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Exhibit 10.7
STATE OF ILLINOIS
DEPARTMENT OF PUBLIC AID
CONTRACT FOR FURNISHING HEALTH SERVICES
BY A
HEALTH MAINTENANCE ORGANIZATION
APRIL 1, 2000
ILLINOIS DEPARTMENT OF PUBLIC AID
DIVISION OF MEDICAL PROGRAMS
BUREAU OF MANAGED CARE
▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
▇▇▇ ▇▇▇▇▇
DIRECTOR
▇▇▇▇ ▇▇▇▇▇▇, ADMINISTRATOR
DIVISION OF MEDICAL PROGRAMS
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TABLE OF CONTENTS
PAGE(s)
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Article I
Definitions...........................................................................................................2
Article II
Terms and Conditions..................................................................................................8
2.1 Specification.............................................................................................8
2.2 Rules of Construction.....................................................................................8
2.3 Performance of Services and Duties........................................................................9
2.4 Language Requirements.....................................................................................9
(a) Key Oral Contacts.............................................................................9
(b) Written Material.............................................................................10
2.5 List of Individuals in an Administrative Capacity........................................................10
2.6 Certificate of Authority.................................................................................10
2.7 Obligation to Comply with other Laws ....................................................................10
Article III
Eligibility..........................................................................................................12
3.1 Determination of Eligibility.............................................................................12
3.2 Enrollment Generally.....................................................................................12
3.3 Enrollment Limits........................................................................................12
3.4 Expansion to Other Contracting Areas.....................................................................13
Article IV
Enrollment, Coverage and Termination of Coverage.....................................................................14
4.1 Enrollment Process.......................................................................................14
4.2 Initial Coverage.........................................................................................16
4.3 Period of Enrollment.....................................................................................17
4.4 Termination of Coverage..................................................................................17
4.5 Preexisting Conditions and Treatment.....................................................................19
4.6 Continuity of Care.......................................................................................19
4.7 Change of Site and Primary Care Provider or Women's Health Care Provider.................................19
Article V
Duties of Contractor.................................................................................................21
5.1 Services.................................................................................................21
(a) Amount, Duration and Scope of Coverage.......................................................21
(b) Enumerated Covered Services..................................................................21
(c) Behavioral Health Services...................................................................22
(d) Services to Prevent Illness and Promote Health...............................................23
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(e) Exclusions from Covered Services.............................................................24
(f) Limitations on Covered Services..............................................................24
(g) Right of Conscience..........................................................................25
(h) Emergency Services...........................................................................25
(i) Post-Stabilization Services..................................................................26
(j) Additional Services or Benefits..............................................................26
(k) Telephone Access.............................................................................27
(l) Pharmacy Formulary...........................................................................27
5.2 Certified Local Health Department Services...............................................................28
5.3 Marketing................................................................................................29
5.4 Inappropriate Activities.................................................................................34
5.5 Obligation to Provide Information .......................................................................35
5.6 Quality Assurance, Utilization Review and Peer Review....................................................36
5.7 Physician Incentive Plan Regulations.....................................................................37
5.8 Prohibited Affiliations..................................................................................37
5.9 Records..................................................................................................38
(a) Maintenance of Business Records..............................................................38
(b) Availability of Business Records.............................................................38
(c) Patient Records..............................................................................38
5.10 Computer System Requirements ............................................................................39
5.11 Regular Report and Submission Requirements...............................................................40
5.12 Health Education.........................................................................................45
5.13 Required Minimum Standards of Care.......................................................................46
(a) Healthy Kids/EPSDT Services to Beneficiaries Under Twenty-One (21) Years.....................46
(b) Preventive Medicine Schedule (Services to Beneficiaries Twenty-One (21) Years of Age and
Over)........................................................................................47
(c) Maternity Care...............................................................................50
(d) Complex and Serious Medical Conditions.......................................................51
(e) Access Standards.............................................................................51
(f) Linkages to Other Services...................................................................52
5.14 Choice of Physicians.....................................................................................53
5.15 Timely Payments to Providers.............................................................................53
5.16 Grievance Procedure and Beneficiary Satisfaction Survey..................................................54
5.17 Provider Agreements and Subcontracts.....................................................................55
5.18 Site Registration and Primary Care Provider/Women's Health Care Provider Approval and Credentialing......57
5.19 Advance Directives.......................................................................................58
5.20 Fees to Beneficiaries Prohibited.........................................................................58
5.21 Fraud and Abuse Procedures...............................................................................58
5.22 Beneficiary-Provider Communications......................................................................59
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Article VIDuties of the Department...................................................................................61
6.1 Enrollment...............................................................................................61
6.2 Payment..................................................................................................61
6.3 Limitation of Payment by the Department..................................................................61
6.4 Department Review of Contractor Materials................................................................61
6.5 Eligible Enrollee Education Program......................................................................62
Article VII
Payment and Funding..................................................................................................63
7.1 Payment Rates............................................................................................63
7.2 Adjustments..............................................................................................64
7.3 Copayments under KidCare.................................................................................64
7.4 Availability of Funds....................................................................................64
7.5 Hold Harmless............................................................................................65
7.6 Payment in Full..........................................................................................65
Article VIII
Term Renewal and Termination.........................................................................................66
8.1 Term.....................................................................................................66
8.2 Continuing Duties in the Event of Termination............................................................66
8.3 Termination With and Without Cause.......................................................................66
8.4 Automatic Termination....................................................................................67
8.5 Reimbursement in the Event of Termination................................................................67
Article IX
General Terms........................................................................................................68
9.1 Records Retention, Audits, and Reviews...................................................................68
9.2 Nondiscrimination........................................................................................69
9.3 Confidentiality of Information...........................................................................69
9.4 Notices..................................................................................................70
9.5 Required Disclosures.....................................................................................70
(a) Conflict of Interest.........................................................................70
(b) Disclosure of Interest.......................................................................71
9.6 HCFA Prior Approval......................................................................................72
9.7 Assignment...............................................................................................72
9.8 Similar Services.........................................................................................72
9.9 Amendments...............................................................................................72
9.10 Sanctions ...............................................................................................73
(a) Failure to Report or Submit .................................................................73
(b) Failure to Submit Encounter Data.............................................................73
(c) Failure to Meet Minimum Standards of Care....................................................74
(d) Imposition of Prohibited Charges.............................................................74
(e) Misrepresentation or Falsification of Information............................................74
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(f) Failure to Comply with the Physician Incentive Plan Requirements.............................74
(g) Failure to Meet Access Standards.............................................................75
(h) Failure to Provide Covered Services..........................................................75
(i) Discrimination Related to Pre-Existing Conditions............................................75
(j) Pattern of Marketing Failures................................................................75
(k) Other Failures...............................................................................75
9.11 Sale or Transfer.........................................................................................76
9.12 Coordination of Benefits for Beneficiaries...............................................................76
9.13 Agreement to Obey All Laws...............................................................................77
9.14 Severability.............................................................................................77
9.15 Contractor's Disputes With Other Providers...............................................................77
9.16 Choice of Law............................................................................................77
9.17 Debarment Certification..................................................................................77
9.18 Child Support, State Income Tax and Student Loan Requirements............................................78
9.19 Payment of Dues and Fees.................................................................................78
9.20 Federal Taxpayer Identification..........................................................................78
9.21 Drug Free Workplace......................................................................................78
9.22 Lobbying.................................................................................................78
9.23 Early Retirement .......................................................................................79
9.24 Sexual Harassment ......................................................................................79
9.25 Independent Contractor .................................................................................79
9.26 Solicitation of Employees ..............................................................................80
9.27 Nonsolicitation..........................................................................................80
9.28 Ownership of Work Product................................................................................80
9.29 Bribery Certification....................................................................................81
9.30 Nonparticipation in International Boycott................................................................81
9.31 Computational Error......................................................................................81
9.32 Survival of Obligations..................................................................................81
9.33 Clean Air Act and Clean Water Act Certification..........................................................81
9.34 Non-Waiver...............................................................................................82
9.35 Notice of Change in Circumstances........................................................................82
9.36 Public Release of Information............................................................................82
9.37 Payment in Absence of Federal Financial Participation....................................................82
9.38 Employment Reporting.....................................................................................82
9.39 Certification of Participation...........................................................................83
9.40 Indemnification..........................................................................................83
9.41 Gifts....................................................................................................83
9.42 Business Enterprise for Minorities, Females and Persons with Disabilities................................84
Attachment I - Rate Sheets
Attachment II - KidCare Participation Option
Attachment III - Drug Free Workplace Agreement
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Attachment IV - Business Enterprise Program Contracting Goal
Exhibit A - Quality Assurance
Exhibit B - Utilization Review/Peer Review
Exhibit C - Summary of Required Reports
Exhibit D - Summary of Required Submissions
Exhibit E - Encounter Data Format Requirements
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STATE OF ILLINOIS
DEPARTMENT OF PUBLIC AID
CONTRACT FOR FURNISHING HEALTH SERVICES
THIS CONTRACT FOR FURNISHING HEALTH SERVICES ("Contract") made,
pursuant to Section 5-11 of the Illinois Public Aid Code (305 ILCS 5/5-11), is
by and between the ILLINOIS DEPARTMENT OF PUBLIC AID ("Department"), acting by
and through its Director, and AMERICAID ILLINOIS, INC. d/b/a/ AMERICAID
COMMUNITY CARE ("Contractor"), who certifies that it is a Health Maintenance
Organization and whose principal office is located at ▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇
▇▇▇▇, ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇.
RECITALS
WHEREAS, the Contractor is a Health Maintenance Organization
operating pursuant to a Certificate of Authority issued by the Illinois
Department of Insurance and wishes to provide Covered Services to Eligible
Enrollees (as defined herein);
WHEREAS, the Department, pursuant to the laws of the State of
Illinois, provides for medical assistance under the Medical Assistance Program
or KidCare to Participants wherein Eligible Enrollees may enroll with the
Contractor to receive Covered Services; and
WHEREAS, the Contractor warrants that it is able to provide and/or
arrange to provide the Covered Services set forth in this Contract to
Beneficiaries under the terms and conditions set forth herein;
NOW, THEREFORE, in consideration of the mutual covenants and
promises contained herein, the parties agree as follows:
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Article I
DEFINITIONS
The following terms as used in this Contract and the attachments,
exhibits and amendments hereto shall be construed and interpreted as follows,
unless the context otherwise expressly requires a different construction and
interpretation:
ABUSE means a manner of operation that results in excessive or unreasonable
costs to the Federal and/or State health care programs.
ADMINISTRATIVE RULES means the rules promulgated by the Department governing the
Medical Assistance Program or KidCare.
AFFILIATED means associated with another party for the purpose of providing
health care services under a Contractor's Plan pursuant to a contract or other
form of written agreement.
AUTHORIZED PERSON means a representative of the Office of Inspector General for
the Department, the Illinois Medicaid Fraud Control Unit, the United States
Department of Health and Human Services, a representative of other State and
federal agencies with monitoring authority related to the Medical Assistance
Program or KidCare, and a representative of any QAO under contract with the
Department.
BENEFICIARY means any Eligible Enrollee whose coverage under the Plan has begun
and remains in effect pursuant to this Contract.
CAPITATION means the reimbursement arrangement in which a fixed rate of payment
per Beneficiary per month is made to the Contractor for the performance of all
of the Contractor's duties and obligations pursuant to this Contract.
CASE means individuals who have been grouped together and assigned a common
identification number by the Department or the Department of Human Services of
which at least one individual in that grouping has been determined by the
Department to be an Eligible Enrollee. An individual is added to a Case when the
Client Information System maintained by the Illinois Department of Human
Services reflects the individual is in the Case.
CERTIFIED LOCAL HEALTH DEPARTMENT means a local government agency that
administers health-related programs and services within its jurisdiction and
that has been certified by the Illinois Department of Public Health pursuant to
77 Ill. Adm. Code 600.
CONTRACT means this document, inclusive of all attachments, exhibits, schedules
and any subsequent amendments hereto.
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CONTRACTING AREA means the area(s) from which the Contractor may enroll Eligible
Enrollees as set forth in Attachment I.
COVERED SERVICES means those benefits and services described in Article V,
Section 5.1.
EARLY INTERVENTION means the program described at 325 ILCS 20/1 et seq., which
authorizes the provision of services to infants and toddlers, birth through two
years of age, who have a disability due to developmental delay or a physical or
mental condition that has a high probability of resulting in developmental delay
or being at risk of having substantial developmental delays due to a combination
of serious factors.
EFFECTIVE DATE shall be April 1, 2000.
ELIGIBLE ENROLLEE means a Participant, except one who:
- is receiving Medical Assistance under Aid to the Aged, Blind and
Disabled; as provided by Title XIX of the Social Security Act (42
U.S.C. Section 1383c) and 305 ILCS 5/3-1 et seq.
- is eligible only through the Transitional Assistance (305 ILCS
5/6-11) or Refugee Assistance Programs under Title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.;
is age 19 or older and eligible only through the State Family and
Children Assistance Program (305 ILCS 5/6-11);
- whose care is subsidized by the Department of Children and Family
Services;
- is residing in a long term care facility including State of
Illinois operated facilities;
- has Medicare coverage under Title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.);
- has significant medical coverage through a third party for Medical
Assistance Participants;
- is eligible only through the Medicaid Presumptive Eligibility for
Pregnant Women program under Title XIX of the Social Security Act
(42 U.S.C. 1396r-1);
- is eligible for Medical Assistance only through meeting a
spend-down obligation;
- is a non-citizen receiving only emergency Medical Assistance; or
is identified with an "R" in the eighth position of a Case
identification number.
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EMERGENCY SERVICES means the provision of those inpatient and outpatient health
care services that are Covered Services, including transportation, needed to
evaluate or stabilize an Emergency Medical Condition that are furnished by a
Provider qualified to furnish emergency services.
EMERGENCY MEDICAL CONDITION means a medical condition manifesting itself by
acute symptoms of sufficient severity (including, but not limited to, severe
pain) such that a prudent lay person, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in (i) 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, (ii) serious impairment to bodily functions, or (iii) serious
dysfunction of any bodily organ or part.
ENCOUNTER means an individual service or procedure provided to a Beneficiary
that would result in a claim if the service or procedure were to be reimbursed
fee-for-service under the Medical Assistance Program or KidCare.
ENCOUNTER DATA means the compilation of data elements, as specified by the
Department in written notice to the Contractor, identifying an Encounter that
includes information similar to that required in a claim for fee-for-service
payment under the Medical Assistance Program or KidCare.
ENROLLMENT means the completion and signing of any necessary Enrollment forms by
or on behalf of an Eligible Enrollee in accordance with Enrollment procedures
prescribed in this Contract and concurrent or subsequent entry of the Eligible
Enrollee's Site selection, by the Department, into its database.
FAMILY CASE MANAGEMENT PROVIDER means any agency contracting with the Illinois
Department of Human Services or its successor agency to provide Family Case
Management Services.
FAMILY CASE MANAGEMENT SERVICES means the program described at 77
Ill. Adm. Code 630.220.
FEDERALLY QUALIFIED HEALTH CENTER or FQHC means a health center
that meets the requirements of 89 Ill. Adm. Code 140.461(d).
FRAUD means knowing and willful deception or misrepresentation, or a reckless
disregard of the facts, with the intent to receive an unauthorized benefit.
HCFA means the Health Care Financing Administration under the United States
Department of Health and Human Services.
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HEALTHY KIDS/EPSDT means the Early and Periodic, Screening, Diagnostic and
Treatment services provided to children under Title XIX of the Social Security
Act (42 U.S.C. Section 1396, et seq.).
INELIGIBLE PERSON means a Person which: (i) is or has been terminated, barred,
suspended or otherwise excluded from participation in or has voluntarily
withdrawn as the result of a settlement agreement in any program under federal
law including any program under Titles XVIII, XIX, XX or XXI of the Social
Security Act; (ii) has not been reinstated in the Medical Assistance Program or
Federal health care programs after a period of exclusion, suspension, debarment,
or ineligibility; or (iii) has been convicted of a criminal offense related to
the provision of health care items or services in the last ten (10) years.
KIDCARE means the program operated pursuant to the Children's Health Insurance
Program Act (215 ILCS 106/1 et seq.), but not including the program operated
pursuant to Subsection 25(a)(1) of the Children's Health Insurance Program Act
(215 ILCS 106/25(a)(1)).
MCO means a "managed care organization" that is a federally qualified HMO that
meets the advance directives requirements of subpart I of part 489 of 42 C.F.R.
or any public or private entity that meets the advance directives requirements
set forth in Article V, Section 5.19 and is determined to meet the following
conditions: i) is organized primarily for the purpose of providing health care
services, ii) makes the services it provides to its Medicaid beneficiaries as
accessible (in terms of timeliness, amount, duration and scope) as those
services are to other Medicaid participants within the area served by the entity
and iii) meets the solvency standards of regulations promulgated under 42 C.F.R.
Part 438.
MAG BENEFICIARY means any Participant who is an Eligible Enrollee with a Case
identification number in which the first two digits are 04 or 06.
MANG BENEFICIARY means any Participant who is an Eligible Enrollee with a Case
identification number in which the first two digits are 94, 96 or 07.
MARKETING means any activities, procedures, materials, information or incentives
used to encourage or promote the Enrollment of Eligible Enrollees with the
Contractor.
MARKETING MATERIALS means materials that are produced in any medium, by or on
behalf of an MCO, are used by the MCO to communicate with Eligible Enrollees or
Beneficiaries, and can reasonably be interpreted as intended to influence them
to enroll in that particular MCO.
MEDICAL ASSISTANCE OR MEDICAL ASSISTANCE PROGRAM means the Illinois Medical
Assistance Program administered under Article V of the Illinois Public Aid Code
(305 ILCS 5/5-1 et seq.) or its successor program and Title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) and Section 12-4.35 of the Illinois Public
Aid Code (305 ILCS 5/12-4.35).
OFFICE OF INSPECTOR GENERAL OR OIG means the Office of Inspector General for the
Illinois Department of Public Aid as set forth in 305 ILCS 5/12-13.1.
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PARTICIPANT means any individual receiving benefits under Medical Assistance or
KidCare.
PERSON means any individual, corporation, proprietorship, firm, partnership,
limited liability company, limited partnership, trust, association, governmental
authority or other entity, whether acting in an individual, fiduciary or other
capacity.
PERSON WITH AN OWNERSHIP OR CONTROLLING INTEREST means a Person that: has a
direct or indirect, singly or in combination, ownership interest equal to five
percent (5%) or more in the Contractor; owns an interest of five percent (5%) or
more in any mortgage, deed of trust, note or other obligations secured by the
Contractor if that interest equals at least five percent (5%) of the value of
the property or assets of the Contractor; is an officer or director of a
Contractor that is organized as a corporation, is a member of the Contractor
that is organized as a limited liability company or is a partner in the
Contractor that is organized as a partnership.
PHYSICIAN means a person licensed to practice medicine in all its branches under
the Medical Practice Act of 1987.
PLAN means the Contractor's program for providing Covered Services pursuant to
this Contract.
POST-STABILIZATION SERVICES means medically necessary non-emergency services
furnished to a Beneficiary after the Beneficiary is stabilized following an
Emergency Medical Condition.
PRELISTING REPORT means the information that the Department provides to the
Contractor prior to the first day of each month of coverage that reflects
changes in Enrollment subsequent to the last monthly payment and that applies to
coverage for the following month.
PRIMARY CARE PROVIDER means a Physician, specializing by certification or
training in obstetrics, gynecology, general practice, pediatrics, internal
medicine or family practice who agrees to be responsible for directing, tracking
and monitoring the health care needs of, and authorizing and coordinating care
for, Beneficiaries.
PROSPECTIVE BENEFICIARY means an Eligible Enrollee who has begun the process of
Enrollment with the Contractor but whose coverage under the Plan has not yet
begun.
PROVIDER means a Person who is approved by the Department to furnish medical,
educational or rehabilitative services to Participants under the Medical
Assistance Program.
QAO means a "Quality Assurance Organization" that is the Department's external
quality review organization under contract to perform quality oversight and
monitoring, medical record reviews and technical assistance for managed care.
REMITTANCE ADVICE means the list that will be supplied to the Contractor with
each monthly payment. The Remittance Advice will list each Beneficiary for whom
payment is being made.
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SITE means any contracted Provider (IPA, PHO, FQHC, individual physician,
physician groups, etc.) through which the Contractor arranges the provision of
primary care to Beneficiaries.
STABILIZATION OR STABILIZED means, with respect to an Emergency Medical
Condition, to provide such medical treatment of the Emergency Medical Condition
as may be necessary to assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result upon discharge or
transfer to another facility.
STATE means the State of Illinois.
TITLE X FAMILY PLANNING PROVIDER means an agency that receives grants from the
Illinois Department of Human Services to provide comprehensive family planning
services pursuant to Title X of the Public Health Services Act, 42 U.S.C. 300
and 77 Ill. Adm. Code 635.
WOMEN'S HEALTH CARE PROVIDER means a Physician, specializing by certification or
training in obstetrics, gynecology or family practice.
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ARTICLE II
TERMS AND CONDITIONS
2.1 SPECIFICATION
This Contract is for the delivery of Covered Services to
Beneficiaries and the administrative responsibilities attendant
thereto. The terms and conditions of this Contract, along with the
applicable Administrative Rules and the Departmental materials
described in this Article II, Section 2.3 below, shall constitute
the entire and present agreement between the parties. This Contract,
including all attachments, exhibits and amendments constitutes a
total integration of all rights, benefits and obligations of both
parties for the performance of all duties and obligations hereunder
including, but not limited to, the provision of, and payment for
Covered Services under this Contract. This Contract is contingent
upon receipt of approval from HCFA.
