, must anticipate and prepare for the loss
of information processing capabilities. The routine backing up of
data and software is required to recover from losses or outages of the computer
system. Data and software essential to the continued operation of
contractor functions must be backed up. The security controls over
the backup resources shall be as stringent as the protection required of the
primary resources. It is recommended that a copy of the backed up data be stored
in a secure, offsite location. The contractor will submit to the
department, annually or upon revision, their written policy for backing up
data
and software.
IV.THE
CONTRACTOR AND DEPARTMENT MUTUALLY AGREE:
A.Effective
Date
|
|
1.This
contract shall begin on September 1, 2007, or on the date on which
the
contract has been signed by both parties, whichever is
later.
|
|
|
2.This
contract shall end on August 31,
2008.
|
B.Termination
1.Termination
at Will
This
contract may be terminated by either party upon no less than sixty (60) calendar
days notice, without cause, unless a lesser time is mutually agreed upon by
both
parties. Said notice shall be delivered by certified mail, return receipt
requested, or in person with proof of hand delivery. In the event the contractor
terminates a contract at will the contractor agrees to submit, at the time
it
serves notice of intent to terminate, a plan which identifies procedures to
ensure services to consumers will not be interrupted or suspended by the
termination.
2.Termination
Because of Lack of Funds
In
the
event funds to finance this contract become unavailable, the agency will notify
the Contractor in writing within twenty-four (24) hours after the agency learns
of such unavailability of funds. Said notice shall be delivered by
certified mail, return receipt requested, or any expedited delivery service
that
provides verification of receipt, or in person with proof of hand
delivery. In the event of a fiscal emergency, the department, in
consultation with the agency may terminate the contract no less than twenty-four
(24) hours after the contractor has received written notice. The
agency shall be the final authority as to the availability of
funds.
11
3.Termination
for Breach
The
department may, by written notice to the Contractor, terminate this contract
if
the provider fails to cure any material breach within thirty (30) days after
the
Contractor receives from the department written notification explaining the
nature of the material breach; provided however, the department may terminate
this contract for material breach upon no less than twenty four (24) hours
written notice to the Contractor if the Contractor has committed a material
breach of the contract which causes an immediate danger to the public health
and
if the Contractor has not cured such breach within the notice period upon no
less than twenty-four (24) hours notice. Said notice shall be
delivered by certified mail, return receipt requested, or in person with proof
of delivery. If applicable, the department may employ the default
provisions in Chapter 60A─1.006(3), Florida Administrative Code.
If
the
Contractor does not receive all or a substantial portion of its capitation
payment within (10) days after it is due, the Contractor shall furnish written
notification to the department and the Contractor may terminate this contract
if
the agency fails to make payment within twenty (20) days after the department’s
receipt of such notice.
Waiver
of
breach of any provisions of this contract shall not be deemed to be a waiver
of
any other breach and shall not be construed to be a modification of the terms
of
this contract. The provisions herein do not limit the department or agency’s
right to remedies or damages at law or in equity.
4.Termination
after Suspension
If
the
department engages any of the suspension provisions contained in Section 1.21
of
Attachment I to this contract, the department may, in its sole discretion,
determine if termination is warranted.
C.Notice
and Contact
|
|
1.The
name, address and telephone number of the contract manager for the
department for this contract is:
|
Department
of Elder Affairs
ATTN:
Contract Manager
▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇
▇▇▇▇▇▇▇▇▇▇▇,
▇▇ ▇▇▇▇▇-▇▇▇▇
(850)
414-Direct Number
|
|
2.The
name, address and telephone number of the representative of the contractor
responsible for administration of the program under this contract
is:
|
|
▇▇▇▇▇
▇▇▇▇▇▇
|
|
Wellcare
|
|
▇.▇.
▇▇▇ ▇▇▇▇▇
|
|
▇▇▇▇▇,
▇▇ ▇▇▇▇▇
|
|
(▇▇▇)
▇▇▇-▇▇▇▇
|
12
|
|
▇.▇▇
the event that different representatives are designated by either
party
after execution of this contract, notice of the name and address
of the
new representative will be rendered in writing to the other party
and said
notification attached to originals of this
contract.
|
D.Renegotiation
or Modification
|
|
1.Modifications
of provisions of this contract shall only be valid when they have
been
reduced to writing and duly signed. The parties agree to renegotiate
this
contract if federal and/or state revisions of any applicable laws,
or
regulations make changes in this contract
necessary.
|
|
|
2.The
payment made pursuant to this contract shall be governed by the terms
and
conditions in Attachment I.
|
▇.▇▇▇▇,
Mailing and Street Address of Payee
|
|
1.The
name (contractor name as shown on page 1 of this contract) and mailing
address of the official payee to whom the payment shall be
made:
|
|
Wellcare
|
|
▇.▇.
▇▇▇ ▇▇▇▇▇
|
|
▇▇▇▇▇,
▇▇ ▇▇▇▇▇
|
|
|
2.The
name of the contractor’s contact person and street address where financial
and administrative records are
maintained:
|
|
▇▇▇▇▇
▇▇▇▇▇▇
|
|
Wellcare
|
|
▇.▇.
▇▇▇ ▇▇▇▇▇
|
|
▇▇▇▇▇,
▇▇ ▇▇▇▇▇
|
F.All
Terms and Conditions Included
This
contract and Attachments I, II, III, IV, and Exhibits ▇, ▇, ▇, ▇, ▇, ▇,
▇, ▇, ▇, ▇, K, and L as referenced, contain all terms and conditions
agreed upon by the parties.
13
IN
WITNESS WHEREOF, the parties hereto have caused this 110 page
contract to be executed by their undersigned officials as duly
authorized.
|
Contractor:
Wellcare
|
STATE
OF FLORIDA DEPARTMENT OF ELDER AFFAIRS
|
|
SIGNED
BY: /s/ ▇▇▇▇ ▇. ▇▇▇▇▇
|
SIGNED
BY: /s/ E. D
Beach
|
|
NAME:
▇▇▇▇ ▇▇▇▇▇
|
NAME:
▇. ▇▇▇▇▇▇▇ BEACH
|
|
TITLE:
President & CEO
|
TITLE:
SECRETARY
|
|
DATE:
8/23/2007
|
DATE:
8/29/2007
|
|
FEDERAL
ID NUMBER: ▇▇▇▇▇▇▇▇▇
(or
SS Number for an individual)
|
|
|
FISCAL
YEAR ENDING DATE:
|
|
|
STATE
AGENCY 29 DIGIT SAMAS CODE:
|
14
ATTACHMENT
I
State
of Florida
Department
of Elder Affairs
Long-Term
Care Community Diversion Pilot Project
Contract
No. ▇▇▇▇-▇▇▇▇-▇▇
|
LONG-TERM
CARE COMMUNITY DIVERSION PILOT PROJECT
Table
of Contents
|
||
|
SECTION
1
|
GENERAL
CONTRACT REQUIREMENTS
|
5
|
|
1 1
|
Entire
Agreement; Conflict
|
5
|
|
1 2
|
Non-Renewal
|
5
|
|
1 3
|
Misuse
of Symbols, Emblems, or Names in Reference to Medicaid
|
5
|
|
1 4
|
Contractor
Qualifications
|
5
|
|
1 5
|
Contract
Management
|
6
|
|
1 6
|
Insolvency
Protection
|
9
|
|
1 7
|
Surplus
Requirements
|
9
|
|
1 8
|
Bonds
|
9
|
|
1 9
|
Insurance
|
10
|
|
1 10
|
Interest
and Savings
|
10
|
|
1 11
|
Third
Party Resources
|
10
|
|
1 12
|
State
Ownership
|
11
|
|
1 13
|
Ownership
and Management Disclosure
|
11
|
|
1 14
|
Independent
Provider
|
13
|
|
1 15
|
Damages
from Federal Disallowances
|
13
|
|
1 16
|
Offer
of Gratuities
|
13
|
|
1 17
|
Attorneys
Fees
|
13
|
|
1 18
|
Venue
or Court of Jurisdiction
|
13
|
|
1 19
|
Legal
Action Notification
|
13
|
|
1 20
|
Force
Majeure
|
14
|
|
1 21
|
Sanctions
|
14
|
|
1 22
|
Applicable
Laws and Regulations
|
15
|
|
1 23
|
Inspection
and Audit of Financial Records
|
16
|
|
1 24
|
Reporting
|
16
|
|
1 25
|
Fiscal
Intermediary
|
16
|
|
1 26
|
Subcontracts
|
16
|
|
1 27
|
Subcontractor
Terminations
|
20
|
|
1 28
|
Termination
|
20
|
|
1 29
|
Assignment
|
21
|
|
SECTION
2
|
RECIPIENT
ELIGIBILITY TO PARTICIPATE IN THE PROJECT
|
22
|
|
2 1
|
Eligibility
Requirements
|
22
|
|
2 2
|
Eligibility
|
22
|
|
2 3
|
Persons
Not Eligible for Enrollment
|
22
|
|
2 4
|
Optional
State Supplementation (OSS)
|
23
|
|
SECTION
3
|
EDUCATIONAL
MATERIALS and CHOICE COUNSELING
|
23
|
|
3 1
|
Educational
Materials
|
23
|
|
3 2
|
Choice
Counseling
|
23
|
|
3 3
|
Prohibited
Activities
|
23
|
|
SECTION
4
|
ENROLLMENT
AND DISENROLLMENT
|
24
|
|
4 1
|
Enrollment
Procedures
|
24
|
|
4 2
|
Effective
Date of Enrollment
|
25
|
|
4 3
|
Transition
Care Planning
|
25
|
|
4 4
|
Orientation
|
25
|
|
4 5
|
Plan
of Care
|
27
|
|
4 6
|
Integration
of Care
|
29
|
|
4 7
|
Disenrollment
|
30
|
|
4 8
|
Disputes
of Appropriate Enrollments
|
31
|
|
4 9
|
Medicaid
Pending
|
31
|
ATTACHMENT
I - Page 2
|
SECTION
5
|
ENROLLEE
RECORDS
|
32
|
|
SECTION
6
|
SERVICE
PROVISIONS
|
33
|
|
6 1
|
General
Provisions
|
33
|
|
6 2
|
Long-Term
Care Services
|
34
|
|
6 3
|
Minimum
Long-Term Care Service Provider Qualifications
|
37
|
|
6 4
|
Acute-Care
Services
|
39
|
|
6 5
|
Acute
Care Provider Qualifications
|
40
|
|
6 6
|
Optional
Services
|
41
|
|
6 7
|
Expanded
Services
|
41
|
|
6 8
|
Availability/Accessibility
of Services
|
41
|
|
6 9
|
Staffing
Requirements
|
41
|
|
6 10
|
Emergency
Care Requirements
|
42
|
|
6 11
|
Out
of Network Use of Non-Emergency Services
|
42
|
|
6 12
|
Adult
Protective Services
|
43
|
|
SECTION
7
|
UTILIZATION
MANAGEMENT
|
43
|
|
SECTION
8
|
QUALITY
ASSURANCE AND IMPROVEMENT REQUIREMENTS
|
45
|
|
8 1
|
General
|
45
|
|
8 2
|
Quality
Assurance Program
|
45
|
|
8 3
|
Quality
Assurance Committee
|
46
|
|
8 4
|
Quality
of Care Studies
|
46
|
|
8 5
|
Independent
Medical Review
|
47
|
|
8 6
|
Extraordinary
Reporting
|
47
|
|
SECTION
9
|
GRIEVANCE/APPEALS
PROCEDURES
|
47
|
|
9 1
|
Grievance
System Requirements
|
47
|
|
9 2
|
Appeal
Process
|
48
|
|
9 3
|
Grievance
Process
|
51
|
|
9 4
|
Medicaid
Fair Hearing System
|
51
|
|
SECTION
10
|
PAYMENT
|
52
|
|
10 1
|
Payment
to ▇▇▇▇▇▇▇▇▇▇
|
▇▇
|
|
▇▇ ▇
|
▇▇▇▇▇▇▇▇▇▇
▇▇▇▇▇
|
▇▇
|
|
▇▇ ▇
|
Payment
in Full
|
53
|
|
10 4
|
Capitation
Payments
|
53
|
|
10 5
|
Payment
Discrepancies
|
53
|
|
SECTION
11
|
PROGRAM
REPORTING REQUIREMENTS
|
53
|
|
11 1
|
General
Requirements
|
53
|
|
11 2
|
834
Transactions
|
56
|
|
11 3
|
Disenrollment
Summary Report
|
56
|
|
11 4
|
Encounter
Data Report
|
57
|
|
11 5
|
Grievance/Appeals
Report
|
57
|
|
11 6
|
Updated
Provider Network Listing
|
57
|
|
11 7
|
Minority
Business Enterprise Contract Reporting
|
58
|
|
11 8
|
Emergency
Management Plan
|
58
|
|
11 9
|
Enrollee
Satisfaction Reporting
|
58
|
|
11 10
|
Hospice
Services
|
58
|
|
SECTION
12
|
FINANCIAL
REPORTING
|
58
|
|
12 1
|
General
Financial Reporting
|
58
|
|
12 2
|
Member
Payment Liability Protection
|
58
|
|
12 3
|
Financial
Reporting Template
|
59
|
|
12 4
|
Audited
Financial Statements
|
59
|
|
12 5
|
Unaudited
Quarterly Financial Statements
|
59
|
|
SECTION
13
|
DEFINITIONS
|
69
|
|
|
|
ATTACHMENT
I - Page 3
|
EXHIBIT
A
|
MULTIPLE
SIGNATURE VERIFICATION AGREEMENT
|
75
|
|
EXHIBIT
B
|
DISENROLLMENT
SUMMARY REPORT
|
77
|
|
EXHIBIT
C
|
ENCOUNTER
DATA REPORTING FORMAT
|
78
|
|
EXHIBIT
D
|
REPORT
OF GRIEVANCES/APPEALS
|
82
|
|
EXHIBIT
E
|
MINORITY
BUSINESS ENTERPRISE CONTRACT REPORTING
|
83
|
|
EXHIBIT
F
|
RECONCILIATION
REPORT
|
84
|
|
EXHIBIT
G
|
DISENROLLMENT
FORM
|
85
|
|
EXHIBIT
H
|
PROVIDER
NETWORK AND STAFF LISTING
|
86
|
|
EXHIBIT
I
|
CAPITATION
RATES
|
88
|
|
EXHIBIT
J
|
PUBLIC
ENTITY CRIMES
|
89
|
|
EXHIBIT
K
|
DEBARMENT
AND SUSPENSION
|
91
|
|
EXHIBIT
L
|
HOSPICE
ENROLLMENT REPORT
|
93
|
ATTACHMENT
I - Page 4
LONG-TERM
CARE COMMUNITY DIVERSION PILOT PROJECT
|
SECTION
1 General Contract Requirements
|
|
|
|
1.1Conflict
|
Correspondence
and project memoranda do not constitute part of this
contract. Pending final determination of any dispute, the contractor
must proceed diligently with the performance of the contract and in accordance
with the department’s direction.
1.2Misuse
of Symbols, Emblems, or Names in Reference to Medicaid
No
person
or contractor may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication,
or
a broadcast, telecast, or other production, alone or with other words, letters,
symbols or emblems the words “Medicaid,” or “Department of Elder Affairs,” or
“Agency for Health Care Administration,” except as required in the
standard contract unless prior written approval is
obtained from the department. Specific written authorization from the
department is required to reproduce, reprint, or distribute any department
or
Agency form, application, or publication, for a fee. State and local
governments are exempt from this prohibition. A disclaimer that
accompanies the inappropriate use of the program or the department or Agency’s
terms does not provide a defense. Each piece of mail or information
constitutes a violation.
1.3Contractor
Qualifications
The
long-term care community diversion pilot project contractor must:
|
|
A.Have
a certificate of authority from the Florida Department of Financial
Services to operate as a health maintenance organization (HMO) pursuant
to
Chapter 641 Part I, F.S., and have a health care provider certificate
from
the Agency for Health Care Administration (Agency) pursuant to Section
641.49, F.S., for those counties in the service area in which the
applicant will apply to provide services
or;
|
|
|
B.Have
a license issued pursuant to Chapter 400 or Chapter 429, F.S., and
meet
the provisions of an “other qualified provider” set forth in Section
430.703(7), F.S. and;
|
|
|
C.Have
prior experience in providing home and community-based long-term
care
services and;
|
|
|
D.Have
the capacity to integrate the delivery of acute and long-term care
services to enrollees and;
|
|
|
▇.▇▇▇▇
all the requirements to enroll as a Medicaid provider
and;
|
|
|
▇.▇▇▇▇
all other requirements in the remaining provisions of this contract
and
its attachments.
|
1.4 Contract
Management
A.State
Responsibilities
The
Department of Elder Affairs (department) in consultation with the Agency for
Health Care Administration (Agency) will oversee contract management
responsibilities. The department will have the right to approve,
disapprove, or require modification of procedures developed by the contractor
under the contract where necessary to assure compliance with department or
Agency rules or the contract.
ATTACHMENT
I - Page 5
B.Department
Responsibilities
|
|
1.Develop,
analyze, and revise policies and procedures for the project in
consultation with the Agency.
|
|
|
2.Approve,
in consultation with the Agency, the contractor’s readiness to deliver
services under the contract.
|
|
|
3.Determine
the clinical eligibility of persons applying for Medicaid long-term
care
assistance through the Comprehensive Assessment and Review for Long-Term
Care Services (CARES) program.
|
|
|
4.Provide
through the CARES program, information regarding long-term care options
to
persons applying for Medicaid long-term care
assistance.
|
|
|
5.Provide
policy and contract clarification, in consultation with the
Agency.
|
|
|
6.Monitor
with the Agency, the contractor’s compliance with the terms of the
contract and impose appropriate corrective and remedial measures
as
warranted.
|
|
|
7.Receive
all materials that must be submitted by the contractor and forward
them to
the appropriate entity except as otherwise stated in the
contract.
|
C.Contractor
Responsibilities
|
|
1.The
contractor is responsible for the administration and management of
all
contractor functions, including all subcontracts, employees, agents
and
anyone acting for or on behalf of the contractor. Any
delegation of activities does not relieve the contractor of this
responsibility.
|
|
|
2.If
the contractor delegates administrative and management functions
to a
third party administrator (TPA), the TPA must be licensed
to do business as a TPA in Florida. Such delegation to a TPA
does not relieve the contractor of responsibility for the administration
and management required under this
contract.
|
|
|
3.The
relationship between management personnel and the governing body
must be
set forth in writing, including each person’s authority, responsibilities,
and function.
|
|
|
4.The
contractor’s governing body shall set policy and has overall
responsibility for the organization. Pursuant to 42 CFR
438.210(b)(2), the contractor is responsible for ensuring consistent
application of review criteria for authorization decisions and consulting
with the requesting subcontractor when
appropriate
|
|
|
5.The
contractor shall comply with all Agency handbooks noticed in or
incorporated by reference in rules relating to the provision of services
set forth in Section 6, Service Provisions, except where the provisions
of
the contract alter the requirements set forth in the handbooks where
applicable. Pursuant to 42 CFR 438.210(a) and (a)(3)(i)-(iii),
the contractor must furnish services up to the limits specified by
the
Medicaid program. The contractor may exceed these
limits. However, service limitations shall not be more
restrictive than the Medicaid fee-for-service
program.
|
|
|
6.Pursuant
to 42 CFR 438.236(b), the contractor shall adopt practice guidelines
that
meet the following requirements:
|
|
|
a)Are
based on valid and reliable clinical evidence or a consensus of healthcare
professionals in the particular field.
|
| b) Consider the needs of the enrollees. |
|
c)Are
adopted in consultation with contracting health care
professionals.
|
|
d)Are
reviewed and updated periodically as appropriate.
The
contractor shall disseminate the guidelines to all affected providers
and,
|
|
|
7.Pursuant
to Section 430.705(2)(b)(3), F.S., the contractor, must
have through performance or other documented means, the capacity
for
prompt payment of claims as specified under Section 641.3155,
F.S.
|
ATTACHMENT
I - Page 6
D.Administrative
Polices and Procedures Section
1.Contractor
will have in place polices and procedures relating to the
following:
|
|
a)Emergency
Management Plan
|
|
|
b)Educational
Materials
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c)Initial
enrollment and Ongoing Eligibility
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d)Transition
Care Planning
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e)Orientation
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f)Disenrollment
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g)Service
Provisions
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h)Network
Adequacy
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i)Sufficient
staff available 24 hours per day
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j)Credentialing
and Re-Credentialing
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k)Plan
for recruiting and retaining minority health
vendors
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l)Integration
of Care
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m)Plan
of Care
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n)Out
of network Use of Non-Emergency
Services
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o)Quality
Assurance Program
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p)Quality
Assurance Committee
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q)Extraordinary
Reporting
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r)Utilization
Management
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s)Grievance/Appeals
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t)Enrollee
Records
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u)Claims
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v)Advance
Directives
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w)Payment
Discrepancies
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x)Reinstatement
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y)Subcontract
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2.Fraud
Prevention Polices and
Procedures
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a)The
policies and procedures for fraud prevention shall provide for use
of the
HHS Office of the Inspector General List of Excluded Individuals
/
Entities Search (▇▇▇▇://▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇.▇▇▇), or its equivalent,
to
identify excluded parties during the process of enrolling providers
to
ensure the contractor providers are not in a non-payment status or
excluded from participation in federal health care programs under
Section
1128 or Section 1128A of the Social Security Act. The
contractor must not employ or contract with excluded providers and
must
terminate providers if they become
excluded.
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b)The
contractor must have written policies and procedures for selection
and
retention of providers. These policies and procedures must not
discriminateagainst particular providers that serve high-risk populations
or specialize in conditions that require costly
treatments.
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c)The
contractor must develop and maintain written polices and procedures
to
implement the provision of the
contract.
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ATTACHMENT
I - Page 7
3. Credentialing
and Re-Credentialing Policies and Procedures
The
contractor’s credentialing and re-credentialing policies and procedures shall
include the following:
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A.Formal
delegations and approvals of the credentialing
process.
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B.A
designated credentialing committee.
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C.Identification
of providers who fall under its scope of
authority.
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D.A
process, which provides for verification of the following core credential
information and the subcontractor’s work
history:
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1.The
subcontractor’s current valid
license.
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2.The
subcontractor’s current valid occupational license, where
applicable.
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3.Medicaid
provider number, if applicable.
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4.Verification
of the following for non-Medicaid
providers:
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(a)Evidence
of the subcontractor’s professional liability claims
history.
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(b)Completion
of a criminal history background check to determine whether subcontactor
has any history of felony convictions, including adjudication withheld
on
a felony, plea of nolo contendere to a felony, or entry into a pretrial
for a felony.
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(c)Any
sanctions imposed by Medicare or Medicaid in any
state.
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(d)Any
disciplinary action taken against any business or professional license
held in this or any other state or surrendered a license in this
or any
state.
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(e)Any
history of loss or limitation of privileges or disciplinary
activity.
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5.Verification
that the contractor obtained information about the subcontractor
on the
HHS Office of the Inspector General’s exclusion website
(▇▇▇▇://▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇.▇▇▇).
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6.Verification
that all subcontractors and their employees with direct contact with
enrollees have completed Abuse, Neglect, and Exploitation
Training.
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E.The
process for periodic re-credentialing which shall include the
following:
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1.The
procedure for re-credentialing shall be implemented at least every
three
(3) years.
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2.The
contractor shall verify the current licensure of the subcontractor
on the
HHS Office of the Inspector Generals’ websites on an annual
basis.
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F.The
contractor shall develop and implement policies and procedures for
approval of new providers, and imposition of sanctions, termination,
suspension, or sanctioning of a
subcontractor.
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G.The
contractor shall develop and implement a mechanism for identifying
quality
deficiencies that result in the contractor’s restriction, suspension,
termination, or sanctioning of a
subcontractor.
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H.The
contractor shall develop and implement an appellate process for sanctions,
restrictions, suspensions and terminations imposed by the contractor
against subcontractors.
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ATTACHMENT
I - Page 8
4.
Health Information Systems
The
contractor shall maintain a health information system that collects, analyzes,
integrates, and reports data and can achieve the objectives of 42 CFR 438.242
and Health Insurance Portability and Accountability Act (HIPAA)
requirements.
1.5Insolvency
Protection
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A.The
contractor must establish and maintain a restricted insolvency protection
account in a bank or savings and loan association located in the
state of
Florida with a balance of at least $100,000 into which monthly deposits
equal to at least 5 percent of premiums received under the project
are
made until the balance equals 2 percent of the total contract amount.
The
account shall be established with such terms as to ensure that funds
may
only be withdrawn with the signature approval of designated department
representatives. A sample form (Signature Verification Agreement)
can be
found in Exhibit A.
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B.If
the contractor’s authorized representatives do not change from subsequent
contract years, an attestation statement indicating such must be
submitted
to the
department.
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▇.▇▇
the event that a determination is made by the department that the
contractor is insolvent as defined in Section 13, the department
may draw
upon the account solely with the authorized signatures of representatives
of the department and funds may be disbursed to meet financial obligations
incurred by the contractor under this contract. The contractor
shall provide a statement of account balance upon request by the
department.
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D.If
the contract is terminated, expired, or not continued, the account
balance
shall be released by the department to the contractor upon receipt
of
proof of satisfaction of all outstanding obligations incurred under
this
contract.
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▇.▇▇
the event the contract is terminated or not renewed and the contractor
is
insolvent, the department may draw upon the insolvency protection
account
to pay any outstanding debts the contractor owes the Agency including,
but
not limited to, overpayments made to the contractor, and fines imposed
under the contract or Section 641.52, F.S., for which a final order
has
been issued. In addition, if the contract is terminated or not
renewed and the contractor is unable to pay all of its outstanding
debts
to health care providers, the department, Agency, and the contractor
agree
to the court appointment of an impartial receiver for the purpose
of
administering and distributing the funds contained in the insolvency
protection account. A receiver must give outstanding debts owed
to the Agency priority over other
claims.
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1.6Surplus
Requirements
All
contractors shall maintain a surplus of at least $1.5 million as determined
by
the department. Each applicant and each provider shall furnish to the department
initial and annual unqualified audited financial statements prepared by a
certified public accountant that expressly confirm that the applicant or
provider satisfies this surplus requirement.
1.7Bonds
The
contractor must secure and maintain during the life of the contract a blanket
fidelity bond from a company doing business in the State of Florida on all
personnel in its employment and its board of directors. The bond must
be issued in the amount of at least $250,000 per occurrence.
ATTACHMENT
I - Page 9
Said
bond
must protect the department and Agency from any losses sustained through any
fraudulent or dishonest act or acts committed by any employees of the provider
and subcontractors, if any. The contractor must submit proof of
coverage within 60 calendar days after execution of the contract and prior
to
the delivery of services. For fidelity bonds to be acceptable, a
surety company must comply with the provisions of Chapter 624,
F.S. The contractor must submit proof of the fidelity bond annually
during the contract renewal period.
1.8Insurance
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A.The
contractor must obtain and maintain, at all times, adequate insurance
coverage including general liability insurance, professional liability
and
malpractice insurance, fire and property insurance, and director’s
omission and error insurance. All insurance coverage must
comply with the provisions set forth in Section 690-191.069, Florida
Administrative Code, except that the reporting, administrative, and
approval requirements will be submitted to the department in addition
to
the Department of Financial Services. All insurance policies
must be written by insurers licensed to do business in the State
of
Florida and be in good standing with the Department of Financial
Services,
unless coverage is not procurable from authorized insurers, in which
case
the provisions of the Surplus Lines Law (Section 626.913 - 626.937,
F.S.)
shall apply. The contractor must submit all policy declaration
pages annually or whenever there is a change in insurer or policy
provisions to the contract manager. Each certificate of
insurance must provide for notification to the department in the
event of
termination of the policy.
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B.The
contractor must secure and maintain during the life of the contract,
worker’s compensation insurance for all of its employees connected with
the work under the contract. Such insurance must comply with
the Florida Worker's Compensation Law, Chapter 440, F.S. Policy
declaration pages must be submitted to the department
annually.
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1.9Interest
and Savings
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A.Interest
generated through investments made by the contractor of funds provided
to
the contractor pursuant to this contract will be the property of
the
contractor and will be used at the contractor’s
discretion.
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B.The
contractor will retain any savings realized under the contract after
all
bills, charges, and fines are paid.
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1.10Third
Party Resources
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A.The
contractor will be responsible for making every reasonable effort
to
determine the legal liability of third parties to pay for services
rendered to enrollees under this contract. The contractor has
the same rights to recovery of the full value of services as the
Agency. (See Section 409.910, F.S.) The following
standards govern recovery.
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B.If
the contractor has determined that third party liability exists for
part
or all of the services provided directly by the contractor to an
enrollee,
the contractor must make reasonable efforts to recover from third
party
liable sources the value of services
rendered.
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C.If
the contractor has determined that third party liability exists for
part
or all of the services provided to an enrollee by a subcontractor
or
referral provider, and the third party is reasonably expected to
make
payment within 120 calendar days, the contractor may pay the subcontractor
or referral provider only the amount, if any, by which the subcontractor's
allowable claim exceeds the amount of the anticipated third party
payment;
or, the contractor may assume full responsibility for third party
collections for service provided through the subcontractor or referral
provider.
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ATTACHMENT
I - Page 10
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D.The
contractor may not withhold payment for services provided to an enrollee
if third party liability or the amount of liability cannot be determined,
or if payment shall not be available within a reasonable time, beyond
120
calendar days from the date of
receipt.
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E.When
both the Agency and the contractor have liens against the proceeds
of a
third party resource, the Agency shall prorate the amount due to
Medicaid
to satisfy such liens under Section 409.910, F.S., between the Agency
and
the contractor. This prorated amount shall satisfy both liens
in full.
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F.All
funds recovered from third parties shall be treated as income for
the
contractor.
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1.11State
Ownership
The
department and Agency will have the right to use, disclose, or duplicate, all
information and data developed, derived, documented, or furnished by the
contractor resulting from the contract. Nothing herein will entitle
the department and Agency to disclose to third parties data or information,
which would otherwise be protected from disclosure by state or federal
law.
1.12Ownership
and Management Disclosure
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A.Federal
and state laws require full disclosure of ownership, management and
control of managed care organizations, including other qualified
providers. Disclosure must be made on forms prescribed by the
department for the areas of ownership and control interest business
transactions (42 CFR 455.105), public entity crimes (Section
287.133(3)(a), F.S.), and debarment and suspension (52 Fed. Reg.,
pages
20360-20369, and Chapter 4707 of the Balanced Budget Act of
1997). The forms are available through the department and are
to be submitted to the department with the initial application and
then
resubmitted on an annual basis. The contractor must disclose
any changes in management as soon as those occur. In addition,
the contractor must submit to the department full disclosure of ownership
and control at least 60 calendar days before any change in the
contractor's ownership or control
occurs.
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B.The
following definitions apply to ownership
disclosure:
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1.A
person with an ownership interest or control interest means a person
or
corporation that:
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a)Owns,
indirectly or directly, five (5) percent or more of the contractor's
capital or stock, or receives five (5) percent or more of its
profits;
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b)Has
an interest in any mortgage, deed of trust, note, or other obligation
secured in whole or in part by the contractor or by its property
or assets
and that interest is equal to or exceeds five (5) percent of the
total
property or assets; or
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c)Is
an officer or director of the contractor if organized as a corporation,
or
is a partner in the contractor if organized as a
partnership.