There are no extrinsic conditions or collateral agreements or
undertakings of any kind. It is the express intention of both the
Department and the Contractor that any and all prior or
contemporaneous agreements, promises, negotiations or
representations, either oral or written, except as provided herein
are to have no force, effect or legal consequences of any kind, nor
shall any such agreements, promises, negotiations or
representations, either oral or written, have any bearing upon this
Contract or the duties or obligations hereunder. This Contract and
any amendment hereto shall be deemed the full and final expression
of the parties' agreement.
2.2 RULES OF CONSTRUCTION
(a) Unless the context otherwise requires:
(1) Provisions apply to successive events and
transactions;
(2) "Or" is not exclusive;
(3) Unless otherwise specified, references to
statutes, regulations, and rules include
subsequent amendments and successors
thereto;
(4) The various headings of this Contract are
provided for convenience only and shall not
affect the meaning or interpretation of this
Contract or any provision hereof;
(5) If any payment or delivery hereunder between
the Contractor and the Department shall be
due on any day that is not a business day,
such payment or delivery shall be made on
the next succeeding business day;
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(6) Words in the plural that should be singular
by context shall be so read, and words in
the singular shall be read as plural where
the context dictates;
(7) Days shall mean calendar days unless
otherwise designated by the context; and
(8) References to masculine or feminine pronouns
shall be interchangeable where the context
requires.
(b) References in the Contract to Eligible Enrollee,
Prospective Beneficiary and Beneficiary shall include
the parent, caretaker relative or guardian where such
Eligible Enrollee, Prospective Beneficiary or
Beneficiary is a minor child or an adult for whom a
guardian has been named.
2.3 PERFORMANCE OF SERVICES AND DUTIES
The Contractor shall perform all services and other duties as set
forth in this Contract in accordance with, and subject to, the
Administrative Rules and Departmental materials, including, but not
limited to, Departmental policies, Department Provider Notices,
Provider Handbooks and any other rules and regulations that may be
issued or promulgated from time to time during the term of this
Contract. The Department shall provide copies of such materials to
the Contractor upon the Contractor's written request, if such are in
existence upon the Effective Date, or upon issuance or promulgation
if issued or promulgated after the Effective Date. Changes in such
materials after the Effective Date shall be binding on the parties
hereto but shall not be considered amendments to the Contract. To
the extent the Department proposes a change in policy that may have
a material impact on the Contractor's ability to perform under this
Contract, the proposed change will be subject to good faith
negotiations between both parties before it shall be binding
pursuant to this Article II, Section 2.3.
2.4 LANGUAGE REQUIREMENTS
(a) Key Oral Contacts
The Contractor shall conduct key oral contacts with
Eligible Enrollees, Prospective Beneficiaries or
Beneficiaries in a language the Eligible Enrollees,
Prospective Beneficiaries and Beneficiaries understand.
Where the language is other than English, the Contractor
shall offer and, if accepted by the Eligible Enrollee,
Prospective Beneficiary or Beneficiary, shall supply
interpretive services. Such services may not be rendered
by any individual who is under the age of eighteen (18).
Key oral contacts include, but are not limited to:
Marketing contacts; enrollment communications;
explanations of benefits; Site, Primary Care and Women's
Health Care Provider selection activity; educational
information; telephone calls to the toll-free hotline(s)
described in Article V, Section 5.1(k); and face-to-face
encounters with Providers rendering care.
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(b) Written Material
Written materials described herein that are to be
provided to Eligible Enrollees, Prospective
Beneficiaries or Beneficiaries shall be easily
understood by individuals who have a sixth grade reading
level. If five percent (5%) or more (according to Census
Bureau data as determined by the Department) of those
low income households in the relevant Department of
Human Services local office area are of a
single-language minority, the Contractor's written
materials provided to Eligible Enrollees, Prospective
Beneficiaries or Beneficiaries must be available in that
language as well as English. Translations of written
material are subject to prior approval by the Department
and must be accompanied by a certification that the
translation is accurate and complete. Written materials,
as described herein, shall mean Marketing Materials,
Beneficiary Handbooks and any information or notices
required to be distributed to Eligible Enrollees,
Prospective Beneficiaries or Beneficiaries by the
Department or regulations promulgated from time to time
under 42 C.F.R. Part 438.
2.5 LIST OF INDIVIDUALS IN AN ADMINISTRATIVE CAPACITY
Upon execution of this Contract, the Contractor shall provide the
Department with a list of individuals who have responsibility for
monitoring and ensuring the performance of each of the duties and
obligations under this Contract. This list shall be updated
throughout the term of this Contract as necessary and as changes
occur, and written notice of such changes shall be given to the
Department within ten (10) business days of such changes occurring.
2.6 CERTIFICATE OF AUTHORITY
The Contractor must obtain and maintain during the term of the
Contract a valid Certificate of Authority as a Health Maintenance
Organization under 215 ILCS 125/1-1, et seq..
2.7 OBLIGATION TO COMPLY WITH OTHER LAWS
No obligation imposed herein on the Contractor shall relieve the
Contractor of any other obligation imposed by law or regulation,
including, but not limited to, those imposed by The Managed Care
Reform and Patient Rights Act (215 ILCS 134/1 et seq.), the federal
Balanced Budget Act of 1997 (Public Law 105-33) and regulations
promulgated by the Illinois Department of Insurance, the Illinois
Department of Public Health or HCFA. The Department shall report all
information it receives indicating a violation of a law or
regulation to the appropriate agency.
If the Contractor believes that it is impossible to comply with a
provision of this Contract because of a contradictory provision of
applicable State or federal law, the Contractor shall immediately
notify the Department. The Department then will make a
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determination of whether a contract amendment is necessary. The fact
that either the Contract or an applicable law imposes a more
stringent standard than the other does not, in and of itself, render
it impossible to comply with both.
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ARTICLE III
ELIGIBILITY
3.1 DETERMINATION OF ELIGIBILITY
The State has the exclusive right to determine an individual's
eligibility for the Medical Assistance Program and KidCare and
eligibility to become a Beneficiary. Such determination shall be
final and is not subject to review or appeal by the Contractor.
Nothing in this Article III, Section 3.1 prevents the Contractor
from providing the Department with information the Contractor
believes indicates that a Beneficiary's eligibility has changed.
3.2 ENROLLMENT GENERALLY
Any Eligible Enrollee who resides, at the time of Enrollment, in the
Contracting Area shall be eligible to become a Beneficiary except as
described in Article IX, Section 9.12. However, an Eligible Enrollee
who is a KidCare Participant is only eligible to become a
Beneficiary if the Contractor has signed Attachment II indicating
that the Contractor will accept KidCare Participants as
Beneficiaries. Enrollment shall be voluntary, except as provided in
Article IV, Section 4.1(b). Except as provided herein, Enrollment
shall be open during the entire period of this Contract until the
Enrollment limit of the Contractor, as set forth in Attachment I, is
reached. The Contractor must continue to accept Enrollment until
such Enrollment limit is reached. Such Enrollment shall be without
restriction and in the order in which Eligible Enrollees apply. The
Contractor shall not discriminate against Eligible Enrollees on the
basis of such individuals' health status or need for health
services. The Contractor shall accept each Beneficiary whose name
appears on the Prelisting Report.
3.3 ENROLLMENT LIMITS
The Department will limit the number of Beneficiaries enrolled with
the Contractor by Contracting Area to a level that will not exceed
its physical and professional capacity. In its determination of
capacity, the Department will only consider Providers that are
approved by the Department. When the capacity is reached, no further
applications will be submitted for Enrollment unless termination or
disenrollment of Beneficiaries create room for additions. The
capacity limits for the Contractor are specified in Attachment I.
Prior to the Contractor's reaching its capacity, the Department will
perform a threshold review at the Enrollment level(s) set forth in
Attachment I. Should the Department determine that the Contractor's
operating or financial performance reasonably indicates a lack of
additional Provider or administrative capacity, the review of
capacity may be conducted prior to the Contractor reaching the
threshold review enrollment level specified in Attachment I. This
threshold review shall examine the Contractor's Provider and
administrative capacity in each Contracting Area. The Department's
standards for the review shall be reasonable and timely and be
consistent with the terms of this Contract. The threshold review
shall take place as
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determined by the Department based on the rate of Enrollment in the
Contractor's Plan in each Contracting Area or upon the request of
the Contractor and the subsequent agreement of the Department. The
Department shall use its best efforts to complete the review before
the Contractor reaches the threshold levels set forth in Attachment
I. Should the Department determine that the Contractor does not have
the necessary Provider and administrative capacity to service any
additional Enrollments, the Department may freeze Enrollment until
such time that the Plan's Provider and administrative capacity have
increased to the Department's satisfaction. Nothing in this Contract
shall be deemed to be a guarantee of any Eligible Enrollee's
Enrollment in the Contractor's Plan.
If the Contractor signs Attachment II indicating that it will accept
KidCare Participants as Beneficiaries and later determines that it
can no longer accept the rates, cost sharing, premium collection or
other program provisions applicable only to KidCare, then upon
written notice to the Department an amendment to this Contract shall
be executed as soon as practicable that ends the Contractor's
participation in KidCare. The amendment shall provide, at a minimum,
60 days for disenrollment. During the disenrollment process, the
Contractor must assist the Department, as the Department requests,
in disenrolling the Beneficiaries who are KidCare Participants and
such assistance will be at no additional cost charged by the
Contractor to the Department. The Contractor shall continue to
provide Covered Services to Beneficiaries who are KidCare
Participants until termination of coverage as a result of
disenrollment or by operation of Article IV, Section 4.6, whichever
is later.
3.4 EXPANSION TO OTHER CONTRACTING AREAS
The Contractor may, during the term of this Contract and any renewal
thereof, request of the Department the opportunity to offer Covered
Services to Eligible Enrollees in areas other than the Contracting
Area(s) specified in Attachment I. The Contractor must make this
request in writing to the Department. To be considered by the
Department, the written request must include a demonstration, by the
Contractor, of a sufficient network of Providers to adequately
provide Covered Services to Eligible Enrollees in the Contracting
Area identified by the Contractor for expansion. The Department will
provide a format and requirements for the written request. The
Department shall review the Contractor's request in a timely manner
and may at any time request additional information of the
Contractor. It is in the sole discretion of the Department, upon
review of the Contractor's written request, the needs of the
Eligible Enrollee population and other factors as determined by the
Department, as to whether the Contractor's request for expansion
shall be granted. Should the Department agree to the expansion
request, the Department and the Contractor shall agree to execute an
amendment to Attachment I of the Contract to reflect the additional
Contracting Areas in which the Contractor will provide Covered
Services.
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ARTICLE IV
ENROLLMENT, COVERAGE AND
TERMINATION OF COVERAGE
4.1 ENROLLMENT PROCESS
(a) The Contractor and the Department, acting directly or
through its agent, shall be responsible for the
Enrollment of Eligible Enrollees.
When the Contractor enrolls an Eligible Enrollee, the
Contractor shall initiate the processing of the
Enrollment by submitting a Managed Care Enrollment ▇▇▇▇,
▇▇▇▇ ▇▇. ▇▇▇ ▇▇▇▇▇, completed in accordance with
Department instructions for completing such forms, and
signed by the individual who is recognized as the
caretaker relative by the Department. This form will be
supplied to the Contractor by the Department. The
Contractor is responsible for submitting such forms to
the Department or its agent, as directed. The Department
agrees to act in good faith and use its best efforts to
see that Managed Care Enrollment Forms submitted for
Eligible Enrollees are processed within fifteen (15)
business days of receipt by the Department or its agent.
Only a caretaker relative may enroll another Eligible
Enrollee. A caretaker relative may enroll all other
Eligible Enrollees in his Case. An adult Eligible
Enrollee, who is not a caretaker relative, may enroll
himself only.
A member of the Contractor's management staff may
correct a Managed Care Enrollment Form only in
accordance with Department instructions. The corrections
must be initialed by the Contractor's manager or his
designated staff person.
(b) The Department may enroll Eligible Enrollees with the
Contractor by means of any process the Department uses
for the Enrollment of Eligible Enrollees into managed
care. This may include any program the Department
implements during the term of this Contract whereby
Eligible Enrollees who do not affirmatively choose
between enrollment in an MCO or the alternative
delivery system offered by the Department will be
enrolled in MCOs.
(c) When the Department receives an Eligible Enrollee's
selection directly, the Department will electronically
communicate a request for Site assignment to the
Contractor on the day after the Department enters the
selection in its records. The Contractor shall
subsequently contact the Eligible Enrollee, assist the
Eligible Enrollee in selecting a Site, Primary Care
Provider or Women's Health Care Provider and provide
education in accordance with this Article IV, Section
4.1(d). Once selected, the Contractor shall
electronically communicate the Site to the
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Department. Upon one hundred and twenty (120) days
notice to Contractor, the Department may require that
the Contractor electronically communicate the Primary
Care Provider or Women's Health Care Provider
selection to the Department. When the Site, and in
the future the Provider, selection is received from
the Contractor, the Department will enroll the
Eligible Enrollee with the Contractor.
(d) The Contractor shall conduct Enrollment activities that
include the information distribution requirements of
Article V, Section 5.5 hereof and are designed and
implemented so as to maximize Eligible Enrollees'
understanding of the following:
(1) that all Covered Services must be received
from or through the Plan with the exception
of family planning and other Medical
Assistance services as described in Article
V, Section 5.1(e) with provisions made to
clarify when such services may also be
obtained elsewhere;
(2) that once enrolled, the Beneficiaries will
receive a card from the Department which
identifies such Beneficiaries as enrolled in
an MCO; and
(3) that the Contractor must inform Eligible
Enrollees of any Covered Services that will
not be offered by the Contractor due to the
Contractor's exercise of a right of
conscience.
(e) Upon the Contractor's request, the Department may refuse
Enrollment for at least a six-month period to those
former Beneficiaries previously terminated from coverage
by the Contractor for "good cause," as specified in
Article IV, Section 4.4(a)(1).
(f) When a Beneficiary, who is a caretaker relative, gives
birth and the newborn is added to a Case before the
newborn is forty-five (45) days old, coverage shall be
retroactive to the date of birth. Coverage for all other
newborns shall be prospective according to standard
Enrollment terms of this Contract.
(g) From birth through age eighteen (18), Eligible
Enrollees who are added to a Case in which all members
of the Case are enrolled with the Contractor, will
also be enrolled with the Contractor automatically.
Coverage shall begin as designated by the Department
on the first day of a calendar month no later than
three (3) calendar months from the date the Eligible
Enrollee was added to the Case.
(h) No later than ten (10) business days following receipt
of the Prelisting Report, the Contractor must provide
new Beneficiaries with an identification card bearing
the
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name of the Contractor's Plan; the effective date
of coverage; the twenty-four-hour telephone number to
confirm eligibility for benefits and authorization for
services and the name and phone number of the Primary
Care Provider or Women's Health Care Provider. The
identification of the Site must appear on the card
until such time as the name and phone number of the
Primary Care Provider and Women's Health Care Provider
can be placed on the card.
(1) If the Contractor requires a female Beneficiary
who wishes to use a Women's Health Care Provider
to designate a specific Women's Health Care
Provider and if a female Beneficiary does so
designate a Women's Health Care Provider, the
name and phone number of that Women's Health Care
Provider must appear on the identification card.
(2) Where the Contractor can make a compelling
argument to the Department that due to its
Plan design it is unable to place the name
of the Primary Care Provider on the card,
the Department in its discretion may allow
the Contractor to place the name of a clinic
or Site on the card.
Samples of the identification cards described above
shall be submitted for Department approval by the
Contractor prior to use by the Contractor and as
revised. The Contractor shall not be required to submit
for prior approval format changes, provided there is no
change in the information conveyed.
4.2 INITIAL COVERAGE
Coverage shall begin as designated by the Department on the first
day of a calendar month no later than three (3) calendar months from
the date the Enrollment is entered into the Department's database.
Enrollment can occur only upon the Prospective Beneficiary's
selection of a Site and the communication of that Site by the
Contractor to the Department.
The Contractor shall provide reasonable coordination of care
assistance to Prospective Beneficiaries to access a Primary Care
Provider or Women's Health Care Provider before the Contractor's
coverage becomes effective, if requested to do so by Prospective
Beneficiaries or if the Contractor has knowledge of the need for
such assistance. The Primary Care Provider or Women's Health Care
Provider selected by the Prospective Beneficiary must provide
necessary service including providing pregnant women with priority
services in an expedient manner in order for such Prospective
Beneficiaries to establish a relationship with the Primary Care
Provider or Women's Health Care Provider, promoting and ensuring
continuity of care, and determining any special needs as early in
the pregnancy as possible. Any payment for those services rendered
to Prospective Beneficiaries described herein shall be made directly
by the Department to such Providers under the provisions of the
Medical Assistance Program or KidCare.
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4.3 PERIOD OF ENROLLMENT
Every Beneficiary shall remain enrolled until the Beneficiary's
coverage is ended pursuant to Article IV, Section 4.4.
4.4 TERMINATION OF COVERAGE
(a) A Beneficiary's coverage shall be terminated, subject to
Department approval, upon the occurrence of any of the
following conditions:
(1) dismissal from the Plan by the Contractor for "good
cause" shown may only occur upon receipt by the
Contractor of written approval of such termination by
the Department. For purposes of this paragraph, "good
cause" may include, but is not limited to fraud or other
misrepresentation by a Beneficiary, threats or physical
acts constituting battery to the Contractor, the
Contractor's personnel or the Contractor's participating
Providers and staff, chronic abuse of emergency rooms,
theft of property from the Contractor's Affiliated
Sites, a Beneficiary's sustained noncompliance with the
Plan physician's treatment recommendations (excluding
preventive care recommendations) after repeated and
aggressive outreach attempts are made by the Plan or
other acts of a Beneficiary presented and documented to
the Department by the Contractor which the Department
determines constitute "good cause." Termination of
coverage shall take effect at 11:59 p.m. on a date
specified by the Department, which shall be no later
than the last day of the third month after the
Department determines that good cause exists;
(2) when the Department determines that the Beneficiary no
longer qualifies as an Eligible Enrollee. Termination of
coverage shall take effect at 11:59 p.m. on the last day
of the month in which the Department determines that the
Beneficiary no longer is an Eligible Enrollee;
(3) upon the Beneficiary's death. Termination of coverage
shall take effect at 11:59 p.m. on the last day of the
month in which the Beneficiary dies;
(4) when a Beneficiary elects to terminate coverage by so
informing the Contractor or the Department, at the
Contractor's Sites, or at such other locations as
designated by the Department. Beneficiaries may elect to
disenroll at any time. The Contractor shall comply with
the Department's policy to promote and allow interaction
between the Contractor and the Beneficiary seeking
disenrollment prior to the disenrollment. The Contractor
shall immediately make available to the Beneficiaries
the Managed Care Disenrollment Form, DPA Form 2575B,
upon request, and shall not delay the provision or
processing of this form for the purpose of
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arranging informational interviews with the
Beneficiaries, or for any other purpose. The Contractor
shall forward to the Department information concerning
the disenrollment by the end of the fifth (5th) business
day following the Beneficiary's completion of a Managed
Care Disenrollment Form. Termination of coverage shall
take effect at 11:59 p.m. on a date specified by the
Department, which shall be no later than the last day of
the third month after the Department is notified of the
request for disenrollment;
(5) when a Beneficiary no longer resides in the Contractor's
Contracting Area, unless waiver of this subparagraph is
approved in writing by the Department and assented to by
the Contractor and Beneficiary. If a Beneficiary is to
be disenrolled at the request of a Contractor, the
Contractor first must provide documentation satisfactory
to the Department that the Beneficiary no longer resides
in the Contractor's Contracting Area. Termination of
coverage shall take effect at 11:59 p.m. on the last day
of the month prior to the month in which the Department
determines that the Beneficiary no longer resides in the
Contractor's Contracting Area. This date may be
retroactive if the Department can determine the month in
which the Beneficiary moved from the Contractor's
Contracting Area;
(6) when a KidCare Participant receives medical confirmation
that she is pregnant and the Department is so notified.
Termination of coverage shall take effect at 11:59 p.m.
on the last day of the month prior to the month in which
the Beneficiary received medical confirmation that she
was pregnant; or
(7) when a Beneficiary has been determined eligible for
Social Security disability benefits (SSI) and the
Department is so notified. Termination of coverage shall
take effect at 11:59 p.m. on the last day of the month
prior to the month in which SSI eligibility begins.
(8) when the Department determines, pursuant to Article IX,
that a Beneficiary has other significant insurance
coverage. The Contractor shall be notified by the
Department of such disenrollment on the monthly
Prelisting Report. Termination of coverage shall take
effect at 11:59 p.m. on a date specified by the
Department, which shall be no later than the last day of
the third month after the Department determines that the
Beneficiary has other significant insurance.
(b) In conjunction with a request by the Contractor to disenroll a
Beneficiary, the Contractor shall furnish to the Department
all information requested regarding the basis for
disenrollment and all information regarding the utilization of
services by
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that Beneficiary.
(c) The Contractor will not seek to terminate Enrollment because
of an adverse change in the Beneficiary's health or cost of
medical care. Such attempts may be considered in violation of
the terms of this Contract.
(d) Except as otherwise provided in this Article IV, Section 4.6,
the termination of this Contract terminates coverage for all
persons who become Beneficiaries under it. Termination of
coverage under this provision will take effect at 11:59 p.m.
on the last day of the last month for which the Contractor
receives payment, unless otherwise agreed to, in writing, by
the parties to this Contract.
4.5 PREEXISTING CONDITIONS AND TREATMENT
The Contractor shall assume, upon the effective date of coverage,
full responsibility for any medical conditions that may have been
preexisting prior to Enrollment in the Contractor's Plan and for any
existing treatment plans under which a Beneficiary is currently
receiving medical care provided that the Beneficiary's current
in-Plan physician determines that such treatment plan is medically
necessary for the health and well-being of the Beneficiary.
4.6 CONTINUITY OF CARE
If a Beneficiary is receiving medical care or treatment as an
inpatient in an acute care hospital at the time coverage commences
under this Contract, the Contractor shall assume responsibility for
the management of such care as of the effective date of coverage and
shall be liable for all claims for covered services from the
effective date of coverage.
If a Beneficiary is receiving medical care or treatment as an
inpatient in an acute care hospital at the time coverage under this
Contract is terminated, the Contractor shall arrange for the
continuity of care or treatment for the current episode of illness
until such medical care or treatment has been fully provided as
evidenced by discharge from the hospital. The subsequent appropriate
payor for the Beneficiary shall be liable for payment for any
medical care or treatment provided after termination of coverage.
4.7 CHANGE OF SITE AND PRIMARY CARE PROVIDER OR WOMEN'S HEALTH
CARE PROVIDER
The Contractor shall permit a Beneficiary to change Site, Primary
Care Provider and Women's Health Care Provider upon request. The
Contractor shall process such changes within thirty (30) days of
receipt of a Beneficiary's request.
Within three (3) business days of processing such change, the
Contractor shall electronically transmit a Site transfer record to
the Department in a format designated by the Department. Such record
shall contain the following data fields: Case name and
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identification number; Beneficiary name and identification number;
old Site number; and, new Site number. The Department will provide
the Contractor with no less than one hundred twenty (120) days
advance notification prior to imposing a requirement that the
Contractor electronically communicate old and new Primary Care
Provider numbers and old and new Women's Health Care Provider
numbers with this record.
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ARTICLE V
DUTIES OF CONTRACTOR
5.1 SERVICES
(a) Amount, Duration and Scope of Coverage
The Contractor shall provide or arrange to have provided
to all Beneficiaries all services described in 89 Ill.
Adm. Code, Part 140 as amended from time to time and not
specifically excluded therein or in this Article V,
Section 5.1 in accordance with the terms of this
Contract. Covered Services shall be provided in the
amount, duration and scope as set forth in 89 Ill. Adm.
Code, Part 140 and this Contract. This duty shall
commence at the time of initial coverage as to each
Beneficiary. The Contractor shall not refer Beneficiaries
to publicly supported health care entities to receive
Covered Services, for which the Contractor receives
payment from the Department, unless such entities are
Affiliated with the Contractor's Plan. Such publicly
supported health care entities include, but are not
limited to, Chicago Department of Public Health and its
clinics, ▇▇▇▇ County Bureau of Health Services, and local
health departments.
(b) Enumerated Covered Services
The following services and benefits shall be specifically
included as Covered Services under this Contract and will
be provided to Beneficiaries whenever medically
necessary:
Assistive/augmentative communication devices;
Audiology services, physical therapy, occupational
therapy and speech therapy;
Behavioral health services, including subacute
alcohol and substance abuse services and mental
health services, in accordance with subsection (c)
hereof;
Blood, blood components and the administration
thereof;
Certified hospice services;
Chiropractic services;
Clinic services (as described in 89 Ill. Adm. Code,
Part 140.62);
Diagnosis and treatment of medical conditions of
the eye;*
Durable and nondurable medical equipment and
supplies;
Emergency Services;
Family planning services;
Home health care services;
Inpatient hospital services (including dental
hospitalization in case of trauma or when related
to a medical condition and acute medical
detoxification);
Inpatient psychiatric care;
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Laboratory and x-ray services; The drawing of blood
for lead screening shall take place within the
Contractor's Affiliated facilities or elsewhere at
the Contractor's expense.**
Medical procedures performed by a dentist;
Nurse midwives services;
Nursing facility services for the first ninety (90)
days;***
Orthotic/prosthetic devices, including prosthetic
devices or reconstructive surgery incident to a
mastectomy;
Outpatient hospital services;
Pharmacy services (including drugs prescribed by
a dentist participating in the Medical Assistance
Program provided they are filled by an Affiliated
pharmacy Provider);
Physicians' services, including psychiatric care;
Podiatric services;
Routine care in conjunction with certain
investigational cancer treatments, as provided in
Public Act 91-0406;
Services required to treat a condition diagnosed as
a result of Healthy Kids/EPSDT services, in
accordance with 89 Ill. Adm. Code 140.485;
Services to Prevent Illness and Promote Health in
accordance with subsection (d) hereof
Transplants covered under 89 Ill. Adm. Code 140
(using transplant providers certified by the
Department, if the procedure is performed in the
State); and
Transportation to secure medical services.
* Covered Services may be provided by an
optometrist operating within the scope of
his license.
** All laboratory tests for children being
screened for lead must be sent to the
Illinois Department of Public Health's
laboratory.
*** Contractors will be responsible for
covering up to a maximum of ninety (90) days
nursing facility care (or equivalent care provided
at home because a skilled nursing facility
is not available) annually per Beneficiary.
Periods in excess of ninety (90) days
annually will be paid by the Department
according to its prevailing reimbursement
system.
(c) Behavioral Health Services
The Contractor will provide behavioral health services
that are Covered Services, including but not limited to
inpatient hospital, pharmaceutical, laboratory,
physician services, and outpatient services. If a
Beneficiary presents himself to the Contractor for
behavioral health services, or is referred through a
third party, the Contractor will complete a behavioral
health assessment.
(1) If the assessment indicates that all services needed
are within the scope of
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Covered Services, the Contractor will arrange for the
provision of all such Covered Services.
(2) If the assessment indicates that outpatient
services are needed beyond the scope of Covered
Services, the Contractor will explain to the
Beneficiary the services needed and the importance
of obtaining them and provide the Beneficiary with
a list of Community Behavioral Health Providers
(CBHP). The Contractor will assist the Beneficiary
in contacting a CBHP chosen by the Beneficiary,
unless the Beneficiary objects.
(3) If a Beneficiary obtains needed comprehensive
services through a CBHP, the Contractor will be
responsible for payment for drugs prescribed by a
Physician and laboratory services in connection
with the comprehensive services provided by the
CBHP. The Contractor shall not be liable for other
Covered Services provided by the CBHP. The
Contractor may require that drugs and laboratory
services are provided by Providers that are
Affiliated with the Contractor.
(d) Services to Prevent Illness and Promote Health
The Contractor shall exercise reasonable efforts to
provide initial health screenings and preventive care to
all Beneficiaries. The Contractor shall provide, or
arrange to provide, the following Covered Services to
all Beneficiaries, as appropriate, to prevent illness
and promote health:
(1) Healthy Kids/EPSDT services in accordance with 89
Ill. Adm. Code 140.485 and described in this
Article V, Section 5.13(a);
(2) Preventive Medicine Schedule which shall address
preventive health care issues for Beneficiaries
twenty-one (21) years of age or older (Article V,
Section 5.13(b));
(3) Maternity care for pregnant Beneficiaries (Article
V, Section 5.13(c)); and
(4) Family planning services and supplies, including
physical examination and counseling provided
during the visit, annual physical examination for
family planning purposes, pregnancy testing,
voluntary sterilization, insertion or injection of
contraceptive drugs or devices, contraceptive
drugs and supplies, and related laboratory and
diagnostic testing.
(e) Exclusions from Covered Services
In addition to those services and benefits excluded from
Covered Services by 89 Ill. Adm. Code, Part 140, as
amended from time to time, the following services
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and benefits shall NOT be included as Covered Services:
(1) Dental services;
(2) Routine examinations to determine visual acuity
and the refractive state of the eye, eyeglasses,
other devices to correct vision, and any
associated supplies and equipment. The Contractor
shall refer Beneficiaries needing such services to
Providers participating in the Medical Assistance
Program able to provide such services, or to a
central referral entity that maintains a list of
such Providers;
(3) Nursing facility services beginning on the
ninety-first (91st) day;
(4) Services provided in an Intermediate Care Facility
for the Mentally Retarded/Developmentally Disabled
and services provided in a nursing facility to
mentally retarded or developmentally disabled
Participants;
(5) Early intervention services, including case
management, provided pursuant to the Early
Intervention Services System Act (325 ILCS 20 et
seq.);
(6) Services provided through school-based clinics as
such clinics are defined by the Department;
(7) Services provided through local education agencies
under an approved individual education plan (IEP);
(8) Services provided under Section 1915(c) home and
community-based waivers;
(9) Services funded through the Juvenile
Rehabilitation Services Medicaid Matching Fund;
and
(10) Services that are experimental and/or
investigational in nature.
(f) Limitations on Covered Services
The following services and benefits shall be limited as
Covered Services:
(1) Termination of pregnancy shall be provided only as
allowed by applicable State and federal law (42
C.F.R. Part 441, Subpart E). In any such case, the
requirements of such laws must be fully complied
with and DPA Form 2390 must be completed and filed
in the Beneficiary's medical record. Termination
of pregnancy shall not be provided to KidCare
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Beneficiaries.
(2) Sterilization services may be provided only as
allowed by State and federal law (see 42 C.F.R.
Part 441, Subpart F). In any such case, the
requirements of such laws must be fully complied
with and a DPA Form 2189 must be completed and
filed in the Beneficiary's medical record.
(3) If a hysterectomy is provided, a DPA Form 1977
must be completed and filed in the Beneficiary's
medical record.
(g) Right of Conscience
The parties acknowledge that pursuant to 745 ILCS 70/1
et seq., a Contractor may choose to exercise a right of
conscience by not rendering certain Covered Services.
Should the Contractor choose to exercise this right, the
Contractor must promptly notify the Department of its
intent to exercise its right of conscience in writing.
Such notification shall contain the services that the
Contractor is unable to render pursuant to the exercise
of the right of conscience. The parties agree that at
that time the Department shall adjust the Capitation
payment to the Contractor and amend the contract
accordingly.
(h) Emergency Services
(1) The Contractor shall cover Emergency Services for
all Beneficiaries whether the Emergency Services
are provided by an Affiliated or non-Affiliated
Provider.
(2) The Contractor shall not impose any requirements
for prior approval of Emergency Services. If a
Beneficiary calls the Contractor to request
Emergency Services, such call shall receive an
immediate response.
(3) The Contractor shall cover Emergency Services for
Beneficiaries who are temporarily away from their
residence and outside the Contracting Area for all
Emergency Services to which they would be entitled
within the Contracting Area.
(4) Elective care or care required as a result of
circumstances that could reasonably have been
foreseen prior to the Beneficiary's departure from
the Contracting Area are not covered. Payment
shall be made for unexpected hospitalization due
to complications of pregnancy. Routine delivery at
term outside the Contracting Area, however, shall
not be covered if the Beneficiary is outside the
Contracting Area against medical advice unless the
Beneficiary is outside of the Contracting Area due
to circumstances beyond her control. The
Contractor must educate the
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Beneficiary of the medical and financial
implications of leaving the Contracting Area
and the importance of staying near the treating
Provider throughout the last month of pregnancy.
(5) The Contractor shall pay for all appropriate
Emergency Services rendered by a Provider with
whom the Contractor does not have arrangements
within thirty (30) days of receipt of a complete
and correct claim. If the Contractor determines it
does not have sufficient information to make
payment, the Contractor shall request all
necessary information from the Provider within
thirty (30) days of receiving the claim, and shall
pay the Provider within thirty (30) days after
receiving such information. Such payment shall be
made at the same rate the Department would pay for
such services according to the level of services
provided. Within the time limitation stated above,
the Contractor may review the need for, and the
intensity of, the services provided by Providers
with whom the Contractor does not have
arrangements. Determination of levels of service
shall be based upon the symptoms and condition of
the Beneficiary at the time the Beneficiary is
initially examined by the Physician and not upon
the final determination of the Beneficiary's
actual medical condition, unless the actual
medical condition is more severe.
(6) The Contractor shall provide ongoing education to
Beneficiaries regarding the appropriate use of
Emergency Services.
(i) Post-Stabilization Services
(1) Subject to the prior approval procedure described
below, the Contractor shall cover
Post-Stabilization Services whether such Services
are provided by an Affiliated or non-Affiliated
Provider.
(2) The Contractor shall pay for all
Post-Stabilization Services as a Covered Service
if the Contractor approved those services or if
the Provider of the services complied with all
legal requirements in attempting to contact the
Contractor and the Contractor could not be
contacted or the Contractor did not deny
authorization within one hour of the request for
authorization.
(j) Additional Services or Benefits
The Contractor shall obtain prior approval from the
Department before offering any additional service or
benefit not required under this Contract to all
Beneficiaries. The Contractor shall notify Beneficiaries
before discontinuing an additional service or benefit.
The notice to Beneficiaries must be approved in advance
by the Department. The Contractor shall continue any
ongoing course of treatment for a Beneficiary then
receiving such service or benefit.
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(k) Telephone Access
The Contractor shall establish a toll-free twenty-four
(24) hour telephone number to confirm eligibility for
benefits and seek prior approval for treatment where
required under the Plan, and shall assure twenty-four
(24) hour access, via telephone(s), to medical
professionals, either to the Plan directly or to the
Primary Care Providers, for consultation to obtain
medical care. The Contractor must also make a toll-free
number available, at a minimum during the business hours
of 9:00 a.m. until 5:00 p.m. on regular business days.
This number also will be used to confirm eligibility for
benefits, for approval for non-emergency services and
for Beneficiaries to call to request Site, Primary Care
Provider, or Women's Health Care Provider changes, to
make complaints or grievances, to request disenrollment
and to ask questions. The Contractor may use one
toll-free number for these purposes or may establish two
separate numbers.
(l) Pharmacy Formulary
The Contractor shall establish a pharmacy formulary that
is no more restrictive than the Department's
pharmaceutical program. In particular, the Contractor
shall comply with the following requirements:
(1) For drugs included in the Department's formulary:
(A) the Contractor may not require prior
approval of any drug product unless the
Department has also placed such drug
product on prior approval under the
fee-for-service Medical Assistance
Program;
(B) the Contractor's formulary must include
every single source drug product covered
by the Department under the Medical
Assistance Program; and
(C) if the Contractor does not provide
coverage for all drugs from
manufacturers having products listed in
the State of Illinois Drug Product
Selection Program's current formulary,
the Contractor shall be considered in
compliance so long as the Contractor's
formulary provides coverage of at least
one manufacturer's product for each drug
covered by the Department under the
Medical Assistance Program that is
listed in the State of Illinois Drug
Product Selection Program's current
formulary.
(2) If the Contractor requires prior approval for
drugs not included in the Department's pharmacy
formulary, decisions must be based on medical
necessity without regard to cost, except for drugs
identified in
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Section 1927(d)(2) of Title XIX of the Social
Security Act.
(3) The Contractor shall provide a mechanism whereby a
prescribing Provider may request approval of drugs
requiring prior approval or drugs not included on
the Contractor's formulary. The Contractor shall
provide a response by telephone or other
telecommunication device within one (1) hour of
receipt of the request in the case of Emergency
Services or Post-Stabilization Services and, in
other cases, within twenty-four (24) hours of
receipt of the request. The Contractor's pharmacy
formulary shall provide a process for appealing
denials of prescription drug coverage that is
timely and not unduly cumbersome.
(4) The Contractor shall not, without the prescriber's
explicit approval, require a pharmacist to
substitute a drug that is not strictly
bioequivalent to the one prescribed.
(5) The Contractor shall inform its Providers of the
pharmacy formulary policy required in this
Section.
(6) The Contractor shall not set a limit on the
quantities of drugs that a Beneficiary may obtain
at one time with a prescription unless that limit
is applied uniformly to all pharmacy providers in
the Contractor's network.
5.2 CERTIFIED LOCAL HEALTH DEPARTMENT SERVICES
(a) The Contractor shall work in good faith to assist the
Department to achieve its objective of supporting Certified
Local Health Departments. To this end, the Contractor shall
seek to negotiate and execute one of the following documents
with each Certified Local Health Department serving a
jurisdiction in which Beneficiaries reside:
(1) the Contractor shall subcontract with Certified Local
Health Departments to provide, at a minimum, the
services listed in this Article V, Section 5.2(b); or
(2) the Contractor shall enter into linkage agreements with
Certified Local Health Departments. Such linkage
agreements shall conform to the Department's model
Certified Local Health Department Linkage Agreement. Any
variation in terms from the model agreements is subject
to the mutual agreement of the Contractor and the
Certified Local Health Department and prior approval by
the Department. A copy of all executed linkage
agreements shall be filed promptly by the Contractor
with the Department.
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(b) The following services, at a minimum, shall be encompassed in
the subcontracts or linkage agreements entered into by the
Contractor pursuant to this Article V, Section 5.2(a) to the
extent these services are within the Certified Local Health
Department's scope of services as established by the
appropriate board of health or other governing body:
(1) the following Healthy Kids/EPSDT Services: childhood
immunizations as recommended by the Advisory Committee
on Immunization Practices and adopted by the Illinois
Department of Public Health, well-child screening, blood
draw for lead testing, make-up visit, hearing screening,
vision screening and developmental screening;
(2) adult immunizations for disease outbreak control and
those determined necessary for public health protection;
(3) testing, screening and initial treatment for sexually
transmitted infections;
(4) tuberculosis screening and one month's initial
treatment; and
(5) HIV screening and counseling.
(c) If the Contractor elects to execute a document described in
this Article V, Section 5.2 (a)(1) with a Certified Local
Health Department, the prospective add-on to the Capitation
rates paid to the Contractor for Beneficiaries residing in
areas covered by such Certified Local Health Department shall
be agreed upon by the Contractor and the Department and
reflected in an amendment to Attachment I and shall be
implemented on a date designated by the Department.
(d) If the Contractor elects to execute a document described in
this Article V, Section 5.2(a)(2) with a Certified Local
Health Department, payment for the services listed in this
Article V, Section 5.2(b) and provided by a Certified Local
Health Department on behalf of Beneficiaries residing in areas
covered by such Certified Local Health Department shall be the
responsibility of the Department. These payments by the
Department will be implemented on a date designated by the
Department.
(e) The Contractor shall be considered to have satisfied the
requirement set forth in this Article V, Section 5.2 if it has
offered to enter into the model Certified Local Health
Department Linkage Agreement, but the Certified Local Health
Department has refused to enter into the model agreement.
5.3 MARKETING
The Contractor shall, initially and as revised, submit to the
Department for the
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Department's prior written approval all of the following materials:
Certificate of Coverage or Document of Coverage; Beneficiary
Handbooks; Marketing Materials, including Marketing brochures and
fliers; Marketing plans, including descriptions of proposed
Marketing approaches and Marketing procedures; training materials
and training schedules relating to services under this Contract;
and all other materials and procedures utilized by the Contractor
in connection with Marketing and training. Any substantive revisions
to the foregoing materials that will either directly or indirectly
affect interpretation of benefits, the delivery of services or the
administration of benefits are subject to the Department's prior
written approval as set forth in this paragraph.
Marketing by mail, mass media advertising and community oriented
Marketing directed at Eligible Enrollees will be allowed subject to
the Department's prior approval. The Contractor shall be responsible
for all costs of mailing, including labor costs. The Department
reserves the right to determine and set the sole process of, cost,
and payment for Marketing by mail, using names and addresses of
Participants supplied by the Department, including the right to
limit Marketing by mail to a vendor under contract to the Department
and the terms and conditions set forth in that vendor contract. The
Contractor shall distribute Marketing materials to the entire
Contracting Area, but to the extent permitted by law and approved by
the Department, Contractors may market selectively by eligibility
category, by Contracting Area, by county, by local Department of
Human Services office area or by other geographic area.
The Contractor agrees to be bound by the following requirements for
Marketing:
(a) The Contractor shall not engage in Marketing practices that
mislead, confuse or defraud either Eligible Enrollees or the
Department;
(b) Marketing Materials must be clear and must include, at a
minimum, the information required in Article V, Section 5.5;
(c) Eligible Enrollees shall be solicited from a geographic area
that does not exceed the Contracting Area(s);
(d) All Eligible Enrollees must be considered as potential
Beneficiaries and may not be discriminated against on the
basis of health status or need for health care services or on
any illegal basis;
(e) The Contractor's Marketing shall be designed to reach a
distribution of Eligible Enrollees across age and sex
categories, as such categories are established for rates as
set forth in Attachment I, in the Contracting Area(s). The
Contractor's Marketing shall not be designed to achieve
favorable reimbursement by enrolling a disproportionate
percentage of Beneficiaries from a particular age and sex
category or family income level;
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(f) The Contractor shall not actively facilitate disenrollment of
Beneficiaries from other plans, by providing Managed Care
Disenrollment Forms or otherwise, including transporting
Beneficiaries for the purpose of their disenrollment. The
Contractor may educate Beneficiaries on the disenrollment
process. The Contractor shall not offer gifts or incentives to
Beneficiaries of other plans that are not offered to all
Eligible Enrollees;
(g) Marketing personnel who engage in Marketing services under
this Contract are considered the agents of the Contractor,
whether they are employees, independent contractors, or
independent insurance brokers. The Contractor shall be held
responsible for any misrepresentation or inappropriate
activities by such Marketing personnel. All Marketing
personnel are required to participate in training sessions
that may be developed and presented by the Department, and
which sessions set forth the Department requirements,
expectations and limitations on Marketing practices in which
the Contractor's personnel will engage. The individual
salaries, benefits or other compensation paid by the
Contractor to each of its Marketing personnel shall consist of
no less than seventy-five percent (75%) salary and benefits
and no more than twenty-five percent (25%) commission in cash
or kind. The salary, benefit and other compensation schedules
for such personnel are subject to audits by the Department,
Office of Inspector General and as set forth in Article IX,
Section 9.1. All salary schedules shall be kept by the
Contractor to enable the Department or any Authorized Persons
to identify a specific enunciation of each Marketing
personnel's total salary, benefit and other compensation, the
percentage of that salary, benefits or other compensation that
was based on commission and the basis for such commission. The
Contractor shall hold the Department harmless for any and all
claims, complaints or causes of action that shall arise as a
result of this contractually imposed salary, benefit and other
compensation structure for Marketing personnel.