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2.The
percentage of direct ownership or control is calculated by multiplying
the
percent of interest that a person owns by the percent of the contractor's
assets used to secure the obligation. Thus, if a person owns 10 percent
of
a note secured by 60 percent of the contractor's assets, the person
owns
six (6) percent of the contractor.
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3.The
percent of indirect ownership or control is calculated by multiplying
the
percentage of ownership in each organization. Thus, if a person
owns 10 percent of the stock in a corporation that owns 80 percent
of the
contractor’s stock, the person
owns eight (8) percent of the
contractor.
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C.Changes
in management are defined as any change in the management control
of the
contractor. Examples of such changes are those listed below or
equivalent positions by another
title.
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ATTACHMENT
I - Page 11
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1.Changes
in the Board of Directors or Officers of the contractor, Medical
Director,
Chief Executive Officer, Administrator, and Chief Financial
Officer;
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2.Changes
in the management of the contractor where the contractor has decided
to
contract out the operation of the contractor to a management
corporation.
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The
contractor must disclose such changes in management control and provide a copy
of the contract agreement to the contract manager for approval at least 60
calendar days prior to the management contract start date.
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▇.▇▇
accordance with Section 409.912(32), F.S., the contractor must annually
conduct a background check with the Florida Department of Law Enforcement
on all persons with five (5) percent or more ownership interest in
the
contractor, or who have executive management responsibility for the
managed care plan, or have the ability to exercise effective control
of
the contractor. The contractor must submit information to the
department for such persons who have a record of illegal conduct
according
to the background check.
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▇.▇▇
accordance with Section 409.907(8)(a), F.S., contractors must submit,
prior to execution of a contract, complete sets of fingerprints of
principals of the contractor to the department for the purpose of
conducting a criminal history record
check.
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2.Principals
of the contractor are defined in Section 409.907(8)(a),
F.S.
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E.The
contractor must submit to the department, within five (5) working
days,
any information on any officer, director, agent, managing employee,
or
owner of stock or beneficial interest in excess of five (5) percent
of the
contractor who has been found guilty of, regardless of adjudication,
or
who entered a plea of nolo contendere or guilty to, any of the offenses
listed in Section 435.03, F.S.
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▇.▇▇
accordance with Section 409.912(10), F.S., the department and Agency
will
not contract with an entity that has an officer, director, agent,
managing
employee, or owner of stock or beneficial interest in excess of five
(5)
percent of the contractor, who has committed any of the listed offenses
as
referenced in Section 435.03, F.S. In order to avoid
contract termination, the contractor must submit a corrective action
plan,
approved by the department, that ensures such person is divested
of all
interest and/or control and has no role in the operation and management
of
the contractor.
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G.The
contract is subject to the provisions of Chapter 112 and Section
430.03,
F.S. The contractor must disclose the name of any officer,
director, or agent who is an employee of the State of Florida, or
any of
its agencies. Further, the contractor must disclose the name of
any state employee who owns, directly or indirectly, an interest
of five
(5) percent or more in the offeror's firm or any of its
branches. The contractor covenants that it presently has no
interest and shall not acquire any interest, direct or indirect,
which
would conflict in any manner or degree with the performance of the
services hereunder. The contractor further covenants that in
the performance of the contract no person having any such known interest
shall be employed. No official or employee of the department or
Agency and no other public official of the State of Florida or the
federal
government who exercises any functions or responsibilities in the
review
or approval of the undertaking of carrying out the contract must,
prior to
completion of this contract, voluntarily acquire any personal interest,
direct or indirect, in this
contract.
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ATTACHMENT
I - Page 12
1.13Independent
Provider
The
contractor and any subcontractors’ employees, agents, and officers in the
performance of this contract, shall act in an independent capacity and not
as
officers and employees of the department, Agency, or the State of
Florida. It is further expressly agreed that this contract shall not
be construed as a partnership or joint venture between the contractor or any
subcontractor and the department, Agency, or the State of Florida.
1.14Damages
from Federal Disallowances
In
addition to any remedies available through the contract, in law or equity,
the
contractor must reimburse the Agency for any federal disallowances or sanctions
imposed on the department or Agency as a result of the contractor's failure
to
abide by the terms of the contract.
1.15Offer
of Gratuities
By
signing this agreement, the contractor signifies that no recipient of or a
delegate of Congress, nor any elected or appointed official or employee of
the
State of Florida, the General Accounting Office, Department of Health and Human
Services, Centers for Medicare and Medicaid Services, or any other federal
Department has or will benefit financially or materially from this
procurement. The department may terminate the contract if it is
determined that gratuities of any kind were offered to or received by any
officials or employees from the offeror, his agent, or employees.
1.16Attorneys’
Fees
In
the
event of a dispute, each party to the contract will be responsible
for attorney’s fees except as otherwise provided by law.
1.17Venue
For
purposes of any legal action occurring as a result of or under the contract,
between the contractor and the department or Agency, the place of proper venue
will be ▇▇▇▇ County, Florida.
1.18Legal
Action Notification
The
contractor must give the department by certified mail immediate written
notification (no later than 30 calendar days after service of process) of any
action or suit filed or of any claim made against the contractor by any
subcontractor, vendor, or other party which results in litigation related to
this contract for disputes or damages exceeding the amount of
$50,000. In addition, the contractor must immediately advise the
department of the insolvency of a subcontractor or of the filing of a petition
in bankruptcy by or against a subcontractor.
1.19Force
Majeure
The
department and Agency will not be liable for any excess cost to the contractor
if the department’s or Agency's failure to perform the contract arises out of
causes beyond the control and without the result of fault or negligence on
the
part of the department or Agency. In all cases, the failure to
perform must be beyond the control without the fault or negligence of the
department or Agency. The contractor will not be liable for performance of
the
duties and responsibilities of the contract when its ability to perform is
prevented by causes beyond its control.
These acts must occur without the fault or negligence of the contractor. These
include destruction to the facilities due to hurricanes, fires, war, riots,
and
other similar acts. Annually by April 30, the contractor must submit
to the department for approval an emergency management plan specifying what
actions the contractor must conduct to ensure the ongoing provisions of health
services in a natural disaster or man-made emergency.
ATTACHMENT
I - Page 13
1.20Sanctions
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▇.▇▇
accordance with Section 4707 of the Balanced Budget Act of 1997,
and
Section 409.912(22), F.S, the following sanctions may be imposed
against
the contractor if it is determined that the contractor has violated
any
provision of this contract, or the applicable statutes or rules governing
Medicaid HMOs:
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1.Suspension
of the contractor’s
enrollment.
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2.Suspension
or revocation of payments to the plan for Medicaid recipients enrolled
during the sanction period. If the contractor has violated the contract,
the contractor may be ordered to reimburse the complainant for
out-of-pocket medically necessary expenses incurred or order the
contractor to pay non-network plan providers who provide medically
necessary services.
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3.Imposition
of a fine for violation of the contract with the department and Agency,
pursuant to Section 409.912(22),
F.S.
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4.Termination
pursuant to paragraph IV B (3) of the standard contract, if the contractor
fails to carry out substantive terms of its contract or fails to
meet
applicable requirements in sections 1932, 1903(m) and 1905(t) of
the
Social Security Act. After the department, in consultation with
the Agency, notifies the contractor that it intends to terminate
the
contract, the department, in consultation with the Agency, may give
the
contractor’s enrollees written notice of the state's intent to terminate
the contract and allow the enrollees to disenroll immediately without
cause.
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B.Unless
the duration of a sanction is specified, a sanction will remain in
effect
until the department is satisfied that the basis for imposing the
sanction
has been corrected and is not likely to
recur.
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C.The
Agency and/or department may impose intermediate sanctions in accordance
with 42 CFR 438.702, including:
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1.Civil
monetary penalties in the amounts specified in Chapter 409.912(22),
F.S.
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2.Appointment
of temporary management for the contractor. Rules for temporary
management pursuant to 42 CFR 438.706 are as
follows:
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a)The
State may impose temporary management only if it finds (through onsite
survey, enrollee complaints, financial audits, or any other means)
that:
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(1)There
is continued egregious behavior by the contractor, including but
not
limited to behavior that is described in 42 CFR 438.700, or that
is
contrary to any requirements of Sections 1903(m) and 1932 of the
Social
Security Act; or
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(2)There
is substantial risk to enrollees' health;
or
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(3)The
sanction is necessary to ensure the health of the contractor’s
enrollees:
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(i)While
improvements are made to remedy violations under 42 CFR 438.700;
or
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(ii)Until
there is an orderly termination or reorganization of the
contractor.
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b)The
State must impose temporary management (regardless of any other sanction
that may be imposed) if it finds that a contractor has repeatedly
failed
to meet substantive requirements in section 1903(m) or section 1932
of the
Social Security Act or 42 CFR 438.706. The State must also
grant enrollees the right to terminate enrollment without cause,
as
described in 42 CFR 438.702(a)(3), and must notify the affected enrollees
of their right to terminate
enrollment.
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ATTACHMENT
I - Page 14
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c)The
State may not delay imposition of temporary management to provide
a
hearing before imposing this
sanction.
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d)The
State may not terminate temporary management until it determines
that the
contractor can ensure that the sanctioned behavior will not
recur.
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3.Granting
enrollees the right to terminate enrollment without cause and notifying
affected enrollees of their right to
disenroll.
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4.Suspension
or limitation of all new enrollment, including default enrollment,
after
the effective date of the sanction.
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5.Suspension
of payment for beneficiaries enrolled after the effective date of
the
sanction and until CMS, the department, or the Agency is satisfied
that
the reason for imposition of the sanction no longer exists and is
not
likely to recur.
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6.Denial
of payments provided for under the contract for new enrollees when,
and
for so long as, payment for those enrollees is denied by CMS in accordance
with 42 CFR 438.730. Before imposing any intermediate
sanctions, the state must give the contractor timely notice according
to
42 CFR 438.710.
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7.Withholding
of three (3) percent of the next monthly capitation payment by the
Agency
pending receipt of the reports.
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1.21Additional
Applicable Laws and Regulations
In
addition to the requirements of Section I.B. of the Standard Contract, the
contractor agrees to comply with all applicable federal and state laws, rules
and regulations including but not limited to: Title 42 Code of
Federal Regulations (CFR) Chapter IV, Subchapter C; Chapters 409 and 641, F.S.;
42 CFR 431, Subpart F, Chapter 409.907(3)(d), F.S., and
Rule 59G-8.100 (24)(b), F.A.C. in regard to the contractor
safeguarding information about beneficiaries; Title VII of the Civil Rights
Act
of 1964 (42 USC 2000e) in regard to employees or applicants for employment;
Chapter 641, parts I and III, F.S., in regard to managed care; Medicare Medicaid
Fraud and Abuse Act of 1978; the federal omnibus budget reconciliation acts;
the
Newborns’ and Mothers’ Health Protection Act of 1996; and the Balanced Budget
Act of 1997. The contractor is subject to any changes in federal and
state law, rules, or regulations.
1.22Inspection
and Audit of Financial Records
The
state
and DHHS may inspect and audit any financial records of the contractor or its
providers. Pursuant to section 1903(m)(4)(A) of the Social Security
Act and State Medicaid Manual 2087.6(A-B), non-federally qualified contractors
must report to the state, upon request, and to the Secretary and the Inspector
General of DHHS, a description of certain transactions with parties of interest
as defined in section 1318(b) of the Social Security Act.
1.23Reporting
The
contractor is responsible for complying with all the reporting and monitoring
requirements in accordance with the contract. The department will provide the
contractor with the appropriate reporting formats, instructions, submission
timetables, and technical assistance when required. The department
reserves the right to modify the reporting and monitoring requirements to which
the contractor must adhere. Failure of the contractor to submit the
required reports accurately and within the time frames specified may result
in
sanction in accordance with Section 1.21.
ATTACHMENT
I - Page 15
1.24Fiscal
Intermediary
If
the
contractor utilizes a fiscal intermediary service organization as defined in
Chapter 641.316, F.S., such organization must be licensed to do business as
a
fiscal intermediary service organization in the state of
Florida. Such delegation does not relieve the contractor of
responsibility for the administration and management required under this
contract.
1.25Subcontracts
The
contractor is responsible for all work performed under this contract, but may,
with the written approval of the department, enter into subcontracts for the
performance of work required under this contract. All subcontracts and
amendments thereto executed by the contractor must meet the requirements listed
in this section. All model provider subcontracts must be approved, in writing,
by the department in advance of implementation and execution of subcontracts.
All subcontractors must be eligible for participation in the Medicaid program;
however, the subcontractor is not required to participate in the Medicaid
program as a provider. Subcontracts are required with all major
providers of services and there shall be no provisions prohibiting service
providers from contracting with other long-term care diversion contractors.
All
direct service providers are required to attend and complete Abuse, Neglect
& Exploitation Training. This training can be given by the department of
Children and Families, the local area agency on aging, the department, and
the
contractor or be accommodated through licensing requirements. The
contractor's training materials shall be approved, in advance, by the
department.
Pursuant
to 42 CFR 438.12(a)(1) if a contractor declines to include individual or groups
of providers in its network; it must give the affected providers written notice
of the reason for its decision. Pursuant to 42 CFR 438.12(b) this
section may not be construed to require the contractor to contract with
providers beyond the number necessary to meet the needs of its enrollees and
the
contract with department of Elder Affairs, preclude the contractor from using
different reimbursement amounts for different practitioners in the same
specialty; or preclude the contractor from establishing measures that are
designed to maintain quality of services and control costs and is consistent
with its responsibilities to the enrollee
In
all
contracts with health care professionals, the contractor must comply with the
requirements specified in 42 CFR 438.214 which includes but is not limited
to
selection and retention of providers, credentialing and re-credentialing
requirements, and nondiscrimination.
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A.Identification
of conditions and method of
payment:
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All
subcontract and amendments must meet the following requirements:
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1.The
contractor agrees to make payment to all providers pursuant to 42
CFR
447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5)
and
42 CFR 447.45(d)(6). If third party liability exists, payment
of claims must be determined in accordance with Section 1.11, Third
Party
Resources.
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2.Provide
for prompt submission of information needed to make
payment.
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3.Make
full disclosure of the method and amount of compensation or other
consideration to be received from the contractor. The provider must
not
charge for any service provided to the recipient at a rate in excess
of
the rates established by the contractor’s subcontract with the provider in
accordance with Section 1128B(d)(1), Social Security Act (enacted
by
Section 4704 of the Balanced Budget Act of 1997). The provider
may not ▇▇▇▇ the recipient any amount greater than would be owed
if the
entity provided the services
directly.
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ATTACHMENT
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4.Require
an adequate record system be maintained for recording services, charges,
dates and all other commonly accepted information elements for services
rendered to recipients under the
contract.
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5.Physician
incentive plans must comply with 42 CFR 417.479. The contractor
shall make no specific payment directly or indirectly under a physician
incentive plan to a physician or physician group as an inducement
to
reduce or limit medically necessary services furnished to an individual
enrollee. Incentive plans must not contain provisions that
provide incentives, monetary or otherwise, for the withholding of
medically necessary care. The contractor must disclose
information on provider incentive plans listed in 42 CFR 417.479(h)(1)
and
42 CFR 417.479(i) at the times indicated in 42 CFR
417.479(d)-(g). All such arrangements must be submitted to the
department for approval, in writing, prior to use. If any other
type of withhold arrangement currently exists, it must be omitted
from all
subcontracts.
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6.Specify
whether the contractor will assume full responsibility for third
party
collections in accordance with Section 1.11, Third Party
Resources.
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B.Provisions
for monitoring and inspections:
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1.Provide
that the department, Agency, and Department of Health and Human Services
(DHHS) may evaluate through inspection or other means the quality,
appropriateness and timeliness of services
performed.
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2.Provide
for inspections of any records pertinent to the contract by the
department, Agency, and DHHS.
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3.Require
that records be maintained for a period not less than five (5) years
from
the close of the contract and retained further if the records are
under
review or audit until the review or audit is complete. (Prior
approval for the disposition of records must be requested and approved
by
the provider if the subcontract is
continuous.)
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4.Provide
for monitoring and oversight by the contractor of the subcontractor
to
provide assurance that all licensed subcontractors are credentialed
in
accordance with Section 1.5.D.3, Credentialing
and
Re-credentialing Policies and
Procedures.
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5.Provide
for monitoring of services rendered to enrollees by the
subcontractor.
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C.Specification
of functions of the subcontractor:
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1.Identify
the population covered by the subcontract and the counties
served.
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2.Specify
the amount, duration and scope of services to be provided by the
subcontractor, including a requirement that the subcontractor continue
to
provide services through the term of the capitation period for which
the
Agency has paid the contractor.
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3.Provide
for timely access to appointments and
services.
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4.Provide
for submission of all reports and clinical information required by
the
contractor.
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5.Provide
for the participation in any internal and external quality improvement,
utilization review, peer review, and grievance procedures established
by
the contractor.
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6.Facility
and Home Health providers will provide notice to the contractor within
24
hours when an enrollee dies, leaves the facility, or moves to a new
residence.
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ATTACHMENT
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D.Protective
clauses:
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1.Require
safeguarding of information about enrollees in accordance with 42
CFR
438.224.
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2.Require
compliance with HIPAA privacy and security
provisions.
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3.Require
an exculpatory clause, which survives subcontract termination including
breach of subcontract due to insolvency, that assures the enrollees,
department, Agency, or DHHS may not be held liable for any debts
of the
subcontractor in accordance with 42 CFR 447.15. In addition, the
recipient
is not liable to the subcontractor for any services for which the
contractor is liable as specified in Section 641.3154,
F.S.
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4.Contain
a clause indemnifying, defending and holding the department, Agency,
DHHS,
and the contractor’s enrollees harmless from and against all claims,
damages, causes of action, costs or expense, including court costs
and
reasonable attorney fees arising from the subcontract
agreement. This clause must survive the termination of the
subcontract, including breach due to insolvency. The department
may waive this requirement for itself, but not the contractor’s enrollees,
for damages in excess of the statutory cap on damages for public
entities
if the subcontractor is a public health entity with statutory
immunity. The department must approve all such waivers in
writing.
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5.Require
that the subcontractor secure and maintain during the life of the
subcontract worker’s compensation insurance for all of its employees
connected with the work under this contract unless such employees
are
covered by the protection afforded by the contractor. Such
insurance must comply with the Florida’s Worker’s Compensation
Law.
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6.Pursuant
to Section 641.315(9), F.S., contain no provision that prohibits
a
physician from providing inpatient services in a contracted hospital
to an
enrollee if such services are determined by the organization to be
medically necessary and covered services under the organization’s contract
with the contract holder.
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7.Contain
no provision restricting the subcontractor’s ability to communicate
information to the subcontractor’s patient regarding medical care or
treatment options for the patient when the subcontractor deems knowledge
of such information by the patient to be in the best interest of
the
health of the patient.
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8.Pursuant
to Section 641.315(10), contain no provision requiring providers
to
contract for more than one long-term care product or otherwise be
excluded.
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9.Pursuant
to Section 641.315(6), F.S., contain no provision that in any way
prohibits or restricts the health care provider from entering into
a
commercial contract with any other
contractor.
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10.Specify
that if the subcontractor delegates or subcontracts any functions
of the
contractor, that the subcontract or delegation include all the
requirements of this section.
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11.Make
provisions for a waiver of those terms of the subcontract that, as
they
pertain to Medicaid recipients, are in conflict with the specifications
of
this contract.
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12.Specify
procedures and criteria for extension, renegotiation, and termination
of
the subcontract.
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13.Specify
that the contractor must give 60 days advance written notice to the
subcontractor, and department, before canceling the contract with
the
contractor for any reason.
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14.Provisions
for nonpayment for goods and services rendered by the subcontractor
to the
contractor is not a valid reason for avoiding the 60 day advance
notice of
cancellation pursuant to Section 641.315(2)(a)(2),
F.S.
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15.Pursuant
to Section 641.315(2)(b), F.S., specify that the contractor will
provide
60 days advance written notice to the subcontractor and the department
before canceling, without cause, the contract with the
subcontractor. However, in a case in which an enrollee’s health
is subject to imminent danger or a physician’s ability to practice
medicine is effectively impaired by an action by the Board of Medicine
or
other governmental agency, notification must be provided to the department
immediately.
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ATTACHMENT
I - Page 18
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E.The
contractor must not
discriminate with respect to participation, reimbursement,
or indemnification as to any
subcontractor who is acting within the scope of the provider’s license, or
certification under applicable state law, solely on the basis of
such
license, or certification, in accordance with Section 4704 of the
Balanced
Budget Act of 1997. This paragraph shall not be construed to
prohibit a contractor from including subcontractors only to the extent
necessary to meet the needs of the contractor’s enrollees or from
establishing any measure designed to maintain quality and control
costs
consistent with the responsibilities of the organization. If
the contractor declines to include individual subcontractors or groups
of
subcontractors in its network, it must give the affected subcontractors
written notice of thereason for
its
decision.
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If
the
contractor wishes to terminate a subcontract with an Assisted Living Facility
or
a Nursing Facility in which any of its project enrollees are currently residing,
written notice must be provided to the department at least ten (10) calendar
days prior to notifying the subcontractor of its intent to
terminate. This requirement is waived if the facility’s license has
been revoked or the department, in consultation with the Agency, waives the
notice period.
The
department may waive the use of the model subcontract and permit the contractor
to enter into a letter of agreement with certain facilities, licensed under
Chapter 400 and Chapter 429, F.S., and enrolled in the Medicare and Medicaid
programs, when it is determined by the department to be in the best interest
of
the enrollee(s) to do so. The letter of agreement shall contain
timeframe provisions for the facility. This exception does not apply
for initial network implementation.
In
accordance with 42 CFR 438.206(b)(4), if the network is unable to provide
necessary services, covered under the contract to a particular enrollee, the
contractor must adequately and timely cover these services out of the network
for the enrollee, for as long as the contractor is unable to provide them within
the network.
In
accordance with 42 CFR 438.206(b)(5), out-of-network subcontractors are required
to coordinate with the contractor with respect to payment to ensure that costs
to the enrollee is no greater than it would be if the services were furnished
within the network.
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▇.▇▇▇▇▇▇▇
Expansion
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The
contractor may expand into new service areas approved by CMS, by providing
the
following information to the plan analyst: letter of expansion
request, copies of the first page and signature page of the executed
subcontracts, applicable licenses, completed provider network template
(electronic and hard copy), and for contractors licensed as a HMO, a copy of
the
health care provider certificate for the requested service area.
ATTACHMENT
I - Page 19
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1.26Subcontractor
Termination
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The
contractor must make a good faith effort to give written notification of a
contracted provider termination
to each enrollee who has been seen by the terminated provider on a regular
basis
within 15 days after receipt or issuance of the termination notice.
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1.27Termination
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▇.▇▇
conjunction with the Standard Contract, Part IV, section B, titled
“Termination” upon termination, procedures to ensure services to consumers
will not be interrupted or suspended by the termination are required
(Termination Plan). Such termination plan must be approved by the
department and Agency prior to notice of termination, and must provide
for
an efficient and timely transfer and/or relocation of all
enrollees.
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B.
The party initiating the termination must render written notice of
termination to the department by certified mail, return receipt requested,
or in person. The notice of termination required by Part IV,
Section B of the Standard Contract must specify the nature of termination,
the extent to which performance of work under the contract is terminated,
the date on which such termination shall become effective, and the
terms
of the Termination Plan. In accordance with section 1932(e)(4),
Social Security Act, the department and Agency shall provide the
contractor with an opportunity for a hearing prior to termination
for
cause.
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▇.▇▇
the event of a notice of termination and unless a written waiver
is
executed by the department or Agency, the contractor
must:
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1.Continue
performance under the terms of the contract until the termination
date.
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2.Immediately
cease enrollment of new enrollees under the
contract.
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3.Immediately
perform the duties as specified in the approved Termination
Plan.
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4.Assign
to the State those subcontracts as directed by the department’s
contracting officer including all the rights, title and interest
of the
contractor for performance of those
contracts.
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▇.▇▇
least 60 calendar days prior to the effective date of the termination,
provide written notification to all enrollees of the date on which
the
contractor will no longer participate in the State’s Medicaid program and
instructions on how to contact the department’s CARES office for
information on their long-term care
options.
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6.Take
such action as may be necessary, or as the department, in consultation
with the Agency may direct, to protect property related to the contract,
which is in the possession of the provider, and in which the department
and Agency have or may acquire an
interest.
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7.Decline
any prepaid payments for requests for payment submitted after the
contract
ends. Any payments due under the terms of the contract may be
withheld until the department receives from the contractor all documents
as required by the written instructions of the
department.
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8.Continue
to serve or arrange for provision of services to the enrollees pursuant
to
the contract on a fee-for-service basis for up to 45 days from the
notification of termination date.
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▇.▇▇
the event the department has terminated this contract in only one
or more
counties of the state, complete the performance of this contract
in all
other areas in which the contractor’s duties have not been
terminated.
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ATTACHMENT
I - Page 20
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1.28Assignment
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A.Except
as provided below or with the prior written approval of the department,
which approval will not be unreasonably withheld, the contract and
the
monies which may become due are not to be assigned, transferred,
pledged
or hypothecated in any way by the
contractor, including by way of an asset or stock purchase of the
contractor and will not be subject to execution, attachment or similar
process by the contractor.
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B.Exceptions
for HMOs licensed under Chapter 641, F.S., are as
follows:
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▇.▇▇
provided by Chapter 409.912(20), F.S., when a merger or acquisition
of a
contractor has been approved by the Office of Insurance Regulation
pursuant to Chapter 628.4615, F.S., the Office of Insurance Regulation
shall approve the assignment or transfer of the appropriate Medicaid
HMO
contract upon the request of the surviving entity of the merger or
acquisition if the contractor and the surviving entity have been
in good
standing with the department and Agency for the most recent 12 month
period, unless the department determines that the assignment or transfer
would be detrimental to the Medicaid recipients or the Medicaid
program.
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▇.▇▇
be in good standing, a contractor must not have failed accreditation
or
committed any material violation of the requirements of Chapter 641.52,
F.S., and must meet the requirements in this
contract.
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3.For
the purposes of this section, a merger or acquisition means a change
in
controlling interest of a contractor, including an asset or stock
purchase.
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C.Exceptions
for Other Qualified Providers licensed under Chapter 400 or Chapter
429,
F.S., are as follows:
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In
determining whether to approve an assignment, the department will consider
whether the contractor and the surviving entity have been in good standing
with
the department and Agency for the most recent 12 month period and will not
approve an assignment or transfer that would be detrimental to the project
enrollees or the Medicaid program.
SECTION
2 Recipient Eligibility to Participate in the
Project
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2.1Eligibility
Requirements
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Recipients
eligible for project enrollment must be:
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A.65
years of age or older.
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B.Has
Medicare Parts A & B as reflected in the Florida Medicaid Management
Information System (FMMIS) through the Medicaid Eligibility Verification
System (MEVS).
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C.Medicaid
eligible with incomes up to the Institutional Care Program level
(ICP).
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D.Reside
in the project service
area.
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E.Determined
by CARES to be at risk of nursing home placement and meet one or
more of
the following clinical criteria:
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1.Require
some help with five or more activities of daily living (ADLs);
or
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2.Require
some help with four ADLs plus requiring supervision or administration
of
medication; or
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3.Require
total help with two or more ADLs;
or
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4.Have
a diagnosis of Alzheimer’s disease or another type of dementia and require
assistance or supervision with three or more ADLs;
or
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5.Have
a diagnosis of a degenerative or chronic condition requiring daily
nursing
services.
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ATTACHMENT
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F.Determined
by CARES to be a person who, on the effective date of enrollment,
can be
safely served with home and community-based
services.
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2.2Eligibility
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A.The
Florida department of Children and Families (DCF) and the federal
Social
Security Administration determine a person’s financial and categorical
Medicaid eligibility. Financial eligibility for the project
will be up to the Medicaid Institutional Care Program (ICP) income
and
asset level.
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B.The
department’s CARES program determines a person’s clinical eligibility for
the project.
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C.The
contractor shall assist enrollees to ensure continuous eligibility
in the
program. This includes financial and clinical eligibility as part
of the
case management responsibilities and a systematic process for tracking
the
eligibility redetermination dates on a monthly
basis.
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D.Enrollees
who lose eligibility and then regain eligibility within 60 days,
are
automatically reinstated to the contractor during the next enrollment
cycle. This possible 60 day period is considered a break in
service. The enrollee’s enrollment eligibility in the plan will remain the
same as if they never left the plan. The Medicaid fiscal agent will
produce two reinstatement reports – one during the monthly enrollment
cycle and another the first business day of the month by 12:00
p.m.
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E.Enrollees
who lose eligibility between the second to the last Saturday and
the end
of the month will be placed on the Supplemental HMO Disenrollment
Report. The Medicaid fiscal agent produces this report on the
first business day of the month by 12:00
p.m.
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2.3Persons
Not Eligible for
Enrollment
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A.Persons
residing outside the project service
area.
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B.Persons
residing in a state hospital, intermediate care facility for persons
with
developmental disabilities, or a correctional
institution.
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C.Persons
participating in or enrolled in another Medicaid waiver
project.
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D.Medicaid
eligible recipients who are served by the Florida Assertive Community
Treatment Team (FACT team).
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E.Persons
enrolled in any other Medicaid capitated long-term care program or
in a
Medicaid HMO or MediPass program.
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2.4Optional
State Supplementation
(OSS)
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A.The
contractor shall inform and assist enrollees who qualify under Chapter
409.212, F.S., with an application for OSS services. OSS is
general revenue cash assistance program. The purpose of the
program is to supplement the enrollees’ income to help pay the cost in an
assisted living facility.
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B.The
local Department of Children & Families Economic Self-Sufficiency
office or Audit Payments Unit will supply the contractor with the
forms
and income qualifications.
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ATTACHMENT
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SECTION
3 Educational materials and Choice Counseling
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3.1Educational
Materials
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A.The
contractor may not market to prospective enrollees
face-to-face.
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B.The
contractor may use mass marketing strategies, approved by the department,
to communicate information regarding the project to prospective
enrollees.
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C.All
materials including, but not limited to print and media for potential
and
current enrollees shall be approved by the
department.
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3.2Choice
Counseling
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A.CARES
staff will provide prospective enrollees with information regarding
their
Medicaid long- term care options. These options may
include: enrolling in the project, participating in another
Medicaid home and community-based services waiver program, placement
in a
nursing home, or declining long-term care
assistance.
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B.CARES
staff will also perform a choice counseling function for the
project. The choice counseling function includes providing the
prospective enrollee with contractor prepared, and department approved,
educational materials, and explaining the
following:
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1.The
concept of managed care and the integrated delivery of acute and
long-term
care.
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2.The
advantages to the enrollees of the integration and coordination of
acute
and long-term care.
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3.The
qualifications for enrollment in the
project.
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4.That
the enrollee has the right to choose any available contractor in
the
service area and may change contractors if the enrollee is not satisfied
with his/her initial choice.
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5.The
benefits provided under the
project.
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6.Pursuant
to 42 CFR 438.10(g)(3), the contractor shall provide information
on the
contractor’s physician incentive plans or on the contractor’s structure
and operation to any Medicaid recipient, upon
request.
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3.3Prohibited
Activities
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▇.▇▇
accordance with 42 CFR 438.104(b)(1)(iv), the entity does not seek
to
influence enrollment in conjunction with the sale or offering of
any
private insurance.
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▇.▇▇
accordance with 42 CFR 438.104(b)(1)(v), the entity does not, directly
or
indirectly, engage in door-to-door, telephone, or other cold-call
marketing activities.