Compensation of independent insurance brokers who hold a
producers license issued by the State of Illinois Department
of Insurance is not subject to the limitations on commission
described in the above paragraph. All other provisions of the
Contract regarding Marketing shall apply to the Contractor
with respect to the activities of independent insurance
brokers.
(h) It shall be the duty and obligation of the Contractor to
credential and where necessary or appropriate, recredential
all Marketing personnel, including trainers and field
supervisors. Recredentialing shall be performed at the time
the Department of Insurance renews the individual's license or
certification. Recredentialing activity that changes the
status of Marketing personnel shall be submitted to the
Department as changes occur. No current or future personnel of
the Contractor may engage in Marketing activities hereunder
without first meeting all credentialing requirements set forth
herein as well as in the regulations,
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guidelines or policies of the Department. At a minimum, all
Marketing personnel of the Contractor, including independent
insurance brokers, must meet the following credentialing
requirements:
(1) must have been trained in all provisions of the
Contractor's Department approved training manual for
marketers;
(2) must hold a valid license or certification as issued by
the State of Illinois, Department of Insurance, a copy
of which must be submitted to the Department prior to
any Marketing personnel's engaging in Marketing
activities hereunder;
(3) may not engage in Marketing activities for any other MCO
that has a contract with the Department;
(4) may not also be Providers of medical services;
(5) may not have been convicted of any felony within the
last ten (10) years;
(6) may not have been terminated from employment in the
previous twelve (12) months by any MCO for engaging in
any prohibited Marketing practices or misconduct
associated with or related to Marketing activities. The
Contractor shall obtain a written consent from all
Marketing personnel for prior employers to release
employment information to the Contractor concerning any
prior or current employment in which Marketing
activities were performed by any Marketing personnel and
contact the previous employer(s). The Contractor may use
any other employment practices it deems appropriate to
obtain and meet these credentialing requirements; and
(7) must not be an Ineligible Person.
(i) The Department may at any time, in its own discretion and
without notification to the Contractor, attend any Marketing
training session conducted by the Contractor.
(j) The Contractor must immediately notify the Department, in
writing, of any individual who is hired by the Contractor who
has previously been employed by an agent for the Department
responsible for the education of Eligible Enrollees about
managed care.
(k) The Contractor shall immediately notify the Department and the
Office of Inspector General, in writing, of any inappropriate
Marketing activities.
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(l) Before any individual may engage in any Marketing activity
under this Contract, the Contractor shall provide, in a format
designated by the Department, the name and Social Security
number and a copy of the Department of Insurance license or
certification of that individual to the Department and certify
to the Department that the individual meets the minimum
credentialing requirements above. The Department must provide
written approval of such individual before the individual may
engage in any Marketing activity under this Contract.
Thereafter, on a monthly basis, the Contractor shall report,
in a format designated by the Department, the name and Social
Security numbers of all Marketing personnel to the Department.
It is the obligation of the Contractor to ensure that the
Department has a current list of all Marketing personnel. The
Contractor must immediately notify the Department, in writing,
of any Marketing personnel who terminate employment with the
Contractor either voluntarily or involuntarily. If termination
is involuntary, the Contractor must notify the Department if
the reason for termination is related to misconduct under this
Contract.
(m) The Contractor shall not engage in any Marketing activities
directed at enrolling Eligible Enrollees while they are
admitted to any inpatient facilities.
(m) Marketing in or immediately outside of any Department or
Department of Human Services field office is strictly
prohibited.
(o) Marketing at Provider offices or facilities is permissible
under the following circumstances:
(1) the Contractor must have a written agreement with the
Provider, signed by the Provider or his designee, a copy
of which shall be kept on file by the Contractor and
submitted to the Department upon request. Such written
agreement shall set forth specifically what Marketing
may be conducted at that Provider office or facility,
the frequency with which those Marketing activities may
occur and a description of the setting in which the
Marketing activities will occur;
(2) no Marketing activities may be conducted in emergency
room waiting areas or in treatment areas at any Provider
office or facility; and
(3) at no time shall any Marketing personnel have access to
an Eligible Enrollee's medical records regardless of
whether such Marketing activity is conducted at the
Provider office or facility or another location.
(p) Direct or indirect door-to-door, telephonic, or other cold
call Marketing is strictly prohibited. Door-to-door Marketing
is direct or indirect "cold call" or unsolicited Marketing
activities at an individual's residence. "Cold call" Marketing
means
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any unsolicited personal contact by MCO personnel with the
Eligible Enrollee at that individual's residence for the
purpose of influencing the individual to enroll with that MCO
and includes unsolicited telephone contact and any other type
of contact made without the individual's written consent. Such
written consent may be obtained at the initiation of a visit
to an individual's residence as long as the Contractor has
obtained the individual's oral consent prior to the visit and
has documented such consent in a written form that identifies
the person granting the consent and the person receiving the
consent, as well as the date, time and place that the oral
consent was given. Any contacts at the individual's residence
must be made within thirty (30) days from the date the
individual gave oral consent. Soliciting individuals to
provide the names of other Eligible Enrollees is also strictly
prohibited. Nothing in this section shall prohibit the
Contractor from distributing unsolicited Marketing materials
via the United States Postal Service or a commercial delivery
service where such service is unrelated to the Contractor.
5.4 INAPPROPRIATE ACTIVITIES
The Contractor shall not:
(a) provide cash to Eligible Enrollees, Prospective Beneficiaries
or Beneficiaries, except for stipends, in an amount approved
by the Department, and reimbursement of expenses provided to
Beneficiaries for participation on committees or advisory
groups;
(b) provide gifts or incentives to Eligible Enrollees or
Prospective Beneficiaries unless such gifts or incentives: (1)
are provided to meet the objectives of the Medical Assistance
Program or KidCare; (2) are related to health care; (3) do not
exceed a nominal value (i.e., an individual gift or incentive
may not exceed ten dollars ($10)); and (4) have been
pre-approved by the Department;
(c) provide gifts or incentives to Beneficiaries unless such gifts
or incentives (1) are provided to promote preventive care; (2)
are not in the form of cash or an instrument that may be
converted to cash; and (3) have been pre-approved by the
Department;
(d) seek to influence an Eligible Enrollee's Enrollment with the
Contractor in conjunction with the sale of any other
insurance;
(e) induce providers or employees of the Department or the
Department of Human Services to reveal confidential
information regarding Participants or otherwise use such
confidential information in a fraudulent manner;
(f) threaten, coerce or make untruthful or misleading statements
to Eligible Enrollees,
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Prospective Beneficiaries or Beneficiaries regarding the
merits of Enrollment in the Contractor's Plan or any other
plan; or
(g) present an incomplete Managed Care Enrollment Form to an
Eligible Enrollee for his signature.
5.5 OBLIGATION TO PROVIDE INFORMATION
The Contractor agrees to provide Basic Information to the
individuals and at the times described below:
(a) to each Beneficiary or Prospective Beneficiary within a
reasonable time after it receives notice of his enrollment;
(b) to any Eligible Enrollee who requests it; or
(c) once a year Contractor must notify its Beneficiaries of their
right to request and obtain the Basic Information.
(d) "Basic Information" as used herein shall mean:
(1) kinds of benefits, and amount, duration and scope of
benefits available under the Plan. There must be
sufficient detail to ensure Beneficiaries receive the
Covered Services to which they are entitled, including
pharmaceuticals, mental health and substance abuse
services;
(2) procedures for obtaining Covered Services, including
approval requirements, if any;
(3) information, as provided by the Department, regarding
any benefits to which they may be entitled under the
Medical Assistance Program or KidCare that are not
provided under the Plan and specific instructions on
where and how to obtain those benefits, including how
transportation is provided and that family planning
services may be obtained from an Affiliated or
non-Affiliated Provider;
(4) any restrictions on a Beneficiary's freedom of choice
among Affiliated Providers;
(5) the extent to which a Beneficiary may obtain Covered
Services from non-Affiliated Providers;
(6) the extent to which after-hours and emergency coverage
are provided;
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(7) policy on referrals for specialty care and for Covered
Services not furnished by a Beneficiary's Primary Care
Provider;
(8) cost sharing, if any;
(9) the rights and responsibilities of a Beneficiary such as
those pertaining to enrollment and disenrollment and
Beneficiary rights under State and Federal law;
(10) complaint, grievance, and fair hearing procedures;
(11) appeal rights and procedures;
(12) names and locations of current Affiliated Providers,
including identification of those who are not accepting
new patients; and
(13) a copy of the Contractor's Certificate of Coverage or
Document of Coverage.
(e) The following additional information must be provided by
Contractor upon request to any Beneficiary, Prospective
Beneficiary, and Eligible Enrollee:
(1) MCO and health care facility licensure; and
(2) information about Affiliated Providers of health care
services, including education, Board certification and
recertification.
5.6 QUALITY ASSURANCE, UTILIZATION REVIEW AND PEER REVIEW
(a) All services provided by or arranged for by the Contractor to
be provided shall be in accordance with prevailing community
standards. The Contractor must have in effect a program
consistent with the utilization control requirements of 42
C.F.R. Part 456. This program will include, when so required
by the regulations, written plans of care and certifications
of need of care.
(b) The Contractor agrees to comply with the quality assurance
standards attached hereto as Exhibit A.
(c) The Contractor shall have a Utilization Review Program that
includes a utilization review plan, a utilization review
committee, and appropriate mechanisms covering
preauthorization and review requirements.
(d) The Contractor shall establish and maintain a Peer Review
Program approved by the Department to review the quality of
care being offered by the Contractor,
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employees and subcontractors.
(e) The Contractor agrees to comply with the utilization review
standards and peer review standards attached hereto as Exhibit
B.
5.7 PHYSICIAN INCENTIVE PLAN REGULATIONS
The Contractor shall comply with the provisions of 42 C.F.R. 434.70.
This shall include submission to the Department, at required
intervals, the information described in 42 C.F.R. 417.479(h) and
(i). If, to conform with these regulations, the Contractor performs
Beneficiary satisfaction surveys, such surveys may be combined with
those required by the Department pursuant to Article V, Section 5.16
of this Contract.
5.8 PROHIBITED AFFILIATIONS
(a) The Contractor shall assure that any Affiliated Provider,
including out-of-State Providers, is enrolled in the Medical
Assistance Program, if such enrollment is required for such
Provider by Department rules or policy in order to submit
claims for reimbursement or otherwise participate in the
Medical Assistance Program. The Contractor shall assure that
any non-Affiliated Illinois provider billing for services is
enrolled in the Medical Assistance Program prior to paying
claims.
(b) The Contractor shall not employ, subcontract with, or
affiliate itself with or otherwise accept any Ineligible
Person into its network.
(c) The Contractor shall screen all current and prospective
employees, contractors, and sub-contractors, prior to engaging
their services under this Contract by: (i) requiring them to
disclose whether they are Ineligible Persons; (ii) reviewing
the OIG's list of sanctioned persons (available on the World
Wide Web at http:▇▇▇.▇▇▇▇▇.▇▇▇/▇▇▇▇) and the HHS/OIG List of
Excluded Individuals/Entities (available on the World Wide Web
at ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇▇/▇▇▇). The Contractor shall annually
screen all current employees, contractors and sub-contractors
providing services under this Contract. The Contractor shall
screen out-of-State non-Affiliated Providers billing for
Covered Services prior to payment and shall not pay such
Providers who meet the definition of Ineligible Persons.
(d) The Contractor shall terminate its relations with any
Ineligible Person immediately upon learning that such Person
or Provider meets the definition of an Ineligible Person and
notify the OIG of the termination.
5.9 RECORDS
(a) Maintenance of Business Records
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The Contractor shall maintain all business and professional
records that are required by the Department in accordance with
generally accepted business and accounting principles. Such
records shall contain all pertinent information about the
Beneficiary including, but not limited to, the information
required under this Article V, Section 5.9. Medical records
reporting requirements shall be adequate to ensure acceptable
continuity of care to Beneficiaries.
(b) Availability of Business Records
Records shall be made available in Illinois to the Department
and Authorized Persons for inspection, audit, and/or
reproduction as required in Article IX, Section 9.1. These
records will be maintained as required by 45 C.F.R. Part 74.
As a part of these requirements, the Contractor will retain
all records for at least five (5) years after final payment is
made under the Contract. If an audit, litigation or other
action involving the records is started before the end of the
five-year (5 year) period, the records must be retained until
all issues arising out of the action are resolved.
(c) Patient Records
(1) Treatment Plans
The Contractor must develop and use treatment plans for
chronic disease follow-up care that are tailored to the
individual Beneficiary. The purpose of the plan is to
assure appropriate ongoing treatment reflecting the
prevailing community standards of medical care designed
to minimize further deterioration and complications.
Treatment plans shall be on file with the permanent
record for each Beneficiary with a chronic disease and
with sufficient information to explain the progress of
treatment.
(2) Permanent Records
A permanent medical record shall be maintained at the
Primary Care Site for every Beneficiary and be available
to the Primary Care Provider, Women's Health Care
Provider and other Providers. Copies of the medical
record shall be sent to any new Site to which the
Beneficiary transfers, provided the Beneficiary consents
to the transfer. The Contractor shall make good faith
efforts to obtain such consent. Copies of records shall
be released only to Authorized Individuals. Original
medical records shall be released only in accordance
with Federal or State law, court orders, subpoenas, or a
valid records release form executed by a Beneficiary.
The Contractor shall ensure that Beneficiaries have
timely access to the records. The Contractor shall
protect the confidentiality and privacy of minors, and
abide by all Federal and State laws regarding the
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confidentiality and disclosure of medical records,
mental health records, and any other information about
Beneficiary. The Contractor shall produce such records
for the Department upon request. Medical records must
include Provider identification and Beneficiary
identification. All entries in the medical record must
be legible and dated, and the following, where
applicable, shall be included:
patient identification;
personal health, social history and family
history, with updates as needed;
obstetrical history (if any) and/or profile;
hospital admissions and discharges;
relevant history of current illness or injury
(if any) and physical findings;
diagnostic and therapeutic orders;
clinical observations, including results of
treatment;
reports of procedure, tests and results;
diagnostic impressions;
patient disposition and pertinent
instructions to patient for follow-up care;
immunization record;
allergy history;
periodic exam record;
growth chart;
referral information, if any;
health education provided; and
family planning and/or counseling.
5.10 COMPUTER SYSTEM REQUIREMENTS
(1) The Contractor must establish and maintain a computer system
compatible with the Department's system, and execute an
electronic communication agreement provided by the Department.
The system must be able to exchange data using Connect Direct,
a product of Sterling Software, or other products as allowed
by the Department.
(2) The Contractor shall pay for a line connection for
communication between the Contractor and the Department that
shall be established by the Department. A 56KB or faster
dedicated telecommunication line or multiple 56KB or faster
circuits will be necessary to interface directly with the
State. All costs associated with interfacing with the
Department shall be borne by the Contractor.
(3) The Contractor must provide staff with proficient knowledge in
telecommunications to ensure communication connectivity is
established and
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maintained.
5.11 REGULAR REPORT AND SUBMISSION REQUIREMENTS
(a) The Contractor shall submit to the Department regular reports
and special reports as set forth in this Section. Reports
shall be submitted in a format and medium designated by the
Department.
(1) Quality Assurance, Utilization Review and Peer Review
Report (QA/UR/PR Report). This report shall provide a
summary review of the effectiveness of the Contractor's
Quality Assurance Plan, including that implemented in
the area of behavioral health. The summary review shall
contain the Contractor's processes for quality
assurance, utilization review and peer review. The
report's content, as determined by the Department, will
include, but is not limited to: quality assurance,
utilization and peer review activities during the fiscal
year; quality indicators and methodology for measuring
those indicators; trending and comparison of clinical,
including behavioral health, and service indicators and
health outcomes; results of the medical record reviews
and quality assurance studies (focused medical studies);
aggregate data on utilization of services, including the
Contractor's progress toward meeting the Department's
established preventive care participation goals set
forth in this Article V, Section 5.13(a), (b), and (c);
summary of oversight activities and outcomes; quality
improvement strategies (including those identified
through the grievance process); implemented and
demonstrated improvements; summary of credentialing and
peer review activities; Beneficiary Satisfaction Survey
analysis; and changes in the Contractor's Quality
Assurance, Utilization Review or Peer Review program
planned for the next fiscal year. In the QA/UR/PR
Report, the five (5) HEDIS indicators mutually selected
by the MCOs and the Department shall be reported. In the
second year of the Contract, an additional set of
mutually agreed upon common HEDIS indicators will be
added and reported in the QA/UR/PR Report.
(2) Summary of Grievances and Resolutions and External
Independent Reviews and Resolutions. This quarterly
report shall provide a summary of the grievances filed
by Beneficiaries and the resolution of such grievances
as well as a summary of all external independent reviews
and the resolution of such reviews. Such report shall
include types of grievances and external independent
reviews by category and totals, the number and levels at
which the grievances/reviews were resolved, the types of
resolutions and the number pending resolution by
category.
(3) Behavioral Health Report. On a quarterly basis, the
Contractor shall
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submit to the Department behavioral health utilization
statistics and analysis as specified in Paragraph 12 of
Exhibit A.
(4) Marketer Training Schedule and Agenda. On a quarterly
basis, two weeks prior to the beginning of the report
quarter, the Contractor shall provide the Department
with its schedule for training of Marketing personnel.
The model agenda for each type of training must
accompany the schedule. The Contractor shall provide the
Department with written notice of any changes to the
quarterly schedule at least seventy-two (72) hours prior
to the scheduled training.
(5) Marketing Representative Listing. On a monthly basis, on
the first of day of the month for that month, the
Contractor shall provide the Department with a list of
all Marketing personnel who are active as well as any
Marketing personnel for whom a change of status has
occurred since the last report month.
(6) Fraud and Abuse Report. The Contractor shall report all
allegations of Fraud, Abuse or misconduct of Providers,
Beneficiaries or Department employees to the OIG
immediately upon knowledge of such Fraud, Abuse or
misconduct. If no Fraud, Abuse or misconduct is reported
to the OIG during a quarter, the Contractor shall file a
certification of such with the OIG within thirty (30)
days of the end of the quarter.
(b) Submissions
(1) Encounter Data
(A) Submission. The Contractor must report, in
accordance with Subsections (B) and (C) of this
Article V, Section 5.11(b)(1), all services
received by Beneficiaries. On a monthly basis, the
Contractor shall provide the Department with files
in the format and medium designated by the
Department, prepared with claims level detail as
required herein and in Exhibit E attached hereto,
for all services received by Beneficiaries during
a given month. This data must be received by the
Department within one hundred twenty (120) days of
the last day of the service month. Any claims
processed by the Contractor for services provided
in a given report month subsequent to submission
of the monthly Encounter Data Report shall be
reported on the next submission of the monthly
Encounter Data Report.
(B) Testing. Upon receipt of each submitted data file,
the Department shall perform two distinct levels
of review. The first level of review
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and edits performed by the Department shall check
the data file format. These edits shall include,
but are not limited to the following: check the
data file for completeness of records; correct
sort order of records; proper field length and
composition; and correct file length. The format
of the file, to be accepted by the Department,
must be one hundred percent (100%) correct.
If the format is correct, the Department shall
then perform the second level of review. This
second review shall be for standard claims
processing edits. These edits shall include, but
are not limited to the following: correct Provider
numbers; valid recipient numbers; valid procedure
and diagnosis codes; cross checks to assure
Provider and recipient numbers match their names;
and the procedures performed are correct for the
age and sex of the recipient. The acceptable error
rate of claims processing edits of the Illinois
Medicaid UB92 Billing Specification data file, the
HCFA National Standard Format for noninstitutional
claims data file, and the IDPA Direct Tape format
for pharmacy claims file shall be determined by
the Department. Once an acceptable error rate has
been achieved, as determined by the Department,
the Contractor shall be instructed that the
testing phase is complete and that data should be
sent in production.
(C) Production. Once the Contractor's testing of data
specified in (B) above is completed, the
Contractor will be certified for production. Once
certified for production, the data shall continue
to be submitted in accordance with (A) above. The
data will continue to be reviewed for correct
format and quality. The Contractor shall submit as
many files as possible in a time frame agreed upon
by the Department and the Contractor, to ensure
all data is current.
(D) Within thirty (30) days of the date of receipt by
the Department, records that fail the edits
described above in (B) or (C) will be returned to
the Contractor for correction. Corrected data must
be returned to the Department for re-processing.