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▇.▇▇
accordance with 42 CFR 438.104(b)(2)(i), the entity does not make
any
assertion or statement (whether written or oral) that the beneficiary
must
enroll with the contractor in order to obtain benefits (Medicaid
State
Plan benefits) or in order to not lose benefits (Medicaid State Plan
benefits).
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▇.▇▇
accordance with Section 409.912(21)(b), F.S., and 42 CFR
438.104(b)(2)(ii), entity does not make any inaccurate false or misleading
claims that the entity is recommended or endorsed by any federal,
state or
county government, the Agency, CMS, department, or any other organization
which has not certified its endorsement in writing to the
contractor.
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ATTACHMENT
I - Page 23
SECTION
4 ENROLLMENT AND DISENROLLMENT
4.1 Enrollment
Procedures
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A.When
a person is determined to be both financially and clinically eligible
and
chooses to enroll in the Long-Term Care Community Diversion Program,
CARES
staff will complete a CARES referral package. CARES staff will
forward the CARES referral package, with the date of enrollment,
to the
contractor.
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B.Upon
receipt, the contractor will log in and date stamp the CARES referral
package.
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C.The
contractor will forward the enrollment information to the Medicaid
fiscal
agent in the HIPAA approved format. This information must be
transmitted to the fiscal agent by the monthly reporting deadline
(usually
the Wednesday preceding the next to last Saturday of the month) in
order
to be effective for the subsequent
month.
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D.The
contractor is responsible to check monthly Medicaid eligibility through
the Medicaid Eligibility Verification System (MEVS). This
includes the following:
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1.Recipient
address is located in the same county as the contractor’s provider service
area
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2.Recipient
program codes (should be MS, MMS, or
MWA)
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3.Residing
in a nursing home
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4.Current
enrollment in a Medicaid HMO
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5.Current
enrollment in the MediPass Program
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6.Has
presence of Medicare Parts A &
B
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If
a
recipient does not have Medicare Parts A & B on MEVS, then the recipient is
not eligible for the program. Once the presence of Medicare Parts A & B is
on MEVS, then the recipient can be submitted for electronic
enrollment.
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E.The
contractor shall not deny enrollment to reinstated
enrollees.
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F.The
contractor accepts individuals eligible for enrollment in the order
in
which they are received from CARES without restriction (unless authorized
by the CMS Regional Administrator), up to the limits set under the
contract (if applicable). The contractor will not discriminate
against individuals eligible to enroll on the basis of race, color,
or
national origin, and will not use any policy or practice that has
the
effect of discriminating on any basis including but not limited to
race,
color, or national origin.
|
4.2 Effective
Date of Enrollment
Enrollment
is effective at 12:01 a.m. on the first day of the calendar month that the
enrollee’s name appears on the report for payment issued by the Medicaid fiscal
agent. Enrollment is in whole months. Retroactive
disenrollment will be considered by the Agency, in consultation with the
department for those enrollees who have moved out of the service area into
an
area where the contracted services are unavailable, deceased enrollees prior
to
the initial enrollment effective date, and potential enrollees who decided
to
remain in the skilled nursing facility for long term care prior to the initial
enrollment effective date.
4.3
Transition Care Planning
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|
A.Transition
care services are those services necessary in order to safely maintain
a
person in the community both prior to and after the effective date
of
their enrollment in the project up until the time the Plan of Care
is
implemented. For recipients who are transferring from another home
and
community based service waiver program, the contractor shall ensure
continuation of needed services during the transition
phase.
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B.CARES
staff will notify the contractor, the lead agency, and when appropriate,
hospital discharge planning staff regarding the need for a transition
care
plan. CARES staff will forward, to each of these entities, any information
collected during the clinical eligibility determination process related
to
the person’s health status, functional status, caregiver, social support
system, living environment and how current service needs are being
met.
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▇.▇▇
the first date of enrollment, (1) the contractor must provide transition
care services in collaboration with CARES staff and (2) assume
responsibility for meeting the enrollee’s care needs. The
contractor must ensure that enrollment in the project does not interrupt
or delay the delivery of services needed by the
enrollee.
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ATTACHMENT
I - Page 24
4.4 Orientation
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A.Prior
to or upon enrollment the contractor must provide each new enrollee
or
their representative with a written notice of the effective date
of
enrollment, a plan ID card which includes the contractor’s name, address,
the member services telephone number, an enrollee handbook, and a
provider
directory.
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B.The
contractor must complete face-to-face project orientation within
five (5)
business days of enrollment for those enrollees in a community setting
(document any exceptions beyond this timeframe). The contractor must
complete face-to-face project orientation within 7 business days
of
enrollment for those enrollees residing in a
facility.
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C.The
enrollee handbook must be written so it can be read and understood
by the
enrollees or their representatives at or below an eighth grade reading
level. The following items must be
included:
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1.Terms
and conditions of enrollment including the reinstatement
process.
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2.An
explanation of the role of the case
manager.
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3.Procedures
for obtaining required and/or covered services, including second
opinions
in accordance with Section 641.51 (5)(c), F.S., and 42 CFR
438.206(b)(3).
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4.The
toll-free telephone number of the Agency for Health Care Administration
Consumer Hotline (▇▇▇) ▇▇▇-▇▇▇▇.
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5.The
toll-free telephone number of the statewide Abuse Hotline (800) 96ABUSE
or
(▇▇▇) ▇▇▇ ▇▇▇▇.
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6.Instructions
on how enrollees obtain access to the services included in their
care
plans.
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7.The
consequences of obtaining care from out-of-network
providers.
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8.Information
regarding the enrollee’s right to disenroll at any time and instructions
to initiate the disenrollment process. Information must explain
that if voluntary disenrollment is requested prior to the fiscal
agent’s
monthly processing deadline, disenrollment will be effective the
first of
the following month.
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9.Information
regarding the enrollee’s rights and
responsibilities.
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10.Grievance
and appeals process.
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11.Information
regarding the confidentiality of enrollee
records.
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12.Notification
to the enrollee that the following items are available to them upon
request:
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a)A
detailed description of the contractor’s authorization and referral
process for services.
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b)A
detailed description of the contractor’s process used to determine whether
services are medically necessary.
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c)A
detailed description of the contractor’s quality assurance
program.
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d)A
detailed description of the contractor’s credentialing
process.
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ATTACHMENT
I - Page 25
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e)The
policies and procedures
relating to the contractor’s prescription drug benefits
program.
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f)The
policies and procedures relating to the confidentiality and disclosure
of
the enrollee’s medical records.
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g)Information
that enrollees may obtain from the contractor regarding quality
performance indicators, including aggregate enrollee satisfaction
data.
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13.Information
that interpretation services for all foreign languages and alternative
communication systems are available, free of charge and how to access
these services.
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14.Information
that post-stabilization services are provided without prior authorization
and other post-stabilization care services rules set forth in 42
CFR
422.113(c).
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15.Information
that services will continue upon appeal of a suspended authorization
and
that the enrollee may have to pay in case of an adverse
ruling.
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16.Information
regarding the health care advanced directives pursuant to Chapter
765,
F.S.. Written information regarding advance directives provided by
the
contractor must reflect changes in state law as soon as possible,
but no
later than 90 days after the effective date of the
change.
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17.The
contractor will provide enrollee information in accordance with 42
CFR
438.10(f). In accordance with 42 CFR 438.10(f)(2), the contractor
must
notify enrollees at least on an annual basis of their right to request
and
obtain information.
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D.The
provider directory must list the providers sorted by county and then
by
service, and contain the following:
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1.Provider
name
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|
2.Service(s)
provided
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3.Provider
location
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4.Provider
telephone number
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E.The
contractor shall assure that appropriate non-English language versions
of
all materials are developed and available to members and potential
members. The contractor shall provide interpreter services in
person where practical, but otherwise by telephone, for applicants
or
members whose primary language is not English. Non-English
versions of materials are required if, as provided annually by the
Agency,
the population speaking a
non-English language in a county is greater than five (5)
percent.
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F.All
materials including, but not limited to print and media for potential
and
current enrollees shall be approved by the
department.
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4.5 Plan
of Care
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|
A.The
contractor is required to develop an individualized written plan
of care,
in a format approved by the department, for every new enrollee within
five
(5) business days of the effective date of enrollment for those enrollees
in a community setting (document any exceptions beyond this timeframe).
The contractor must develop an individualized written plan of care,
in a
format approved by the department within seven (7) business days
of
enrollment for those enrollees residing in a
facility.
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|
B.This
does not relieve the contractor of it’s obligation as set forth in Section
4.3 of Attachment I to this
contract.
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|
▇.▇▇▇▇▇▇▇▇
included in the plan of care will be determined by the contractor
in
conjunction with the initial assessment information provided by the
CARES
office, in consultation with the enrollee or their representative
and be
necessary to address all health and social service needs of the enrollee
identified through an assessment.
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|
D.The
plan of care must be based on a comprehensive assessment of the enrollee’s
health status, physical and cognitive functioning, environment, social
supports, and end-of-life decisions. The plan of care must
clearly identify barriers to the enrollee and caregivers, if
applicable. The case manager must discuss barriers and explore
potential solutions with the enrollee, and caregivers when
applicable. The plan of care must detail all interventions
designed to address specific barriers to independent
functioning. The plan may include services provided through the
enrollee’s own informal network or by volunteers from community social
service agencies or other organizations such as churches and
synagogues.
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ATTACHMENT
I - Page 26
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|
E.The
Plan of Care summary given to the enrollee or the enrollee’s caregiver
must include at minimum the following components as specified in
42CFR
441.351(f):
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|
a.The
enrollee’s name
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|
|
b.The
enrollee’s Medicaid ID number
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|
|
c.Plan
of Care effective date
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|
d.Plan
of care review date
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e.Covered
services provided including routine medical and HCBS
services
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f.Begin
date and end date
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g.Providers
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h.Amount
and frequency
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▇.▇▇▇▇
manager’s signature
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j.Enrollee
or the enrollee’s authorized representative’s signature and
date
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▇.▇▇
developing the plan of care, the contractor
must:
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|
|
1.Assess
the immediacy of the new enrollee’s services needs and include a
description of the project participant’s condition (e.g., ADL
and IADL limitations, incontinence, cognitive impairment, arthritis,
high
blood pressure), as identified through an appropriate comprehensive
assessment and a medical history
review.
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|
2.Identify
any existing care plans and service providers and assess the adequacy
of
current services.
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|
3.Provide
for continuous care to the new enrollee if the enrollee is receiving
active treatment prior to the effective date of
enrollment.
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|
4.Pursuant
to 42 CFR 438.208(c)(3) and (c)(4), the contractor must produce a
plan
of
care that addresses the health, social service, and special health
care
needs of the enrollee identified through an assessment. The
plan of care must be:
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|
|
a)Developed
by the enrollee’s primary care provider with enrollee participation, and
in consultation with any specialists caring for the
enrollee.
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|
b)Approved
by the managed care provider in a timely manner, if the managed care
provider requires an approval.
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c)In
accordance with any applicable state quality assurance and utilization
review standards.
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|
5.Ensure
that the care plan contains, at a minimum, information about the
enrollee’s medical condition, the type of services to be furnished, the
amount, frequency and duration of each service, and the type of provider
to furnish each service.
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|
6.Ensure
that treatment interventions address identified problems, needs,
and
conditions. In consultation with the enrollee and, as
appropriate, the enrollee’s representative or caregiver, the plan of care
must specify the long-term care service interventions, and when such
services are the responsibility of the contractor, the medical
interventions for the enrollee.
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ATTACHMENT
I - Page 27
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|
7.Ensure
that review of the care plan is performed through face-to-face contact
with the enrollee at least every ninety days to determine the
appropriateness and adequacy of services and to ensure that the services
furnished are consistent with the nature and severity of the enrollee’s
needs.
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|
|
8.Ensure
that the care plan is reviewed sooner than the minimum required time
frame
if in the opinion of any person or person(s) involved in the care
of the
enrollee there is reason to believe significant changes have occurred
in
the enrollee’s condition or in the services the enrollee receives, or an
enrollee or an enrollee’s representative requests another review due to
the changes in the enrollee’s physical or mental
condition.
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|
|
9.Ensure
the maintenance or creation of an enrollee’s informal network of
caregivers and services providers. Primary caregivers, family,
neighbors and other volunteers will be integrated into an enrollee’s plan
of care when it is determined through multi-disciplinary assessment
and
care planning that these services would improve the enrollee’s capability
to live safely in the home setting and are agreed to by the
enrollee.
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|
10.Implement
a systematic process for determining whether enrollees have advance
directives, health care powers of attorney, do not resuscitate orders,
or
a legally appointed guardian if applicable. This information
will become part of the enrollee’s medical record and these orders and
preferences will be integrated into the care coordination
process. The contractor shall include a copy of the enrollee’s
health care powers of attorney or the legally appointed guardian
documents
in the enrollee’s file. The contractor will discuss with the
enrollee the importance of the need for advance directives and do
not
resuscitate orders and note the enrollee’s response in the case
file.
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G.A
copy of the plan of care must be forwarded to the enrollee’s primary care
physician.
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H.A
copy of the plan of care must be forwarded to the department’s CARES
office within 30 days of
development.
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I.Revisions
to the plan of care must be done in consultation with the enrollee,
the
caregiver, and when feasible, the primary care physician. If
the primary care physician is not under contract with the contractor
to
deliver services to the enrollee, an effort must be made by the case
manager to obtain physicians input regarding plan of care
revisions. Changes in service provision resulting from a plan
of care review must be implemented within five (5) business days
of the
review date.
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|
J.The
contractor will send a Form 2515 to the local CARES office and DCF
informing them of any changes in an enrollee’s
address.
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4.6 Integration
of Care
|
|
A.Project
case managers are responsible for long-term care planning and at
least
annual assessments, for developing and carrying out strategies to
coordinate and integrate the delivery of all acute and long-term
care
services to enrollees.
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|
B.For
those persons enrolled in the contractor’s Medicare Advantage plan (where
applicable), the contractor must have protocols to ensure that all
acute
care services and long-term care services are coordinated. The
enrollee’s case manager must coordinate with the primary care physician,
as well as the enrollee or other appropriate person, in the development
of
acute and long-term care plans. The contractor must ensure that
all subcontractors, delivering services covered by the contract,
agree to
cooperate with the goal of an integrated and coordinated service
delivery
system for the enrollee.
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C.When
contract enrollees elect to remain in the Medicare fee-for-service
system,
the contractor must establish protocols to ensure that services are
coordinated to the maximum extent feasible. The case manager must
actively
pursue coordination with the enrollee’s primary care physician and other
care providers.
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|
▇.▇▇
addition, the contractor will be responsible for the following activities
to facilitate care coordination and continuity of
care:
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ATTACHMENT
I - Page 28
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|
1.The
contractor must implement a systematic process for generating or
receiving
referrals and with the enrollee’s written consent, sharing clinical and
treatment plan information, including management of
medications.
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|
|
2.The
contractor must implement a systematic process for obtaining consent
from
enrollees or their representatives to share confidential medical
and
treatment planning information with
providers.
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|
|
3.The
contractor must implement a systematic process for coordinating care
with
organizations which are not part of the contractor’s network of providers
but are otherwise important to the health and well being of
enrollees.
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4.For
enrollees in an assisted living or nursing facility, the contractor
will
ensure coordination with the medical, nursing, or administrative
staff
designated by the facility to ensure that the enrollees have timely
and
appropriate access to the contractor’s providers and to coordinate care
between those providers and the facility’s
providers.
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5.The
contractor must implement a systematic process for tracking the Medicaid
eligibility redetermination dates on a monthly basis to ensure continuity
of care without a break in
eligibility.
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|
|
E.Pursuant
to 42 CFR 438.208(b), the contractor must implement procedures to
coordinate health care service for all enrollees
that:
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|
|
1.Ensure
each enrollee has an ongoing source of primary care appropriate to
his/her
needs and a person or entity formally designated as primarily responsible
for coordinating the health care services furnished to the
enrollee.
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|
2.Coordinate
the services the contractor furnishes to the enrollee with services
the
enrollee receives from any other managed care entity during the same
period of enrollment.
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3.Share
with other managed care organizations serving the enrollee with special
health care needs the results of its identification and assessment
of the
enrollee's needs to prevent duplication of those
activities.
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|
4.Ensure
in the process of coordinating care, each enrollee's privacy is protected
in accordance with the privacy requirements in 45 CFR Part 160 and
164
Subparts A
and E, to the extent that they are
applicable.
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4.7 Disenrollment
|
|
A.Enrollees
must be allowed to voluntarily disenroll at any time. If voluntary
disenrollment is requested prior to the fiscal agent’s monthly processing
deadline, disenrollment will be effective the first of the following
month. If voluntary disenrollment is requested after the fiscal
agent’s monthly processing deadline, disenrollment will not take place
until the first of the month subsequent to the next
month.
|
|
|
B.The
contractor must ensure that it does not restrict the enrollee's right
to
voluntarily disenroll in any way, and that it does not deter the
enrollee’s contact with the State. Disenrollment shall be in
accordance with 42 CFR 438.56(b)(3) and
(d)(3).
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C.Immediately
upon receiving a voluntary request for disenrollment, the contractor
must
inform the enrollee of disenrollment
procedures.
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|
|
D.The
contractor must make
disenrollment assistance available during business hours. This assistance
must be available through a toll-free telephone number or face-to-face
contact. The contractor’s written disenrollment procedure must list the
staff responsible for this type of
assistance.
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|
|
E.The
contractor must keep a daily log of all verbal and written disenrollment
requests and the disposition of such requests. The contractor
must ensure that disenrollment request logs are maintained in an
identifiable manner, and enrollees who wish to file a grievance are
afforded appropriate notice and opportunity to do
so.
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ATTACHMENT
I - Page 29
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|
F.The
contractor shall assure that appropriate non-English language versions
of
all disenrollment materials are developed and available to
members. The contractor shall provide interpreter services in
person where practical, but otherwise by telephone, for members whose
primary language is not English. Non-English language versions
of disenrollment materials are required if, as provided annually
by the
Agency, the population speaking a particular non-English language
in a
county is greater than five (5)
percent.
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G.Involuntary
disenrollments are limited to the following
reasons:
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|
|
1.Enrollee
death.
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|
|
2.Ineligibility
for Medicaid.
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|
3.Ineligibility
for the project.
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|
4.Moving
outside the project’s service area.
|
|
|
5.Fraudulent
use of the enrollee’s Medicaid ID
card.
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|
|
6.Incarceration.
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|
|
7.Non-cooperation,
subject to department approval.
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|
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H.After
providing at least one verbal and at least one written warning of
the full
implications of failure to follow a recommended plan of care, the
contractor may submit an involuntary disenrollment request to the
department for an enrollee who continues not to comply. The
department may approve such a request provided that a written explanation
of reason for disenrollment is given to the enrollee prior to the
effective date and provided that the enrollee’s actions are not related to
the enrollee’s medical or mental condition. Enrollees must be
given a reasonable opportunity to comply with the plan of care subsequent
to each verbal and written warning before disenrollment is made effective
except in instances where the enrollee’s actions threaten the health,
safety, or well being of service providers or contractor’s staff or
representatives. Enrollees who are disenrolled through this
section are not eligible for re-enrollment without the permission
of the
contractor.
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I.The
contractor may also submit an involuntary disenrollment request for
an
enrollee whose behavior is disruptive, unruly, abusive, or uncooperative
to the extent that his or her
enrollment with the contractor seriously impairs the contractor’s ability
to furnish services to either the enrollee or other
enrollees. The contractor must provide at least one verbal and
one written warning to the enrollee regarding the implications of
his or
her actions. A written explanation of the reason for
disenrollment must be given to the enrollee prior to submitting the
disenrollment request. The department will approve, such
requests in writing, provided the contractor has documented the actions
described above and the enrollee’s actions are not related to the
enrollee’s medical or mental condition, involuntary disenrollment
documents are maintained in an identifiable enrollee record, and
enrollees
who are disenrolled through this action are not eligible for re-enrollment
without the permission of the contractor. The contractor shall
be prohibited from requesting a disenrollment based on a change in
the
enrollee’s health status pursuant 42 CFR
438.56(b)(2). Involuntary disenrollments without the
department’s consent will be considered an express or intentional
violation of the contract. Repeated occurrences will be
considered a cause for termination as specified in Section
1.28.
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|
|
J.Disenrollment
request forms must be completed in their entirety whether completed
by the
contractor or the enrollee, , and submitted on DOEA Form LTCD-002,
Exhibit
G.
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ATTACHMENT
I - Page 30
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K.All
disenrollments, including those subject to prior approval, shall
be
completed through the submission of the HIPAA approved format to
the
Medicaid fiscal agent.
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L.The
contractor must provide disenrollment data via the HIPAA approved
format
on the first available transmission to the Medicaid fiscal agent
after the
date of receipt of the disenrollment request. In no event will
the contractor submit a disenrollment with an effective date later
than 49
calendar days after the contractor’s receipt of a voluntary disenrollment
request.
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|
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M.A
copy
of the disenrollment form will be sent to the CARES office within
48 hours
of receipt and a copy will be placed in the contractor’s case management
file.
|
4.8
Disputes of Appropriate Enrollments
Disputes
relating to the appropriateness of enrollments authorized by CARES staff
pursuant to section 2.1 of Attachment I to this contract, will be decided by
the
department in consultation with the Agency. This provision excludes
matters brought forth by enrollees. The department must reduce its
decision to writing and serve a copy on the contractor. The decision
of the department will be final and conclusive.
4.9 Medicaid
Pending
|
|
A.Section
430.705(5), F.S., designates Medicaid Pending as individuals who
apply for
the Long-Term Care Community Diversion Pilot Project and are determined
medically eligible by CARES, but have not been determined financially
eligible for Medicaid by the Department of Children and Families
(DCF).
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|
|
B.Individuals
will be offered the option to receive services under the Medicaid
Pending
initiative.
|
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|
▇.▇▇▇▇▇▇▇▇▇▇▇
may elect to provide the Medicaid Pending option by completing and
returning Attachment Number IV to the
department.
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D.CARES
staff will refer individuals identified as Medicaid Pending, and
who
choose to receive Medicaid Pending services, to the chosen
contractor. Included with the referral will be the Freedom of
Choice ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇ ▇▇▇▇, ▇▇▇▇, and Informed
Consent.
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E.If
individuals are determined financially eligible by DCF, the contractor
will be reimbursed a capitated rate for services rendered retroactive
to
the first of the month following the CARES medical eligibility
determination.
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F.If
the individual is not financially eligible for Medicaid as determined
by
DCF, the contractor may terminate services and seek reimbursement
from the
individual. The contractor may seek reimbursement from the individual
in
accordance with the Medicaid Coverage and Limitations Handbooks and
the
associated fee schedules.
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G.The
contractor will assist Medicaid Pending individuals in submitting
the
ACCESS Florida Application (on-line or hard
copy)(▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇) to
DCF. Additionally, the contractor must forward, at a minimum,
the following documentation to DCF: Financial Release (CF FS
2613, Notification of Level of Care (DOEA-CARES 603), and the
Certification of Enrollment Status (HCBS)(CF-AA
2515).
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|
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H.Once
the individual is determined financially eligible, the contractor
must
notify CARES and provide a copy of the Notice of Case Action or
verification of Medicaid eligibility within two (2) business days
of
receipt.
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I.The
contractor will submit 834 enrollment transactions for the Medicaid
Pending individuals to the Medicaid fiscal agent one week prior to
the
monthly submission date. Additionally, the Florida Medicaid
Management Information System (FMMIS) is designed to process the
enrollment date retroactive up to a maximum of four (4) months prior
to
the first of the month following the CARES eligibility
determination. If circumstances require a determination of
Medicaid eligibility by DCF for a Medicaid Pending individual that
exceeds
four months, the request for enrollment must be submitted via the
manual
enrollment process.
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ATTACHMENT
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SECTION
5 Enrollee Records
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A.The
contractor is responsible for a complete long-term care record for
each
enrollee.
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B.The
contractor must use procedures that promote the development of a
centralized, comprehensive medical and long-term care record for
enrollees. The contractor must ensure, with written consent of
the enrollee or their representative, all providers involved in the
enrollee’s care have access to the enrollee’s record for the purpose of
providing care.
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C.The
contractor must maintain an enrollee records system, which is consistent
with professional standards and permits the prompt retrieval of
information. Each record must include timely and accurately
documented information and must be readily available to all appropriate
and authorized practitioners involved in the integration and coordination
of care.
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D.The
contractor will ensure all subcontracted providers, including medical
specialists and long-term care providers, properly document the care
provided to enrollees including, diagnoses, medications, and treatment
plans.
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E.The
contractor will ensure enrollee record information is accessible
only to
authorized persons in accordance with written consent or an executed
authorization granted by the enrollee or the enrollee’s representative and
with all applicable federal and state laws, rules and
regulations.
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F.The
contractor must disclose enrollee records, including enrollee and
caregiver identifying information, to the department and Agency.
It is the
department and Agency’s obligation to oversee the performance or to
conduct assessment, investigation, or evaluation of this
contract. Not withstanding provisions to the contrary, release
of material to the department and Agency will not be construed as
public
disclosure of confidential
information.
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G.All
records must contain documentation that the member was provided written
information concerning the member’s rights regarding advanced directives,
and whether or not the member has executed an advance
directive. The contractor shall not, as a condition of
treatment, require the member to execute or waive an advance directive
in
accordance with Section 765.110, F.S. The contractor must
comply with the requirements of 42 CFR 422.128 for maintaining written
policies and procedures for advance
directives.
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SECTION
6 SERVICE PROVISIONS
General
Provisions
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A.The
contractor must bear the underwriting risk of all services covered
under
this contract. The contractor shall establish and maintain a
network in conformance with 42 CFR
438.206(b).
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are to be provided in accordance with an individualized plan of
care. The plan of care is developed by the contractor in
consultation with the enrollee and must include those services that
are
determined through assessment to be necessary to address the health
and
social service needs of the
enrollee.
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ATTACHMENT
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C.The
contractor must directly provide case management services as listed
in
Section 6.2.
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D.The
contractor may provide services beyond those required in this contract
providing such services are safe, legal, medically prudent, and provided
equally to any enrollee with similar needs without
discrimination. Such extra contractual services must be paid
from program cost savings and may not be included in encounter data
as
reported under Section 11.4.
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E.The
contractor must not require any co-payment or cost sharing from the
enrollees except where the Florida Department of Children and Families
has
assessed a patient responsibility amount for financial contributions
by
the enrollee toward nursing facility and assisted living
services.
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F.The
contractor must not allow enrollees to be charged for missed
appointments.
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G.The
contractor is responsible for Medicare co-insurance and deductibles
for
contractor covered services. The contractor shall reimburse
providers or enrollees for Medicare deductibles and co-insurance
payments
made by the providers or enrollees, according to Medicaid guidelines
or
the rate negotiated with the
provider.
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H.All
services delivered by the contractor to enrollees, either directly
or
through a subcontract, must be guided by the following service delivery
principles:
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▇.▇▇▇▇▇▇▇▇
must be individualized as a result of a competent, comprehensive
understanding of an enrollee’s multiple
needs.
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must be delivered in a timely fashion in the least restrictive,
cost-effective, and appropriate
setting.
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3.The
contractor must allow each enrollee to choose his or her service
delivery
provider. The contractor assures that each enrollee will be
given free choice of all qualified providers of each service included
in
his or her written plan of care.
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4.Each
contractor shall provide the department with documentation of compliance
with access requirements no less frequently than the
following:
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a)At
the time it enters into a contract with the
department.
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b)At
any time there has been a significant change in the contractor’s
operations that would affect adequate capacity and services, such
as
contractor services, benefits, or geographic service
area.
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5.Long-term
care services must be based upon an enrollee’s plan of care and include
goals, objectives, and specific treatment strategies. Any
limitations on amount, duration, and scope may be off set by alternative
services to address the health and social services needs of an
enrollee.
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must be coordinated to address comprehensive needs and provide continuity
of care.
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must be delivered regardless of geographic location within the service
area, level of functioning, cultural heritage, or degree of illness
of the
enrollee.
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8.The
project’s administration and service delivery system must ensure the
participation of the enrollee in care planning and delivery, as
appropriate, allow for the participation of the family, significant
others, and caregivers.
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9.The
contractor shall provide interpreter services in person where practical,
but otherwise by telephone, for applicants or enrollees whose primary
language is not English. Non-English versions of materials are
required if, the population speaking a particular non-English language
in
a county is greater than five (5) percent, as determined annually
by the
Agency.
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must be delivered by qualified providers as defined in Sections 6.4,
6.5,
6.6, and 6.7. The contractor must have a credentialing system
approved by an accreditation organization that has been approved
by the
Agency pursuant to Chapter 641.512, F.S. The system must
include procedures for credentialing long-term care
providers.
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ATTACHMENT
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11.The
contractor must be approved by an accreditation organization that
has been
approved by the Agency pursuant to Chapter 641.512,
F.S.
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12.All
facilities providing services to enrollees must be accessible to
persons
with disabilities, be smoke-free, and have adequate space, supplies,
good
sanitation, and fire and safety
procedures.
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13.For
contractor performance that is not in compliance with the contract, the
department shall require a corrective action plan. Failure to
provide a corrective action plan within the time specified shall
result in
penalties or sanctions as specified by the contract or governing
statutes
and federal regulations.
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6.2Long-Term
Care Services
With
the
exception of nursing facility services, the long-term care services in this
section are authorized under the Medicaid home and community-based
waiver. As required by Section 430.705(2)(b)2., F.S., the contractor
shall have at least two (2) subcontractors for each service as listed below
(with the exception of case management services, which are directly provided
by
the contractor):
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▇.▇▇▇▇▇
Companion Services: Non-medical care, supervision and
socialization provided to a functionally impaired
adult. Companions assist or supervise the enrollee with tasks
such as meal preparation or laundry and shopping, but do not perform
these
activities as discrete services. The provision of companion
services does not entail hands-on nursing care. This service
includes light housekeeping tasks incidental to the care and supervision
of the enrollee.
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Day Health Services: Services provided pursuant to Chapter 429,
Part III, F.S. For example, services furnished in an outpatient
setting, encompassing both the health and social services needed
to ensure
optimal functioning of an enrollee, including social services to
help with
personal and family problems, and planned group therapeutic activities.
Adult day health services include nutritional meals. Meals are
included as a part of this service when the patient is at the center
during meal times. Adult day health care provides medical
screening emphasizing prevention and continuity of care including
routine
blood pressure checks and diabetic maintenance
checks. Physical, occupational and speech therapies indicated
in the enrollee's plan of care are furnished as components of this
service. Nursing services which include periodic evaluation,
medical supervision and supervision of self-care services directed
toward
activities of daily living and personal
hygiene are also a component of this service. The inclusion of physical,
occupational and speech therapy services and nursing services as
components of adult day health services does not require the contractor
to
contract with the adult day health provider to deliver these services
when
they are included in an enrollee’s plan of care. The contractor may
contract with the adult day health provider for the delivery of these
services or the contractor may contract with other providers qualified
to
deliver these services pursuant to the terms of this
contract.