(2) Provider Network Submissions. The Contractor shall
submit to the Department, in a format and medium
designated by the Department, Provider network reports
that shall include the following: monthly Provider
Affiliation with Sites as set forth in the format given
to the Contractor by the Department; monthly updating of
all Providers who have either become a Provider in the
Contractor's network or who have left the network since
the last report; New Site Provider Affiliations as new
Sites are added; Site terminations immediately as they
occur; and Beneficiary Site Assignments/Site Transfers
as they occur. New Site/PCP
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information shall be reported in a format and medium as
required by the Department. During the term of this
Contract, this report shall be converted to electronic
data transmission. The Department will give the
Contractor no less than one hundred twenty (120) days
notice prior to conversion of this report to electronic
data transmission.
(3) Disclosure Statements. The Contractor shall submit
disclosure statements to the Department initially,
annually, on request and as changes occur.
(4) Beneficiary Materials:
(A) Certificate or Document of Coverage and Any
Changes or Amendments. The Contractor shall submit
these documents to the Department for prior
approval initially and as revised.
(B) Beneficiary Handbook. The Contractor shall submit
the handbook to the Department for prior approval
initially and as revised. The Contractor shall not
be required to submit for prior approval format
changes, provided there is no change in the
information conveyed.
(C) Identification Card. The Contractor shall submit
the identification card to the Department for
prior approval initially and as revised. The
Contractor shall not be required to submit for
prior approval format changes, provided there is
no change in the information conveyed.
(5) Subcontracts and Provider Agreements:
(A) Model Subcontracts and Provider Agreements. The
Contractor shall provide copies of model
subcontracts and Provider agreements related to
Covered Services, assignment of risk and data
reporting functions, including the form of all
proposed schedules or exhibits, intended to be
used therewith, and any substantial deviations
from these model subcontracts and Provider
agreements to the Department initially and as
revised.
(B) Executed Subcontracts and Provider Agreements. The
Contractor shall provide copies of any subcontract
and Provider agreement to the Department upon
request.
(C) Executed Linkage Agreements. The Contractor shall
provide copies of executed linkage agreements to
the Department immediately upon execution by the
Contractor.
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(6) Marketing Materials. The Contractor shall submit
all Marketing Materials to the Department for
prior approval initially and as revised. The
Contractor shall not be required to submit for
prior approval format changes, provided there is
no change in the information conveyed.
(7) Marketing Representative Terminations. The
Contractor shall submit names of Marketing
personnel who have terminated employment or
association with the Contractor as such
terminations occur. The submission shall indicate
whether the termination was voluntary or
involuntary and, if involuntary, shall state
whether the reason for termination was related to
misconduct under this Contract.
(8) Quality Assurance/Medical:
(A) Quality Assurance, Utilization Review,
▇▇▇▇▇ Review and Health Education Plans.
The Contractor shall submit such plans
to the Department for prior approval
initially and as revised. The Contractor
shall not be required to submit for
prior approval format changes, provided
there is no change in the information
conveyed.
(B) QA/UR/PR Committee Meeting Minutes. The
Contractor shall submit the minutes of
these meetings to the Department on a
quarterly basis.
(C) Grievance Procedures. The Contractor
shall submit Grievance Procedures to the
Department for prior approval initially
and as revised. The Contractor shall not
be required to submit for prior approval
format changes, provided there is no
change in the information conveyed.
(c) Additional Reports. The Contractor shall submit to the
Department additional reports or submissions at the
frequency set forth in Exhibit C and Exhibit D and all
other reports and information required by the provisions
of this Contract.
(d) Unless otherwise specified, the Contractor shall submit
all reports to the Department within thirty (30) days
from the last day of the reporting period or as defined
in Exhibit C and Exhibit D. All reports and submissions
listed in this Article V, Section 5.11 must be submitted
to the Department in a Department designated format and
at the intervals set forth in Exhibit C and Exhibit D.
The Department may require additional reports throughout
the term of this Contract. The Department will provide
adequate notice before requiring production of any new
reports or information, and will consider concerns
raised by Contractors about potential burdens associated
with producing the proposed additional reports. The
Department will provide the basis (reason) for any such
request. Failure of
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the Contractor to follow reporting requirements shall subject
the Contractor to the sanctions in Article IX, Section 9.10.
A schedule of all reports and the reporting frequency required
under this Contract is provided in Exhibit C. A schedule of
all submissions and the submitting frequency required under
this Contract is provided in Exhibit D. For purposes of this
Article V, Section 5.11, the following terms shall have the
following meanings:
annual shall be defined by the State fiscal year
beginning July first of each year and ending on but
including June thirtieth of the following year; and
quarter shall be defined as three consecutive calendar
months of the State's fiscal year.
(e) Unless otherwise stated, all reports required herein shall
differentiate between MAG Beneficiaries, MANG Beneficiaries
and KidCare Beneficiaries, where applicable, and insofar as
Beneficiaries can be differentiated by an identifiable code
available to the Contractor.
5.12 HEALTH EDUCATION
The Contractor shall establish and maintain an ongoing program of
health education as delineated in its written plan and submitted
annually to the Department. The health education program will advise
Beneficiaries concerning appropriate health care practices and the
contributions they can make to the maintenance of their own health.
All health education materials must be approved by the Contractor's
medical director. Providing material during Marketing and Enrollment
does not satisfy the requirements of this Article V, Section 5.12.
The Contractor must make good faith efforts to ensure that Primary
Care Providers are active participants in the health education
program. The health education program shall provide, at a minimum,
the following:
(a) Information on how to use the Plan, including information on
how to receive Emergency Services in and out of the
Contracting Area.
(b) Information on preventive care including the value and need
for screening and preventive maintenance.
(c) Counseling and patient education as to the health risks of
obesity, smoking, alcoholism, substance abuse and improper
nutrition, and specific information for persons who have a
specific disease.
(d) Information on disease states, that may affect the general
population.
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(e) Educational material in the form of printed, audio, visual or
personal communication.
(f) Information will be provided in language that the Beneficiary
understands and that meets the requirements set forth in
Article II, Section 2.4.
(g) A single individual appointed by the Contractor to be
responsible for the coordination and implementation of the
program.
The Contractor further agrees to review the health education
program, at reasonable intervals, for the purpose of amending same,
in order to improve said program. The Contractor further agrees to
supply the Department or its designee with the information and
reports prescribed in its approved health education program or the
status of such program.
5.13 REQUIRED MINIMUM STANDARDS OF CARE
The Contractor shall make a good faith effort to provide or arrange
to provide to all Beneficiaries medical care consistent with
prevailing community standards at locations serving the Contracting
Area that assure reasonable availability and accessibility to
Beneficiaries.
The Contractor will provide a system to notify Beneficiaries on an
ongoing basis of the need for and benefits of health screenings and
physical examinations. The Contractor will exercise reasonable
efforts to provide or arrange to provide such examinations to all
its Beneficiaries.
(1) Healthy Kids/EPSDT Services to Beneficiaries Under Twenty-One
(21) Years
All Beneficiaries under twenty-one (21) years of age should
receive screening examinations including appropriate childhood
immunizations at intervals as specified by the Healthy
Kids/EPSDT Program as set forth in Sections 1902(a)(43)and
1905(a)(4)(B) of the Social Security Act and 89 Ill. Adm. Code
140.485. Any condition discovered during the screening
examination or screening test requiring further diagnostic
study or treatment must be provided if within the scope of
Covered Services. The Contractor shall refer the Beneficiary
to an appropriate source of care for any required services
that are not Covered Services. If, as a result of Healthy
Kids/EPSDT services, the Contractor determines a Beneficiary
is in need of services that are not Covered Services but are
services otherwise provided for under the Medical Assistance
Program, the Contractor will ensure that the Beneficiary is
referred to an appropriate source of care. The Contractor
shall have no obligation to pay for services that are not
Covered Services.
At a minimum, the Contractor shall provide or arrange to
provide all appropriate
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screening and vaccinations in accordance with OBRA 1989
guidelines to eighty percent (80%) of Beneficiaries younger
than twenty-one (21) years of age.
(b) Preventive Medicine Schedule (Services to Beneficiaries
Twenty-One (21) Years of Age and Over)
The following preventive medicine services and age schedule is
the minimum acceptable range and scope of required services
for adults. The Contractor may substitute an alternate
schedule for adult preventive medicine services as long as
such schedule is based upon recognized guidelines such as
those recommended by the current U.S. Preventive Services Task
Force's "Guide to Clinical Preventive Services" and the
Contractor submits the schedule to the Department and receives
the Department's written approval for the alternate schedule
prior to implementing it.
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Service
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1 Complete To be provided during first year
history/physical of Enrollment, plus complete
physical exam when indicated, but minimally
at five (5) years when there are no other
indications.
2 Circulatory & When indicated in any Beneficiary,
Fundoscopy but every year in diabetics,
Evaluation hypertensives, and those with
prior history of circulatory
and/or retinal disease.
3 Rectal Exam & hemocult Minimally every year in any Beneficiaries
with history of G.I. bleeding, disease of
colon, history of colon polyps and any history of
prior carcinoma of G.I. tract. An annual digital
rectal exam for asymptomatic men age
fifty (50) and over, African-American men age
forty (40) and over; and men age 40 and over with
a family history of prostate cancer.
4 Clinical Breast 1. Minimally, every year in any Beneficiary
Examination with history of fibrocystic disease or
other benign lump in breast, and in those
with prior carcinoma.
2. Every two (2) years in all females with no other
indications for exam.
3. For all females, patient instruction in
self-examination of breasts.
5 CBC When indicated by complaints, history or physical
findings.
6 Urinalysis When indicated by complaints, history or physical
findings, at least annually in all diabetics,
hypertensives and those with history of renal or
prostatic disease. Should also document urine culture
and sensitivity in all recurrent or chronic urinary or
prostatic infections prior to any long-term antibiotic
therapy.
7 Blood Chemistries, When indicated by complaints, history or physical findings,
Enzymes, or other and as indicated by specific diagnosis and/or therapy as
Laboratory Profiles as blood sugar in diabetics or dilantin level in epileptics,
and including annual prostate-specific antigen tests for
males.
8 EKG Baseline, at age fifty (50), if not before; only when
indicated thereafter.
9 Mammography 1. Baseline in females at age thirty-five (35) or
older;
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2. Every year for women age forty (40) and
older; and
3. As indicated for women with personal or
family history.
10 Sigmoidoscopy With each complete physical exam, whenever
indicated.
11 Respiratory In all patients with a chronic respiratory disease
Testing diagnosis and, as baseline, in all patients who smoke.
(Recommendations made to this patient after examination
and testing should be documented).
12 Blood Pressure Annually after age eighteen (18).
Check
13 Papanicolaou Smear Routine annual screening including a cervical smear or
Papanicolaou Smear and pelvic-exam for females who are
eighteen (18) years of age and older, or at the onset of
becoming sexually active, whichever is earlier.
14 Prostate Specific Annually for asymptomatic men age
Antigen Test fifty (50) and older, African
American men age forty (40) and
older, and all men age forty (40)
and older with a family history of
prostate cancer.
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At a minimum, the Contractor shall make good faith efforts to
provide or arrange to provide the initial history and physical
examination to fifty percent (50%) of all Beneficiaries in
their first twelve (12) months of coverage, to seventy percent
(70%) of all Beneficiaries in their second twelve (12) months
of coverage and eighty percent (80%) of all Beneficiaries in
their third twelve (12) months of coverage or more. For
purposes of this subsection, "twelve (12) months of coverage"
may include up to forty-five (45) days interrupted coverage.
(c) Maternity Care
The Contractor shall provide or arrange to provide quality
care for pregnant Beneficiaries. At a minimum, the Contractor
shall make good faith efforts to provide, or arrange to
provide, and document:
(1) A comprehensive prenatal evaluation and care in
accordance with the latest standards published by the
American College of Obstetrics and Gynecology or the
American Academy of Family Physicians. The specific
areas to be addressed in regard to the provision of care
include, but are not limited to, the following items:
content of the initial assessment, including history,
physical, lab tests and risk assessment including HIV
counseling and voluntary HIV testing; follow-up
laboratory testing; nutritional assessment and
counseling; frequency of visits; content of follow-up
visits; anticipatory guidance and appropriate referral
activities.
(2) At least seventy percent (70%) of all pregnant
Beneficiaries shall receive the minimum level of
prenatal visits adjusted for the date of coverage under
the Plan. For the exclusive purpose of calculating this
rate, women who deliver within sixty (60) days of the
first day of coverage under the Plan shall be excluded.
(3) The Contractor shall provide or arrange to provide
nutritional assessment and counseling to all pregnant
Beneficiaries. Individualized diet counseling is to be
provided as indicated.
(4) The Contractor shall require its Primary Care Providers
and Women's Health Care Providers to identify maternity
cases presenting the potential for high-risk maternal or
neonatal complications and arrange appropriate referral
to physician specialist or transfer to Level III
perinatal facilities as required. The Contractor shall
utilize, for such high-risk consultation or referrals,
the standards of care promulgated by the Statewide
Perinatal Program of the Illinois Department of Human
Services.
(5) The consulting physician at the perinatal center will
determine the
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management of the Beneficiary at that point in time. Should
transport be required, the consultant at the perinatal center
will identify the most appropriate mode of transport for such
a transfer. Should the perinatal center be unable to accept
the Beneficiary due to bed unavailability, that center will
arrange for admission of the Beneficiary to an alternate Level
III perinatal center. All records required for appropriate
management of the high-risk Beneficiary receiving consultation
or referral to a perinatal center will be provided to the
consulting physician as indicated. The Contractor will obtain
from the consulting physician all necessary correspondence to
enable the Primary Care Provider to provide, or arrange for
the provision of, appropriate follow-up care for the mother or
neonate following discharge.
(d) Complex and Serious Medical Conditions
(1) The Contractor shall provide or arrange to provide quality
care for Beneficiaries with complex and serious medical
conditions. At a minimum, the Contractor shall provide and
document the following:
(A) Timely identification of Beneficiaries with complex and
serious medical conditions.
(B) Assessment of such conditions and identification of
appropriate medical procedures for monitoring or
treating them.
(C) Implementation of a treatment plan in accordance with
this Article V, Section 5.9(c)(1).
(e) Access Standards
(1) Appointments
Time specific appointments for routine, preventive care shall
be made available within five (5) weeks from the date of
request for such care. Beneficiaries with more serious
problems not deemed Emergency Medical Conditions shall be
triaged and provided same day service, if necessary.
Beneficiaries with problems or complaints that are not deemed
serious shall be seen within three (3) weeks from the date of
request for such care. The Contractor shall have an
established policy that scheduled Beneficiaries shall not
routinely wait for more than one (1) hour to be seen by a
Provider and no more than six (6) scheduled appointments shall
be made for each Primary Care Provider per hour.
Notwithstanding this limit, the Department recognizes that
physicians supervising other licensed health care Providers
may routinely account for more than six (6)
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appointments per hour.
(2) Services Requiring Prior Authorization
The Contractor shall provide, or arrange for the provision of,
Covered Services as expeditiously as the Beneficiary's health
condition requires. Ordinarily, Covered Services shall be
provided within fourteen (14) calendar days after receiving
the request for service from a Provider, with a possible
extension of up to fourteen (14) calendar days, if the
Beneficiary requests the extension or the Contractor provides
written justification to the Department that there is a need
for additional information and the Beneficiary will not be
harmed by the extension. If the Physician indicates, or the
Contractor determines that following the ordinary time frame
could seriously jeopardize the Beneficiary's life or health,
the Contractor shall provide, or arrange for the provision of,
the Covered Service no later than seventy-two (72) hours after
receipt of the request for service, with a possible extension
of up to fourteen (14) calendar days, if the Beneficiary
requests the extension or the Contractor provides written
justification to the Department that there is a need for
additional information and the Beneficiary will not be harmed
by the extension.
(f) Linkages to Other Services
(1) The Contractor shall use reasonable efforts to encourage
the Plan Providers and subcontractors to cooperate with
and communicate with other service providers who serve
Beneficiaries. Such other service providers may include:
CBHPs; Women-Infant and Children (WIC) programs; Head
Start programs; Early Intervention programs; Public
Health providers; school-based clinics; and school
systems. Such cooperation may include performing annual
physical examinations for school and the sharing of
information (with the consent of the Beneficiary).
(2) The Contractor shall participate in the Family Case
Management Program, which shall include, but is not
limited to:
(A) Coordinating services and sharing information with
existing Family Case Management Providers for its
Beneficiaries;
(B) Developing internal policies, procedures, and
protocols for the organization and its provider
network for use with Family Case Management
Providers serving Beneficiaries; and
(C) Conducting periodic meetings with Family Case
Management
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Providers performing problem resolution and
handling of grievances and issues, including
policy review and technical assistance.
5.14 CHOICE OF PHYSICIANS
The Contractor shall afford to each Beneficiary a Primary Care
Provider and, where appropriate, a Women's Health Care Provider.
In each Contracting Area, there shall be at least one (1) full-time
equivalent Physician for each 1,200 Beneficiaries, including one (1)
full-time equivalent Primary Care Provider for each 2,000
Beneficiaries. In each Contracting Area, there shall be at least one
(1) Women's Health Care Provider for each 2,000 female Beneficiaries
between the ages of eighteen (18) and forty-four (44), at least one
(1) Physician specializing in obstetrics for each 300 pregnant
female Beneficiaries and at least one (1) pediatrician for each
2,000 Beneficiaries under age seventeen (17). All Physicians
providing services shall have and maintain admitting privileges and,
as appropriate, delivery privileges at an Affiliated Plan hospital;
or, in lieu of these admitting and delivery privileges, the
Physicians shall have a written referral agreement with a Physician
who is in the Contractor's network and who has such privileges at an
Affiliated Plan hospital. The agreement must provide for the
transfer of medical records and coordination of care between
Physicians.
In any Contracting Area in which the Contractor does not satisfy the
full-time equivalent provider requirements set forth above, the
Contractor may demonstrate compliance with these requirements by
demonstrating that (i) the Contractor's full time equivalent
Physician ratios exceed ninety percent (90%) of the requirements set
forth above, and (ii) that Covered Services are being provided in
such Contracting Area in a manner which is timely and otherwise
satisfactory. The Contractor shall comply with Section 1932(b)(7) of
the Social Security Act.
5.15 TIMELY PAYMENTS TO PROVIDERS
The Contractor shall make payments to Providers for Covered Services
on a timely basis consistent with the Claims Payment Procedure
described at 42 U.S.C. Section 1396a(a)(37)(A), unless the Provider
and the Contractor agree to an alternate payment schedule.
Complaints or disputes concerning payments for the provision of
services as described in this paragraph shall be subject to the
Contractor's Provider grievance resolution system.
The Contractor shall pay for all appropriate Emergency Services
rendered by a Provider with whom the Contractor does not have
arrangements within thirty (30) days of receipt of a complete and
correct claim. If the Contractor determines it does not have
sufficient information to make payment, the Contractor shall request
all necessary information from the Provider within thirty (30) days
of receiving the claim, and shall pay the Provider within thirty
(30) days after receiving such information. Such payment shall be
made at
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the same rate the Department would pay for such services
according to the level of services provided.
The Contractor shall pay for all authorized Post-Stabilization
services rendered by a non-Affiliated hospital Provider at the same
rate the Department would pay for such services unless a different
rate was agreed upon by the Contractor and Provider. Authorized
Post-Stabilization services include such services rendered under the
circumstances described in Section 70(c)(2) of the Illinois Managed
Care Reform and Patient Rights Act.
The Contractor shall accept claims from non-Affiliated Providers for
at least one (1) year after the date the services are provided. The
Contractor shall not be required to pay for claims initially
submitted by such Providers more than one (1) year after the date of
service.
5.16 GRIEVANCE PROCEDURE AND BENEFICIARY SATISFACTION SURVEY
(a) The Contractor shall establish and maintain a procedure for
reviewing complaints registered by Beneficiaries. The
Contractor's procedures must: (1) be submitted to the
Department in writing and approved in writing by the
Department; (2) provide for prompt resolution, and (3) assure
the participation of individuals with authority to require
corrective action. The Contractor must have a Grievance
Committee for reviewing administrative complaints registered
by its Beneficiaries, and Beneficiaries must be represented on
the Grievance Committee. At a minimum, the following elements
must be included in the grievance process:
(1) An informal system, available internally, to attempt to
resolve all complaints;
(2) A formally structured system that is compliant with
Section 45 of the Managed Care Reform and Patient Rights
Act to handle all complaints subject to the provisions
of that section of the Act;
(3) A formally structured Grievance Committee must be
available for Beneficiaries whose complaints cannot be
handled informally and are not appropriate for the
procedures set up under the Managed Care Reform and
Patient Rights Act. All Beneficiaries must be informed
that such a system exists. Complaints at this stage must
be in writing and sent to the Grievance Committee for
review;
(4) The Grievance Committee must have at least twenty-five
percent (25%) representation by members of Contractor's
prepaid plans, with at least one (1) Beneficiary of
Contractor's services under this Contract on the
Committee. The Department may require that one (1)
member of the
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Grievance Committee be a representative of the
Department;
(5) Final decisions under the Managed Care Reform and
Patient Rights Act procedures and those of the Grievance
Committee may be appealed by the Beneficiary to the
Department under its Fair Hearings system;
(6) A summary of all complaints heard by the Grievance
Committee and by independent external reviewers and the
responses and disposition of those matters must be
submitted to the Department quarterly;
(7) A Beneficiary may appoint a guardian, caretaker
relative, Primary Care Provider, Women's Health Care
Provider, or other Physician treating the Beneficiary to
represent him throughout the complaint and appeal
process.