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C.Assisted
Living Services: Personal care services, homemaker services,
chore services, attendant care, companion services, medication oversight,
and therapeutic social and recreational programming provided in a
home-like environment in an assisted living facility licensed pursuant
to
Chapter 429 Part I, F.S., in conjunction with living in the
facility. This service does not include the cost of room and
board furnished in conjunction with residing in the
facility. This service includes 24-hour on-site response staff
to meet scheduled or unpredictable needs in a way that promotes maximum
dignity and independence, and to provide supervision, safety and
security. Individualized care is furnished to persons who
reside in their own living units (which may include dual occupied
units
when both occupants consent to the arrangement) which may or may
not
include kitchenette and/or living rooms and which contain bedrooms
and
toilet facilities. The resident has a right to
privacy. Living units may be locked at the discretion of the
resident, except when a physician or mental health professional has
certified in writing that the resident is sufficiently cognitively
impaired as to be a danger to self or others if given the opportunity
to
lock the door. The facility must have a central dining room,
living room or parlor, and common activity areas, which may also
serve as
living rooms or dining rooms. The resident retains the right to
assume risk, tempered only by a person's ability to assume responsibility
for that risk. Care must be furnished in a way that fosters the
independence of each consumer to facilitate aging in
place. Routines of care provision and service delivery must be
consumer-driven to the maximum extent possible, and treat each person
with
dignity and respect. Assisted living services may also
include: physical therapy, occupational therapy, speech
therapy, medication administration, and periodic nursing
evaluations. The contractor may arrange for other authorized
service providers to deliver care to residents of assisted living
facilities in the same manner as those services would be delivered
to a
person in their own home. The contractor shall be responsible
for placing enrollees in the appropriate Assisted Living Facility
setting. Note: Assistive Care Services are
covered under this contract and cannot be billed separately by the
Assisted Living Facility.
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ATTACHMENT
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▇.▇▇▇▇
Management Services: Services which facilitate enrollees
gaining access to other needed medical, social, and educational services
regardless of the funding source for the services, and which contribute
to
the coordination and integration of care delivery. Case
management services contribute to the coordination and integration
of care
delivery through the ongoing monitoring of services as prescribed
in each
enrollee’s plan of care. The contractor will provide this
service directly and the ratio of enrollees to case managers shall
be
appropriate to support the needs of the
enrollees.
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E.Chore
Services: Services needed to maintain the home as a clean,
sanitary and safe living environment. This service includes
heavy household chores such as washing floors, windows and walls,
tacking
down loose rugs and tiles, and moving heavy items of furniture in
order to
provide safe entry and exit.
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F.Consumable
Medical Supply Services: The provision of disposable supplies used
by the
enrollee and care giver, which are essential to adequately care for
the
needs of the enrollee. These supplies enable the enrollee to
perform activities of daily living or stabilize or monitor a health
condition. Consumable medical supplies include adult disposable
diapers, tubes of ointment, cotton balls and alcohol for use with
injections, medicated
bandages, gauze and tape, colostomy and catheter supplies, and other
consumable supplies. Not included are items covered under the
Medicaid home health service, personal toiletries, and household
items
such as detergents, bleach, and paper towels, or prescription
drugs.
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G.Environmental
Accessibility Adaptation Services: Physical adaptations to the
home required by the enrollee's plan of care which are necessary
to ensure
the health, welfare and safety of the enrollee or which enable the
enrollee to function with greater independence in the home and without
which the enrollee would require institutionalization. Such
adaptations may include the installation of ramps and grab-bars,
widening
of doorways, modification of bathroom facilities, or installation
of
specialized electric and plumbing systems to accommodate the medical
equipment and supplies which are necessary for the welfare of the
enrollee. Excluded are those adaptations or improvements to the
home that are of general utility and are not of direct medical or
remedial
benefit to the enrollee, such as carpeting, roof repair, or central
air
conditioning. Adaptations which add to the total square footage
of the home are not included in this benefit. All services must
be provided in accordance with applicable state and local building
codes.
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H.Escort
Services: Personal escort for enrollees to and from service
providers. An escort may provide language interpretation for
people who have hearing or speech impairments or who speak a language
different from that of the provider. Escort providers assist
enrollees in gaining access to services. This service does not
include transportation.
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ATTACHMENT
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Training Services: Training and counseling services for the
families of enrollees served under this contract. For purposes
of this service, "family" is defined as the individuals who live
with or
provide care to a person served by the contractor and may include
a
parent, spouse, children, relatives, ▇▇▇▇▇▇ family, or
in-laws. "Family" does not include persons who are employed to
care for the enrollee. Training includes instruction and
updates about treatment regimens and use of equipment specified in
the
plan of care to safely maintain the enrollee at
home.
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▇.▇▇▇▇▇▇▇▇▇
Assessment/Risk Reduction Services: Assessment and guidance to
the caregiver and enrollee with respect to financial
activities. This service provides instruction for and/or actual
performance of routine, necessary, monetary tasks for financial management
such as budgeting and ▇▇▇▇ paying. In addition, this service
also provides financial assessment to prevent exploitation by sorting
through financial papers and insurance policies and organizing them
in a
usable manner. This service provides coaching and counseling to
enrollees to avoid financial abuse, to maintain and balance accounts
that
directly relate to the enrollees living arrangement at home, or to
lessen
the risk of nursing home placement due to inappropriate money
management.
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K.Home
Delivered Meals: Nutritionally sound meals to be delivered to
the residence of an enrollee who has difficulty shopping for or preparing
food without assistance. Each meal is designed to provide 1/3
of the Recommended Dietary Allowance (RDA). Home delivered
meals may be hot, cold, frozen, dried, canned or a combination of
hot,
cold, frozen, dried, or canned with a satisfactory storage
life. These meals must comply with all federal and state
requirements for procurement, preparation, transportation and
storage. Religious preferences in the selection and preparation
of menu items shall be given consideration and accommodated, if
available.
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L.Homemaker
Services: General household activities (meal preparation and
routine household care) provided by a trained
homemaker.
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M.Nutritional
Assessment/Risk Reduction Services: An assessment, hands-on
care, and guidance to caregivers and enrollees with respect to
nutrition. This service teaches caregivers and enrollees to
follow dietary specifications that are essential to the enrollee’s health
and physical functioning, to prepare and eat nutritionally appropriate
meals and promote
better health through improved nutrition. This service may
include instructions on shopping for quality food and on food
preparation.
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N.Personal
Care Services: Assistance with eating, bathing, dressing,
personal hygiene, and other activities of daily living. This
service includes assistance with preparation of meals, but does not
include the cost of the meals. This service may also include housekeeping
chores such as bed making, dusting and vacuuming, which are incidental
to
the care furnished or which are essential to the health and welfare
of the
enrollee, rather than the enrollee's
family.
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O.Personal
Emergency Response Systems (PERS): The installation and service
of an electronic device which enables enrollees at high risk of
institutionalization to secure help in an emergency. The PERS is
connected
to the enrollee’s telephone ▇▇▇▇ or electrical receptacle and programmed
to signal a response center once a "help" button is activated. The
enrollee may also wear a portable "help" button to allow for mobility.
PERS services are generally limited to those enrollees who live alone
or
who are alone for significant parts of the day and who would otherwise
require extensive supervision.
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ATTACHMENT
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P.Respite
Care Services: Services provided to enrollees unable to care
for themselves furnished on a short-term basis due to the absence
or need
for relief of persons normally providing the care. Respite care
does not substitute for the care usually provided by a registered
nurse, a
licensed practical nurse or a therapist. Respite care is
provided in the home/place of residence, licensed hospital, nursing
facility, or assisted living
facility.
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Q.Occupational
Therapy: Treatment to restore, improve or maintain impaired
functions aimed at increasing or maintaining the enrollee’s ability to
perform tasks required for independent functioning when determined
through
a multi-disciplinary assessment to improve an enrollee’s capability to
live safely in the home setting.
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R.Physical
Therapy: Treatment to restore, improve or maintain impaired
functions by using activities and chemicals with heat, light, electricity
or sound, and by massage and active, resistive, or passive exercise
when
determined through a multi-disciplinary assessment to improve an
enrollee’s capability to live safely in the home
setting.
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S.Speech
Therapy: The identification and treatment of neurological
deficiencies related to feeding problems, congenital or trauma-related
maxillofacial anomalies, autism, or neurological conditions that
effect
oral motor functions. Therapy services include the evaluation
and treatment of problems related to an oral motor dysfunction when
determined through a multi-disciplinary assessment to improve an
enrollee’s capability to live safely in the home
setting.
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T.Nursing
Facility Services: Services furnished in a health care facility
licensed under Chapter 395 or Chapter 400,
F.S.
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6.3Minimum
Long-Term Care Service Provider Qualifications
The
long-term care services authorized in this project must be provided in
accordance with the following requirements.
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▇.▇▇▇▇▇
Companion Services: Providers must be employed by a licensed
home health agency pursuant to Chapter 400, Part III, F.S., or
organizations having a certificate of registration issued by the
Agency
for Health Care Administration pursuant to Section 400.509, F.S.,
or be a
Community Care for the Elderly (CCE) provider as defined in Section
430.203, F.S., and registered in accordance with
Section 400.509, F.S., or individuals contracted by a nurse
registry pursuant to Sections 400.462(18) and 400.506,
F.S.
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Day Health Services: Providers must be licensed by the Agency for
Health
Care Administration as an adult day care center pursuant to Chapter
429,
Part III, F.S., or meet the adult day care center exemption requirements
in Section 429.905, F.S.
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C.Assisted
Living Facility Services: Providers must be licensed pursuant
to Chapter 429, Part I, F.S.
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Management Services: Case managers must be a registered nurse;
or have a Bachelor’s Degree in Social Work, Sociology, Psychology,
Gerontology or a related field; or have a Bachelor’s Degree in an
unrelated field and at least two (2) years of related case management
experience; or be a Licensed Practical Nurse (LPN) with four (4)
years of
geriatric experience. Case managers must attend and complete the
following
training annually: four (4) hours of in-service training,
Abuse, Neglect and Exploitation training, and Alzheimer’s disease and
related disorders continuing
education.
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E.Chore
Services: Providers must be a lead agency as defined in Section
430.203(9), F.S.; or a home health agency licensed in accordance
with
Chapter 400, Part III, F.S.; or a pest control business licensed
pursuant
to Section 482.071, F.S.; or a contractor licensed to do home repair;
or a
person, employed by or under the supervision of the contractor, who
is
qualified by training or experience to provide chore
services.
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ATTACHMENT
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F.Consumable
Medical Supply Services: Providers must be pharmacies permitted
under Section 465.022, F.S.; or home medical equipment providers
licensed
pursuant to Chapter 400, Part VII, F.S.; or home health agencies
licensed
pursuant to Chapter 400, Part III, F.S.; or be a licensed
vendor.
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G.Environmental
Accessibility Adaptation Services: Providers must be properly
licensed pursuant to state and local building requirements, and be
confirmed by the provider to have knowledge and experience needed
to
satisfactorily perform the service.
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H.Escort
Services: Providers must be a lead agency as defined in Section
430.203(9), F.S.; or home health agencies licensed pursuant to Chapter
400, Part III, F.S.; or an individual contracted by a nurse registry
pursuant to Section 400.506, F.S.; or persons employed by the
contractor and trained in the following areas: communication and
assistance with hearing and visually impaired patients; emergency
procedures; and enrollee
confidentiality.
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Training Services: Providers must be a home health agency
licensed pursuant to Chapter 400, Part III, F.S.; or a lead agency
as
defined in Section 430.203(9), F.S.; or a medical practitioner licensed
under Chapter 464 or 491, F.S., providing training or counseling
within
the scope of their practice.
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Assessment/Risk Reduction Services: Providers must be home
health agencies licensed pursuant to Chapter 400, Part III, F.S.;
or a
lead agency as defined in Section 430.203(9), F.S.; or persons confirmed
to be qualified to perform the service by experience and training,
such as
certified financial planners, bank employees, or individual bookkeepers;
or qualified persons employed or contracted by the
contractor.
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K.Home
Delivered Meal Providers: Providers must be a lead agency as
defined in Section 430.203(9), F.S., with a contract or referral
agreement for the preparation of meals; employed by or under
contract with the contractor and meet the food service standards
as
defined in Chapters 500 and 509, F.S.; Older American’s Act providers as
defined in Chapter 58A-1, Florida Administrative Code
(FAC).
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L.Homemaker
Service Providers: Services must be provided by a home health
agency licensed pursuant to Chapter 400, Part III, F.S.; or a lead
agency
as defined in Section 430.203(9), F.S.; or individuals contracted
by a
nurse registry pursuant to Sections 400.462(18) and 400.506, F.S.;
or have
a certificate of registration issued by the Agency pursuant to Section
400.509, F.S.
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M.Nutritional
Assessment Risk Reduction Services: Services must be provided by
Registered Licensed Dietitians or other health professionals functioning
in their legal scope of practice. A dietetic technician (DTR)
may, according to the American Dietetic Association, assist a dietitian
and assume full responsibility under supervision of a Registered
Licensed
Dietitian for a wide range of duties including counseling enrollees
on
specific diets. Nutritional education materials must be
approved by a Registered Licensed Dietitian. Providers may
include lead agencies as defined in Section 430.203(9),
F.S.
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N.Nursing
Facility Services: Providers must be licensed under Chapter 395
or Chapter 400, F.S.
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O.Personal
Care Providers: Providers must be lead agencies as defined in
Section 430.203(9), F.S.; Certified Nursing Assistants or home health
aides contracted under Nurse Registries licensed pursuant to Section
400.506, F.S.; or home health agencies licensed pursuant to Chapter
400,
Part III, F.S.
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P.Respite
Care Providers: Providers must be employed by a licensed home
health agency pursuant to Chapter 400, Part III, F.S.; or have a
certificate of registration issued by the Agency for Health Care
Administration pursuant to Section 400.509, F.S.; or be a lead agency
as
defined in Section 430.203(9), F.S.; or be an Adult Day Care Center
licensed pursuant to Chapter 429, Part III, F.S.; or be an Assisted
Living
Facility licensed pursuant to Chapter 429, Part I, F.S.; or be a
Nursing
Facility licensed pursuant to Chapter 400, Part I, F.S.; or be individuals
contracted by a nurse registry pursuant to Section 400.506, F.S.;
or be a
hospice licensed pursuant to Chapter 400, Part IV,
F.S.
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Q.Occupational,
Physical, and Speech Therapy Providers: Providers must be home
health agencies licensed pursuant to Chapter 400, Part III, F.S.,
or
providers holding current registration, certification, or licenses
pursuant to Chapters 455, 468, and 486,
F.S.
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R.Personal
Emergency Response System Service Providers: Providers must
meet the requirements as set forth in Section 489.505(15) or (16),
F.S.
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ATTACHMENT
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6.4Acute-Care
Services
The
following services are covered for Medicaid recipients based on the Medicaid
state plan approved by the federal Centers for Medicare and Medicaid
Services. These services are covered in the project to the extent
that they are not covered by Medicare or are reimbursed by Medicaid pursuant
to
Medicaid’s Medicare cost-sharing policies.
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▇.▇▇▇▇▇▇▇▇▇
Mental Health Services: Community-based rehabilitative
services, which are psychiatric in nature, recommended or provided
by a
psychiatrist or other physician. Such services must be provided
in accordance with the policy and service provisions specified in
the
Medicaid Community Mental Health Coverage and Limitations
Handbook except that the provider need not be a community mental
health center.
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▇.▇▇▇▇▇▇
Services: Medically necessary emergency dental care limited to
emergency oral examination, necessary radiographs, extractions, incision
and drainage of abscess and full or partial dentures. Dentures
are limited to one set of full or partial dentures a
lifetime. Such services must be provided in accordance with the
policy and service provisions specified in the Medicaid Dental
Services Coverage and Limitations Handbook, and must be provided by
providers licensed under Chapter 466,
F.S.
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C.Hearing
Services: Medically necessary hearing evaluations and
diagnostic testing for hearing aid candidacy every three (3)
years. A hearing aid fitting and dispensing for each ear every
three (3) years. Three (3) hearing aid repairs a year outside
the warranty period. One cochlear implant for either ear, but
not both, if medical criterion is met through prior
authorization. Prior authorization may be granted for cochlear
implant repairs outside the warranty period. Such services must
be provided in accordance with the policy and service provisions
specified
in the Medicaid Hearing Services Coverage and Limitations
Handbook, and must be provided by providers licensed under Chapter
484, Part II, F.S.
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D.Home
Health Care Services: Intermittent or part-time nursing
services provided by a registered nurse or licensed practical nurse,
or
personal care services provided by a licensed home health aide, with
accompanying necessary medical supplies, appliances, and
durable medical equipment. Such services must be provided in
accordance with the policy and service provisions specified in the
Medicaid Home Health Coverage and Limitations
Handbook.
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E.Independent
Laboratory and Portable X-ray Services: Medically necessary and
appropriate diagnostic laboratory procedures and portable x-rays
ordered
by a physician or other licensed practitioner of the healing arts
as
specified in the Independent Laboratory and Portable X-ray Services
Coverage and Limitations
Handbook.
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F.Inpatient
Hospital Services: Medically necessary services, including
ancillary services, furnished to inpatient enrollees, provided under
the
direction of a physician or dentist, in a hospital maintained primarily
for the care and treatment of patients with disorders other than
mental
diseases. Such services must be provided in accordance with the
policy and service provisions specified in the Medicaid Hospital
Coverage and Limitations
Handbook.
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ATTACHMENT
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G.Outpatient
Hospital/Emergency Medical Services: Outpatient preventive,
diagnostic, therapeutic, or palliative care provided under the direction
of a physician at a licensed hospital. Such services include
emergency room, dressings, splints, oxygen, physician ordered services
and
supplies necessary for the clinical treatment of a specific diagnosis
or
treatment as specified in the Medicaid Hospital Coverage and
Limitations Handbook.
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H.Physician
Services: Those services and procedures rendered by a licensed
physician at a physician’s office, patient’s home, hospital, nursing
facility or elsewhere when dictated by the need for preventive,
diagnostic, therapeutic or palliative care, or for the treatment
of a
particular injury, illness, or disease as specified in the Medicaid
Physicians Coverage and Limitations
Handbook.
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I.Prescribed
Drug Services: Prescribed drug services for dual eligible
Medicaid beneficiaries are covered as per the Medicare Modernization
Act
(MMA). However, Section 103(c) of the MMA added §1935(d)(2) to
the Social Security Act to allow State Medicaid programs to continue
to
provide and receive Federal Financial Participation (FFP) for certain
drugs not included in the Medicare Prescription Drug benefit (Part
D).
Drugs excluded from Part D coverage are listed in §1927(d)(2) of the
Act. Contractors shall provide certain drugs not included in
Part D as described in the Medicaid Prescribed Drugs Services and
Limitations Handbook. The contractor’s pharmacy
benefits management program must comply with all applicable federal
and
state laws.
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▇.▇▇▇▇▇▇
Services: Medically necessary eye
examinations. Eyeglass repairs and
adjustments. Eyeglasses are limited to two pair every 365
days. Such services must be provided in accordance with the
policy and service provisions specified in the Medicaid Vision
Services Coverage and Limitations Handbook, and must be provided by
providers licensed under Chapter 484, Part I, or 463,
F.S..
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K.Hospice
Services: End of life services provided to enrollees electing
hospice services. Services will be provided in accordance with
the policy and services provisions specified in the Hospice Services
Coverage and Limitations
Handbook.
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6.5
Acute Care Provider Qualifications
For
the
acute care services that are covered under the contract and are also covered
by
Medicare, the provider qualifications will be those of the Medicare
program.
For
the
acute care services covered under the contract that are not covered by Medicare,
the contractor must meet the provider requirements of the Medicaid programs
except that provider type limitations associated with certain services will
not
apply when other provider types can legally perform the service.
6.6
Optional Services
Transportation
Services may be rendered within Medicaid guidelines at the option of the
contractor. These services are the arrangement and provision of an appropriate
mode of transportation for enrollees to receive necessary medical
services. Types of transportation services include: ambulance,
non-emergency medical vehicles, public and private transportation vehicles,
and
air ambulances as specified in the Medicaid Transportation Coverage and
Limitations Handbook.
6.7
Expanded Services
The
contractor may offer incentive programs for enrollees. The contractor
shall receive written approval from the department prior to the use of any
special incentives for enrollees. Any incentive program offered must
be provided to all eligible individuals and will not be used to direct
individuals to select a specific contractor.
ATTACHMENT
I - Page 40
6.8
Availability/Accessibility of Services
The
contractor must make available and accessible sufficient facilities, service
locations, service sites, and personnel to provide the services. The
contractor’s network of providers must be accessible to the enrollees in its
service area. Services covered under this contract must be available to
enrollees to the same extent that such services are available in the project
service area to persons with comparable functional impairment and health
conditions that are not served under this contract.
The
contractor must establish appropriate scheduling guidelines for service
delivery. These guidelines must be communicated in writing to providers in
the
contractor’s network. The contractor must develop a process for monitoring the
scheduling of service delivery and the actual time enrollees must wait to
receive the service. When the service delivery scheduling or waiting times
are
excessive, the contractor must take appropriate action to ensure adequate
service delivery.
The
contractor must arrange for a 24-hour on-call system for each enrollee. The
system may vary by enrollee and should be reflected in the enrollee’s plan of
care. The system should provide for the availability of a qualified
person with information regarding the enrollee’s plan of care.
6.9
Staffing Requirements
The
contractor is responsible for the following staffing requirements:
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A.A
full time administrator designated to be responsible for the
administration of the day-to-day business activities of the
contract.
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B.A
licensed physician, with demonstrated experience in geriatric medicine,
to
serve as a medical director to oversee and be responsible for the
proper
provisions of covered services for the
contract.
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C.A
person, qualified by training, to be responsible for the contract’s
quality assurance and improvement
systems.
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D.A
person designated to be responsible for the contractor’s orientation,
outreach and educational activities who is qualified by training
and
experienced in working with frail
elders.
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E.A
person designated to be responsible for the health information and/or
the
enrollee records system.
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F.A
person designated to be responsible for the processing and resolution
of
grievances/appeals.
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G.Sufficient
support staff to conduct daily business in an orderly manner, including
having enrollee services staff directly available during business
hours
for enrollee services consultation, as determined through management
and
medical reviews.
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H.The
contractor must maintain sufficient staff available 24 hours per
day to
handle care inquiries.
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I.A
person designated to be responsible for the contractor’s utilization
control.
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▇.▇
person designated to be responsible for case management and qualified
case
managers in sufficient numbers to ensure that the case management
requirements are met.
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K.A
person, graduated from a four-year program, designated on a full-time
basis, to be responsible for the data needs of the program, including
but
not limited to, enrollment and disenrollment transactions, HIPAA
compliance transactions, report reconciliations, data collection,
and
reporting.
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L.A
plan for recruiting and retaining health care practitioners who are
minority persons as defined in Section 288.703(3), F.S., as required
by
Section 641.217, F.S.
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ATTACHMENT
I - Page 41
6.10Emergency
Care Requirements
In
accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the contractor must also
cover post-stabilization services without authorization, regardless of whether
the enrollee obtains the service within or outside the contractor’s network, for
the following situations:
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A.Post-stabilization
care services that were pre-approved by the contractor, or were not
pre-approved by the contractor because the contractor did not respond
to
the treating provider’s request for pre-approval within one (1) hour after
being requested to approve such care, or could not be contacted for
pre-approval.
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B.Post-stabilization
services are services subsequent to an emergency that a treating
physician
views as medically necessary after an emergency medical condition
has been
stabilized. These are not emergency services, but are
non-emergency services that the contractor could choose not to cover
out-of-contractor except in the circumstances described
above.
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6.11Out
of Network Use of Non-Emergency Services
Unless
otherwise specified in this document, when an enrollee uses non-emergency
services available under the project from a non-subcontracted provider, the
contractor is not liable for the cost of such utilization unless the contractor
referred the enrollee to the non-subcontracted provider or authorized such
out-of-network utilization. The contractor must provide timely
approval or denial of authorization of out-of-network use through the assignment
of a prior authorization number that refers to and documents the
approval. A contractor may not require paper authorization as a
condition of an enrollee receiving treatment if the contractor has an automated
authorization system. Written follow-up documentation of the approval
must be provided to the out-of-network provider within one business day from
the
request for approval. The enrollee is liable for the cost of such
unauthorized use of contract-covered services from non-subcontracted
providers. However,
in accordance with the Balanced Budget Act of 1997, and pursuant to 42 CFR
422.100(b)(1)(iii), the plan must also cover post-stabilization services without
authorization, regardless of whether the enrollee obtains the service within
or
outside the plan’s network, for the following situations:
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A.Post-stabilization
care services that were pre-approved by the plan; or were not pre-approved
by the plan because the plan did not respond to the treating provider’s
request for pre-approval within one hour after being requested to
approve
such care, or could not be contacted for
pre-approval.
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B.Post-stabilization
services are services subsequent to an emergency that a treating
physician
views as medically necessary after an emergency medical condition
has been
stabilized. These are not emergency services, but are
non-emergency services that the plan chooses not to cover out-of-plan
except in the circumstances described
above.
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ATTACHMENT
I - Page 42
6.12Adult
Protective Services
The
Department of Elder Affairs and the Department of Children and Families (DCF)
have defined processes for ensuring elderly victims of abuse, neglect or
exploitation in need of home and community-based services are referred to the
aging network, tracked, and served in a timely manner. Requirements
for serving elderly victims of abuse, neglect and exploitation can be found
in
Section 430.205 (5)(a), F.S.
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A.DCF
assigns a risk-level designation of “low,” “intermediate” or “high” for
each referral. If the individual needs immediate protection
from further harm, which can be accomplished completely or in part
with
the provision of home and community-based services, the referral
is
designated "high” risk. Individuals designated “high” risk must
be served within 72 hours after being referred to the AAA or lead
agency,
as mandated by Florida statute.
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1.Reports
of abuse, neglect and exploitation begin with the DCF-administered
Florida
Abuse Hotline. Victims aged 60 and older in need of home and
community-based services are referred to the appropriate Area Agency
on
Aging (AAA) or Community Care for the Elderly (CCE) lead
agency.
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2.Reports
received on individuals determined to be enrolled in the diversion
program
will be referred to the appropriate
contractor.
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B.Upon
receipt of a referral, the AAA or CCE lead agency will contact the
contractor via the telephone using the contact information
provided. Any changes to the names or phone numbers of the
primary, secondary or 24-hour contacts must be sent to your contract
manager at the Department of Elder Affairs. Once the contractor
is contacted and provides assurance that the enrollee’s needs will be met,
the AAA or CCE lead agency will fax or hand-deliver to the contractor
the
DCF referral packet, which contains the
following:
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▇.▇▇▇▇▇
Protective Services Referral Form,
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▇.▇▇▇▇▇
Safety Assessment of Safety
Factors,
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3.Capacity
to Consent Form (if the referral has the capacity to consent) OR
Provision
of Voluntary Protective Services Form (required if consent is provided
by
the caregiver/guardian),
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4.Court
Order, if services were court
ordered,
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C.The
contractor is responsible for contacting the AAA or CCE lead agency
once
the crisis is resolved. All contact and discussions with AAA or
CCE lead agency staff must be included in the contractor’s case manager’s
notes. In addition, a copy of the referral packet must be kept
in the case file for each referral.
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D.When
contacted by the AAA or CCE lead agency in regard to a high-risk
referral,
the contractor will be required to provide assurance that the crisis
will
be addressed. If the CCE lead agency or AAA attempts to contact
the contractor during business hours and the contractor cannot be
contacted or cannot provide assurance that the crisis will be addressed,
the CCE lead agency is required to provide the crisis resolving services
until such assurance is received. If contacted by the AAA or
lead agency after business hours (including evenings, weekends and
holidays), assurance that the crisis will be addressed must be provided
to
the AAA or lead agency within 24 hours. The cost of the crisis
resolving services provided by the CCE lead agency while awaiting
assurance outside of the allowable delay will be reimbursed by the
contractor.
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ATTACHMENT
I - Page 43
SECTION
7 UTILIZATION MANAGEMENT
The
contractor’s service authorization systems shall provide authorization numbers,
effective dates for the authorization, and written confirmation to the
contractor of denials, as appropriate. Pursuant to 42 CFR
438.210(b)(3), any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, must be made by a health care professional who has appropriate
clinical expertise in treating the enrollee's condition or
disease. Pursuant to 42 CFR 438.210(c), the contractor must notify
the requesting provider of any decision to deny a service authorization request
or to authorize a service in an amount, duration, or scope that is less than
requested. The notice to the provider need not be in
writing. The contractor must notify the enrollee in writing of any
decision to deny a service authorization request or to authorize a service
in an
amount, duration, or scope that is less than requested. Pursuant to
42 CFR 438.210(e), the contractor must provide that compensation to individuals
or entities that conduct utilization management activities is not structured
so
as to provide incentives for the individual or entity, deny, limit, or
discontinue medically necessary services to any enrollee.
Pursuant
to 42 CFR 438.404(a), 42 CFR 438.404(c) and 42 CFR 438.210(b) and (c), the
contractor must give the enrollee written notice of any "action" as defined
in
Section 13, Definitions, within the time frames for each type of
action. Pursuant to 42 CFR 438.404(b) and 42 CFR 438.210(c), the
notice must explain:
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1.The
action the contractor has taken or intends to
take.
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2.The
reasons for the action.
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3.The
enrollee’s or the provider's right to file a
grievance/appeal.
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4.The
enrollee's right to request a Medicaid Fair
Hearing.
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5.Procedures
for exercising enrollee rights to appeal or
grieve.
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6.Circumstances
under which expedited resolution is available and how to request
it.
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7.Enrollee
rights to request that benefits continue pending the resolution of
the
appeal, how to request that benefits be continued, and the circumstances
under which the enrollee may be required to pay the costs of these
services.
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Pursuant
to 42 CFR 438.404 (a) and (c), the notice must be in writing and must meet
the
language and format requirements of 42 CFR 438.10(c) and (d) to ensure ease
of
understanding.
The
contractor must mail the notice within the following time frames:
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1.For
termination, suspension, or reduction of previously authorized
Medicaid-covered services, within the time frames specified in 42
CFR
431.211, 431.213, and 42 CFR
431.214.
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2.For
denial of payment, at the time of any action affecting the
claim.
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3.For
standard service authorization decisions that deny or limit services,
within the time frame specified in 42 CFR
438.210(d)(1).
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4.If
the contractor extends the time frame in accordance with 42 CFR
438.210(d)(1), it must:
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a)Give
the enrollee written notice of the reason for the decision to extend
the
time frame and inform the enrollee of the right to file a grievance
if he
or she disagrees with that
decision.
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b)Issue
and carry out its determination as expeditiously as the enrollee's
health
condition requires and no later than the date the extension
expires.
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5.For
service authorization decisions not reached within the time frames
specified in 42 CFR 438.210(d) (which constitutes a denial and is
thus an
adverse action), on the date that the time frames
expire.
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ATTACHMENT
I - Page 44
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6.For
expedited service authorization decisions, within the time frames
specified in 42 CFR 438.210(d).
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SECTION
8Quality Assurance and Improvement Requirements
8.1General
The
contractor’s quality assurance program must address the needs of enrollees,
promote improved clinical outcomes and quality of life, identify and address
service delivery issues, and monitor the quality and appropriateness of care
furnished to enrollees with special health care needs. The quality assurance
program required by this section must comply with applicable provisions of
Section 409.912(27), F.S., and Section 641.51, F.S., and be incorporated into
an
existing quality improvement system.