(b) The Contractor agrees to review its grievance procedures, at
reasonable intervals, for the purpose of amending same when
necessary. The Contractor shall amend the procedures only upon
receiving the prior written consent of the Department. The
Contractor further agrees to supply the Department and/or its
designee with the information and reports prescribed in its
approved procedure. This information shall be furnished to the
Department upon its request.
(c) The Contractor shall annually conduct a uniform Beneficiary
Satisfaction Survey. The Survey shall be administered in a
manner consistent with the Department's required procedures
and analyzed by the Contractor. The Department shall use
reasonable efforts to assure that its required procedures
comport with the accreditation requirements which the
Contractor must follow when seeking accreditation from NCQA,
JCAHO or other accrediting bodies; however, nothing in this
Contract shall require such accreditation. The Contractor
shall submit its findings and explain what actions it will
take on its findings as part of the comprehensive QA/UR/PR
Report.
5.17 PROVIDER AGREEMENTS AND SUBCONTRACTS
(a) The Contractor may provide or arrange to provide any Covered
Services identified in Article V, Section 5.1 with Affiliated
Providers or fulfill any other obligations under this Contract
by means of subcontractual relationships.
(1) All Provider agreements and/or subcontracts entered into
by the Contractor must be in writing and are subject to
the following conditions:
(A) The Affiliated Providers and subcontractors shall
be bound by the terms and conditions of this
Contract that are appropriate to the service or
activity delegated under the subcontract. Such
requirements include, but are not limited to, the
record keeping and
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audit provisions of this Contract, such that the
Department or Authorized Persons shall have the
same rights to audit and inspect subcontractors as
they have to audit and inspect the Contractor.
(B) The Contractor shall remain responsible for the
performance of any of its responsibilities
delegated to Affiliated Providers or
subcontractors.
(C) No Provider agreement or subcontract can terminate
the legal responsibilities of the Contractor to
the Department to assure that all the activities
under this Contract will be carried out.
(D) All Affiliated Providers providing Covered
Services for the Contractor under this Contract
must currently be enrolled as Providers in the
Medical Assistance Program. The Contractor shall
not contract or subcontract with an Ineligible
Person or a Person who has voluntarily withdrawn
from the Medical Assistance Program as the result
of a settlement agreement.
(E) All Provider agreements and subcontracts must
comply with the Lobbying Certification contained
in Article IX, Section 9.22 of this Contract.
(b) With respect to all Provider agreements and subcontracts made
by the Contractor, the Contractor further warrants:
(1) That such Provider agreements and subcontracts are
binding;
(2) That it will promptly terminate contracts with Providers
who are terminated, barred, suspended, or have
voluntarily withdrawn as a result of a settlement
agreement in any program under federal law including any
program under Titles XVIII, XIX, XX or XXI of the Social
Security Act or are otherwise excluded from
participation in the Medical Assistance Program or
KidCare; and
(3) That all laboratory testing Sites providing services
under this Contract must possess a valid Clinical
Laboratory Improvement Amendments ("CLIA") certificate
and comply with the CLIA regulations found at 42 C.F.R.
Part 493.
(c) The Contractor will submit to the Department copies of model
Provider agreements and/or subcontracts, initially and
revised, that relate to Covered Services, assignment of risk
and data reporting functions and any substantial deviations
from these model Provider agreements or subcontracts. The
Contractor
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shall provide copies of any other model Provider agreement or
subcontract or any actual Provider agreement or subcontract to
the Department upon request. The Department reserves the right
to require the Contractor to amend any Provider agreement or
subcontract as necessary to conform with the Contractor's
duties and obligations under this Contract.
The Contractor may designate in writing certain information
disclosed under this Article V, Section 5.17 as confidential
and proprietary. If the Contractor makes such a designation,
the Department shall consider said information exempt from
copying and inspection under Section 7(1)(b) or (g) of the
State Freedom of Information Act (5 ILCS 140/1 et seq.). If
the Department receives a request for said information under
the State Freedom of Information Act, however, it may require
the Contractor to submit justification for asserting the
exemption. Additionally, the Department may honor a criminal
subpoena or civil subpoena for such documents without such
being deemed a breach of this Contract or any subsequent
amendment hereto.
(d) Prior to entering into a Provider agreement or subcontract,
the Contractor shall submit a disclosure statement to the
Department specifying any Provider agreement or subcontract
and Providers or subcontractors in which any of the following
have a five percent (5%) or more financial interest:
(1) any Person also having a five percent (5%) or more
financial interest in the Contractor or its affiliates
as defined by 42 C.F.R. 455.101;
(2) any director, officer, trustee, partner or employee of
the Contractor or its affiliates; or
(3) any member of the immediate family of any Person
designated in (1) or (2) above.
(e) Any contract or subcontract between the Contractor and a
Federally Qualified Health Center ("FQHC") or a Rural Health
Clinic ("RHC") shall be executed in accordance with
1902(a)(13)(C) and 1903(m)(2)(A)(ix) of the Social Security
Act, as amended by the Balanced Budget Act of 1997 and shall
provide payment that is not less than the level and amount of
payment which the Contractor would make for the Covered
Services if the services were furnished by a Provider which is
not an FQHC or a RHC.
5.18 SITE REGISTRATION AND PRIMARY CARE PROVIDER/WOMEN'S HEALTH CARE
PROVIDER APPROVAL AND CREDENTIALING
(a) The Contractor shall register with the Department each Site
prior to assigning Beneficiaries to that Site to receive
primary care. A fully executed Provider
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agreement must be in place between the Contractor and the Site
prior to registration of the Site. All FQHCs and RHCs must be
registered as unique sites. The Contractor must give advance
notice to the Department as soon as practicable of the
anticipated closing of a Site. If it is not possible to give
advance notice of a closing of a Site, the Contractor shall
notify the Department immediately when a Site is closed.
(b) The Contractor shall submit to the Department for approval the
name, license numbers, and other information requested in a
format designated by the Department of all proposed Primary
Care Providers and Women's Health Care Providers, as such new
Primary Care Providers and Women's Health Care Providers are
added to the Contractor's network through executed Provider
agreements. A Primary Care Provider or Women's Health Care
Provider may not be offered to Beneficiaries until the
Department has given its written approval of the Primary Care
Provider or Women's Health Care Provider.
(c) All Primary Care Providers and Women's Health Care Providers
must be credentialed by the Contractor. The credentialing
process may be two-tiered, and the Contractor may assign
Beneficiaries to the Primary Care Provider or Women's Health
Care Provider following preliminary credentialing. Full
credentialing must be completed within a reasonable time
following the assignment of Beneficiaries to the Primary Care
Provider or Women's Health Care Provider. The Contractor must
notify the Department when the credentialing process is
completed and the results of the process.
5.19 ADVANCE DIRECTIVES
The Contractor shall comply with all rules concerning the
maintenance of written policies and procedures with respect to
advance directives as promulgated by HCFA as set forth in 42 C.F.R.
489, Subpart I and any amendments thereto. The Contractor shall
provide adult Beneficiaries with oral and written information on
advance directives policies, and include a description of applicable
State law. Such information shall reflect changes in State law as
soon as possible, but no later than ninety (90) days after the
effective date of the change.
5.20 FEES TO BENEFICIARIES PROHIBITED
Neither the Contractor nor its Affiliated Providers shall seek or
obtain funding through fees or charges to any Beneficiary receiving
Covered Services pursuant to this Contract, except as permitted or
required by the Department in 89 Ill. Adm. Code 125. The Contractor
acknowledges that imposing charges in excess of those permitted
under this Contract is a violation of Section 1128B(d) of the Social
Security Act and subjects the Contractor to criminal penalties. The
Contractor shall have language in all of its Provider subcontracts
reflecting this requirement.
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5.21 FRAUD AND ABUSE PROCEDURES
(a) The Contractor shall have an affirmative duty to timely report
suspected Fraud and/or Abuse in the Medical Assistance Program
or KidCare by the Beneficiaries or others, suspected criminal
acts by Providers or the Contractor's employees, or Fraud or
misconduct of Department employees to the Public Aid Office of
Inspector General. To this end, the Contractor shall establish
the following procedures, in writing:
(1) the Contractor shall appoint a single individual to
serve as liaison to the Department regarding the
reporting of allegations of Fraud, Abuse, or misconduct;
(2) the Contractor's procedure shall ensure that any of
Contractor's personnel or subcontractors who identify
suspected Fraud, Abuse, or misconduct shall make a
report to Contractor's liaison;
(3) the Contractor's procedure shall ensure that the
Contractor's liaison shall provide notice of any
allegation to the OIG immediately upon receiving such
report. If no reports are received in a quarter, the
liaison shall certify, in writing, to the OIG that no
such reports were received. Reports shall be considered
timely if they are made as soon as the Contractor knew
or should have known of the suspected Fraud, Abuse, or
misconduct, or if no reports were filed, the
certification is received within thirty (30) days after
the end of the quarter; and
(4) the Contractor shall ensure that all its personnel and
subcontractors receive notice of these procedures.
(b) The Contractor shall not conduct any investigation of the
suspected Fraud, Abuse, or misconduct of Department personnel,
but shall report all incidents immediately to the OIG.
The Contractor may conduct investigations of its personnel,
Providers, subcontractors, or Beneficiaries. If the
investigation discloses potential Fraud and Abuse, as defined
in this Contract, the Contractor must immediately notify the
OIG and, if so directed, cease its internal investigation.
Should the allegation or investigation disclose potential
criminal acts by the Contractor's personnel, Providers,
subcontractors, or Beneficiaries, the Contractor shall cease
its internal investigation and immediately notify the OIG.
(c) The Contractor shall cooperate with all investigations of
suspected Fraud, Abuse, or Department employee misconduct.
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5.22 BENEFICIARY-PROVIDER COMMUNICATIONS
Subject to this Article V, Section 5.1(g), and in accordance with
the Managed Care Reform and Patient Rights Act, the Contractor shall
not prohibit or otherwise restrict a Provider from advising a
Beneficiary about the health status of the Beneficiary or medical
care or treatment for the Beneficiary's condition or disease
regardless of whether benefits for such care or treatment are
provided under this Contract, if the Provider is acting within the
lawful scope of practice, and shall not retaliate against a Provider
for so advising a Beneficiary.
ARTICLE VI
DUTIES OF THE DEPARTMENT
6.1 ENROLLMENT
Once the Department has determined that an individual is an Eligible
Enrollee and after the Eligible Enrollee has selected the
Contractor's Plan, such individual shall become a Prospective
Beneficiary. A Prospective Beneficiary shall become a Beneficiary on
the effective date of coverage. Coverage shall begin as designated
by the Department no later than the first day of a calendar month no
later than three (3) calendar months from the date the Enrollment is
entered into the Department's database, after Site assignment, to
ensure that Contractor's Plan is reflected on the Department-issued
medical card. The Department shall transmit to the Contractor, prior
to the first day of each month of coverage, a Prelisting Report.
6.2 PAYMENT
The Department shall pay the Contractor for the performance of the
Contractor's duties and obligations hereunder. Such payment amounts
shall be as set forth in Article VII of this Contract and Attachment
I hereto. Unless specifically provided herein, no payment shall be
made by the Department for extra charges, supplies or expenses,
including, but not limited to, Marketing costs incurred by the
Contractor.
6.3 LIMITATION OF PAYMENT BY THE DEPARTMENT
The payments made by the Department to the Contractor for services
rendered pursuant to this Contract will not exceed the upper payment
limits set forth in 42 C.F.R. 447.361, namely that "Medicaid
payments to the Contractor, for a defined scope of services to be
furnished to a defined number of recipients, may not exceed the cost
to the agency of providing those same services on a fee-for-service
basis to an actuarial equivalent nonenrolled population group." This
payment limit has been utilized in determining the monthly
Capitation rate specified in Attachment I.
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6.4 DEPARTMENT REVIEW OF CONTRACTOR MATERIALS
Review of all Marketing Materials required by this Contract to be
submitted to the Department for prior approval shall be completed by
the Department on a timely basis not to exceed thirty (30) days from
the date of receipt by the Department. The date of receipt shall be
as confirmed by the Department to the Contractor via facsimile. If
the Department does not notify the Contractor of approval or
disapproval of submitted materials within such thirty (30) days, the
Contractor may begin to use such materials. However, the Department,
at any time, reserves the right to disapprove any materials that did
not receive the Department's express written approval. In the event
the Department disapproved any materials, the Contractor immediately
shall cease use and/or distribution of such materials.
6.5 ELIGIBLE ENROLLEE EDUCATION PROGRAM
If the Department implements the enrollment process described in
Article IV, Section 4.1(b), the Department will develop and
implement, either internally or through a contractor, a program to
educate Eligible Enrollees about their choice of health care
delivery systems and the advantages of each, as well as other health
care issues. The program will be designed to reach Eligible
Enrollees early in the process of applying for Medical Assistance
and KidCare.
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ARTICLE VII
PAYMENT AND FUNDING
7.1 PAYMENT RATES
(a) The Department will pay the Contractor on a Capitation basis,
based on the eligibility classification, age and gender
categories of the Beneficiary as shown on the applicable
tables in Attachment I, a sum equal to the product of the
approved Capitation rate and the number of Beneficiaries
enrolled in that category as of the first day of that month.
(b) The Capitation for Beneficiaries residing in areas served by a
Certified Local Health Department with which the Contractor
has executed a subcontract, pursuant to Article V, Section
5.2(c), shall be adjusted by the amount of the Certified Local
Health Department add-on specified in Attachment I. Pursuant
to Article V, Section 5.2(c), this provision concerning
Certified Local Health Departments shall be implemented on a
date designated by the Department.
(c) Fee-for-service Equivalent
The maximum which the Contractor's rate may not exceed is
based on the fee-for-service experience of an equivalent
population for an equivalent scope of benefits.
(1) Capitation
Specific geographic estimates of the maxima for the
eligibility classification, age and gender categories
are developed based on actual paid claims for a date of
service (DOS) period. In order to account for all claims
related to the DOS period, historical data are used and
inflated forward to the midpoint of the period for which
the fee-for-service equivalents are being calculated.
The total dollars expended for the DOS period are then
aggregated by eligibility classification, age and gender
category of the fee-for-service population eligible
during the DOS period. (The age cohorts utilized by the
Department are listed in Attachment I.)
The total dollar amount expended for the DOS period is
then divided by the total number of eligible recipient
months for the DOS period, resulting in a per member per
month fee-for-service equivalent amount, based on the
fee levels paid by the Department to Providers, and
anticipated levels of service utilization.
(2) Upper Payment Limit
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This formula is the required calculation for the upper
payment limits for Capitation and other payments (the
fee-for-service equivalent). The sum of the Capitation
and other rates set forth in Attachment I do not exceed
those limits and are the rates agreed to by the parties
hereto.
(d) The financial impact of any new services added to the
Contractor's responsibilities will be actuarially evaluated by
the Department and, if material, this Contract shall be
amended accordingly.
7.2 ADJUSTMENTS
Monthly payments to the Contractor will be adjusted for retroactive
disenrollments of Beneficiaries, retroactive Enrollments of
newborns, changes to Beneficiary information that affect the monthly
Capitation rate (i.e., region of residence, eligibility
classification, age, gender), financial sanctions imposed in
accordance with Article IX, Section 9.10, rate changes in accordance
with amendments to Attachment I or third-party liability collections
received by the Contractor, or other miscellaneous adjustments
provided for herein.
7.3 COPAYMENTS UNDER KIDCARE
The Contractor may charge copayments to KidCare Participants in a
manner consistent with 89 Ill. Adm. Code, Part 125. If the
Contractor desires to charge such copayments, the Contractor must
provide written notice to the Department before charging such
copayments. Such written notice to the Department shall include a
copy of the policy the Contractor intends to give the Providers in
its network. This policy must set forth the amount, manner, and
circumstances in which copayments may be charged. Such policy is
subject to the prior written approval of the Department. In the
event the Contractor wishes to impose a charge for copayments after
enrollment of a KidCare Participant, it must first provide at least
sixty (60) days prior written notice to such KidCare Participant.
The Contractor shall be responsible for promptly refunding to a
KidCare Participant any copayment that, in the sole discretion of
the Department, has been inappropriately collected for Covered
Services. The Contractor shall not charge copayments to any
Beneficiary who is an American Indian or Alaska Native. The
Department will prospectively identify Beneficiaries who are
American Indians or Alaska Natives.
7.4 AVAILABILITY OF FUNDS
Payment of obligations of the Department under this Contract are
subject to the availability of funds and the appropriation authority
as provided by law. Obligations of the State will cease immediately
without penalty of further payment being required if in any State
fiscal year the Illinois General Assembly or federal funding source
fails to appropriate or otherwise make available sufficient funds
for this Contract within thirty (30) days of the end of the State's
fiscal year.
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(a) If State funds become unavailable, as set forth herein, to
meet the Department's obligations under this Contract in whole
or in part, the Department will provide the Contractor with
written notice thereof prior to the unavailability of such
funds, or as soon thereafter as the Department can provide
written notice.
(b) In the event that funds become unavailable to fund this
Contract in whole, this Contract shall terminate in accordance
with Article VIII, Section 8.4(c) of this Contract. In the
event that funds become unavailable to fund this Contract in
part, it is agreed by both parties that this Contract may be
renegotiated (as to premium or scope of services) or amended
in accordance with Article IX, Section 9.9(c). Should the
Contractor be unable or unwilling to provide fewer Covered
Services at a reduced Capitation rate, or otherwise be
unwilling or unable to amend this Contract within ten (10)
business days after receipt of a proposed amendment, the
Contract shall be terminated on a date set by the Department
not to exceed thirty (30) days from the date of such notice.
7.5 HOLD HARMLESS
The Contractor shall indemnify and hold the Department harmless from
any and all claims, complaints or causes of action which arise as a
result of the Contractor's failure to pay either any Provider for
rendering Covered Services to Beneficiaries or any vendor,
subcontractor, or the Department's mail vendor, either on a timely
basis or at all, regardless of the reason or for any dispute arising
between the Contractor and a vendor, mail vendor, Provider, or
subcontractor; provided, however, that this provision will not
nullify the Department's obligation under Article V, Sections 5.1
and 5.2 to cover services that are not Covered Services under this
Contract, but that are eligible for payment by the Department.
The Contractor warrants that Beneficiaries will not be liable for
any of the Contractor's debts should the Contractor become insolvent
or subject to insolvency proceedings as set forth in 215 ILCS
125/1-1 et seq.
7.6 PAYMENT IN FULL
Acceptance of payment of the rates specified in this Article VII for
any Beneficiary is payment in full for all Covered Services provided
to that Beneficiary.
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ARTICLE VIII
TERM RENEWAL AND TERMINATION
8.1 TERM
This Contract shall take effect on April 1, 2000 and shall continue
for a period of one calendar year. This Contract shall renew
automatically for two consecutive one-year terms, unless either
party gives the other party written notice ninety (90) days prior to
the end of the then-current term. Once either party receives notice
of the other party's intent not to renew, such nonrenewal shall be
irrevocable.
8.2 CONTINUING DUTIES IN THE EVENT OF TERMINATION
Upon termination of this Contract, the parties are obligated to
perform those duties which remain under this Contract. Such duties
include, but are not limited to, payment to Affiliated or
non-Affiliated Providers, completion of customer satisfaction
surveys, cooperation with medical records review, all reports for
periods of operation, including Encounter Data, and retention of
records. Termination of this Contract does not eliminate the
Contractor's responsibility to the Department for overpayments which
the Department determines in a subsequent audit may have been made
to the Contractor, nor does it eliminate any responsibility the
Department may have for underpayments to the Contractor. The
Contractor warrants that if this Contract is terminated, the
Contractor shall promptly supply all information in its possession
or that may be reasonably obtained, which is necessary for the
orderly transition of Beneficiaries and completion of all Contract
responsibilities.
8.3 TERMINATION WITH AND WITHOUT CAUSE
(a) This Contract may be terminated by the Department with cause
upon, at least, fifteen (15) days written notice to the
Contractor for any reason set forth in Section 1932(e)(4)(A)
of the Social Security Act. In the event such notice is given,
the Contractor may request in writing a hearing, in accordance
with Section 1932 of the Balanced Budget Act of 1997 by the
date specified in the notice. If such a request is made by the
date specified, then a hearing under procedures determined by
the Department will be provided prior to termination. The
Department reserves the right to notify Beneficiaries of the
hearing and its purpose, to inform them that they may
disenroll, and to suspend further Enrollment with the
Contractor during the pendency of the hearing and any related
proceedings.
(b) This Contract may be terminated by the Department or the
Contractor without cause upon ninety (90) days written notice
to the other party. Any such date of termination established
by the Contractor shall coincide with the last day of a
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coverage month.
8.4 AUTOMATIC TERMINATION
This Contract may, in the sole discretion of the Department,
automatically terminate on a date set by the Department for any of
the following reasons:
(a) refusal by the Contractor to sign an amendment to this
Contract as described in Article IX, Section 9.9(c); or
(b) legislation or regulations are enacted or a court of competent
jurisdiction interprets a law so as to prohibit the
continuance of this Contract or the Medical Assistance
Program; however, this provision shall not apply should
KidCare be terminated; or
(c) funds become unavailable as set forth in Article VII, Section
7.4(b); or
(d) the Contractor fails to maintain a Certificate of Authority,
as required by Article II, Section 2.6.
8.5 REIMBURSEMENT IN THE EVENT OF TERMINATION
In the event of termination of this Contract, reimbursement for any
and all claims for Covered Services rendered to Beneficiaries prior
to the effective termination date shall be the Contractor's
responsibility.
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ARTICLE IX
GENERAL TERMS
9.1 RECORDS RETENTION, AUDITS, AND REVIEWS
The Contractor shall maintain all business, professional and other
records in accordance with 45 C.F.R. Part 74 and the specific terms
and conditions of this Contract and pursuant to generally accepted
accounting and medical practice. The Contractor shall maintain, for
a minimum of five (5) years after completion of the Contract and
after final payment is made under the Contract, adequate books,
records, and supporting documents to verify the amounts, recipients,
and uses of all disbursements of funds passing in conjunction with
the Contract. If an audit, litigation or other action involving the
records is started before the end of the five (5) year period, the
records must be retained until all issues arising out of the action
are resolved.
The Contract and all books, records, and supporting documents
related to the Contract shall be made available, at no charge, in
Illinois, by the Contractor for review and audit by the Department,
the Auditor General or other Authorized Persons. The Contractor
agrees to cooperate fully with any audit conducted by the
Department, the Auditor General or other Authorized Persons and to
provide full access in Illinois to all relevant materials.
Failure to maintain the books, records, and supporting documents
required by this Section shall establish a presumption in favor of
the State for the recovery of any funds paid by the State under the
Contract for which adequate books, records, and supporting
documentation are not available, in Illinois, to support their
purported disbursement.
The Contractor shall provide any information necessary to disclose
the nature and extent of all expenditures made under this Contract.
Such information must be sufficient to fully disclose all
compensation of Marketing personnel pursuant to Article V, Section
5.3(g). The Department, the Auditor General or other Authorized
Persons may inspect and audit any financial records of the
Contractor or its subcontractors relating to the Contractor's
capacity to bear the risk of financial losses.
The Department, the Auditor General or other Authorized Persons may
also evaluate, through inspection or other means, the quality,
appropriateness, and timeliness of services performed under this
Contract.
The Department shall perform quality assurance reviews to determine
whether the Contractor is providing quality and accessible health
care to Beneficiaries under this Contract. The reviews may include,
but are not limited to, a sample review of medical records of
Beneficiaries, Beneficiary surveys and examination by consultants.
The specific points of quality assurance which will be reviewed
include, but are not limited to:
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(1) legibility of records
(2) completeness of records
(3) peer review and quality control
(4) utilization review
(5) availability, timeliness, and accessibility of care
(6) continuity of care
(7) utilization reporting
(8) use of services
(9) quality and outcomes of medical care
The Department shall provide for an annual (as appropriate) external
independent review of the above that is conducted by a qualified
independent entity.
The Department shall adjust future payments or final payments if the
findings of a Department audit indicate underpayments or
overpayments to the Contractor. If no payments are due and owing to
the Contractor, the Contractor shall immediately refund all amounts
which may be due the Department.
9.2 NONDISCRIMINATION
(a) The Contractor shall abide by all Federal and state laws,
regulations, and orders that prohibit discrimination because
of race, color, religion, sex, national origin, ancestry, age,
physical or mental disability, including, but not limited to,
the Federal Civil Rights Act of 1964, the Americans with
Disabilities Act or 1990, the Federal Rehabilitation Act of
1973, the Illinois Human Rights Act, and Executive Orders
11246 and 11375. The Contractor further agrees to take
affirmative action to ensure that no unlawful discrimination
is committed in any manner including, but not limited to, the
delivery of services under this Contract.
(b) The Contractor will not discriminate against Eligible
Enrollees, Prospective Beneficiaries, or Beneficiaries on the
basis of health status or need for health services.
9.3 CONFIDENTIALITY OF INFORMATION
All information, records, data and data elements collected and
maintained for the operation of the Plan and pertaining to
Providers, Beneficiaries, applicants for public assistance,
facilities, and associations shall be protected by the Contractor
and the Department from unauthorized disclosure, pursuant to 305
ILCS 5/11.9, 5/11.10, and 5/11.12; 42 U.S.C. 654(2)(b); 42 C.F.R.
Part 431, Subpart F; and 45 C.F.R. Part 303.21.
9.4 NOTICES
Notices required or desired to be given either party under this
Contract, unless
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specifically required to be given by a specific method, may be given
by any of the following methods: 1) United States mail, certified,
return receipt requested; 2) a recognized overnight delivery
service; or 3) via facsimile. Notices shall be deemed given on the
date sent and shall be addressed as follows:
Contractor: AMERICAID Illinois, Inc.
d/b/a Americaid Community Care
▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ #▇▇▇▇
▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
Attn: ▇▇▇▇▇▇ ▇▇▇▇▇, MD, President and CEO
Department: Illinois Department of Public Aid
Bureau of Managed Care
▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇
Facsimile: (▇▇▇) ▇▇▇-▇▇▇▇
9.5 REQUIRED DISCLOSURES
(a) Conflict of Interest
(1) The Contractor, by signing this Contract, covenants that
the Contractor is not prohibited from contracting with
State on any of the bases provided in 30 ILCS 500/50-13.
The Contractor further covenants that it neither has nor
shall acquire any interest, public or private, direct or
indirect, which conflicts in any manner with the
performance of Contractor's services and obligations
under this Contract. The Contractor further covenants
that it shall not employ any person having such an
interest in connection with the Contractors performance
hereunder. The Contractor shall be under a continuing
obligation to disclose any conflicts to the Department,
which shall, in its good faith discretion, determine
whether any conflict is cause for the nonexecution or
termination of this Contract and any amendments hereto.
(2) The Contractor will provide information intended to
identify any potential conflicts of interest regarding
its ability to perform the duties of this Contract
through the filing of a disclosure statement upon the
execution of this Contract, annually on or before the
anniversary date of this Contract, and within
thirty-five (35) days of any change occurring or of any
request by the Department. The disclosure statement
shall contain the following information:
(A) The identities of any Persons that directly or
indirectly provide
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service or supplies to the Medical Assistance
Program or KidCare with which the Contractor has
any type of business or financial relationship;
and
(B) A statement describing how the Contractor will
avoid any potential conflict of interest with
such Persons related to its duties under this
Contract.
(b) Disclosure of Interest
The Contractor shall comply with the disclosure requirements
specified in 42 C.F.R. Part 455, including, but not limited
to, filing with the Department upon the execution of this
Contract and within thirty-five (35) days of a change
occurring, a disclosure statement containing the following:
(1) The name, FEIN and address of each Person With An
Ownership Or Controlling Interest in the Contractor, and
for individuals include home address, work address, date
of birth, Social Security number and gender.
(2) Whether any of the individuals so identified are related
to another so identified as the individual's spouse,
child, brother, sister or parent.
(3) The name of any Person With an Ownership or Controlling
Interest in the Contractor who also is a Person With an
Ownership or Controlling Interest in another managed
care organization that has a contract with the
Department to furnish services under the Medical
Assistance Program or KidCare, and the name or names of
the other managed care organization.
(4) The name and address of any Person With an Ownership or
Controlling Interest in the Contractor or who is an
agent or employee of the Contractor who has been
convicted of a criminal offense related to that Person
With an Ownership or Controlling Interest's involvement
in any program under Federal law including any program
under Titles XVIII, XIX, XX or XXI of the Social
Security Act, since the inception of such programs.
(5) Whether any Person identified in subsections (1) through
(4) of this section, is currently terminated, suspended,
barred or otherwise excluded from participation, or has
voluntarily withdrawn as the result of a settlement
agreement, in any program under Federal law including
any program under Titles XVIII, XIX, XX or XXI of the
Social Security Act or has within the last five (5)
years been reinstated to participation in any program
under Federal law including any program under Titles
XVIII, XIX, XX or XXI of the Social Security Act and
prior to said reinstatement had been terminated,
suspended, barred or otherwise
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excluded from participation or has voluntarily withdrawn
as the result to a settlement agreement in such
programs.
(6) Whether the Medical Director of the Plan is a Person
With an Ownership or Controlling Interest.
9.6 HCFA PRIOR APPROVAL
The parties acknowledge that the terms of this Contract and any
amendments must receive the prior approval of HCFA, and that failure
of HCFA to approve any provision of this Contract will render that
provision null and void. The parties understand and agree that the
Department's duties and obligations under this Contract are
contingent upon such approval.
9.7 ASSIGNMENT
This Contract, including the rights, benefits and duties hereunder,
shall not be assignable by either party without the prior written
consent of the other party.
9.8 SIMILAR SERVICES
Nothing in this Contract shall prevent the Contractor from
performing similar services for other parties. However, the
Contractor warrants that at no time will the compensation paid by
the Department for services rendered under this Contract exceed the
rate the Contractor charges for the rendering of a similar benefit
package of services to others in the Contracting Area. The
Contractor also warrants that the services it provides to its
Beneficiaries will be as accessible to them (in terms of timeliness,
amount, duration and scope) as those services are to nonenrolled
Participants within the Contracting Area.
9.9 AMENDMENTS
(a) This Contract may be modified or amended by the mutual consent
of both parties at any time during its term. Amendments to
this Contract must be in writing and signed by authorized
representatives of both parties.
(b) No change in, addition to or waiver of any term or condition
of this Contract shall be binding on the Department or the
Contractor unless approved in writing by authorized
representatives of both parties.
(c) The Contractor shall, upon request by the Department and upon
receipt of a proposed amendment to this Contract, amend this
Contract, if and when required in the opinion of the
Department, to comply with federal or State laws or
regulations. If the Contractor refuses to sign such amendment
by the date specified by the Department, which may not be less
than ten (10) business days
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after receipt, this Contract may terminate as provided in
Article VIII, Section 8.4(a).
9.10 SANCTIONS
In addition to termination for cause pursuant to Article VIII,
Section 8.3(a), the Department may impose sanctions on the
Contractor for the Contractor's failure to substantially comply with
the terms of this Contract. Monetary sanctions imposed pursuant to
this section may be collected by deducting the amount of the
sanction from any payments due to the Contractor or by demanding
immediate payment by the Contractor. The Department, at its sole
discretion, may establish an installment payment plan for payment of
any sanction. The determination of the amount of any sanction shall
be at the sole discretion of the Department, within the ranges set
forth below. Self-reporting by the Contractor will be taken into
consideration in determining the sanction amount.
The Department shall not impose any sanction where the noncompliance
is directly caused by the Department's action or failure to act or
where an act of God delays performance by the Contractor. The
Department, in its sole discretion, may waive the imposition of
sanctions for failures that it judges to be minor or insignificant.
Upon determination of substantial noncompliance, the Department
shall give written notice to the Contractor describing the
noncompliance, the opportunity to cure the noncompliance where a
cure is allowed under this Contract and the sanction which the
Department will impose hereunder.
(a) Failure to Report or Submit
If the Contractor fails to submit any report or other material
required by the Contract to be submitted to the Department,
other than Encounter Data, by the date due, the Department
will give notice to the Contractor of the late report or
material and the Contractor must submit it within thirty (30)
days following the notice. If the report or other material has
not been submitted within thirty (30) days following the
notice, the Department will give the Contractor notice of its
continued failure to submit and the Contractor must submit the
report or other material within thirty (30) days following the
second notice. If the Contractor has not submitted the report
or other material within (30) days following the second
notice, the Department, without further notice, shall impose a
sanction of $1,000.00 to $5,000.00 for the late report.
(b) Failure to Submit Encounter Data
If the Department determines that the Contractor has not
been making good faith efforts for a period of at least
thirty (30) days to work with Department in making
progress toward compliance with the requirement of
Article V, Section 5.11(b)(1)
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regarding Encounter Data, the Department will send the
Contractor a notice of non-compliance. If the Contractor does
not show good faith efforts to comply with these requirements
by the end of the thirty day period following the notice, the
Department, without further notice, may impose a sanction of
$1,000.00 to $5,000.00. At the end of each subsequent period
of thirty (30) days in which no good faith efforts are made
toward compliance, the Department may, without further
notice, impose a further sanction of $1,000.00 to $5,000.00.
(c) Failure to Meet Minimum Standards of Care
If the Department determines that the Contractor has not
been making good faith efforts to meet any of the
minimum standards of care set forth in Article V,
Section 5.13, the Department will send the Contractor a
notice of noncompliance. If the Contractor does not show
good faith efforts to establish an acceptable plan to
meet the minimum standard of care referenced in the
notice by the end of the thirty day period following the
notice, the Department will send another notice of
noncompliance. If the Contractor does not show good
faith efforts to comply with these requirements by the
end of the thirty (30) day period following the second
notice the Department may, without further notice,
impose a sanction of $1,000.00 to $5,000.00. At the end
of each subsequent period of thirty (30) days in which
no good faith efforts are made toward compliance, the
Department may, without further notice, impose a further
sanction of $1,000.00 to $5,000.00.
(d) Imposition of Prohibited Charges
If the Department determines that the Contractor has
imposed a charge on a Beneficiary that is prohibited by
this Contract, the Department may impose a sanction of
$1,000.00 to $5,000.00.
(e) Misrepresentation or Falsification of Information
If the Department determines that the Contractor has
misrepresented or falsified information furnished to an
Eligible Enrollee, Prospective Beneficiary, Beneficiary,
Provider, the Department or HCFA, the Department may
impose a sanction of $1,000.00 to $5,000.00.
(f) Failure to Comply with the Physician Incentive Plan
Requirements
If the Department determines that the Contractor has
failed to comply with the Physician Incentive Plan
requirements of Article V, Section 5.7, the Department
may impose a sanction of $1,000.00 to $5,000.00.
(g) Failure to Meet Access Standards
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If the Department determines that the Contractor has not
met the Provider to Beneficiary access standards
established in Article V, Section 5.13(e) the Department
will send the Contractor a notice of noncompliance. If
the Contractor does not show good faith efforts to
comply with these requirements by the end of the thirty
day period following the notice the Department may
impose a sanction of $1,000.00 to $5,000.00, the
Department may, without further notice, suspend
Enrollment of Eligible Enrollees with the Contractor or
the Department may impose both sanctions.
(h) Failure to Provide Covered Services
If the Department determines that the Contractor has
failed to provide, or arrange to provide, a medically
necessary service that the Contractor is required to
provide under law or this Contract, the Department may
impose a sanction of $5,000.00 to $25,000.00.
(i) Discrimination Related to Pre-Existing Conditions
If the Department determines that discrimination related
to pre-existing conditions has occurred, the Department
may impose a sanction of $5,000.00 to $25,000.00, the
Department may suspend Enrollment of Eligible Enrollees
with the Contractor or the Department may impose both
sanctions.
(j) Pattern of Marketing Failures
Where the Department determines a pattern of Marketing
failures, the Department may impose a sanction of
$5,000.00 to $25,000.00, the Department may suspend
Enrollment of Eligible Enrollees with the Contractor or
the Department may impose both sanctions.
(k) Other Failures
If the Department determines that the Contractor is in
substantial noncompliance with any material terms of
this Contract not specifically enunciated herein and
which the Department reasonably deems sanctionable, the
Department shall provide written notice to the
Contractor setting forth the specific failure or
noncompliant activity. If the Contractor does not
correct the noncompliance within thirty (30) days of the
notice the Department, without further notice, may
impose a sanction of $1,000.00 to $5,000.00.
9.11 SALE OR TRANSFER
The Contractor shall provide the Department with the earliest
possible actual notice of any sale or transfer of the Contractor's
business as it relates to this Contract. If the
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Contractor is otherwise subject to SEC rules and regulations,
actual notice shall be given to the Department as soon as those SEC
rules and regulations permit. The Department agrees that any such
notice shall be held in the strictest confidence until such sale or
transfer is publicly announced or consummated. The Department shall
have the right to terminate the Contract and any amendments
thereto, without cause, upon notification of such sale or transfer,
in accordance with Article VIII, Section 8.3(b).
9.12 COORDINATION OF BENEFITS FOR BENEFICIARIES
(a) The Department is responsible for the identification of
Beneficiaries with health insurance coverage provided by a
third party and ascertaining whether third parties are liable
for medical services provided to such Beneficiaries. Money
which the Department receives as a result of these collection
activities shall belong to the Department to the extent the
Department has incurred any expense or paid any claim and
thereafter any excess receipts shall belong to the
Contractor, to the extent the Contractor has incurred any
expense or paid any claim, to the extent permitted by law.
(b) The Contractor will conduct a data match for the Department
to identify Illinois Medical Assistance Program and KidCare
Participants with active private health insurance through the
Contractor. The Department will assume the reasonable and
customary costs of these semi-annual matches. The discovery
of a third party liability match will prevent the Department
from paying premiums for recipients already covered by the
Contractor. The Contractor will further make available to
the Department a contact person from whom the Department can
request to make third party liability inquiries for the
purpose of maintaining accurate eligibility information for
these recipients.
(c) Upon the Department's verification that a Beneficiary has
third party coverage for major medical benefits, the
Department shall disenroll such Beneficiary from the
Contractor's Plan. Such disenrollment shall be effective the
first day of the calendar month no later than three (3)
months from the date the disenrollment is entered into the
Department's computer system. The monthly Capitation
payments shall be adjusted accordingly on the first day of
the month the disenrollment is effective. The Contractor
shall be notified of the disenrollment on the Prelisting
Report.
(d) The Contractor shall report with the reported Encounter Data
any and all third party liability collections it receives so
the Department can offset the next month's Capitation payment
accordingly.
(e) The Contractor shall report to the Department any health
insurance coverage for Beneficiaries it discovers at any
time.
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9.13 AGREEMENT TO OBEY ALL LAWS
The Contractor's obligations and services hereunder are hereby made
and must be performed in compliance with all applicable federal and
State laws, including, but not limited to, applicable provisions of
45 C.F.R. Part 74 not hereto specified.
9.14 SEVERABILITY
Invalidity of any provision, term or condition of this Contract for
any reason shall not render any other provision, term or condition
of this Contract invalid or unenforceable.
9.15 CONTRACTOR'S DISPUTES WITH OTHER PROVIDERS
All disputes between the Contractor and any Affiliated or
non-Affiliated Provider, or between the Contractor and any other
subcontractor, shall be solely between such Provider or
subcontractor and the Contractor.
9.16 CHOICE OF LAW
This Contract shall be governed and construed in accordance with the
laws of the State of Illinois. Should any provision of this Contract
require judicial interpretation, the parties agree and stipulate
that the court interpreting or considering this Contract shall not
apply any presumption that the terms of this Contract shall be more
strictly construed against a party who itself or through its agents
prepared this Contract. The parties acknowledge that all parties
hereto have participated in the preparation of this Contract either
through drafting or negotiation and that each party has had full
opportunity to consult legal counsel of choice before execution of
this Contract. Any claim against the Department arising out of this
Contract must be filed exclusively with the Illinois Court of Claims
(as defined in 705 ILCS 505/1) of, if jurisdiction is not accepted
by that court, with the appropriate State or federal court located
in Sangamon County, Illinois. The State does not waive sovereign
immunity by entering into this Contract.
9.17 DEBARMENT CERTIFICATION
The Contractor certifies that it is not barred from being awarded a
contract or subcontract under Section 50-5 of the Illinois
Procurement Code (30 ILCS 500/1-1). The Contractor certifies that it
has not been barred from contracting with a unit of State or local
government as a result of a violation of 720 ILCS 5/33-E3 or
5/33-E4.
9.18 CHILD SUPPORT, STATE INCOME TAX AND STUDENT LOAN REQUIREMENTS
The Contractor certifies that its officers, directors and partners
are not in default on an educational loan as provided in 5 ILCS
385/0.01 et seq., and is in compliance with State income tax
requirements and with child support payments imposed upon it
pursuant to a
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court or administrative order of this or any state. The Contractor
will not be considered out of compliance with this requirement if
(a) the Contractor provides proof of payment of past due amounts in
full or (b) the alleged obligation of past due amounts is being
contested through appropriate court or administrative agency
proceedings and the Contractor provides proof of the pendency of
such proceedings or (c) the Contractor provides proof of entry into
payment arrangements acceptable to the appropriate State agency are
entered into. For purposes of this paragraph, a partnership shall
be considered barred if any partner is in default.
9.19 PAYMENT OF DUES AND FEES
The Contractor certifies that it is not prohibited from selling
goods or services to the State because it pays dues or fees on
behalf of its employees or agents or subsidizes or otherwise
reimburses them for payment of dues or fees to any club which
unlawfully discriminates (See 775 ILCS 25/1--25/3).
9.20 FEDERAL TAXPAYER IDENTIFICATION
Under penalties of perjury, the Contractor certifies that it has
affixed its correct Federal Taxpayer Identification Number on the
signature page of this Contract. The Contractor certifies that it
is not: 1) a foreign corporation, partnership, limited liability
company, estate, or trust; or 2) a nonresident alien individual
except for those corporations registered in Illinois as a foreign
corporation.
9.21 DRUG FREE WORKPLACE
The Contractor certifies that it is in compliance with the
requirements of 30 ILCS 580/1 et seq., and has completed Attachment
III to this Contract.
9.22 LOBBYING
The Contractor certifies to the best of his knowledge and belief,
that:
(a) No federal appropriated funds have been paid or will be paid
by or on behalf of the Contractor, 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 the awarding of any federal contract, the making of any
federal loan or grant, the entering into of any cooperative
agreement, or the extension, continuation , renewal,
amendment, or modification of any federal contract, grant,
loan, or cooperative agreement.