8.2Quality
Assurance Program
The
contractor must formally adopt a quality assurance program for
enrollees. The quality assurance program must include written goals,
policies, and procedures that ensure enhancement of quality of life for
enrollees, emphasize quality patient outcomes, and to promote the coordination
of acute and long-term care services. The quality assurance program
must have a system to identify and prioritize problem areas for resolution
and a
process to design and implement strategies to resolve identified
problems. The system must include: a process for changing the current
quality assurance program as needed; a protocol that dictates the active
involvement of the medical director, the quality assurance director,
medical/clinical providers, and the director of the program; and a description
of the mechanism for measuring the success of quality assurance strategies
and
for providing feedback to all providers involved in the
program. Specifically, the contractor must have a quality assurance
program that includes the following:
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A.A
written description of the quality assurance
program.
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B.Written
responsibilities of the governing body for monitoring, evaluating,
and
improving care.
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C.A
procedure for quality assurance program
supervision.
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D.Assurance
of adequate resources to carry out the program’s specified activities
effectively.
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E.A
protocol for provider participation in the quality assurance
program.
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F.A
procedure for delegation of quality assurance responsibilities to
designated personnel.
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G.A
procedure for credentialing and re-credentialing
providers.
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H.A
procedure for informing enrollees about their rights and
responsibilities.
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I.Assurance
of availability of and accessibility to services and
care.
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▇.▇
procedure to ensure the accessibility and availability of medical
and
long-term care records, as well as proper record keeping, and a process
for record review.
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K.A
procedure for utilization review.
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L.A
procedure for quality assurance program
documentation.
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M.A
procedure for coordination of quality assurance activities with other
management activities.
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N.A
continuity of care system.
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O.An
active quality assurance committee.
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ATTACHMENT
I - Page 45
8.3Quality
Assurance Committee
The
contractor must have a quality assurance committee that is either a separate
mechanism for addressing the quality assurance concerns of eligible frail
enrollees, or incorporated into an existing quality assurance
committee.
The
quality assurance committee must:
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A.Oversee
quality of life indicators such as, but not limited to, the degree
of
personal autonomy, provision of services and supports to assist people
in
exercising medical and social choices, self-direction of care and
maximum
use of natural support networks.
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▇.▇▇▇▇▇▇
grievances and appeals identified through the contractor’s policies and
procedures and through external
oversight.
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▇.▇▇▇▇▇▇
case records of all fair hearings and document internal
complaint/grievance steps involved in the fair hearing, as well as
other
pertinent information for the
enrollee.
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▇.▇▇▇▇▇▇
quality assurance policies, standards, and written procedures to
ensure
that the needs of the enrollees are adequately
addressed.
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▇.▇▇▇▇▇▇
utilization of services with adverse or unexpected outcomes for
enrollees.
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F.Develop
and periodically review written guidelines, procedures and protocols
on
areas of concern in the care of the frail elderly; for example: falls,
incontinence, dementia, depression, congestive heart failure, inadequate
family care, family caregiver stress, family conflict, out-of-home
placements, alcohol problems, and problems of compliance in procedures
of
medical treatment.
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G.Develop
an ethics committee to review ethical questions such as end-of-life
decisions and advance directives.
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H. Develop
a system of peer review by physicians and other service
providers.
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8.4Quality
of Care Studies
The
contractor must conduct quarterly reviews to monitor the quality of care for
this program. In accordance with Section 409.912(27)(b) F.S., the
studies must:
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▇.▇▇▇▇▇▇
specific conditions and health service delivery issues appropriate
to
enrollees for focused monitoring and
evaluation.
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B.Use
clinical care standards or practice guidelines to objectively evaluate
health services delivery issues and the care the contractor delivers
or
fails to deliver for acute and long-term care
conditions.
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C.Use
quality indicators derived from the clinical care standards or practice
guidelines to screen and monitor care and services
delivered.
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The
reviews must include quarterly monitoring of long-term care records of enrollees
who have received services during the previous quarter. The contractor’s
selection of conditions and issues to study should be based on member profile
data. There should be a minimum of three quality of care studies.
Review elements include management of diagnosis, appropriateness and timeliness
of care, comprehensiveness of and compliance with the plan of care, and evidence
of special screening
for, and monitoring of, high-risk persons and conditions.
8.5Independent
Medical Review
In
accordance with 42 CFR 438.204(d), the Agency shall provide for an independent
review of all Medicaid services provided or arranged by the
contractor. The contractor shall provide information necessary for
the review based upon the requirements of the Agency or the Agency’s independent
peer review contractor. The information shall include quality
outcomes concerning timeliness of, and access to, services covered under the
contract. The review shall be performed at least annually by an
entity outside state government. If the medical audit indicates that
quality of care is unacceptable pursuant to contractual requirements, the Agency
and the department may restrict the contractor’s enrollment activities pending
attainment of acceptable quality of care.
ATTACHMENT
I - Page 46
8.6Incident
Reporting
The
contractor shall implement a systematic process for Incident Reporting in
accordance with Section Q. Incident Reporting of the Standard
Agreement.
The
contractor is required to maintain an incident log which shall be submitted
to
the department within 30 days of the file closure date via e-mail to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or via U.S. mail with password protection
for
HIPAA related information.
SECTION
9Grievance/Appeals
Procedures
9.1Grievance
System Requirements
The
contractor must have a grievance system in place for enrollees that includes
a
grievance process, an appeal process, and access to the Medicaid fair hearing
system. The contractor must develop, implement and maintain a
grievance system that complies with the requirements in s. 641.511, F.S., and
with federal laws and regulations, including 42 CFR 431.200 and 438, Subpart
F,
“Grievance System.” The system must include written policies and
procedures that are approved by the department. The contractor shall
refer all enrollees and providers who are dissatisfied with the contractor
or
its action to the grievance/appeal coordinator for processing and documentation
in accordance with this contract and the approved policies and
procedures. The nature of the complaint, using the definitions in
this contract, determines which of the two processes the contractor must
follow. The grievance process is the procedure for addressing
enrollee grievances, which are expressions of dissatisfaction about any matter
other than an action, as “action” is defined in Section 13,
Definitions. The appeal process is the procedure for addressing
enrollee appeals, which are requests for review of an action, as “action” is
defined in Section 13, Definitions.
The
contractor must give enrollees reasonable assistance in completing forms and
other procedural steps, and must provide interpreter services and toll-free
numbers with TTY/TDD and interpreter capability. The contractor must
acknowledge receipt of each grievance and appeal in writing. The
contractor must ensure that decision makers on grievances and appeals were
not
involved in previous levels of review or decision-making. The decision makers
must be health care professionals with clinical expertise in treating the
enrollee’s condition or disease when deciding any of the following:
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1.An
appeal of a denial based on lack of medical
necessity.
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2.A
grievance regarding denial of expedited resolution of an
appeal.
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3.A
grievance or appeal involving clinical
issues.
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ATTACHMENT
I - Page 47
The
contractor must provide information on grievance, appeal, and fair hearing,
and
its respective policies, procedures, and time frames, to all providers at the
time they enter into a contract. Procedural steps must be clearly
specified in the member handbook for members and the provider manual for
providers, including the address, telephone number, and office hours of the
grievance coordinator. The information must include:
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1.Enrollee
rights to Medicaid fair hearing, the method for obtaining a hearing,
the
rules that govern representation at the hearing, and the DCF address
for
pursuing a fair hearing, which is:
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Office
of Public Assistance Appeals
Hearings
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▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, Building 5, Room
203
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▇▇▇▇▇▇▇▇▇▇▇,
▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
|
|
|
2.Enrollee
rights to file grievances and appeals, and the requirements and time
frames for filing.
|
|
|
3.The
availability of assistance in the filing
process.
|
|
|
4.The
toll-free numbers to file oral grievances and
appeals.
|
|
|
5.Enrollee
rights to appeal to the Agency and the Subscriber Assistance Program
(SAP)
if enrolled with contractors licensed under 641, F.S. The
contractor’s appeal or grievance process must be exhausted in accordance
with s. 408.7056 and 641.511, F.S., with the following exception:
a
grievance or appeal taken to Medicaid fair hearing will not be considered
by the SAP. The information must explain that a request for SAP review
must be made by the enrollee within one year of receipt of the final
decision letter from the contractor. The information must
explain how to initiate such a review and include the SAP’s address and
telephone number as follows:
|
Agency
for Health Care Administration
Bureau
of Managed Health Care, Building 1, Room 339
▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇
▇-▇▇▇-▇▇▇-▇▇▇▇
|
|
6.Notice
that the contractor must continue enrollee benefits
if:
|
|
|
(a)The
appeal is filed timely, meaning on or before the later of the
following:
|
|
|
(1)Within
ten (10) days of the date on the notice of action (or 15 days if
the
notice is sent via U.S. mail).
|
|
|
(2)The
intended effective date of the contractor’s proposed
action.
|
|
|
(b)The
appeal involves the termination, suspension, or reduction of a previously
authorized course of treatment;
|
|
|
(c)The
services were ordered by an authorized
contractor;
|
|
|
(d)The
authorization period has not expired;
and
|
|
|
(e)The
enrollee requests extension of
benefits.
|
The
contractor must maintain records of grievances and appeals in accordance with
the terms of this contract.
|
|
9.2
Appeal Process
|
An
appeal
is a request for review of an “action” as defined in Section 13,
Definitions. An enrollee may file an appeal, and a provider, acting
on behalf of the enrollee and with the enrollee’s written consent, may file an
appeal. The appeal procedure must be the same for all
enrollees.
|
|
A.
Filing Requirements
|
|
|
1.The
enrollee or provider may file an appeal within 30 days of the date
of the
notice of action. If the contractor does not issue a written notice
of
action, the enrollee or provider may file an appeal within one year
of the
action.
|
|
|
2.The
enrollee or provider may file an appeal either orally or in writing
and
must follow an oral filing with a written
|
ATTACHMENT
I - Page 48
|
|
B.Contractor
Duties
|
The
contractor must:
|
|
1.Ensure
enrollee oral inquiries seeking to appeal an action are treated as
appeals
and confirm those inquiries in writing, unless the enrollee or the
provider
|
|
|
2.Provide
a reasonable opportunity to present evidence and allegations of fact
or
law, in person, as well as in
writing.
|
|
|
3.Allow
the enrollee and representative an opportunity before and during
the
appeals process to examine the enrollee’s case file, medical records, and
any other documents and records.
|
|
|
4.Consider
the enrollee, representative, or estate representative of a deceased
enrollee as parties to the appeal.
|
|
|
5.Resolve
each appeal and provide notice, as expeditiously as the enrollee’s health
condition requires, within State-established time frames not to exceed
45
days from the day the contractor receives the
appeal.
|
|
|
6.Continue
the enrollee's benefits if:
|
|
|
a)The
appeal is filed timely on or before the later of the
following:
|
|
|
(1)Within
ten (10) days of the date on the notice of action (or 15 days if
the
notice is sent via U.S. mail).
|
|
|
(2)The
intended effective date of the contractor’s proposed
action.
|
|
|
b)The
appeal involves the termination, suspension
|
|
|
c)The
services were ordered by an authorized
provider;
|
|
|
d)The
authorization period has not expired;
and
|
|
|
e)The
enrollee requests extension of
benefits.
|
|
|
7.Provide
written notice of disposition that includes the results and date
of appeal
resolution, and for decisions not wholly in the enrollee’s favor, that
includes:
|
|
|
a)Notice
of the right to request a Medicaid fair
hearing.
|
|
|
b)Information
about how to request a Medicaid fair hearing, including the DCF address
for pursuing a fair hearing, which
is:
|
Office
of Public Assistance Appeals Hearings
▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, Bldg. 5, Room 203,
▇▇▇▇▇▇▇▇▇▇▇,
▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
|
|
c)Notice
of the right to continue to receive benefits pending a
hearing.
|
|
|
d)Information
about how to request the continuation of
benefits.
|
|
|
e)Notice
that if the contractor’s action is upheld in a hearing, the enrollee may
be liable for the cost of any continued
benefits.
|
|
|
f)Notice
that if the appeal is not resolved to the satisfaction of the enrollee,
the enrollee has one year in which to request review of the contractor’s
decision concerning the appeal by the Subscriber Assistance Program,
as
provided in Chapter 408.7056, F.S. The notice must explain how
to initiate such a review and must include the addresses and toll-free
telephone numbers of the Agency and the Subscriber Assistance
Program.
|
|
|
8.Provide
the department with a copy of the written notice of disposition upon
request.
|
|
|
9.Ensure
punitive action is not taken against a provider who files an appeal
on an
enrollee’s behalf or supports an enrollee’s
appeal.
|
|
|
10.The
contractor may extend the resolution time frames by up to 14 calendar
days
if the enrollee requests the extension or the contractor documents
there
is a need for additional information and the delay is in the enrollee’s
interest. If the extension is not requested by the enrollee,
the contractor must give the enrollee written notice of the reason
for the
delay.
|
ATTACHMENT
I - Page 49
|
|
11.If
the contractor continues or reinstates enrollee benefits while the
appeal
is pending, the benefits must be continued until one of following
occurs:
|
|
|
a)The
enrollee withdraws the appeal.
|
|
|
b)Ten
days pass from the date of the contractor’s adverse contractor decision
and the enrollee has not requested a Medicaid fair hearing with
continuation of benefits until a Medicaid fair hearing decision is
reached. (or 15 days if the notice is sent via U.S.
mail.)
|
|
|
c)A
Medicaid fair hearing decision adverse to the enrollee is
made.
|
|
|
d)The
authorization expires or authorized service limits are
met.
|
|
|
12.If
the final resolution of the appeal is adverse to the enrollee, the
contractor may recover the cost of the services furnished while the
appeal
was pending, to the extent that they were furnished solely because
of the
requirements of this section.
|
|
|
13.The
contractor must authorize or provide the disputed services promptly,
and
as expeditiously as the enrollee's health condition requires, if
the
services were not furnished while the appeal was pending and the
disposition reverses a decision to deny, limit, or delay
services.
|
|
|
14.The
contractor must pay for disputed services, in accordance with State
policy
and regulations, if the services were furnished while the appeal
was
pending and the disposition reverses a decision to deny, limit, or
delay
services.
|
|
|
C.Expedited
Process
|
Each
contractor must establish and maintain an expedited review process for appeals
when the contractor determines or the provider indicates that taking the time
for a standard resolution could seriously jeopardize the enrollee's life or
health or ability to attain, maintain, or regain maximum function.
The
enrollee or provider may file an expedited appeal either orally or in
writing. The contractor must:
|
|
1.Inform
the enrollee of the limited time available for the enrollee to present
evidence and allegations of fact or law, in person and in
writing.
|
|
|
2.Resolve
each expedited appeal and provide notice, as expeditiously as the
enrollee’s health condition requires, within State-established time frames
not to exceed 72 hours after the contractor receives the
appeal.
|
|
|
3.Provide
written notice of disposition.
|
|
|
4.Make
reasonable efforts to also provide oral notice of
disposition.
|
|
|
5.Ensure
that punitive action is not taken against a subcontractor who requests
an
expedited resolution on the enrollee’s behalf or supports an enrollee’s
request for expedited resolution.
|
|
|
6.The
contractor may extend the resolution time frames by up to 14 calendar
days
if the enrollee requests the extension or the contractor documents
that
there is a need for additional information and that the delay is
in the
enrollee’s interest. If the extension is not requested by the
enrollee, the contractor must give the enrollee
written notice of the reason for the
delay.
|
If
the
contractor denies a request for expedited resolution of an appeal, the
contractor must:
|
|
1.Transfer
the appeal to the standard time frame of no longer than 45 days from
the
day the contractor receives the appeal with a possible 14-day
extension.
|
|
|
2.Make
reasonable efforts to provide prompt oral notice of the
denial.
|
ATTACHMENT
I - Page 50
|
|
3.Provide
written notice of the denial within two (2) calendar
days.
|
|
|
4.Fulfill
all contractor duties listed above.
|
|
|
9.3Grievance
Process
|
A
grievance is an expression of dissatisfaction about any matter other than an
action, as “action” is defined in Section 13, Definitions. A grievance may be
filed by an enrollee or a provider acting on behalf of the enrollee and with
the
enrollee’s written consent.
|
|
A.Filing
Requirements
|
|
|
1.The
enrollee or provider may file a grievance within one (1) year after
the
date of occurrence that initiated the
grievance.
|
|
|
2.The
enrollee or provider may file a grievance either orally or in
writing. An oral request may be followed up with a written
request, but the time frame for resolution begins the date the contractor
receives the oral filing.
|
|
|
B.Contractor
Duties
|
The
contractor must:
|
|
1.Resolve
each grievance, and provide notice, as expeditiously as the enrollee’s
health condition requires, within State established time frames not
to
exceed 90 days from the day the contractor receives the
grievance.
|
|
|
2.Provide
written notice of this disposition including the results and date
of
grievance resolution.
|
|
|
3.Provide
the department with a copy of the written notice of disposition upon
request.
|
|
|
4.Ensure
punitive action is not taken against a provider who files a grievance
on
an enrollee’s behalf or supports an enrollee’s
grievance.
|
The
contractor may extend the resolution time frames by up to 14 calendar days
if
the enrollee requests the extension or the contractor documents there is need
for additional information and the delay is in the enrollee’s
interest. If the extension is not requested by the enrollee, the
contractor must give the enrollee written notice of the reason for the
delay.
|
|
9.4Medicaid
Fair Hearing System
|
The
Medicaid fair hearing policy and process is detailed in Rule 65-2.042,
F.A.C. The contractor’s grievance system policy and appeal and
grievance processes shall state the enrollee has the right to request a Medicaid
fair hearing at any time, in addition to, pursuing the contractor’s grievance
process. A provider acting on behalf of the
enrollee and with the enrollee’s written consent may request a Medicaid fair
hearing. Parties to the Medicaid fair hearing include the contractor,
as well as the enrollee and his or her representative or the representative
of a
deceased enrollee’s estate.
|
|
A.Request
Requirements
|
|
|
1.The
enrollee or provider may request a Medicaid fair hearing within 90
days of
the date of the notice of action.
|
|
|
2.The
enrollee or provider may request a Medicaid fair hearing by contacting
DCF
at the Office of Public Assistance Appeals Hearings, ▇▇▇▇ ▇▇▇▇▇▇▇▇
▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇-▇▇▇▇.
|
|
|
B.Contractor
Duties
|
The
contractor must:
ATTACHMENT
I - Page 51
|
|
1.Continue
the enrollee's benefits while Medicaid fair hearing is pending
if:
|
|
|
a)The
Medicaid fair hearing is filed timely on or before the later of the
following:
|
|
|
(1)
Within 10 days of the date on the notice of action (Add five (5)
days if
the notice is sent via U.S. mail).
|
|
|
(2)
The intended effective date of the plan’s proposed
action.
|
|
|
b)The
Medicaid fair hearing involves the termination, suspension, or reduction
of a previously authorized course of
treatment;
|
|
|
c)The
services were ordered by an authorized
provider;
|
|
|
d)The
authorization period has not expired;
and
|
|
|
e)The
enrollee requests extension of
benefits.
|
|
|
2.Ensure
punitive action is not taken against a provider who requests a Medicaid
fair hearing on the enrollee’s behalf or supports an enrollee’s request
for a Medicaid fair hearing.
|
|
|
C.If
the contractor continues or reinstates enrollee benefits while the
Medicaid fair hearing is pending, the benefits must be continued
until one
of following occurs:
|
|
|
1.The
enrollee withdraws the request for Medicaid fair
hearing.
|
|
|
2.Ten
days pass from the date of the contractor’s adverse contractor decision
and the enrollee has not requested a Medicaid fair hearing with
continuation of benefits until a Medicaid fair hearing decision is
reached. (Add five (5) days if the notice is sent via U.S.
mail.)
|
|
|
3.A
Medicaid fair hearing decision adverse to the enrollee is
made.
|
|
|
4.The
authorization expires or authorized service limits are
met.
|
The
contractor must authorize or provide the disputed services promptly, and as
expeditiously as the enrollee's health condition requires, if the services
were
not furnished while the Medicaid fair hearing was pending and the Medicaid
fair
hearing officer reverses a decision to deny, limit, or delay
services.
The
contractor must pay for disputed services, in accordance with State policy
and
regulations, if the services were furnished while the Medicaid fair hearing
was
pending and the Medicaid fair hearing officer reverses a decision to deny,
limit, or delay services.
SECTION
10Payment
|
|
10.1Payment
to Contractor
|
The
Agency, through the Medicaid fiscal agent, will make a payment to the contractor
on a monthly basis for the contractor’s satisfactory performance of its duties
and responsibilities as set forth in this contract and its
attachments.
|
|
10.2Capitation
Rates
|
|
|
A.The
capitation rate paid to the contractor is indicated in Exhibit I.
The
Agency and department, working in conjunction with a licensed actuary,
shall review and, if necessary, recalculate the capitation
rate. Legislatively mandated changes in Medicaid services will
also be considered in reviewing the capitation rate. If as a result
of the
review,
the capitation rate is recalculated, notice shall be provided to
the
contractor. The contractor shall have 30 days from the date of the
notice
to provide written comments to the department on the proposed recalculated
capitation rate.
|
|
|
B.The
contractor, department, and the Agency acknowledge that the capitation
rate paid under this contract as specified in Exhibit I of this contract
is subject to approval by the federal
government.
|
|
|
▇.▇▇
accordance with 42 CFR 438.6(c)(1)(i), capitation rates are to be
developed and certified as actuarially sound, appropriate for the
populations to be covered, and the services to be furnished under
the
contract.
|
ATTACHMENT
I - Page 52
|
|
10.3Payment
in Full
|
The
contractor must accept the capitation payment received each month as payment
in
full for all services provided to enrollees covered under this contract and
the
administrative costs incurred by the contractor in providing or arranging for
such services.
10.4Capitation
Payments
|
|
A.Adjustments
to funds previously paid and to be paid may be required. Funds
previously paid will be adjusted when capitation payment(s) are determined
to have been in error, or an error is made in enrolling an ineligible
person. In such events, the contractor agrees to refund any
overpayment and the Agency agrees to pay any
underpayment.
|
|
|
B.The
Agency agrees to reflect changes in the Medicaid fee-for-service
program. The rate of payment and total dollar amount may be
adjusted with a properly executed amendment when Medicaid fee-for-service
expenditure changes have been established through the appropriations
process and subsequently identified in the Agency’s operating
budget. Legislatively mandated changes will take effect on the
dates specified in the legislation.
|
|
|
10.5Payment
Discrepancies
|
|
|
A.If
after an enrollment and disenrollment submission, a discrepancy is
discovered either by the contractor, the Agency, or the department,
the
contractor has five (5) business days to submit correct detailed
information on the Reconciliation Form (Exhibit F) to the
department.
|
|
|
B.After
receipt of the fiscal agent remittance vouchers, the contractor has
ten
(10) business days to submit correct detailed information on the
Reconciliation Form (Exhibit F) to the
department.
|
|
|
C.Failure
to respond within the above time periods may result in a loss and/or
forfeiture of any money due the
contractor.
|
SECTION
11ProgramReporting Requirements
11.1
General Requirements
The
contractor is responsible for complying with all reporting requirements
established by the department and Agency. The contractor will be
responsible for assuring the accuracy and completeness of all required reports
as well as the timely submission of each report. The contractor will
be furnished with the appropriate reporting formats, instructions, submission
timetables and technical assistance as required. The contractor shall
review all monthly reports, as well as remittance vouchers, received from the
fiscal agent for accuracy and will notify the department and Agency if
discrepancies are found. The discrepancies shall be reported as
specified
in Attachment I, Section 10.5.
|
|
A.Level
of Analysis: The following levels of analysis will be used, as
indicated, for the required
reports:
|
|
|
1.Individual
Level - One report is required for each enrollee, e.g., one grievance
record for each grievance, one record per long-term care
service.
|
ATTACHMENT
I - Page 53
|
|
2.Location
Level - One report required for each nine-digit Medicaid provider
number
the contractor has under contract.
|
|
|
3.Contractor
Level - One report is required for each seven-digit Medicaid provider
number the contractor has under
contract.
|
Example:
ABC Health Plan, Medicaid Provider Number 1234567, operates three locations:
ABC
of Palm Beach (123456701), ABC of Indian River (123456702), and ABC of ▇▇▇▇▇▇
(123456703). A contractor level report would be summarized over all
plans with the seven-digit Medicaid Provider number (1234567). A
location level report would have one report for each nine-digit provider number
(123456701, 123456702, and 123456703).
The
following table summarizes the required data reporting for the
project:
|
Report
Name
|
Level
of Analysis
|
Reporting
Frequency
|
Submission
Method
|
Reporting
Location
|
|
834
Transactions
|
Location
|
Monthly,
by 4:00 PM on the Wednesday preceding the second to last
Saturday.
|
Secured
Internet website supplied by the fiscal agent; file upload and download
on
secured website
|
Fiscal
Agent
|
|
Supplemental
834 Transaction
|
Location
|
Monthly,
by 4:00 PM on the Wednesday prior to 834 transactions
|
Secured
Internet website supplied by the fiscal agent; file upload and download
on
secured website
|
Fiscal
Agent
|
|
Disenrollment
Summary Report
|
Location
|
Monthly
within 5 calendar days after the beginning of the reporting
month
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related information)
|
Department
|
ATTACHMENT
I - Page 54
|
Report
Name
|
Level
of Analysis
|
Reporting
Frequency
|
Submission
Method
|
Reporting
Location
|
|
Encounter
Data Report
|
Individual
|
Quarterly,
within 3 months of the end of reporting calendar quarter
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related information)
|
Department
|
|
Grievance/Appeals
Report
|
Individual
|
Quarterly
within 5 calendar days of end or reporting calendar
quarter
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related information)
|
Department
|
|
Updated
Provider Network and Staff Listing
|
Location
|
Quarterly,
within 5 calendar days of end of reporting calendar
quarter
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇
or
mail via a compact disk or diskette (with password protection for
HIPAA
related information)
|
Department
|
|
Minority
Business Enterprise Contract Reporting
|
Contractor
|
April
15, July 5, October 15, January 15
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related information)
|
Department
|
|
Financial
Statements
|
Contractor
|
Quarterly,
within 45 days of end of reporting quarter
|
Agency
Supplied Template on Compact Disc, Diskette or Hard Copy
|
Department
|
|
Audited
Financial Statement
|
Contractor
|
Annually,
within 120 days of end of contractor’s fiscal year
|
Electronic
Mail, Compact Disc Diskette or Hard Copy
|
Department
|
|
Emergency
Management Plan
|
Contractor
|
Annually,
April 30
|
Electronic
Mail, Compact Disc, Diskette or Hard Copy
|
Department
|
|
Enrollee
Satisfaction Survey
|
Contractor
|
Annually,
May 15
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related information)
|
Department
|
ATTACHMENT
I - Page 55
|
Report
Name
|
Level
of Analysis
|
Reporting
Frequency
|
Submission
Method
|
Reporting
Location
|
|
Insolvency
Fund Statements
|
Contractor
|
Monthly
Statements
|
Electronic
Mail or Hard Copy
|
Department
|
|
Reconciliation
Report
|
Individual
|
Within
five (5) days of receipt of fiscal agent reports and ten (10) days
of
receipt of remittance vouchers
|
Electronic
Mail (with password protection for HIPAA related information) to
▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk or diskette
(with password protection for HIPAA related
information)
|
Department
|
11.2 834
Transactions
|
|
A.These
reports are to be submitted monthly to the Florida Medicaid fiscal
agent. These reports shall be transmitted to the Medicaid
fiscal agent using the communications protocol through the secured
Internet site supplied by the fiscal agent. The contractor is required
to
submit the report for every person who is to be enrolled or disenrolled
during the reporting period.
|
|
|
B.The
fiscal agent is authorized to process the enrollment input data as
an
electronic transaction in which payment is generated for each enrollee
according to the established capitation rate. On specified
dates each month the contractor will receive the remittance invoice
accompanied by a payment warrant, in hard copy or contract
format. The amount of payment is determined by the number of
enrollees enrolled in each capitation category and any adjustments
that
may apply.
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▇.▇▇▇▇▇▇▇▇▇▇▇
must comply with all the federal requirements of administrative
simplification, as documented in the National Electronic Data Interchange
Transaction Set Implementation Guide for the Benefit Enrollment and
Maintenance ASC X12N 834 Transaction, as well as the ACS/AHCA ANSI
ASC
X12N 834 Companion Guide.
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D.The
monthly transmission shall be sent to the fiscal agent the Wednesday
preceding the second to the last Saturday of each
month. The enrollment transactions will include all
enrollments submitted from the CARES office and disenrollment requested
by
enrollees or their representative. These enrollments and
disenrollments will be effective the first of the next
month.
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E.The
supplemental transmission shall be sent to the fiscal agent the Wednesday
prior to the monthly transaction. The supplemental transactions
will include Medicaid pending, referrals from the CARES office received
after the monthly cutoff date, and enrollments that did not process
the
previous month.
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11.3 Disenrollment
Summary Report
This
report provides a uniform means of reporting each contractor's monthly
disenrollments. The report
is
required to assess the reasons for each disenrollment and to ensure that
disenrollments are in compliance with contract guidelines.
This
report must be provided as a Microsoft Excel spreadsheet in the format specified
in Exhibit B of this contract. Disenrollments shall be numbered, and
information shall be listed in alphabetized ascending order by enrollee last
name, then by enrollee first name. Information shall pertain only to
disenrollments that are effective for the month being reported. A report will
be
required if there are no disenrollments filed during the given month. For
example, the November 2002 report of disenrollments would include information
on
an enrollee that expired on October 28, 2002. October 28, 2002, would
be provided as the Disenrollment Reason Occurrence Date for that enrollee in
the
Disenrollment Summary Report.
ATTACHMENT
I - Page 56
11.4 Encounter
Data Report
The
contractor shall provide encounter level service utilization data as specified
in Exhibit C of this contract. The services reported represent the
comprehensive array of services that might be necessary to maintain a member
at
home while avoiding nursing home placement, including acute and long-terms
care
services.
The
contractor may resubmit files with more current data during the subsequent
reporting quarter to replace the data previously submitted. If files
are resubmitted, the previously submitted data will be discarded, and the more
recent data will be utilized.
11.5 Grievance/Appeals
Report
This
report provides a uniform means of reporting each contractor’s quarterly
grievances/appeals, and is needed in order to track the number of
grievances/appeals, as well as the reason and disposition of grievances/appeals.
Grievance/appeals reporting provides a method by which to assess the
contractor’s ability to manage formal grievances/appeals through its internal
grievance/appeals process.
The
Grievance/Appeals Report must be provided as a Microsoft Excel spreadsheet
in
the format specified in Exhibit D of this contract. The Grievance/Appeals Report
shall be submitted by the contractor to report all grievances, appeals or
updates to previously reported grievances, appeals, or to report whether there
have been any new grievances/appeals during the reporting quarter.
11.6 Updated
Provider Network and Staff Listing
This
updated listing provides current information on the contractor’s provider
network and staffing to ensure that adequate resources are available to
enrollees at all times.
The
Provider Network and Staff Listing shall be provided electronically in a format
specified by the department. The network listing shall be submitted to the
department via Electronic Mail (with password protection for HIPAA related
information) to ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or mail via a compact disk
or
diskette (with password protection for HIPAA related information). The Provider
Network Listing shall be updated to include information on providers who joined
the contractor’s provider network, or who were terminated from the contractor’s
provider network during the reporting quarter. The terminated providers shall
be
indicated by a strikethrough and a termination date. The first page
and signature page of the subcontract will be submitted for each new provider
added to the network.
If
the
contractor has not added or terminated a subcontract to its provider network
within the reporting quarter, a statement to that effect shall be provided
to
the department in lieu of an updated Provider Network and Staff
Listing.
ATTACHMENT
I - Page 57
11.7
Minority Business Enterprise Contract Reporting
This
report will be submitted in accordance with the Standard Contract Section J.3,
Equity in Contracting. This format is specified in Exhibit
E.
11.8
Emergency Management Plan
The
contractor must submit an emergency management plan to the department for
approval specifying what actions the contractor must conduct to ensure the
ongoing provisions of health services in a natural disaster or man-made
emergency. This plan shall also address service delivery post
disaster or emergency, i.e. shelf-stable meals for those affected enrollees
whose care plan includes home delivered meals. This plan is due
annually April 30.
11.9 Enrollee
Satisfaction Reporting
The
contractor shall conduct the enrollee satisfaction survey by March 1st of each
year. A copy of the survey shall be sent to the Department for
approval by November 1st of the state fiscal year. The contractors shall report
the survey results to the department by May 15th of each year. This
survey shall be conducted in English or in an alternative language, if the
population speaking a particular non-English language in a county is greater
than five (5) percent. The sampling for the survey shall be a
statistically significant sample for members having received long term care
services during the period reflected in the report.
The
enrollee satisfaction survey results submitted to the department shall include
an attestation statement signed by an authorized representative that addresses
the validity, reliability, and unbiasedness of the survey. The
attestation must describe how the validity and reliability was statistically
or
otherwise established. The attestation of unbiasedness must include
the measures the provider took to ensure the independence of the survey and
the
trust of the respondent.
11.10 Hospice
Services
Hospice
Services shall be submitted monthly on the Hospice Enrollment Report (Exhibit
L), indicating new enrollees receiving hospice services.
SECTION
12Financial Reporting
12.1
General
The
reporting requirements outlined in this section are designed in accordance
with
the Agency’s Medicaid prepaid plan contract financial reporting
requirements.
12.2
Member Payment Liability Protection
The
contractor shall not hold members liable for the following in accordance with
Section 1932 (b)(6), Social Security Act (enacted by Section 4704 of the
Balanced Budget Act of 1997):
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A.For
debts of the contractor, in the event of the contractor’s
insolvency.
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B.For
payment of covered services provided by the contractor if the contractor
has not received payment from the Agency for the services, or if
the
health care provider, under contract or other arrangement with the
contractor, fails to receive payment from the Agency or the
contractor.
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C.For
payments to the health care providers that furnished covered services
under a contract, or other arrangement with the contractor, that
are in
excess of the amount that normally would be paid by the member if
the
service had been received directly from the
contractor.
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ATTACHMENT
I - Page 58
12.3
Financial Reporting Template
The
contractor will be supplied with a template for financial reporting that can
be
used with Excel spreadsheet applications. The spreadsheets are to be
completed and the diskette or compact disk mailed to the
department.
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A.Master
financial sheet - This is the balance sheet, profit and loss statement
and
changes in financial position that reflects four (4) quarters plus
the
contractor’s fiscal year totals. Variances have been placed
within the quarters to track fluctuations on a line-item
basis. Ratios have been created to monitor or detect material
weaknesses in the contractor.
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B.Enrollment
sheet - Consists of quarterly summaries of enrollment detailed by
county
penetration. Indicators have been placed to reflect potential
over or under enrolling practices.
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C.Profit
and Loss sheets - Contains three (3) sheets to track individual
performance by commercial, Medicare, and Medicaid product
lines.
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D.Aggregate
write-in sheets - These four (4) sheets track any information recorded
on
the balance sheet or profit and loss statements, which needs further
explanation.
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E.Certification
page - Showing the contractor’s name, address, telephone number, and other
elements.
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12.4
Audited Financial Statements
The
contractor must submit annual audited financial statements prepared by a
certified public accountant that expressly confirm that the contractor satisfies
the surplus requirements as per Section 430.705(b)(5) and summarizes the
contractor’s financial activities for the contract period. In
addition, the contractor must annually send a statement, signed by the president
of the organization, attesting that no assets of the contractor have been
pledged to secure personal loans. The financial statements must be
submitted to the department no later than four calendar months after the end
of
the contractor’s fiscal year and must be prepared by an independent certified
public accountant on the accrual basis of accounting in accordance with
generally accepted accounting principles as established by the American
Institute of Certified Public Accountants (AICPA). Audits performed
to meet the requirements of OMB Circular 128 satisfy this
requirement. For government owned and operated facilities operating
on a cash method of accounting, data based on such a method of accounting will
be acceptable. The certified public accountant (CPA) preparing the
financial statements must sign statements as the preparer and in a separate
letter state the scope of his work and opinion in conformity with generally
accepted auditing standards and AICPA statements on auditing
standards. The annual audited report will be for the contractor
unless prior approval is obtained from the department for some other
alternative.
If
the
period covered by this contract is less than six months, the contractor may
request of the department’s contract manager, in writing, an exemption from the
requirements of this section for this contract period. The
department’s contract manager will grant the exception provided that all other
performance measures are satisfactory and the contractor provides a complete
set
of financial statements accompanied by an attestation of accuracy signed by
a
corporate officer.
12.5
Unaudited Quarterly Financial Statements
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The
contractor must submit the following unaudited quarterly financial
statements: Balance Sheet, Statement of Revenues,
Expenses, and Net Worth, and Statement of Changes in Financial
Position
and Net Worth.
ATTACHMENT
I - Page 59
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A.These
statements must be filed, on a diskette using the supplied spreadsheet
template and are due 45 days after the end of each quarter in a
contractor’s fiscal year. Quarterly financial reports are to be specific
to the operation of the contractor rather than to a parent or umbrella
organization.
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B.The
reporting date, and the name of the provider, must be plainly written
or
stamped on the certification page, along with the Chief Executive
Officer’s (CEO) signature.
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▇.▇▇
not leave blanks. If no entry is to be made, write ANONE, @ not
applicable (N/A) or "-0-" in the space provided. Any item that
cannot be readily classified under one of the printed items should
be
entered as an aggregated item and adequately
described.
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D.If
additional supporting statements or schedules are added in connection
with
providing information on the financial statement, the additions should
be
properly keyed to the item being answered (Example - "Current Assets,
#4").
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▇.▇▇▇
copy of the financial template is required to be filed with the
diskette.
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F.Minimum
requirements needed to run the financial report program
include: IBM compatible computer with an 80286 processor or
higher, 3.5@ disk drive; hard disk drive, graphics display monitor
EGA or
VGA, 4 Mb of memory, mouse, MS-DOS 3.1 or later and Microsoft Windows
3.1
or later, Excel 5.0.
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1.Balance
Sheet
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(a)Balance
Sheet Asset Definitions:
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1)Current
Assets - These assets are relatively liquid and usually held for less
than one year. Restricted assets for grants, contracts and
reserves are not included. Five general types of assets are
usually included in the current asset
classification.
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▇.▇▇▇▇
- Money in any form, cash awaiting deposit, balances on deposit in
checking accounts and certificates of deposit. Funds with
availability for current use that are restricted by contract, state
reserve requirements or other formal arrangements are reported as
Other
Assets. Loan funds held in escrow are reported as Other Assets.
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ii.Secondary
Cash Resources - Various investments that are readily marketable, held
for less than one year or intended for sale within a twelve-month
period. Any funds with availability for current use but
restricted by contract, state requirement or other formal arrangements
are
excluded.
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iii.Short-Term
Receivables - Open accounts receivable and notes receivable with
short-term maturities of less than one
year.
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iv.Short-Term
Prepayments - Expenses, such as insurance, taxes, rent, paid for in
advance of use in operations. These items are usually referred
to as prepaid expenses.
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v.Other
- Includes inventories that are consumable supplies, such as x-ray,
laboratory and other operating supplies. The category includes
items that will be consumed by the contractor during the current
period in
ordinary course of operation and items that are held for resale such
as
pharmacy inventories.
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2)Other
Assets - Assets including insolvency requirements, contracts, grants
and reserves.
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3)Property
and Equipment - Fixed assets including land, building improvements,
furniture and equipment.
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ATTACHMENT
I - Page 60
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(b)Balance
Sheet Asset Lines:
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1)Cash
- Cash in the bank or on hand, available for current use and does
not
include restricted cash.
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2)Short-Term
Investments - Readily saleable investments acquired with temporarily
unneeded cash and do not include restricted
securities.
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3)Premiums
Receivable - Net-Gross amounts collectible from groups or enrollees
who receive services from the contractor, less the amount accrued
for
premiums determined to be uncollectible for the period. This
should not include fee-for-service.
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4)Interest
Receivable - Interest earned on investments but not
received.
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5)Other
Receivables - Net-Gross amounts collectible from sources other than
enrollees or groups, less the amount accrued for receivables determined
to
be uncollectible during the period. Example:
fee-for-service. This should not include restricted
receivables.
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6)Prepaid
Expenses - Future expenses paid in advance such as unexpired
insurance.
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7)Aggregate
Write-ins For Current Assets - Enter the total of the write-ins listed
on the aggregate write-in sheet for current
assets.
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8)Total
Current Assets - Total of the above
categories.
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9)Restricted
Assets - Assets restricted for statutory insolvency
requirements.
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10)Restricted
Funds
- Assets held for contract (i.e., Medicaid) grants, reserves including
cash, securities, receivables, and
other.
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11)Loan
Escrow -
Funds for which loan notes have been signed by the provider but not
drawn
down. Funds may be held by the provider or an escrow
agent.
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12)Long-Term
Investments - Investments held for a period longer than twelve
months.
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13)Intangible
Assets
and Goodwill Net - Assets of no physical substance. These
may include patents, copyrights, licenses, and
franchises. Provide gross amount less
amortization.
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14)Aggregate
Write-ins
for Other Assets - Enter the total of the write-ins listed on lines
1501 through 1597.
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15)Total
Other
Assets - Total of the above
categories.
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16)Land
- Real
estate owned by the contractor.
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17)Buildings
&
Improvements - Buildings owned by the contractor and improvements made
to provider-owned buildings.
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18)Construction
in
Progress - Buildings or improvements in progress or under
construction. These items will be capitalized upon completion
or utilization.
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19)Furniture
and
Equipment - Includes medical equipment, office equipment and furniture
owned by the contractor.
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20)Aggregate
Write-ins
for Other Equipment - Enter the total of the write-ins listed on the
aggregate write-in for property and
equipment.
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ATTACHMENT
I - Page 61
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21)Total
Property and
Equipment-Net - Total of Property and Equipment categories, less
Accumulated Depreciation. The cumulative amount of depreciation
on property and equipment. Depreciation is an accounting
practice recognizing the consumption of the value of a fixed asset
during
the asset's useful life. Depreciation expenses are charged to
the expense categories representing the cost center to which the
fixed
asset is assigned.
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22)Total
Assets -
Total of Current Assets, Other Assets and Net Property and
Equipment.
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23)Details
of Write-ins
Aggregated for Current Assets - Show non-restricted current assets,
including inventories, not included in the other Current Assets
categories.
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24)Details
of Write-ins
Aggregated for Other Assets - Show non-current assets not included in
the Other Assets categories.
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25)Details
of Write-ins
Aggregated for Other Equipment - Include automobiles, fixtures, and
other fixed assets not reported in other Property and Equipment
categories.
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(c)Balance
Sheet Liabilities and Net Worth
Definitions:
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1)Current
Liabilities - Obligations whose liquidation is reasonably expected to
occur within one year. Three main classes or liabilities fall
within this definition.
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2)Obligations
for goods and services that were acquired for use in the operating
cycle - These include claims for hospital and physician services and
accounts payable.
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3)Other
debts that may be expected to require payment within the operating
cycle
or one year - This includes short-term notes and the currently
maturing portion of long-term
obligations.
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4)Revenues
received and recorded prior to being earned - These advances are often
described as "deferred revenues." The obligation to furnish the
services or to refund the payment is recognized as a
liability. These include unearned
premiums.
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5)Other
Liabilities - Liabilities of a long-term nature; liquidation of
liabilities is not expected in the current
year.
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6)Net
Worth -
Includes ownership or donated capital, restricted funds, reserves,
and
earnings or losses.
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(d)Balance
Sheet Liabilities and Net Worth
Lines:
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1)Accounts
Payable - Amounts due to creditors for the acquisition of goods and
services (trade and vendors rather than health care providers) on
a credit
basis.
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2) Claims
Payable (Reported) - Claims reported and booked as
payables.
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3)Accrued
Inpatient Claims (Not reported) - Hospital and institutional care
claims incurred but not reported and/or booked as
payables.
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4)Accrued
Physician Claims (Not reported) - Claims incurred but not reported
and/or booked as payables for physicians and ancillary (such as lab
and
x-ray) services by providers under an arrangement with the prepaid
health
plan. These may include capitation payments to medical groups
or fees to IPAs.
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ATTACHMENT
I - Page 62
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5)Accrued
Referral Claims (Not reported) - Claims incurred but not reported
and/or booked as payables for consultants and referrals to providers
outside a contractor arrangement. These claims are usually paid
on a fee-for-service basis.
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6)Accrued
Other Medical (Not Reported) - Other incurred medical expenses but not
reported and/or booked as payables including emergency room, out-of-area
services, and payroll.
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7)Accrued
Medical Incentive Pool - Accruals for withholds from IPA’s or
capitated medical groups and other such arrangements in which the
provider
may return incentive funds to
contractors.
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8)Unearned
Premiums - Income received or booked in advance of the period to which
it applies. A liability exists to render service in the
future.
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9)Loans
and Notes Payable - The principal amount on loans due within one
year.
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10)Aggregate
Write-Ins
for Current Liabilities - Enter the total of the write-ins listed on
the aggregate write-ins for current
liabilities.
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11)Total
Current
Liabilities - Total of Current Liability
Categories.
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12)Loans
and Notes
- Loans and notes signed by the contractor not including current
portion payable. Include federal
loans.
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13)Statutory
Liability - Reserve required as a liability by statute (e.g.,
government purchaser requirements).
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14)Aggregate
Write-ins
for Other Liabilities - Enter the total of the write-ins listed on the
aggregate write-ins for other
liabilities.
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15)Total
Other
Liabilities - Total of Other Liability
Categories.
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16)Total
Liabilities - Lines 4 and 8.
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17)Donated
Capital
- Capital donated to nonprofit organization. Do not include
loans. Describe the nature of donation as well as any
restrictions on this capital in the notes to financial
statements.
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18)Capital
- Par
Value of stock. Stated amount of owner’s direct equity in
provider.
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19)Paid
in Surplus
- Amount over stated value of Line 10. Reflects actual amount
in excess of par or stated value.
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20)Unassigned
Surplus - Unassigned Retained Earnings. Cumulative earnings
or deficit from operations, net of reserves and restricted
funds.
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21)Aggregate
Write-ins
for Other Net Worth Items - Enter the total of the write-ins listed on
the aggregate write-ins for net
worth.
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22)Total
Net Worth
- Total of Lines 9 to 13.
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23)Total
Liabilities
and Net Worth - Total of Lines 9 and
15.
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24)Details
of Write-ins
Aggregated for Current Liabilities - Show current liabilities not
included in other Current Liabilities categories; include accrued
payroll
and taxes.
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25)Details
of Write-ins
Aggregated for Other Liabilities - Show other liabilities of a
long-term nature.
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ATTACHMENT
I - Page 63
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25)Details
of Write-ins
Aggregated for Other Net Worth Items - May include statutory
reserves, subordinated debt, and accrued interest on subordinated
debt.
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2.Statement
of Revenues, Expenses, and Net
Worth
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(a)Revenue
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Components
are broken down to show the sources of income and revenue dependency on public
or private enrollment bases. Coordination of Benefits (C.O.B.) and
Insurance Recoveries are also shown. Expenses: Medical,
Services, Administration and Marketing components are shown. The
report includes a contra item for year-end adjustments to the full expenses
reported and for withholds or incentives claimed. Report full-accrued
revenues and expenses as defined below for the period. Full expenses,
whether or not the contractor ultimately bears financial responsibility, should
be shown. For example, the full hospital and institutional expenses
are shown in "Inpatient" line. Offsets to these expenses such as
C.O.B. and Insurance Recoveries are shown as revenue. Similarly, full
physician service expenses are shown with a year end adjustment for withholds
or
other offsets returned to the provider as a contra category. Project staff
should footnote differences in reporting if they are unable to report in lines
similar to these revenue/expense accounts.
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(b)Statement
of Revenues, Expenses, and Net Worth
Lines
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1)Premium
- Revenue recognized on a prepaid basis from enrollees and groups
for
provision of a specified range of health services over a defined
period of
time, normally one month. Also included are premiums from
Medicare Wrap-Around subscribers for health benefits which supplement
Medicare coverage. If advance payments are made to the
contractor for more than one reporting period, the portion of the
payment
that has not yet been earned must be treated as a liability.
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2)Fee-for-Service
- Revenue recognized by the contracting entity for provision of health
services to non-enrollees by contractor providers and to enrollees
through
provision of health services excluded from their prepaid benefit
packages.
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3)Co-payments
- Revenue recognized by the contracting entity from enrollees on
a
utilization related basis for certain health services included in
the HMO
benefit package.
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4)Title
XVIII Medicare - Revenue as a result of an arrangement between a
provider and the Centers for Medicare and Medicaid Services for services
to a Medicare beneficiary.
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5)Title
XIX Medicaid - Revenue as a result of an arrangement
between a contractor and a Medicaid state agency for services to
a
Medicaid beneficiary.
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6)Interest
- Interest earned from all sources, including the federal loan in
escrow
and reserve accounts.
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7)C.O.B.
and Insurance Recoveries - Income from Coordination of Benefits and
insurance recoveries.
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8)Reinsurance
Recoveries - Income from the settlement of stop-loss (reinsurance)
claims.
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9)Other
Revenue - Revenue from sources not covered in the previous revenue
accounts, such as recovery of bad debts or gain on sales of capital
assets.
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10)Total
Revenue - Total of the above revenue
accounts.
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ATTACHMENT
I - Page 64
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11)Medical
and Hospital - Expenses for health service delivery including the
following components:
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i. Physician
Services - Expenses for physician services provided under contractual
arrangement to the contractor including the
following: salaries, including fringe benefits, paid to
physicians for delivery of medical services; capitated payments paid
by
the contractor to physicians for delivery of medical services to
contractor subscribers; and fees paid by the contractor to physicians
on a
fee-for-service basis for delivery of medical services to contractor
subscribers. This includes capitated referrals. Do
not include expenses for medical personnel time devoted to administrative
tasks.
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ii. Other
Professional Services - Compensation, including fringe benefits, paid
by the contractor to non-physician providers engaged in the delivery
of
services and to personnel engaged in activities in direct support
of the
provision of medical services. This includes dentists,
psychologists, optometrists, podiatrists, extenders, nurses, clinical
personnel such as ambulance drivers, technicians, para professionals,
janitors, quality assurance analysts, administrative supervisors,
secretaries to medical personnel, and medical record
clerks.
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iii. Outside
Referrals - Expenses for services from providers not under provider
arrangement such as consultations.
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iv. Emergency
Room, Out-of-Area, Other - Expenses for other non-contracted health
delivery services incurred by contractor enrollees for which the
contractor is responsible on a fee-for-service basis. These
include emergency room costs and out-of-area emergency physician
and
hospital costs.
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v. Occupancy,
Depreciation and Amortization - Expenses associated with medical
services including the amount of depreciation and amortization expense
which is directly associated with the delivery of medical
services. The costs of occupancy to the contractor which are
directly associated with the delivery of medical
services. Included in occupancy are costs of using a facility,
fire and theft insurance, utilities, maintenance, and
lease.
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vi. Inpatient
- Inpatient hospital costs of routine and ancillary services
for enrollees while confined to an acute care
hospital. Does not include out-of-area
hospitalization.
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vii. Routine
hospital service- includes regular room and board (including intensive
care units, coronary care units, and other special inpatient hospital
units), dietary and nursing services, medical surgical supplies,
medical
social services, and the use of certain equipment and facilities
for which
the contractor does not customarily make a separate
charge.
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viii. Ancillary
services- may also include laboratory, radiology, drugs, delivery room
and physical therapy services. Ancillary services may also
include other special items and services for which charges are customarily
made in addition to routine service charge. Charges for
non-contractor physician services provided in a hospital are included
in
this line item only if included as an undefined portion of charges
by a
hospital to the contractor. Include the cost of utilizing
skilled nursing and intermediate care facilities. Skilled
nursing facilities are primarily engaged in providing skilled nursing
care
and related services for patients who require medical or nursing
care or
rehabilitation service. Intermediate care facilities are for
enrollees who do not require the degree of care and treatment which
a
hospital or nursing care facility provides, but do require care and
services above the level of room and
board.
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ATTACHMENT
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ix. Reinsurance
Expenses - Expenses for Reinsurance or "Stop-loss"
insurance.
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x. Other
Medical - Costs directly associated with the delivery of medical
services under contractor arrangement which are not appropriately
assigned
to the medical expense categories defined above, e.g., costs of medical
supplies, medical administration expense (except compensation),
malpractice insurance, etc.
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xi. Incentive
Pool Adjustment - A contra category for adjusting the full medical
expenses reported. For example, physician withholds or hospital
volume discounts returned by or to the provider should be included
here. Adjustments should be made only on the annual
report.
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(c)Administration
- Costs associated with the overall management and operation of the
contractor including the following
components:
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1)Compensation
- All expenses for administrative services including compensation
and
fringe benefits for personnel time devoted to or in direct support
of
administration. Include expenses for management
contracts. Do not include marketing
expenses. However, when a management company pays rent,
insurance, and other non-salary or non-commission payments, these
amounts
should not be reported as
compensation.
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2)Interest
Expenses - Interest on loans paid during
period.
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3)Occupancy,
Depreciation and Amortization - Expenses associated with
administrative services including the costs of occupancy to the contractor
entity which are directly associated with contractor
administration. Included in occupancy are costs of using a
facility, fire and theft insurance, utilities, maintenance, and
lease. Do not include expenses for marketing in this
category.
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4)The
amount of
depreciation and amortization expense which is directly associated
with
administrative services. Depreciation expense is the
incremental consumption of the value of a fixed asset during the
asset's
useful life.
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5)Amortization
Expense - the cost of certain assets are spread over their estimated
service lives, e.g., leasehold
improvements.
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6)Marketing
- Expenses directly related to marketing activities including
advertising, printing, marketing representative compensation and
fringe
benefits, commissions, broker fees, travel, occupancy, and other
expenses
allocated to the marketing
activity.
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7)Other
- Costs which are not appropriately assigned to the health plan
administration categories defined above. Included are costs to
update enrollee records, servicing of enrollee inquiries and complaints,
claims adjudication and payment, legal, audit, data processing,
accounting, insurance, bad debts, and all taxes except federal income
taxes. Do not include marketing
expenses.
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ATTACHMENT
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8)Total
Administration - Total of the above
categories.
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9)Total
Expenses - Total of Medical and Hospital and Administration
Expenses.
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10)Income
(Loss) - Excess or deficiency of total revenues over total
expenses.
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11)Extraordinary
Item - A nonrecurring gain or loss that meets the following
criteria:
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i. The
event must be unusual. It should be highly abnormal and
unrelated to, or only incidentally related to, the ordinary activities
of
the entity.
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ii.
The event must occur infrequently. It should be of a type that
would not reasonably be expected to recur in the foreseeable
future.
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iii.
The following gains and losses are specifically not
extraordinary: write-down or write-off of accounts receivable,
inventory, or intangible assets; gains or losses from changes in
the value
of foreign currency; gains or losses on disposal of a segment of
a
business; gains or losses from the disposal of fixed assets; effects
of a
strike; and adjustments of accruals on long-term
contracts.
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12)Provision
for taxes - State and federal taxes for the period (for-profit
organizations only).
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13)Net
Income (Loss) - Excess or deficiency of total revenues over total
expenses less state and federal taxes for the
period.
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3.Statement
of Changes in Financial Position and Net
Worth
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This
report reflects the concept of funds as working capital, rather than the more
limited cash concept. Use brackets to show negative
balances. Inclusion of statutory reserves as a component of working
capital is dependent in each situation on the use of the reserve as defined
by
the regulatory authority. The applicable test is whether the reserve
is available for use in current operations. This report shows funds
generated and applied to operations. Sources and applications of
funds indicate funds generated (or lost) from operations, as well as other
sources and applications. Net worth indicates changes in components
of net worth over the past year. Sources of funds used in operations
including the following:
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(a)Statement
of Changes in Financial Position and Net Worth
Lines
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1)Net
Income (Loss) - Report the figure calculated for this
line.
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2)Add
items not affecting working capital in the current period - depreciation,
amortization and deferred taxes are expenses not affecting working
capital. These expenses are added
back.
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3)Depreciation
and Amortization
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4)Deferred
Taxes - These are accrued taxes expensed for the period which are
held
for payment to the government during a later
period.
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5)Show
other expenses not affecting working
capital.
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6)Other
Additions to Working Capital: Additions are generally from
borrowing or from liquidating non-current assets and include the
following:
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i.Proceeds
from borrowing - Additions from borrowing which increase current
asset
accounts.
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▇▇.▇▇▇▇
other additions to working capital.
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▇▇▇.▇▇▇▇▇
Sources of Funds - Total of the above
categories.
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ATTACHMENT
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7)Applications
- Uses of Working Capital, usually additions to non-current assets
or
reductions in long term liabilities, including the
following:
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i.Additions
to Property and Equipment - Increase in property and equipment from
last
period.
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ii.Reductions
in Long-Term Debt - Decrease in long-term liabilities from last
period.
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▇▇▇.▇▇▇▇
other uses of Working Capital.
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▇▇.▇▇▇▇▇
Applications of Funds - Total of the above
categories.
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8)Increase
(Decrease) in Working Capital - Excess or deficiency of Sources over
Applications of Funds.
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9)Net
Worth Beginning of Period
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10)Increase
(Decrease) in Donated Capital
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11)Increase
(Decrease) in Capital - (Current year less previous
year)
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12)Increase
(Decrease) in Reserves and Restricted Funds - (Current year less
previous
year)
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13)Increase
(Decrease) in Unassigned Surplus - (Current year less previous
year)
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14)Net
Worth End of Period
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ATTACHMENT
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SECTION
13 DEFINITIONS
The
following terms as used in this contract, shall be construed and/or interpreted
as follows, unless the context otherwise expressly requires a different
construction and/or interpretation.
Action
- 42 CFR 438.400 - 1. The denial or limited authorization of a
requested service, including the type or level of service. 2. The
reduction, suspension, or termination of a previously authorized
service. 3. The denial, in whole or in part, of payment for a
service. 4. The failure to provide services in a timely manner, as
defined by the state. 5. The failure of the plan to act
within the timeframes provided in 42 CFR 438.408(b). 6. For a
resident of a rural area with only one managed care entity, the denial of a
Medicaid enrollee's request to exercise his or her right, under 42 CFR
438.52(b)(2)(ii), to obtain services outside the network
ADL
- Activities of Daily Living; include, dressing, grooming, bathing,
eating, transferring in and out of bed or a chair, walking, climbing stairs,
toileting, bladder/bowel control, and the wearing and changing of incontinent
briefs.
Advance
Directives- refers to oral and written
instructions authorizing another to act as one’s agent or attorney regarding
future medical care. (Examples: Living Will and Durable Power of
Attorney)
Adverse
Determination - Adverse determination means any
instance in which coverage for the requested service is denied, reduced, or
terminated. The contractor’s decision to deny, reduce or terminate
coverage must be based on the review of whether an admission, availability
of
care, continued stay, or other service required in accordance with this contract
meets the contractor’s requirements for medical necessity, appropriateness,
health care setting, level of care, or effectiveness.
Agency
- State of Florida, Agency for Health Care Administration.
Ancillary
Services - Services provided at a hospital
include, but are not limited to, radiology, pathology, neurology, and
anesthesiology as specified in the Hospital Coverage and Limitations
Handbook.
Appeal
- 42 CFR 438.400 - A request for review of action.
Area
Agency on Aging - an agency designated by the
department to develop and administer a plan for a comprehensive and coordinated
system of services for older persons.
Assessment –an
individualized comprehensive appraisal of an individual’s medical,
developmental, mental, social, financial, and environmental status conducted
by
a qualified individual for the purpose of determining the need for long term
care services.
Benefits
- a schedule of medical or social services to be delivered to enrollees
covered under this contract.
CMS–
Centers for Medicare and Medicaid Services.
Capitation
Rate - the monthly fee paid by the Agency to the
contractor for each enrollee enrolled under the contract for the provision
of
services during the payment period.
Care
Plan - See Plan of Care.
CARES
- Comprehensive Assessment and Review for Long Term Care
Services. A nursing home pre-admission assessment program, which
provides a comprehensive, on-site assessment of individuals seeking admission
to
a nursing home under a state assisted program. The program explores
all available options to nursing home placement and recommends, and may
facilitate alternative placements for individuals who are determined able to
remain in the community.
CFR
- Code of Federal Regulations.
ATTACHMENT
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Cold-call
marketing - Any unsolicited personal contact by
the contractor or subcontractors with a potential enrollee for the purpose
of
marketing.
Complaints–
See Grievance
Contractor
- the organizational entity serving as the primary contractor and with
whom this agreement is executed. The term contractor shall include
all employees, subcontractors, agents, volunteers, and anyone acting on behalf
of, in the interest of, or for a contractor.
Covered
Services - see Benefits.
Department
- Department of Elder Affairs.
DCF- Department
of Children and Families
DHHS
- United States Department of Health and Human Services.
Disenrollment
- the discontinuance of an enrollee's membership in the contractor’s
plan.
Durable
Medical Equipment - medical equipment that can
withstand repeated use; is primarily and customarily used to serve a medical
purpose; is generally not useful in the absence of illness or injury; and is
appropriate for use in the recipient's home.
Emergency
Medical Condition– according to 42 CFR 438.114(a)
means 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 the following:
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(1)
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.
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(2)
Serious impairment to bodily functions.
(3)
Serious dysfunction of any bodily organ or part.
Emergency
Services - according to 42 CFR 438.114(a) means
covered inpatient and outpatient services that are as follows:
(1)
Furnished by a provider that is qualified to furnish these services
under this title.
(2)
Needed to evaluate or stabilize an emergency medical
condition.
Enrollee
- according to 42 CFR 438.10(a) means a Medicaid recipient who is
currently enrolled in a MCO as defined in 42 CFR 438.10(a). See
“Member.”
Enrollment
- the process by which an eligible Medicaid recipient becomes an
enrollee in the Long Term Care Community Diversion Pilot Project.
Existing
diversion provider - an entity that is
approved by the department on or before June 30, 2007, to provide services
to
consumers through any Long-Term Care Community Diversion Pilot Project
authorized under Chapter 430.701- 430.709, F.S..
Extraordinary
Reporting – reporting
of awareness or discovery of conditions that may
materially affect the contractor’s ability to perform services under this
contract.
Facility
- any premises (a) owned, leased, used or operated directly or
indirectly by or for the contractor or its affiliates for purposes related
to
this contract; or (b) maintained by a sub-contractor to provide services on
behalf of the contractor.
Fair
Hearing - the opportunity to present one’s case to
a reviewing authority in accordance with the terms and conditions in 42 CFR
Part
431, State Organization and General Administration, Subpart E, and 59G-1.030,
Florida Administrative Code.
Fiscal
Agent - any corporation or other legal entity that
has contracted with the Agency to receive, process and adjudicate claims under
the Medicaid program.
ATTACHMENT
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FMMIS-
Florida Medicaid Management Information System, Medicaid fiscal agent utilizes
this system
for all Medicaid related data and information.
Furnished
- means supplied, given, prescribed, ordered, provided, or directed
to
be provided in any manner.
Grievance -
means an expression of dissatisfaction about any matter other than
an
action, as "action" is defined in this section. The term is also used
to refer to the overall system that includes grievances and appeals
handled at the contractor level and access to the Medicaid fair hearing
process. (Possible subjects for grievances include, but are not
limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a contractor or employee, or
failure to respect the enrollee's rights.) (42 CFR
438.2)
Grievance
Procedure - the procedure for addressing
enrollees' grievances. A grievance is an enrollee’s expression of
dissatisfaction with any aspect of their care other than the appeal of actions
(which is an appeal).
Grievance
System - the system for reviewing and resolving
enrollee grievances or appeals. Components must include a grievance
process, an appeal process, and access to the Medicaid fair hearing
system.
Grievant
- an enrollee, subcontractor, or other service provider that files a
grievance with the contractor.
Health
Care Professional - means a physician or any of
the following: a podiatrist, optometrist, chiropractor, psychologist,
dentist, physician assistant, physical or occupational therapist, therapist
assistant, speech-language pathologist, audiologist, registered or practical
nurse (including nurse practitioner, clinical nurse specialist, certified
registered nurse anesthetist, and certified nurse midwife), licensed certified
social worker, registered respiratory therapist, and certified respiratory
therapy technician.
HMO
- Health Maintenance Organization as certified pursuant to Chapter 64l,
F.S..
Hospital
- a facility licensed in accordance with the provisions of Chapter 395,
F.S., or the applicable laws of the state in which the service is
furnished.
IADL
- Instrumental Activities of Daily Living; include making and answering
telephone calls, shopping, transportation ability, preparing meals, laundry,
light housekeeping, heavy chores, taking medication, and managing
money.
ICP
- The Medicaid Institutional Care Program.
Ineligible
Recipient - a Medicaid recipient that does not
qualify for enrollment in the Long Term Care Community Diversion
Program.
Insolvency/Insolvent
- A financial condition that exists when an entity is unable to pay
its
debts as they become due in the usual course of business, or when the
liabilities of the entity exceed its assets.
Lead
Agency - means an entity designated by an area
agency on aging and given the authority and responsibility to coordinate
services for functionally impaired elderly persons.
Long-Term
Care Record - a record that includes information
regarding the medical and long-term care services an enrollee is receiving
including the plan of care and documentation of case management activities
including efforts to coordinate and integrate the delivery of all services
to
the enrollee.
Marketing
- any activity conducted by or on behalf of the contractor where
information regarding the services offered by the contractor is disseminated
in
order to encourage eligible enrollees to enroll or accept any application for
enrollment in the Long Term Care Community Diversion Program developed under
this contract.
ATTACHMENT
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Medicaid
- the medical assistance program authorized by Title XIX of the federal
Social Security Act,
42
U.S.C. s.1396 et seq., and regulations there under, as administered in this
state by the Agency under Chapter 409.901 et seq., F.S.
Medicaid
HMO– an HMO as defined in the Medicaid State
Plan.
Medically
Necessary or Medical Necessity - services provided
in accordance with 42 CFR 438.210(a)(4) and as defined in Section
59G-1.010(166), F.A.C., to include that medical or allied care, goods, or
services furnished or ordered must:
A.
Meet the following conditions:
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necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe
pain;
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individualized, specific, and consistent with symptoms or confirmed
diagnosis of the illness or injury under treatment, and not in excess
of
the patient’s needs;
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▇.▇▇
consistent with the generally accepted professional medical standards
as
determined by the Medicaid program, and not experimental or
investigational;
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▇.▇▇
reflective of the level of service that can be safely furnished,
and for
which no equally effective and more conservative or less costly treatment
is available, statewide; and
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▇.▇▇
furnished in a manner not primarily intended for the convenience
of the
recipient, the recipient’s caretaker, or the
contractor.
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B. “Medically
necessary” or “medical necessity” for inpatient hospital services requires
that those services furnished in a hospital on an inpatient basis
could
not, consistent with the provisions of appropriate medical care,
be
effectively furnished more economically on an outpatient basis or
in an
inpatient facility of a different
type.
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C.The
fact that a contractor has prescribed, recommended, or approved medical
or
allied goods, or services does not, in itself, make such care, goods
or
services medically necessary or a medical necessity or a covered
service.
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Medicare
- the medical assistance program authorized by Title XVIII of the
federal Social Security Act, 42 U.S.C. s. 1395 et seq., and regulations there
under.
Nursing
Facility - an institutional care facility licensed
under Chapter 395, F.S., or Chapter 400, F.S., that furnishes medical or allied
inpatient care and services to individuals needing such services.
Other
Qualified Provider– a contracted provider who
meets the qualifications of Chapter 430.703(7), F.S..
Outpatient
- a patient of an organized medical facility or distinct part of that
facility who is expected by the facility to receive and who does receive
professional services for less than a 24-hour period regardless of the hour
of
admission, whether or not a bed is used, or whether or not the patient remains
in the facility past midnight.
Peer
Review - an evaluation of the professional
practices of a provider by peers of the provider in order to assess the
necessity, appropriateness, and quality of care furnished as such care is
compared to that customarily furnished by the provider's peers and to recognized
health care standards.
Plan
of Care - A plan which describes the service needs
of each recipient, showing the projected duration, desired frequency, type
of
provider furnishing each service, and scope of the services to be
provided.
Potential
Enrollee - according to 42 CFR 438.10(a) means a
Medicaid recipient who is subject to mandatory enrollment or may voluntarily
elect to enroll in a given managed care program, but is not yet an enrollee
of a
specific managed care program.
ATTACHMENT
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Prepaid
Health Plan or Plan - the prepaid health care plan
developed by the contractor in performance of its duties and responsibilities
under this contract; or a contractual arrangement between the Agency and a
comprehensive health care contractor for the provision of Medicaid care, goods,
or services on a prepaid basis to Medicaid recipients.
Primary
Care Physician - a Medicaid-participating or
prepaid health plan-affiliated physician practicing as a general or family
practitioner, internist, pediatrician, obstetrician, gynecologist, or other
specialty approved by the Agency, who furnishes primary care and patient
management services to an enrollee.
Prior
Authorization - the act of authorizing specific
services before they are rendered.
Project
- Long Term Care Community Diversion Program.
Protocols
- written guidelines or documentation outlining steps to be followed
for handling a particular situation, resolving a problem, or implementing a
plan
of medical, social, nursing, psycho social, developmental and educational
services.
Provider
- a person or entity who is responsible for or
directly provides any medical or social services authorized by this
contract.
Provider
Handbook - a document that provides information to
a Medicaid provider regarding enrollee eligibility, claims submission and
processing, provider participation, covered care, goods, or services and
limitations, procedure codes and fees, and other matters related to Medicaid
program participation.
Quality
Assurance - the process of assuring that the
delivery of health care is appropriate, timely, accessible, available, and
medically necessary.
Recipient
- any individual whom the Department of Children and Families
determines is eligible, pursuant to federal and state law, to receive medical
or
allied care, goods, or services for which the Agency may make payments under
the
Medicaid program and is enrolled in the Medicaid program.
Risk
- the potential for loss that is assumed by an entity and that may
arise because the cost of providing care, goods, or services may exceed the
capitation or other payment made by the Agency to the plan under terms of the
contract.
Service
Area - the designated geographical area within
which the contractor is authorized by contract to furnish covered services
to
enrollees and within which the enrollees reside.
State
- State of Florida.
Subcontract
- an agreement entered into by a contractor for the provision of
benefits to enrollees or to perform any administrative function or service
for
the contractor specifically related to securing or fulfilling the contractor’s
obligations under this contract. Subcontracts include, but are not
limited to the following: agreements with all providers of medical or
ancillary services, unless directly employed by the contractor; management
or
administrative agreements; third party billing or other indirect
administrative/fiscal services, including provision of mailing lists or direct
mail services; and any contract which benefits any person with a control
interest in the contractor’s organization.
Subcontractor
- any person to which the contractor has contracted or delegated some
of its functions, services or its obligations under this contract.
Surplus
- Net worth, i.e., total assets minus total liabilities. Surplus has
the same meaning as in Chapter 641.19(19), F.S..
ATTACHMENT
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Third
Party Resources - an individual, entity, or
program, excluding Medicaid, that is, may be, could be, should be, or has been
liable for all or part of the cost of medical services related to any medical
assistance covered by Medicaid. An example is an individual’s auto
insurance company, which typically provides payment of some medical expenses
related to automobile accidents and injuries.
Transportation
- an appropriate means of conveyance furnished to an enrollee to obtain
services authorized under this contract.
Transition
Care Services– services necessary in order to
safely maintain a person in the community both prior to and after the effective
date of their enrollment in the project until the initial Plan of Care is
implemented.
Transition
Period - the period of time from the effective
date of enrollment until the initial Plan of Care is effective.
Urgent
Grievance - an adverse determination when the
standard timeframe of the grievance procedure would seriously jeopardize the
life or health of an enrollee, or the enrollee’s ability to regain maximum
function.
Violation
- each determination by the department and/or Agency that a contractor
failed to act as specified in the contract or in applicable statutes or rules
governing Medicaid prepaid health plans. Each day that an ongoing
violation continues may be considered for the purposes of this contract to
be a
separate violation. In addition, each instance of failing to furnish
necessary and/or required services or items to enrollees is considered for
purposes of this contract to be a separate violation.
ATTACHMENT
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EXHIBIT
A
MULTIPLE
SIGNATURE VERIFICATION AGREEMENT
Account
Number: ________________
In
consideration of the mutual promises and undertakings expressed herein, this
Agreement is entered into between _____________ Bank (“Bank”) and ____________
Contractor (“Contractor”), effective as of the ______ day of _____________,
2007.
1.Contractor
is opening a restricted insolvency protection
account referenced by number above (“the Account”),
pursuant to the conditions contained in the Long-Term Care Nursing Home
Diversion Contract no. ▇▇▇▇-▇▇▇▇-▇▇ entered between Contractor and the State
of
Florida, Department of Elder Affairs, (“Department”) dated (Date contract is
signed).
2.Pursuant
to its agreement with Department, Contractor desires, and Bank agrees to
provide, a “hold” on the account so that withdrawals may be made only by
properly authorized written request, and upon manual examination of the
requests, which service shall be subject to the terms and restrictions set
forth
below.
▇.▇▇▇▇
will only honor written requests for withdrawals that bear a total of two
signatures of persons designated by the Department. Department will provide
to
Bank examples of the signatures of the authorized representatives.
4.Contractor
will present the written, properly executed requests for withdrawal of interest
funds to _________________, at Bank, located at
____________________________________._________, Florida, _______, between the
hours of 8:00 am and 4:00 pm, EST, during banking business days. The
request will contain the Account number, the amount of the funds to be
withdrawn, a description of the payee who shall receive the funds, and the
signatures of the two authorized representatives, designated in paragraph
3.
▇.▇▇▇▇
agrees to verify the signatures; draft the Account for the amount of the
requested withdrawal, and prepare a Bank Official Check in the withdrawn amount,
in accordance with the terms of the request. Bank agrees to undertake
the above and make the Check available to Contractor no later than the close
of
the banking day following the banking day in which the request was presented
to
Bank in accordance with Paragraph 4, above.
▇.▇▇▇▇
shall return to Contractor any request that does not meet the above-described
requirements. Bank shall have the sole discretion to determine
whether the requirements have been met.
7.Pursuant
to its agreement with Department, Contractor agrees that in the event that
the
Department, in consultation with the Agency determines Contractor to be
insolvent and notifies Bank of its determination, Department may make
withdrawals on the account solely with the two authorized signatures of
representatives of the Department, without authorized signatures from
Contractor. Bank shall not be responsible or liable for determining
insolvency. Bank shall not be required to permit withdrawals upon the
sole order of Department until written notification is received from Department
at the address described in Paragraph 4, and Bank has had a reasonable time
to
act thereon but in no event later than two (2) business days.
8.Except
to the extent that Bank is negligent in performing its duties under this
Agreement, Contractor shall indemnify and hold Bank harmless against any claim,
loss, liability, damage, cost or expense (including reasonable attorneys’ fees
incurred by Bank) arising out of or in any way relating to Bank’s compliance
with the terms of this Agreement.
9.This
Agreement shall supplement the Bank Deposit Agreement, any corporate or other
resolution of Contractor relating to the Account, and any other agreements
or
terms affecting the Account. All legal rights and obligations of
Contractor and Bank under such other documents and pursuant to any applicable
laws and banking regulations shall remain in effect, except as expressly
modified by this Agreement.
10.This
Agreement shall be executed by all currently authorized signors on the Account,
and it shall continue
ATTACHMENT
- Page 75
in
effect
notwithstanding any subsequent change of authorized signors, and without any
requirement that it be re-executed or amended.
11.This
Agreement may be terminated at any time by Bank or Contractor, provided
Contractor provides Bank written approval from Department, and provided that
the
indemnification provision of paragraph 7 above shall continue in effect after
any such termination with respect to any withdrawals or requests handled by
Bank
prior to such termination. This Agreement shall be binding upon and
shall inure to the benefit of any successors and assigns of Contractor,
Department, and Bank.
The
undersigned parties have executed this Agreement through their duly authorized
representatives as of the date shown above.
| BANK | CONTRACTOR |
| By: | By: |
| Title: | Title: |
CONTRACTOR’S
CERTIFICATION OF AUTHORITY
The
undersigned hereby certifies that: (1) (s)he is the Secretary of
__________ Contractor; and (2) the foregoing Agreement is consistent with any
corporate or other resolution(s) of Contractor previously or contemporaneously
provided to Bank.
By:
___________________
Title:
__________________
Date
of
Certification:
AUTHORIZED
SIGNATURES
DEPARTMENT
OF ELDER AFFAIRS
|
____________________________
Primary
Signature
|
________________________________
Alternate
Signature
|
| Print Name: | Print Name: |
| Title: | Title: |
Print
Name:Print Name:
Title:
_______________________________Title:
_______________________________
ATTACHMENT
- Page 76
EXHIBIT
B
Long-Term
Care Community Diversion Pilot Project
Disenrollment
Summary Report
|
(Plan
Name)
(Reporting
Month)
Were
any disenrollments filed
during this
reporting
month?
YES NO
|
|||||||||||
|
DISENROLLMENT
|
|||||||||||
|
Last
Name
|
First
Name
|
Medicaid
ID#
|
County
Name
|
Provider
Number
|
Disenrollment
Reason Code*
|
Disenrollment
Reason Occurrence Date
|
|||||
|
1
|
|||||||||||
|
2
|
|||||||||||
|
3
|
|||||||||||
|
4
|
|||||||||||
|
5
|
|||||||||||
|
*
Disenrollment Reason Codes:
|
|||||||||||
|
EXP
= Death
|
NET
= Left Provider Network
|
VOL
= Voluntary for Reason Other than Above
|
|||||||||
|
ELG
= Lost Medicaid Eligibility
|
CTY
= Moved Outside of Service Area
|
FRD
= Fraudulent Use of Medicaid or Plan ID Card
|
|||||||||
|
INV =
Involuntary for Reason Other than Above
|
|||||||||||
|
SUMMARY
|
|||||||||||
|
Total
Disenrollments:
|
__________________
|
||||||||||
ATTACHMENT
- Page 77
EXHIBIT
C
Encounter
Data Reporting Format
Service
Utilization Reporting
|
The
plan shall provide recipient-specific service utilization data in
the
electronic format as specified below. The services reported
represent the comprehensive array of services that might be necessary
to
maintain a member at home while avoiding nursing home placement,
including
acute and long-term care services.
|
These
reports must be provided as ASCII, fixed length text files, with two files,
per recipient, per month. There will be one file for long-term care services
and one file for acute care services. For example, if a recipient were enrolled
for an entire quarter, you would have three separate records in each of two
separate files that are submitted once for the entire quarter. These two files,
the LTC Services file and the Acute Care Services file, must be submitted once
every quarter to your DOEA/AHCA contract manager. You will have up to three
months after the last month in a specific quarter to submit the quarterly
report. Contractors must also resubmit acute care services and
long-term care services updated encounter data for the previous quarter along
with the current quarter.
If
no
units of service are provided in a category or if the category is not applicable
to you, fill that field with the specified number of spaces (using the spacebar)
that match that particular field length. Right justify all fields unless noted
otherwise. For amount paid, include the sum of Medicaid and Medicare
crossover claims (deductibles and co-pays for Medicare claims).* If you have questions about the
definitions of these services please reference the appropriate Medicaid coverage
and limitations handbook for Medicaid state plan services. Note: Please do
not
use commas between fields and round currency to the nearest dollar
amount.
The
contractors shall use the data validation software provided by the department
to
generate data validation reports for long-term care and acute care
services. All “red flag” items on the data validation reports must be
corrected or certified by the contractor. The contractor shall submit
one password protected zipped file that includes the long-term and acute care
services data files, validation report files, and if applicable, certification
files. The contractor shall adhere to the file-naming format located
below.
FILE
1: Long-Term Care Services
|
Field
Name
|
Description
|
Unit
of Measurement
|
Field
Length
|
Start
Col.
|
End
Col.
|
Text/Numeric
|
|
SSN
|
Social
Security Number (left justify)
|
▇▇▇▇▇▇▇▇▇
|
9
|
1
|
9
|
Numeric
|
|
MEDICAID
|
Medicaid
ID Number
|
0000000000
|
10
|
10
|
19
|
Numeric
|
|
ENROLL
|
Initial
Date of Program Enrollment
|
MMYYYY
|
6
|
20
|
25
|
Numeric
|
|
DISENROL
|
Date
of Disenrollment, if Applicable
|
MMYYYY
|
6
|
26
|
31
|
Numeric
|
|
REINST
|
Reinstate
date
|
MMYYYY
|
6
|
32
|
37
|
Numeric
|
|
ALF
|
ALF
Resident Indicator
|
1=Yes;
2=No
|
1
|
38
|
38
|
Numeric
|
|
MONTH
|
Report
Month
|
MMYYYY
|
6
|
39
|
44
|
Numeric
|
|
ADMINS
|
Administrative
Costs
|
Amount
Paid
|
6
|
45
|
50
|
Numeric
|
|
Long-term
care
SERVICES
|
DESCRIPTION
|
UNIT
OF SERVICE/ COST
|
||||
|
ADCOMP
|
Adult
Companion Services
|
15
Minute Unit
|
4
|
51
|
54
|
Numeric
|
|
ADCOMPS
|
Adult
Companion Services
|
Amount
Paid
|
6
|
55
|
60
|
Numeric
|
|
ADAYHLTH
|
Adult
Day Health Services
|
15
Minute Unit
|
4
|
61
|
64
|
Numeric
|
*
Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
enrollees who are also eligible for Medicare.
ATTACHMENT
- Page 78
|
ADAYHL$
|
Adult
Day Health Services
|
Amount
Paid
|
6
|
65
|
70
|
Numeric
|
|
ALFSVS
|
Assisted
Living Services
|
Days
|
2
|
71
|
72
|
Numeric
|
|
ALFSVS$$
|
Assisted
Living Services
|
Amount
Paid
|
6
|
73
|
78
|
Numeric
|
|
ATTCARE
|
Attendant
Care Services
|
15
Minute Unit
|
4
|
79
|
82
|
Numeric
|
|
ATTCARE$
|
Attendant
Care Services
|
Amount
Paid
|
6
|
83
|
88
|
Numeric
|
|
CASEAID
|
Case
Aide
|
15
Minute Unit
|
4
|
89
|
92
|
Numeric
|
|
CASEAID$
|
Case
Aide
|
Amount
Paid
|
6
|
93
|
98
|
Numeric
|
|
CASEMGMT
|
Case
Management (Internal)
|
15
Minute Unit
|
4
|
99
|
102
|
Numeric
|
|
CASEMGT$
|
Case
Management (Internal)
|
Amount
Paid
|
6
|
103
|
108
|
Numeric
|
|
CHORE
|
Chore
Services
|
15
Minute Unit
|
2
|
109
|
110
|
Numeric
|
|
CHORE$
|
Chore
Services
|
Amount
Paid
|
6
|
111
|
116
|
Numeric
|
|
COM_MH
|
Community
Mental Health
|
Visit
|
2
|
117
|
118
|
Numeric
|
|
COM_MH$
|
Community
Mental Health
|
Amount
Paid
|
6
|
119
|
124
|
Numeric
|
|
CNMS_$$
|
Consumable
Medical Supplies
|
Amount
Paid
|
6
|
125
|
130
|
Numeric
|
|
COUNSEL
|
Counseling
|
15
Minute ▇▇▇▇
|
▇
|
▇▇▇
|
▇▇▇
|
▇▇▇▇▇▇▇
|
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
▇▇▇▇
|
6
|
135
|
140
|
Numeric
|
|
|
DME_$$
|
Durable
Medical Equipment
|
Amount
Paid
|
6
|
141
|
146
|
Numeric
|
|
ENVIRAA
|
Environmental
Accessibility Adaptations
|
Job
|
2
|
147
|
148
|
Numeric
|
|
ENVIRRAA$
|
Environmental
Accessibility Adaptations
|
Amount
Paid
|
6
|
149
|
154
|
Numeric
|
|
ESCORT
|
Escort
Services
|
15
Minute Unit
|
4
|
155
|
158
|
Numeric
|
|
ESCORT$
|
Escort
Services
|
Amount
Paid
|
6
|
159
|
164
|
Numeric
|
|
FAMT_I
|
Family
Training Services (Individual)
|
15
Minute Unit
|
2
|
165
|
166
|
Numeric
|
|
FAMT_I$
|
Family
Training Services (Individual)
|
Amount
Paid
|
6
|
167
|
172
|
Numeric
|
|
FAMT_G
|
Family
Training Services (Group)
|
15
Minute Unit
|
2
|
173
|
174
|
Numeric
|
|
FAMT_G$
|
Family
Training Services (Group)
|
Amount
Paid
|
6
|
175
|
180
|
Numeric
|
|
FINARRS
|
Financial
Assessment/Risk Reduction Services
|
15
Minute Unit
|
4
|
181
|
184
|
Numeric
|
|
FINARR$
|
Financial
Assessment/Risk Reduction Services
|
Amount
Paid
|
6
|
185
|
190
|
Numeric
|
|
FINM_RRS
|
Financial
Maintenance/Risk Reduction Services
|
15
Minute Unit
|
4
|
191
|
194
|
Numeric
|
|
FINM_RR$
|
Financial
Maintenance/Risk Reduction Services
|
Amount
Paid
|
6
|
195
|
200
|
Numeric
|
|
HDMEAL
|
Home
Delivered Meals
|
Meal
|
2
|
201
|
202
|
Numeric
|
|
HDMEAL$
|
Home
Delivered Meals
|
Amount
Paid
|
6
|
203
|
208
|
Numeric
|
|
HOMESRVS
|
Homemaker
Services
|
15
Minute Unit
|
4
|
209
|
212
|
Numeric
|
|
HOMESRVC$
|
Homemaker
Services
|
Amount
Paid
|
6
|
213
|
218
|
Numeric
|
|
MH_CM
|
Mental
Health Case Management
|
15
Minute Unit
|
4
|
219
|
222
|
Numeric
|
|
MH_CM$
|
Mental
Health Case Management
|
Amount
Paid
|
6
|
223
|
228
|
Numeric
|
|
SNF
|
Nursing
Facility Services- Long-term
|
Days
|
2
|
229
|
230
|
Numeric
|
|
SNF
$$
|
Nursing
Facility Services-Long-term
|
Amount
Paid
|
6
|
231
|
236
|
Numeric
|
|
NUTR_RRS
|
Nutritional
Assessment/Risk Reduction Services
|
15
Minute Unit
|
4
|
237
|
240
|
Numeric
|
|
NUTR_RR$
|
Nutritional
Assessment/Risk Reduction Services
|
Amount
Paid
|
6
|
241
|
246
|
Numeric
|
|
OT
|
Occupational
Therapy
|
15
Minute Unit
|
4
|
247
|
250
|
Numeric
|
|
OT$
|
Occupational
Therapy
|
6
|
251
|
256
|
||
|
PCS
|
Personal
Care Services
|
15
Minute Unit
|
4
|
257
|
260
|
Numeric
|
|
PC$
|
Personal
Care Services
|
Amount
Paid
|
6
|
261
|
266
|
|
|
PERS_I
|
Personal
Emergency Response System Installation
|
Job
|
2
|
267
|
268
|
Numeric
|
|
PERS_I$
|
Personal
Emergency Response System Installation
|
Amount
Paid
|
6
|
269
|
274
|
Numeric
|
|
PERS_M
|
Personal
Emergency Response System – Maintenance
|
Day
|
2
|
275
|
276
|
Numeric
|
|
PERS_M$
|
Personal
Emergency Response System-Maintenance
|
Amount
Paid
|
6
|
277
|
282
|
Numeric
|
|
PEST_I
|
Pest
Control – Initial Visit
|
Job
|
2
|
283
|
284
|
Numeric
|
|
PEST_I$
|
Pest
Control-Initial Visit
|
Amount
Paid
|
6
|
285
|
290
|
Numeric
|
|
PEST_M
|
Pest
Control – Maintenance
|
Month
|
1
|
291
|
291
|
Numeric
|
ATTACHMENT
- Page 79
|
PEST_M$
|
Pest
Control- Maintenance
|
Amount
Paid
|
6
|
292
|
297
|
Numeric
|
|
PT
|
Physical
Therapy
|
15
Minute ▇▇▇▇
|
▇
|
▇▇▇
|
▇▇▇
|
▇▇▇▇▇▇▇
|
|
▇▇▇
|
Physical
Therapy
|
Amount
Paid
|
6
|
302
|
307
|
Numeric
|
|
RISKREDU
|
Physical
Risk Assessment and Reduction
|
15
Minute Unit
|
4
|
308
|
311
|
Numeric
|
|
RISKRED$
|
Physical
Risk Assessment and Reduction
|
Amount
Paid
|
6
|
312
|
317
|
Numeric
|
|
PRIVNURS
|
Private
Duty Nursing Services
|
15
Minute Unit
|
4
|
318
|
321
|
Numeric
|
|
PRIVNUR$
|
Private
Duty Nursing Services
|
Amount
Paid
|
6
|
322
|
327
|
Numeric
|
|
PT_R
|
Registered
Physical Therapist
|
Visit
|
2
|
328
|
329
|
Numeric
|
|
PT_R$
|
Registered
Physical Therapist
|
Amount
Paid
|
6
|
330
|
335
|
Numeric
|
|
RSPTH
|
Respiratory
Therapy
|
15
Minute Unit
|
4
|
336
|
339
|
Numeric
|
|
RSPTH$
|
Respiratory
Therapy
|
Amount
Paid
|
6
|
340
|
345
|
Numeric
|
|
RESP_HM
|
Respite
Care – In Home
|
15
Minute Unit
|
4
|
346
|
349
|
Numeric
|
|
RESP_HM$
|
Respite
Care- In Home
|
Amount
Paid
|
6
|
350
|
355
|
Numeric
|
|
RESP_FAC
|
Respite
Care – Facility-Based
|
Days
|
2
|
356
|
357
|
Numeric
|
|
RESP_FA$
|
Respite
Care- Facility-Based
|
Amount
Paid
|
6
|
358
|
363
|
Numeric
|
|
NURSE
|
Skilled
Nursing
|
Visit
|
4
|
364
|
367
|
Numeric
|
|
NURSE$
|
Skilled
Nursing
|
Amount
Paid
|
6
|
368
|
373
|
Numeric
|
|
SPTH
|
Speech
Therapy
|
15
Minute Unit
|
4
|
374
|
377
|
Numeric
|
|
SPTH$
|
Speech
Therapy
|
Amount
Paid
|
6
|
378
|
383
|
Numeric
|
|
TRANSPOR
|
Transportation
Services (not included in Escort or Adult Day Health
services)
|
Trips
|
3
|
384
|
386
|
Numeric
|
|
TRANSPOR$
|
Transportation
Services (not included in Escort or Adult Day Health
services)
|
Amount
Paid
|
6
|
387
|
392
|
Numeric
|
|
OTH_UNIT
|
Other
LTC Service not listed (unit)
|
Unit/
Visit
|
6
|
393
|
398
|
Numeric
|
|
DESCR_1
|
Description
of other LTC service
|
35
|
399
|
433
|
Text
|
|
|
OTH_$$
|
Other
LTC service not listed (amount)
|
Amount
Paid
|
6
|
434
|
439
|
Numeric
|
|
DESCR_2
|
Description
of other LTC service
|
35
|
440
|
474
|
Text
|
File
2: Acute Care Services
|
Code
|
Field
Name
|
Description
|
Unit
of Measurement
|
Field
Length
|
Start
Col.
|
End
Col.
|
Text/Numeric
|
|
ACUTE
SERVICES
|
DESCRIPTION
|
UNITS
OF SERVICE/ COST
|
|||||
|
SSN
|
Social
Security Number (left justify)
|
000000000
|
9
|
1
|
9
|
Numeric
|
|
|
MEDICAID
|
Medicaid
ID Number
|
0000000000
|
10
|
10
|
19
|
Numeric
|
|
|
MONTH
|
Report
Month
|
MMYYYY
|
6
|
20
|
25
|
Numeric
|
|
|
CLINIC
|
Clinic
Services
|
Visit
|
2
|
26
|
27
|
Numeric
|
|
|
CLINIC$$
|
Clinic
Services Costs
|
Amount
Paid
|
6
|
28
|
33
|
Numeric
|
|
|
DENTAL
|
Dental
Services
|
Visit
|
6
|
34
|
39
|
Numeric
|
|
|
DENTAL$$
|
Dental
Services Costs
|
Amount
Paid
|
6
|
40
|
45
|
Numeric
|
|
|
DIALYSIS
|
Dialysis
Center
|
Visit
|
2
|
46
|
47
|
Numeric
|
|
|
DIALYS$$
|
Dialysis
Center Costs
|
Amount
Paid
|
6
|
48
|
53
|
Numeric
|
|
|
ER
|
Emergency
Room Services
|
Visit
|
2
|
54
|
55
|
Numeric
|
|
|
ER_$$
|
Emergency
Room Services Costs
|
Amount
Paid
|
6
|
56
|
61
|
Numeric
|
|
|
FQHC
|
FQHC
Services
|
Visit
|
2
|
62
|
63
|
Numeric
|
|
|
FQHC_$$
|
FQHC
Services Costs
|
Amount
Paid
|
6
|
64
|
69
|
Numeric
|
|
|
HEAR
|
Hearing
Services including hearing aids
|
Amount
Paid
|
6
|
70
|
75
|
Numeric
|
|
|
INPTSVS
|
Inpatient
Hospital Services
|
Day
|
3
|
76
|
78
|
Numeric
|
|
|
INPTSV$$
|
Inpatient
Hospital Services Costs
|
Amount
Paid
|
6
|
79
|
84
|
Numeric
|
|
|
LAB
|
Independent
Laboratory or Portable X-ray Services
|
Amount
Paid
|
6
|
85
|
90
|
Numeric
|
|
|
ARNP
|
Nurse
Practitioner Services
|
Visit
|
2
|
91
|
92
|
Numeric
|
|
|
ARNP_$$
|
Nurse
Practitioner Services Costs
|
Amount
Paid
|
6
|
93
|
98
|
Numeric
|
|
|
RX_$$
|
Pharmaceuticals
|
Amount
Paid
|
6
|
99
|
104
|
Numeric
|
ATTACHMENT
- Page 80
|
PA
|
Physical
Assistant
|
Visit
|
2
|
105
|
106
|
Numeric
|
|
|
PA_$$
|
Physical
Assistant Costs
|
Amount
Paid
|
6
|
107
|
112
|
Numeric
|
|
|
MD
|
Physician
Services
|
Visit
|
2
|
113
|
114
|
Numeric
|
|
|
MD_$$
|
Physician
Services Costs
|
Amount
Paid
|
6
|
115
|
120
|
Numeric
|
|
|
OUTPT
|
Outpatient
Hospital Services
|
Encounter
|
3
|
121
|
123
|
Numeric
|
|
|
OUTPT_$$
|
Outpatient
Hospital Services Costs
|
Amount
Paid
|
6
|
124
|
129
|
Numeric
|
|
|
PODIATRY
|
Podiatry
|
Visit
|
2
|
130
|
131
|
Numeric
|
|
|
PODIAT$$
|
Podiatry
Costs
|
Amount
Paid
|
6
|
132
|
137
|
Numeric
|
|
|
RURAL
|
Rural
Health Services
|
Visit
|
2
|
138
|
139
|
Numeric
|
|
|
RURAL$$
|
Rural
Health Services Costs
|
Amount
Paid
|
6
|
140
|
145
|
Numeric
|
|
|
SNFREHA
|
Skilled
nursing facility services- rehabilitation
|
Days
|
2
|
146
|
147
|
Numeric
|
|
|
SNFREHA$
|
Skilled
nursing facility services- rehabilitation**
|
Amount
Paid
|
6
|
148
|
153
|
Numeric
|
|
|
EYE_$$
|
Visual
Services including eyeglasses
|
Amount
Paid
|
6
|
154
|
159
|
Numeric
|
|
|
OTH_UNIT
|
Other
Acute Service not listed (unit)
|
Unit/
Visit
|
6
|
160
|
165
|
Numeric
|
|
|
OTH_$$
|
Other
Acute service not listed (amount)
|
Amount
Paid
|
6
|
166
|
171
|
Numeric
|
|
|
DESCR_1
|
Description
of other Acute service
|
35
|
172
|
206
|
Text
|
||
|
DESCR_2
|
Description
of other Acute service
|
35
|
207
|
241
|
Text
|
**Medicare
Crossovers
Encounter
Data File Naming Format
Replace
*** with the contractor’s prearranged 3-character file code, MON with the
beginning month of the reporting quarter and YY with the reporting
year.
|
Long-Term
Care Services
|
Acute
Care Services
|
|
|
Data
File
|
***
MON YY LTC.txt
|
***
MON YY ACS.txt
|
|
Validation
Report
|
***
MON YY LTC DV.pdf
|
***
MON YY ACS DV.pdf
|
|
Certification
File
(if
applicable)
|
***
MON YY LTC CERT.doc
|
***
MON YY ACS CERT.doc
|
|
ZIP
file
|
***
MON YY.zip
|
|
ATTACHMENT
- Page 81
EXHIBIT
D
Report
of Grievances/Appeals
(Plan
Name)
|
Were
any new grievances filed during this reporting
quarter? YES
|
NO
|
|
Enrollee's Last Name
|
Enrollee's
First Name
|
Enrollee's
Medicaid ID#
|
Enrollee's
Social Security #
|
Grievance
Type
*
|
Grievance
Date
|
Expedited
Request? (Y or N)
|
Disposition
Type **
|
Disposition
Date
|
Resolved?
(Y
or N)
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
|
|
|
|
4
|
|
|
|
|
|
|
|
|
|
|
|
5
|
|
|
|
|
|
|
|
|
|
|
(Reporting
Quarter)
Were
any new appeals filed
during this reporting
quarter? YES NO
|
Enrollee's Last Name
|
Enrollee's
First Name
|
Enrollee's
Medicaid ID#
|
Enrollee's
Social Security #
|
Appeals
Type *
|
Appeals
Date
|
Expedited
Request? (Y or N)
|
Disposition
Type **
|
Disposition
Date
|
Resolved?
(Y
or N)
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
|
|
|
|
4
|
|
|
|
|
|
|
|
|
|
|
|
5
|
|
|
|
|
|
|
|
|
|
|
|
*
Grievance/Appeals Type
|
**
Disposition Type
|
|||
|
1
= Quality of Care
|
7
= Enrollment/Disenrollment
|
1
= Reassigned Case Manager
|
7
= Disenrolled Self
|
|
|
2
= Access to Care
|
8
= Termination of Contract
|
2
= Service Added to Plan of Care
|
8
= Disenrolled by plan
|
|
|
3
= Not Medically
Necessary svcs
|
9
= Unauthorized out of plan
|
3
= Service Increased
|
9
= In QA Review
|
|
|
4
= Excluded Benefit
|
10
= Unauthorized in-plan svcs
|
4
= Changed to Another Provider
|
10
= In Grievance/Appeal
Process
|
|
|
5
= Billing Dispute
|
11
= Benefits available in plan
|
5
= Reinstated in Plan
|
11
= Lost Contact with Enrollee
|
|
|
6
= Contract Interpretation
|
12
= Other
|
6
= Billing Issue Resolved
|
12
= Other
|
|
ATTACHMENT
- Page 82
EXHIBIT
E
Minority
Business Enterprise Contract Reporting
|
Vendor
Name ___________
|
|
|
Quarterly
Vendor
|
|
|
Expenditure
Activity
|
|
|
Reporting
Timeframe
|
Due
Date
|
|
Quarter
1 (January thru March)
|
April
15
|
|
Quarter
2 (April thru June)
|
July
05
|
|
Quarter
3 (July thru September)
|
October
15
|
|
Quarter
4 (October thru December)
|
January
15
|
|
Subcontractor
Name
|
Subcontractor
Address
|
Subcontractor
Telephone #
|
Subcontractor
Federal Identification # or Social Security #
|
Total
Amount Expended
With
Subcontractor (Current Reporting Quarters Only)
|
Total
Amount Expended
With
Subcontractor (Prior Reporting Quarters)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Completed
By:
|
|
|
Telephone
#:
|
|
|
Completion
Date:
|
ATTACHMENT
- Page 83
EXHIBIT
F
Long-Term
Care Community Diversion Pilot Project
Reconciliation
Report
For
(Contractor name) (Month/Year)
|
Last
Name
|
First
Name
|
Medicaid
ID Number
|
Provider
Number
|
Error
Code
|
Comments
|
|
|
1
|
||||||
|
2
|
||||||
|
3
|
||||||
|
4
|
||||||
|
5
|
||||||
|
6
|
||||||
|
7
|
||||||
|
8
|
||||||
|
9
|
||||||
|
10
|
|
Error
Codes
|
Error
Summary Description
|
Error
Codes
|
Error
Summary Description
|
|
01
|
Action
Code Invalid
|
14
|
Recipient
Ineligible
|
|
02
|
HMO
Number Invalid
|
15
|
Recipient
Already enrolled
|
|
03
|
HMO
Number Not Found
|
16
|
Invalid
Recipient AID Cat
|
|
04
|
Recipient
ID Not Found
|
17
|
Capitation
Group Not Covered
|
|
05
|
Recipient
ID Not on File
|
18
|
Transaction
Date Invalid
|
|
06
|
Recipient
Date of Birth Invalid
|
19
|
Transaction
Date Incorrect
|
|
07
|
Recipient
Date of Birth Unmatched
|
20
|
Outpatient
Dollars Invalid
|
|
08
|
Recipient
Has Major Medical
|
21
|
Inpatient
Units Invalid
|
|
09
|
HMO
Not A Medicaid Provider
|
22
|
Invalid
Fiscal Year
|
|
10
|
Recipient
Amount Not Met
|
23
|
Bad
Capitation Update
|
|
11
|
Recipient
Not Enrolled
|
24
|
Cancelled
by Choice Counselor
|
|
12
|
Recipient
Enrolled In Other HMO
|
25
|
Recipient
In a Nursing Home
|
|
13
|
Enrollment
Error
|
ATTACHMENT
- Page 84
EXHIBIT
G
DEPARTMENT
OF ELDER AFFAIRS
LONG-TERM
CARE DIVERSION PILOT PROJECT
REQUEST
FOR DISENROLLMENT
CURRENT
PROVIDER NAME: _________________________ COUNTY:
_____________________________
PROVIDER
ADDRESS: ___________________________
TELEPHONE
NUMBER:( )
FAX:( )
PARTICIPANT
NAME: ________________________________________
MEDICAID
#: __________________________ SS#: ____________________________DOB:_________________________________
PARTICIPANT
ADDRESS:______________________________________________________________________________________
COUNTY:_____________________________________
TELEPHONE
NUMBER:
( )
EFFECTIVE DATE:
____________________________________________
COMMENTS:
________________________________________________________________________________________________
Does
enrollee wish to file a grievance?[ ]
Yes[ ] No
|
VOLUNTARY
(Check All That Apply):
|
|
|
□Dissatisfied
with services
□Dissatisfied
with plan
□Moving
to out-of-network nursing home
|
□Moving
to out-of-network ALF
□No
longer wish to participate in diversion program
□Request
new provider
|
|
Signature
of Participant or Authorized Representative
|
Date
|
|
|
If
representative, please print name
|
Please
state relationship to participant
|
FOR
DIVERSION PROVIDER USE ONLY
|
INVOLUNTARY
(Check All That Apply):
|
|
|
□Death
(Date: ____________________)
□Not
eligible for program
□Moving
out of the service area
□Fraudulent
use of Medicaid ID card
|
□Incarceration
□Non-cooperation,
subject to Department approval
□Other
|
|
Case
Manager Signature
|
Date
CARES Office Notified
|
|
|
Program
Administrator Signature
|
CARES
Fax Number
|
|
|
□REQUEST
FOR TRANSFER TO NEW PROVIDER
NAME
OF NEW
PROVIDER: COUNTY:
|
||
ATTACHMENT
- Page 85
EXHIBIT
H
|
Provider
Name
|
|
|
|
|
|
|
|
|
|
|
▇▇▇▇▇▇
▇▇▇▇▇▇▇
|
|
|
|
|
|
|
|
|
|
|
▇▇▇▇,
▇▇ ZIP
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Phone:
|
Plan
Contact:
|
|
|
|
|
|
|
|
|
|
FAX
:
|
Email:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
List
Date x/xx/xx
|
|
|
|
|
|
|
|
|
|
|
Covered
Services
|
Provider
Name
|
Name
of Provider Contact
|
Phone
Number
|
Street
Address
|
City
|
State
|
Zip
Code
|
County
Served
|
Comments
|
|
Adult
Companion Services
|
|||||||||
|
Adult
Companion Services
|
|||||||||
|
Adult
Day Health Services
|
|||||||||
|
Adult
Day Health Services
|
|||||||||
|
Assisted
Living Services
|
|||||||||
|
Assisted
Living Services
|
|||||||||
|
Case
Management Services
|
|||||||||
|
Chore
Services
|
|||||||||
|
Chore
Services
|
|||||||||
|
Consumable
Medical Supply Services
|
|||||||||
|
Consumable
Medical Supply Services
|
|||||||||
|
Dental
|
|||||||||
|
Dental
|
|||||||||
|
Environmental
Accessibility Adaptation Services
|
|||||||||
|
Environmental
Accessibility Adaptation Services
|
|||||||||
|
Escort
Services
|
|||||||||
|
Escort
Services
|
|||||||||
|
Family
Training Services
|
|||||||||
|
Family
Training Services
|
|||||||||
|
Financial
Assessment/Risk Reduction Services
|
|||||||||
|
Financial
Assessment/Risk Reduction Services
|
|||||||||
|
Hearing
|
|||||||||
|
Hearing
|
|||||||||
|
Home
Delivered Meals
|
|||||||||
|
Home
Delivered Meals
|
ATTACHMENT
- Page 86
|
Homemaker
Services
|
|||||||||
|
Homemaker
Services
|
|||||||||
|
Nursing
Facility Services
|
|||||||||
|
Nursing
Facility Services
|
|||||||||
|
Nutritional
Assessment/Risk Reduction Services
|
|||||||||
|
Nutritional
Assessment/Risk Reduction Services
|
|||||||||
|
Occupational
Therapy
|
|||||||||
|
Occupational
Therapy
|
|||||||||
|
Personal
Care Services
|
|||||||||
|
Personal
Care Services
|
|||||||||
|
Personal
Emergency Response Systems (PERS):
|
|||||||||
|
Personal
Emergency Response Systems (PERS):
|
|||||||||
|
Physical
Therapy
|
|||||||||
|
Physical
Therapy
|
|||||||||
|
Respite
Care Services
|
|||||||||
|
Respite
Care Services
|
|||||||||
|
Speech
Therapy
|
|||||||||
|
Speech
Therapy
|
|||||||||
|
Vision
|
|||||||||
|
Vision
|
|||||||||
|
Optional
Services
|
|||||||||
|
Transportation
Services
|
|||||||||
|
Expanded
Services
|
|
Staff
Positions
|
Staff
Name
|
Phone
Number
|
Email
|
Fax
Number
|
|
Contract
Manager / Plan Administrator
|
||||
|
Case
Management Supervisor
|
||||
|
Case
Manager
|
||||
|
Data
Processing
|
||||
|
Grievance
Coordinator
|
||||
|
Medical
Director
|
||||
|
Medical
Records Coordinator
|
||||
|
Member
Services
|
||||
|
Quality
Assurance Coordinator
|
||||
|
Training
Coordinator
|
||||
|
Utilization
Review
|
ATTACHMENT
- Page 87
EXHIBIT I
Capitation
Rates
|
Provider
ID
|
Provider
Name
|
County
Name
|
9/1/07
– 8/31/2008 Diversion Capitation Rate
|
|
015077100
|
WellCare
|
Orange
|
$1,364.51
|
|
015077101
|
WellCare
|
Osceola
|
$1,364.51
|
|
015077102
|
WellCare
|
Seminole
|
$1,364.51
|
|
015077103
|
WellCare
|
▇▇▇▇▇
|
$1,425.92
|
The following table lists the initial rates for prospective expansions.
|
PSA
|
Counties
|
2007-2008
Diversion
Capitation
Rate
|
|||||
|
1
|
Escambia,
Okaloosa, Santa ▇▇▇▇, and ▇▇▇▇▇▇
|
$ |
1534.02
|
||||
|
2
|
Bay,
Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, ▇▇▇▇▇▇▇▇▇, ▇▇▇▇,
Liberty, Madison, Taylor, Wakulla, and Washington
|
$ |
1534.02
|
||||
|
3
|
Alachua,
Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, ▇▇▇▇, ▇▇▇▇▇▇, Putnam, Sumter, Suwannee, and
Union
|
$ |
1564.84
|
||||
|
4
|
Baker,
Clay, Duval, Flagler, Nassau, St. ▇▇▇▇▇, and Volusia
|
$ |
1425.92
|
||||
|
5
|
Pasco
and Pinellas
|
$ |
1590.39
|
||||
|
▇
|
▇▇▇▇▇▇,
▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇, Manatee, and Polk
|
$ |
1563.27
|
||||
|
▇
|
▇▇▇▇▇▇▇,
▇▇▇▇▇▇, ▇▇▇▇▇▇▇ and Seminole
|
$ |
1364.51
|
||||
|
8
|
Charlotte,
Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
|
$ |
1549.66
|
||||
|
9
|
Indian
River, ▇▇▇▇▇▇, Okeechobee, Palm Beach and St. Lucie
|
$ |
1531.56
|
||||
|
10
|
Broward
|
$ |
1579.69
|
||||
|
11
|
Miami-Dade
and Monroe
|
$ |
1591.75
|
||||
ATTACHMENT
- Page 88
EXHIBIT J
SWORN
STATEMENT PURSUANT TO CHAPTER 287.133(3)(a),
FLORIDA
STATUTES, ON PUBLIC ENTITY CRIMES
THIS
FORM
MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL
AUTHORIZED TO ADMINISTER OATHS.
|
|
1.This
sworn statement is submitted to the Florida Department of Elder
Affairs by
▇▇▇▇ ▇. ▇▇▇▇▇, President & CEO for
WellCare of Florida, Inc. dba WelllCare Senior Partnership whose
business address is ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ and,
if applicable, its Federal Employer Identification Number (FEIN)
is
___________________If
the entity has no FEIN, include the Social Security Number of the
individual signing this sworn statement:
_____________________________________
|
|
|
2.I
understand that a "public entity crime" as defined in Paragraph
287.133(1)(g), Florida Statutes, means a violation of any state or
federal law by a person with respect to and directly related to the
transaction of business with any public entity or with an agency
or
political subdivision of any other state or of the United States,
including, but not limited to, any bid or contract for goods or services
to be provided to any public entity or an agency or political subdivision
of any other state or of the United States and involving antitrust,
fraud,
theft, bribery, collusion, racketeering, conspiracy, or material
representation.
|
|
|
3.I
understand that "convicted" or "conviction" as defined in Paragraph
287.133(1)(b), Florida Statutes, means a finding of guilt or a
conviction of a public entity crime, with or without an adjudication
of
guilt, in any federal or state trial court of record relating to
charges
brought by indictment or information after July 1, 1989, as a result
of a
jury verdict, non-jury trial, or entry of a plea of guilty or nolo
contendere.
|
|
|
4.I
understand that an "affiliate" as defined in Paragraph 287.133(1)(a),
Florida Statutes, means:
|
|
|
a.A
predecessor or successor of a person convicted of a public entity
crime;
or
|
|
|
b.An
entity under the control of any natural person who is active in the
management of the entity and who has been convicted of a public entity
crime. The term "affiliate" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents
who are
active in the management of the affiliate. The ownership by one
person of shares constituting a controlling interest in another person,
or
a pooling of equipment or income among persons when not for fair
market
value under an arm's length agreement, shall be a prima facie case
that
one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted
of a
public entity crime in Florida during the preceding 36 months shall
be
considered an affiliate.
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5.I
understand that a "person" as defined in Paragraph 287.133(1)(e),
Florida Statutes, means any natural person or entity organized
under the laws of any state or of the United States with the legal
power
to enter into a binding contract and which bids or applies to bid
on
contracts for the provision of goods or services let by a public
entity,
or which otherwise transacts or applies to transact business with
a public
entity. The term "person" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents
who are
active in management of an entity.
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6.Based
on information and belief, the statement which I have marked below
is true
in relation to the entity submitting this sworn
statement. (Indicate which statement
applies.)
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x
Neither the entity submitting this sworn statement, nor any of its officers,
directors, executives, partners, shareholders, employees, members, or agents
who
are active in the management of the entity, nor any affiliate of the entity
has
been charged with and convicted of a public entity crime subsequent to July
1,
1989.
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, or agents
who
are active in the management of the entity, or an affiliate of the entity has
been charged with and convicted of a public entity subsequent to July 1,
1989.
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, or agents
who
are active in the management of the entity, or an affiliate of the entity has
been charged with and convicted of a public entity subsequent to July 1,
1989. However, there has been a subsequent proceeding before a
Hearing Officer of the State of Florida, Division of Administrative Hearings
and
the Final Order entered by the Hearing Officer determined that it was not in
the
public interest to place the entry submitting this sworn statement on the
convicted vendor list. (Attach a copy of the final
order.)
I
UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR
IN
WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE
PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD
PROVIDED IN CHAPTER 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY
CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
/s/ ▇▇▇▇ ▇▇▇▇▇
(signature)
8/23/07
(date)
STATE
OF
Florida
COUNTY
OF
Hillsborough
PERSONALLY
APPEARED BEFORE ME, the
undersigned authority, ▇▇▇▇ ▇▇▇▇▇
who,
after first being sworn by me, affixed his/her signature in the
(name
of
individual signing)
space
provided above on this 23 day of August, 2007.
ATTACHMENT
- Page 89
| INSTRUCTIONS |
CONTRACT#▇▇▇▇-▇▇▇▇-▇▇
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CERTIFICATION
REGARDING DEBARMENT,
SUSPENSION, INELIGIBILITY
AND
VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS
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EXHIBIT
K
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1.Each
recipient or vendor whose contract equals or exceeds $100,000 in
federal
monies must sign this debarment certification prior to contract
execution. Independent auditors who audit federal programs
regardless of the dollar amount are required to sign a debarment
certification form. Neither the Department of Elder Affairs nor
its contract recipients or vendors can contract with subrecipients
if they
are debarred or suspended by the federal
government.
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2.This
certification is a material representation of fact upon which reliance
is
placed when this contract is entered into. If it is later
determined that the signed knowingly rendered an erroneous certification,
the Federal Government may pursue available remedies, including suspension
and/or debarment.
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3.The
recipient or vendor shall provide immediate written notice to the
contract
manager at any time the recipient or vendor learns that its certification
was erroneous when submitted or has become erroneous by reason of
changed
circumstances.
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4.The
terms “debarred,” “suspended,” “ineligible,” “person,” “principal,” and
“voluntarily excluded,” as used in this certification, have the meanings
set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549 and 45 CFR (Code of Federal Regulations), Part
76. You may contact the contract manager for assistance in
obtaining a copy of those
regulations.
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5.The
recipient or vendor further agrees by submitting this certification
that,
it shall not knowingly enter into any subcontract with a person who
is
debarred, suspended, declared ineligible, or voluntarily excluded
from
participation in this contract unless authorized by the Federal
Government.
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6.The
recipient or vendor further agrees by submitting this certification
that
it will require each subrecipient of this contract whose payment
will
equal or exceed $100,000 in federal monies, to submit a signed copy
of
this certification with each
contract.
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7.The
Department of Elder Affairs and its contract recipients or vendor
may rely
upon a certification of a recipient/subrecipients that is not debarred,
suspended, ineligible, or voluntarily exclude from
contracting/subcontracting unless it knows that the certification
is
erroneous.
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8.If
the recipient or vendor is an Area Agency on Aging (AAA), the AAA
may rely
upon a certification of a recipient/subrecipient or vendor entity
that is
not debarred, suspended, ineligible, or voluntarily
excluded from
contracting/subcontracting unless the
AAA knows that the
certification is
erroneous.
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9.The
signed certifications of all
subrecipients or vendors shall
be kept on file with
recipient.
|
DOEA
FORM
112A
(Revised
May 2002)
ATTACHMENT
- Page 90
| INSTRUCTIONS |
|
|
CERTIFICATION
REGARDING DEBARMENT,
SUSPENSION, INELIGIBILITY
AND
VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS
|
This certification is required by the regulation implementing Executive Order 12549, Debarment and Suspension, signed February; 18, 1986. The guidelines were published in the May 29, 1987 Federal Register (52 Fed. Reg., pages 20360-20369).
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(1)The
prospective recipient or
vendor certifies, by signing this certification, that neither he
nor his principals is presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation
in contracting with the Department of Elder Affairs by any federal
department or agency.
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(2)Where
the prospective recipient or vendor is unable
to
certify to any of the statements in this certification, such prospective
recipient or vendor shall attach an explanation to this
certification.
|
Signature
/s/ ▇▇▇▇ ▇. ▇▇▇▇▇
Date:
8/23/07
▇▇▇▇ ▇▇▇▇▇, President &
CEO
Name
and
Title of Authorized Individual
(Print
or
type)
WellCare
of Florida, Inc.
Name
of
Organization
DOEA
FORM
112B
(Revised
May 2002)
ATTACHMENT
- Page 91
EXHIBIT
L
|
HOSPICE
ENROLLMENT REPORT
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||||
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Number
of new enrollees electing hospice by month
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||||
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Contractor
_______________________________
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||||
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Month
of _____________________
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||||
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County
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Number
of new enrollees
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For
Profit
|
Not
for Profit
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1
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||||
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2
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3
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4
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5
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6
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8
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9
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10
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12
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13
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15
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16
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25
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Submitted
by:____________________________
|
||||
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Submit
to your contract manager by the 15 days after the reporting
month.
|
||||
ATTACHMENT
- Page 92
ATTACHMENT
II
CERTIFICATION
REGARDING LOBBYING
CERTIFICATION
FOR CONTRACTS, GRANTS, LOANS AND
COOPERATIVE
AGREEMENT
The
undersigned certifies, to the best of his or her knowledge and belief,
that:
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(1)No
federal appropriated funds have been paid or will be paid, by or
on behalf
of the undersigned, to any person for influencing or attempting to
influence an officer or employee of any state or federal agency,
a member
of congress, an officer or employee of congress, an employee of a
member
of congress, or an officer or employee of the state legislator, in
connection with the awarding of any federal grant, the making of
any
federal loan, the entering into of any cooperative agreement, and
the
extension, continuation, renewal, amendment, or modification of any
federal contract, grant, loan, or cooperative
agreement.
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(2)If
any funds other than federal appropriated funds have been paid or
will be
paid to any person for influencing or attempting to influence an
officer
or employee of any agency, a member of congress, an officer or employee
of
congress, or an employee of a member of congress in connection with
this
federal contract, grant, loan, or cooperative agreement, the undersigned
shall complete and submit Standard Form-LLL, "Disclosure Form to
Report
Lobbying," in accordance with its
instructions.
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(3)The
undersigned shall require that the language of this certification
be
included in the award documents for all sub-awards at all tiers (including
subcontracts, sub-grants, and contracts under grants, loans and
cooperative agreements) and that all sub-recipients shall certify
and
disclose accordingly.
|
This
certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of
this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, Title 31, U.S. Code. Any person
who fails to file the required certification shall be subject to a civil penalty
of not less than $10,000 and not more than $100,000 for each such
failure.
Signature
/s/ ▇▇▇▇ ▇. ▇▇▇▇▇
Date:
8/23/07
▇▇▇▇
▇▇▇▇▇
Nameof
Authorized Individual
(Print
or
type)
XQ744
Application
or Contract Number
WellCare
of Florida, Inc. ▇.▇ ▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇, ▇▇ ▇▇▇▇▇
Name
of
Organization
DOEA
FORM
112B
(Revised
May 2002)
ATTACHMENT
II -Page 1
ATTACHMENT III
CERTIFICATION
REGARDING DATA INTEGRITY COMPLIANCE
|
|
FOR
CONTRACTS, GRANTS, LOANS
AND
|
COOPERATIVE
AGREEMENTS
The
undersigned, an authorized representative of the recipient named in the contract
or agreement to which this form is an attachment, hereby certifies
that:
|
|
(1)The
recipient and any sub-recipients of services under this contract
have
financial management systems capable of providing certain information,
including: (1) accurate, current, and complete disclosure of the
financial
results of each grant-funded project or program in accordance with
the
prescribed reporting requirements; (2) the source and application
of funds
for all contract supported activities; and (3) the comparison of
outlays
with budgeted amounts for each award. The inability to process
information in accordance with these requirements could result in
a return
of grant funds that have not been accounted for
properly.
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(2)Management
Information Systems used by the recipient, sub-recipient(s), or any
outside entity on which the recipient is dependent for data that
is to be
reported, transmitted or calculated, have been assessed and verified
to be
capable of processing data accurately, including year-date dependent
data.
For those systems identified to be non-compliant, recipient(s) will
take
immediate action to assure data
integrity.
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(3)If
this contract includes the provision of hardware, software, firmware,
microcode or imbedded chip technology, the undersigned warrants that
these
products are capable of processing year-to-date dependent data accurately.
All versions of these products offered by the recipient (represented
by
the undersigned) and purchased by the State will be verified for
accuracy
and integrity of data prior to
transfer.
|
In
the
event of any decrease in functionality related to time and date related codes
and internal subroutines that impede the hardware or software programs from
operating properly, the recipient agrees to immediately make required
corrections to restore hardware and software programs to the same level of
functionality as warranted herein, at no charge to the State, and without
interruption to the ongoing business of the state, time being of the
essence.
|
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(4)The
recipient and any sub-recipient(s) of services under this contract
warrant
their policies and procedures include a disaster plan to provide
for
service delivery to continue in case of an emergency including emergencies
arising from data integrity compliance
issues.
|
The
recipient shall require that the language of this certification be included
in
all subcontracts, subgrants, and other agreements and that all sub-contractors
shall certify compliance accordingly.
This
certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of
this certification is a prerequisite for making or entering into this
transaction imposed by OMB Circulars A-102 and A-110.
|
WellCare
of Florida, Inc. bda WellCare Senior Partnership, ▇▇▇▇ ▇▇▇▇▇▇▇▇▇
▇▇▇▇
▇▇▇▇▇, ▇▇ ▇▇▇▇▇
|
||
|
Name
and Address of Recipient
|
||
|
/s/ ▇▇▇▇
▇. ▇▇▇▇▇
|
President
& CEO
|
8/23/07
|
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Signature
|
Title
|
Date
|
|
▇▇▇▇
▇. ▇▇▇▇▇
|
||
|
Name
of Authorized ▇▇▇▇▇▇
|
||
ATTACHMENT
III -Page 1
ATTACHMENT IV
AGREEMENT
TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID
PENDING
|
_______
|
No,
contractor does not elect to provide services to individuals designated
as
Medicaid Pending.
|
|
_______
|
Yes,
contractor elects to provide services to individuals designated as
Medicaid Pending.
|
By
checking YES above, contractor agrees to provide services to individuals
referred to them by CARES who have been designated as Medicaid Pending in
accordance with Section 430.705(5), Florida Statutes. The contractor
will meet all conditions of this contract and the following:
|
|
a.The
contractor is responsible for compliance with all pertinent insurance
laws
and regulations prior to providing services to Medicaid Pending
individuals.
|
|
|
b.CARES
staff will refer individuals, identified as Medicaid pending and
who
choose to receive Medicaid Pending services, to the chosen
contractor. Included with the referral will be the Freedom of
Choice form, 701 B Assessment, 3008, Informed Consent, and the Level
of
Care.
|
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c.The
contractor may assist Medicaid pending individuals through the Medicaid
financial eligibility process by submitting the ACCESS Florida Application
(online or hardcopy) to the Department of Children and Families and
when
contacted by DCF, forward at a minimum the following documentation:
Financial Release (CF ES 2613), CARES’ level of care decision (Form 603)
and the Certification of Enrollment Status (HCBS) (CF-AA
2515). Applications may be completed and submitted online at
the following
website: ▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇▇
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d.Once
the individual is determined financially eligible, the contractor
must
notify CARES and provide a copy of the Notice of Case Action within
two
business days of receipt.
|
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e.The
contractors will be responsible for submitting 834 enrollment transactions
to the Medicaid fiscal agent one week prior to the regular submission
date
for only the Medicaid pending individuals. The enrollment date
will be retroactive to the first of the month following the CARES
eligibility determination, not to exceed four (4)
months.
|
|
|
▇.▇▇▇▇▇▇▇▇
must be in place on the first of the month following the CARES eligibility
determination.
|
|
|
g.The
contractor will be paid the capitation rate for services rendered
retroactive to the first of the month following the CARES eligibility
determination, not to exceed four (4) months. The
contractor shall make available, on request from the department,
proof of
services, which meet the timeframes listed
above.
|
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h.Payment
will be made once full financial eligibility has been
determined.
|
|
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▇.▇▇
the event the individual is
determined not to be financially eligible by the Department of Children
& Families, the contractor must notify CARES and can seek
reimbursement from the individual in accordance with the Medicaid
Coverage
and Limitations Handbooks and the associated fee
schedules.
|
Signature
/s/ ▇▇▇▇ ▇.
▇▇▇▇▇
Date
8/23/2007
▇▇▇▇
▇. ▇▇▇▇▇, President & CEO
Name
and
Title of Authorized Individual (Print or type)
ATTACHMENT
IV -Page 1