(b) 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
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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 Contractor shall complete and submit a Federal
Standard Form LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions. Such Disclosure Form may be
obtained by request from the Illinois Department of Public
Aid, Bureau of Fiscal Operations.
(c) The Contractor shall require that the language of this
certification be included in all subcontracts and shall
ensure that such subcontracts 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 the transaction imposed by 31 U.S.C. Section 1352. Any
person who fails to file the required certification shall be subject
to a civil penalty of not less than ten thousand dollars
($10,000.00) and not more than one hundred thousand dollars
($100,000.00) for each such failure.
9.23 EARLY RETIREMENT
If the Contractor is an individual, the Contractor certifies it has
informed the director of the Department in writing if it was
formerly employed by that agency and has received an early
retirement incentive under Section 14-108.3 or Section 16-133.3 of
the Illinois Pension Code (40 ILCS 5/13 et seq.). Contractor
acknowledges and agrees that if such early retirement incentive was
received, this Contract is not valid unless the official executing
the Contract has made the appropriate filing with the Auditor
General prior to execution.
9.24 SEXUAL HARASSMENT
The Contractor shall have written sexual harassment policies that
shall comply with the requirements of 75 ILCS 5/2-105.
9.25 INDEPENDENT CONTRACTOR
The Contractor is an independent contractor for all purposes under
this Contract. The Contractor is not a Provider as defined by the
Public Aid Code and the Administrative Rules. Employees of the
Contractor are not employees of the State of Illinois, and are,
therefore, not entitled to any benefits provided employees of the
State under the Personnel Code and regulations or other laws of the
State of Illinois. The Contractor shall be responsible for
accounting for the reporting of State and Federal Income Tax and
Social Security Taxes, if applicable.
9.26 SOLICITATION OF EMPLOYEES
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The Contractor and the Department agree that they shall not, during
the term of this Contract and for a period of one (1) year after its
termination, solicit for employment or employ, whether as employee
or independent contractor, any person who is or has been employed by
the other during the term of this Contract, in a managerial or
policy-making role relating to the duties and obligations under this
Contract, without written notice to the other. However, should an
employee of the Contractor, without the prior knowledge of the
management of the Department, take and pass all required employment
examinations and meet all relevant employment qualifications, the
Department may employ that individual and no breach of this Contract
shall be deemed to have occurred. The Contractor shall immediately
notify the Department's Ethics Officer in writing if the Contractor
solicits or intends to solicit for employment any of the
Department's employees during the term of this Contract. The
Department will be responsible for keeping the Contractor informed
as to the name and address of the Ethics Officer.
9.27 NONSOLICITATION
The Contractor warrants that it has not employed or retained any
company or person, other than a bona fide employee working solely
for the Contractor, to solicit or secure this Contract, and that he
has not paid or agreed to pay any company or person, other than a
bona fide employee working solely for the Contractor, any fee,
commission, percentage, brokerage fee, gifts or any other
consideration contingent upon or resulting from the award or making
of this Contract. For breach or violation of this warranty, the
Department shall have the right to annul this Contract without
liability, or in its discretion, to deduct from compensation
otherwise due the Contractor the commission, percentage, brokerage
fee, gift or contingent fee.
9.28 OWNERSHIP OF WORK PRODUCT
Any documents prepared by the Contractor solely for the Department
upon the Department's request or as required under this Contract,
shall be the property of the Department, except that the Contractor
is hereby granted permission to use, without payment, all such
materials as it may desire. Standard documents and reports, claims
processing data and Beneficiary files and information prepared or
maintained by the Contractor in order to perform under this Contract
are and shall remain the property of the Contractor, subject to
applicable confidentiality statutes; however, the Department shall
be entitled to copies of all such documents, reports or claims
processing information which relate to Beneficiaries or services
performed hereunder. In the event of any termination of the
Contract, the Contractor shall cooperate with the Department in
supplying any required data in order to ensure a smooth termination
and provide for continuity of care of all Beneficiaries enrolled
with the Contractor. Notwithstanding anything to the contrary
contained in this Contract, all computer programs, electronic data
bases, electronic data processing documentation and source materials
collected, developed, purchased or used by the Contractor in order
to perform its duties under this Contract, shall be and remain the
sole property of the Contractor.
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9.29 BRIBERY CERTIFICATION
By signing this Contract, the Contractor certifies that neither it
nor any of its officers, directors, partners, or subcontractors have
been convicted of bribery or attempting to bribe an officer or
employee of the State of Illinois, nor has the Contractor, its
officers, directors, or partners made an admission of guilt of such
conduct which is a matter of record, nor has an official, agent, or
employee of the Contractor committed bribery or attempted bribery on
behalf of the Contractor, its officers, directors, partners or
subcontractors and pursuant to the direction or authorization of any
responsible official of the Contractor. The Contractor further
certifies that it will not subcontract with any subcontractors who
have been convicted of bribery or attempted bribery.
9.30 NONPARTICIPATION IN INTERNATIONAL BOYCOTT
The Contractor certifies that neither it nor any
substantially owned Affiliated company is participating or
shall participate in an international boycott in violation
of the provisions of the U.S. Export Administration Act of
1979 or the regulations of the U.S. Department of Commerce
promulgated under that Act.
9.31 COMPUTATIONAL ERROR
The Department reserves the right to correct any mathematical or
computational error in payment subtotals or total contractual
obligation. The Department will notify the Contractor of any such
corrections.
9.32 SURVIVAL OF OBLIGATIONS
The Contractor's and the Department's obligations under this
Contract that by their nature are intended to continue beyond the
termination or expiration of this Contract will survive the
termination or expiration of this Contract.
9.33 CLEAN AIR ACT AND CLEAN WATER ACT CERTIFICATION
The Contractor certifies that it is in compliance with all
applicable standards, orders or regulations issued pursuant to the
Clean Air Act (42 U.S.C. 7401 et seq.) and the Federal Water
Pollution Control Act, as amended (33 U.S.C. 1251 et seq.). The
Department shall report violations to the United States Department
of Health and Human Services and the appropriate Regional Office of
the United States Environmental Protection Agency.
9.34 NON-WAIVER
Failure of either party to insist on performance of any term or
condition of this Contract or to exercise any right or privilege
hereunder shall not be construed as a continuing or
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future waiver of such term, condition, right, or privilege.
9.35 NOTICE OF CHANGE IN CIRCUMSTANCES
In the event the Contractor, its parent or related corporate entity
becomes a party to any litigation, investigation, or transaction
that may reasonably be considered to have a material impact on the
Contractor's ability to perform under this Contract, the Contractor
will immediately notify the Department in writing.
9.36 PUBLIC RELEASE OF INFORMATION
News releases directly pertaining to this Contract or the services
or project to which it relates shall not be made without prior
approval by, and in coordination with, the Department, subject
however, to any disclosure obligations of the Contractor under
applicable law, rule or regulation.
The parties will cooperate in connection with media inquiries and in
regard to media campaigns or media initiatives involving this
project.
The Contractor shall not disseminate any publication, presentation,
technical paper or other information related to the Contractor's
duties and obligations under this Contract unless such dissemination
has been approved in writing by the Department.
9.37 PAYMENT IN ABSENCE OF FEDERAL FINANCIAL PARTICIPATION
In addition to any assessment of sanctions, pursuit of actual
damages, or termination or nonextension of this Contract, if any
failure of the Contractor to meet the requirements, including time
frames, of this Contract results in the deferring or disallowance of
federal funds from the State, the Department will withhold and
retain an equivalent amount from payment(s) to the Contractor until
such federal funds are released to the State (at which time the
Department will release to the Contractor such funds as the
Department was retaining as a result thereof).
9.38 EMPLOYMENT REPORTING
The Contractor certifies that it shall comply with the requirements
of 820 ILCS 405/1801.1, concerning newly hired employees.
9.39 CERTIFICATION OF PARTICIPATION
(a) The Contractor certifies that neither it, nor any employees,
partners, officers or shareholders owning at least five
percent (5%) of said Contractor is currently barred, suspended
or terminated from participation in the Medicaid or Medicare
programs, nor are any of the above persons currently under
sanction for, or serving a sentence for conviction of any
Medicaid or Medicare program offenses.
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(b) If Contractor, any employee, partner, officer or shareholder
owning at least five percent (5%) was ever (but is not
currently) barred, suspended or terminated from participation
in the Medicaid or Medicare programs or was ever sanctioned
for or convicted of any Medicaid or Medicare program offenses,
the Contractor must immediately report to the Department in
writing, including for each offense, the date the offense
occurred, the action causing the offense, the penalty or
sentence assessed and the date the penalty was paid or the
sentence completed.
9.40 INDEMNIFICATION
To the extent allowed by law, the Contractor and the Department
agree to indemnify, defend and hold harmless the other party, its
officers, agents, designees, and employees from any and all claims
and losses accruing or resulting in connection with the performance
of this Agreement which are due to the negligent or willful acts or
omission of the other party. In the event either party becomes
involved as a party to litigation in connection with services or
products provided under this Agreement, that party agrees to
immediately give the other party written notice. The Party so
notified, at its sole election and cost, may enter into such
litigation to protect its interests.
This indemnification is conditioned upon (1) the right of the
Department or the Contractor when such party is the indemnifying
party pursuant to this Article IX, Section 9.40 ("indemnifying
party") to defend against any such action or claim and to settle,
compromise or defend same in the sole discretion of the indemnifying
party; (2) receipt of written notice by the indemnifying party as
soon as practicable after the party seeking indemnification's first
notice of an action or claim for which indemnification is sought
hereunder; and (3) the full cooperation of the party seeking
indemnification in defense or handling of any such action or claim.
9.41 GIFTS
(a) The Contractor and the Contractor's principals, employees, and
subcontractors are prohibited from giving gifts to employees
of the Department, and are prohibited from giving gifts to, or
accepting gifts from, any Person who has a contemporaneous
contract with the Department involving duties or obligations
related to the Contract.
(2) The Contractor will provide the Department with advance notice
of the Contractor's providing gifts, excluding charitable
donations, given as incentives to community-based
organizations in Illinois and Participants or KidCare
Participants in Illinois to assist the Contractor in carrying
out its responsibilities under this Contract.
9.42 BUSINESS ENTERPRISE FOR MINORITIES, FEMALES AND PERSONS WITH
DISABILITIES.
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The Contractor certifies that it is in compliance with 30 ILCS
575/0.01 et seq., and has completed attachment IV.
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IN WITNESS WHEREOF, the Department and the Contractor hereby execute
and deliver this Contract effective as of the Effective Date.
STATE OF ILLINOIS
DEPARTMENT OF PUBLIC AID
BY:
▇▇▇ ▇▇▇▇▇
TITLE: Director
DATE:
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CONTRACTOR
BY:
TITLE:
DATE:
FEIN:
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ATTACHMENT I
RATE SHEETS
(a) Contractor Name: AMERICAID Illinois, Inc.
d/b/a Americaid Community Care
Address: ▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ #▇▇▇▇
▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇
(b) Contracting Area(s) Covered by the Contractor and Enrollment Limit:
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Contracting Area Enrollment Limit
-------------------------------------------------------------------------------------------------------------------------------
Region IV 100,000
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
(c) Total Enrollment Limit for all Contracting Areas: 100,000
(d) Threshold Review Levels: 80,000
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(e) Standard Capitation Rates for MAG Beneficiaries for each Region:
------------------------------------------------------------------------------------------------------
Age/Gender Region I Region II Region III Region IV Region V
(N.W. (Central (Southern (▇▇▇▇ (Collar
Illinois) Illinois) Illinois) County) Counties)
PMPM PMPM PMPM PMPM PMPM
------------------------------------------------------------------------------------------------------
0-2 F $214.19 $149.47 $206.08 $254.29 $181.15
------------------------------------------------------------------------------------------------------
0-2 M $242.48 $183.18 $263.92 $300.07 $183.68
------------------------------------------------------------------------------------------------------
3-13 F $39.63 $41.98 $47.02 $40.55 $32.21
------------------------------------------------------------------------------------------------------
3-13 M $47.40 $52.61 $55.95 $49.60 $40.28
------------------------------------------------------------------------------------------------------
14-20 F $209.65 $181.58 $204.84 $169.14 $167.32
------------------------------------------------------------------------------------------------------
14-20 M $74.37 $70.44 $75.51 $63.46 $46.99
------------------------------------------------------------------------------------------------------
21-44 F $201.77 $186.87 $206.99 $203.22 $181.66
------------------------------------------------------------------------------------------------------
21-44 M $100.41 $111.11 $132.34 $148.11 $102.05
------------------------------------------------------------------------------------------------------
45+ F $324.75 $292.50 $269.83 $245.81 $236.39
------------------------------------------------------------------------------------------------------
45+ M $195.92 $304.26 $291.83 $221.72 $177.78
------------------------------------------------------------------------------------------------------
Certified Local Health Department add-on: To be determined.
(f) Standard Capitation Rates for MANG Beneficiaries for each Region:
----------------------------------------------------------------------------------------------------------
Age/Gender Region I Region II Region III Region IV Region V
(N.W. (Central (Southern (▇▇▇▇ (Collar
Illinois) Illinois) Illinois) County) Counties)
PMPM PMPM PMPM PMPM PMPM
----------------------------------------------------------------------------------------------------------
0-2 F $277.63 $270.73 $276.42 $221.95 $175.33
----------------------------------------------------------------------------------------------------------
0-2 M $337.39 $320.77 $236.83 $259.94 $203.36
----------------------------------------------------------------------------------------------------------
3-13 F $46.02 $44.62 $52.51 $43.55 $39.42
----------------------------------------------------------------------------------------------------------
3-13 M $58.45 $63.44 $67.51 $55.10 $51.37
----------------------------------------------------------------------------------------------------------
14-20 F $260.15 $234.40 $246.15 $238.15 $260.81
----------------------------------------------------------------------------------------------------------
14-20 M $79.62 $119.09 $121.82 $82.31 $181.38
----------------------------------------------------------------------------------------------------------
21-44 F $245.64 $245.87 $226.89 $266.25 $244.39
----------------------------------------------------------------------------------------------------------
21-44 M $145.22 $107.80 $103.83 $98.85 $119.40
----------------------------------------------------------------------------------------------------------
45+ F $279.44 $329.92 $300.30 $255.70 $270.54
----------------------------------------------------------------------------------------------------------
45+ M $340.30 $205.30 $239.31 $247.28 $292.90
----------------------------------------------------------------------------------------------------------
Certified Local Health Department add-on: To be determined.
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(g) Capitation Rates for KidCare Participants for each Region:
----------------------------------------------------------------------------------------------------------
Age/Gender Region I Region II Region III Region IV Region V
(N.W. (Central (Southern (▇▇▇▇ (Collar
Illinois) Illinois) Illinois) County) Counties)
PMPM PMPM PMPM PMPM PMPM
----------------------------------------------------------------------------------------------------------
1-2 F $66.34 $67.54 $73.13 $74.63 $60.58
----------------------------------------------------------------------------------------------------------
1-2 M $92.26 $75.87 $96.90 $86.82 $73.08
----------------------------------------------------------------------------------------------------------
3-13 F $39.25 $41.38 $46.47 $40.71 $32.31
----------------------------------------------------------------------------------------------------------
3-13 M $47.00 $51.79 $55.68 $49.87 $40.63
----------------------------------------------------------------------------------------------------------
14-18 F $87.57 $85.98 $99.19 $77.53 $73.22
----------------------------------------------------------------------------------------------------------
14-18 M $73.14 $69.51 $75.56 $63.48 $46.69
----------------------------------------------------------------------------------------------------------
Certified Local Health Department add-on: To be determined.
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ATTACHMENT II
KIDCARE PARTICIPATION OPTION
The Contractor shall indicate by signing the appropriate line below whether
or not it agrees to accept KidCare Participants as Beneficiaries in
accordance with the terms and conditions of this Contract.
KIDCARE PARTICIPATION
The Contractor agrees to accept KidCare Participants as Beneficiaries in
accordance with the terms of this Contract.
CONTRACTOR
By:
-------------------------------------
Its:
------------------------------------
Date:
-----------------------------------
MEDICAL ASSISTANCE PARTICIPATION ONLY
The Contractor does not agree to accept KidCare Participants as
Beneficiaries under this Contract.
CONTRACTOR
By:
-------------------------------------
Its:
------------------------------------
Date:
-----------------------------------
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ATTACHMENT III
DRUG FREE WORKPLACE AGREEMENT
The contractor certifies that he/she/it will not engage in the unlawful
manufacture, distribution, dispensation, possession, or use of a controlled
substance in the performance of the Agreement.
CHECK THE BOX THAT APPLIES:
This business or corporation does not have twenty-five (25) or more
employees.
This business or corporation has twenty-five (25) or more employees,
and the contractor certifies and agrees that it will provide a drug
free workplace by:
A) Publishing a statement:
1) Notifying employees that the unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance, including
cannabis, is prohibited in the grantee's or contractor's workplace.
2) Specifying the actions that will be taken against employees for
violations of such prohibition.
3) Notifying the employees that, as a condition of employment on such
contract, the employee will:
a) abide by the terms of the statement; and
b) notify the employer of any criminal drug statute conviction
for a violation occurring in the workplace no later than five
(5) days after such conviction.
B) Establishing a drug free awareness program to inform employees about:
1) the dangers of drug abuse in the workplace;
2) the contractor's policy of maintaining a drug free workplace;
3) any available drug counseling, rehabilitation, and employee
assistance programs; and
4) the penalties that may be imposed upon an employee for drug
violations.
C) Providing a copy of the statement required by subparagraph (a) to each
employee
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engaged in the performance of the contract or grant and to post the
statement in a prominent place in the workplace.
D) Notifying the contracting or granting agency within ten (10) days after
receiving notice under part (B) or paragraph (3) of subsection (a) above
from an employee or otherwise receiving actual notice of such conviction.
E) Imposing a sanction on, or requiring the satisfactory participation in a
drug abuse assistance or rehabilitation program by, any employee who is so
convicted, as required by section 5 of the Drug Free ▇▇▇▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇
Illinois Compiled Statute, 30 ILCS 580/5.
F) Assisting employees in selecting a course of action in the event drug
counseling, treatment, and rehabilitation is required and indicating that
a trained referral team is in place.
G) Making a good faith effort to continue to maintain a drug free workplace
through implementation of the Drug Free ▇▇▇▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇ Illinois
Compiled Statute, 30 ILCS 580/1 et seq.
THE UNDERSIGNED AFFIRMS, UNDER PENALTIES OF PERJURY, THAT HE OR SHE IS
AUTHORIZED TO EXECUTE THIS CERTIFICATION ON BEHALF OF THE DESIGNATED
ORGANIZATION.
Printed Name of Organization
Signature of Authorized Representative Requisition/Contract/Grant ID Number
Printed Name and Title Date
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ATTACHMENT IV
BUSINESS ENTERPRISE PROGRAM CONTRACTING GOAL
The Business Enterprise Program Act for Minorities, Females and Persons with
Disabilities (30 ILCS 575/1) establishes a goal that not less than 12% of the
total dollar amount of State contracts be awarded to businesses owned and
controlled by persons who are minority, female or who have disabilities (the
percentages are 5%/5%/2% respectively) and have been certified as such ("BEPs").
This goal can be met by contracts let directly to such businesses by the State,
or indirectly by the State's contractor ordering goods or services from BEPs
when suppliers or subcontractors are needed to fulfill the contract. Call the
Business Enterprise Program at 312/814-4190 (Voice & TDD), 800/356-9206 (Toll
Free), or 800/526-0844 (Illinois Relay Center for Hearing Impaired) for a list
of certified businesses appropriate for the particular contract.
1. If you are a BEP, please identify which agency certified the business and
in what capacity by checking the applicable blanks:
Certifying Agency: Capacity:
___ Department of Central Management Services ___ Minority
___ Women's Business Development Center ___ Female
___ Chicago Minority Business Development Council ___ Person with Disability
___ Illinois Department of Transportation ___ Disadvantaged
___ Other (identify)
2. If the "Capacity" blank is not checked, do you have a written policy or
goal regarding contracting with BEPs?
Yes ___ No ___
- If "Yes", please attach a copy.
- If "No", will you make a commitment to contact BEPs and
consider their proposals?
Yes ___ No ___
3. Do you plan on ordering supplies or services in furtherance of this
project from BEPs?
Yes ___ No ___
- If "Yes", please identify what you plan to order, the
estimated value as a percentage of your total proposal, and
the names of the BEPs you plan to use.
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98
This information is submitted on behalf of
(Name of Vendor)
Name (printed): Title:
Signature: Date:
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EXHIBIT A
QUALITY ASSURANCE (QA)
1. All services provided by or arranged by the Contractor to be provided
shall be in accordance with prevailing professional community standards.
The Contractor shall establish a program that systematically and routinely
collects data to review that includes quality oversight and monitoring
performance and patient results. The program shall include provision for
the interpretation of such data to the Contractor's practitioners. The
Contractor shall have in effect a program consistent with the utilization
control requirements of 42 C.F.R. Part 456. This program will include,
when required by the regulations, written plans of care and certifications
of need of care.
2. The Contractor shall establish procedures such that the Contractor shall
be able to demonstrate that it meets the requirements of the HMO Federal
qualification regulations (42 C.F.R. 417.106 and/or the Medicare HMO/CMP
regulations (42 C.F.R. 417.418(c)). These regulations require that an
HMO/CMP have an ongoing fully implemented Quality Assurance program for
health services that:
a. monitors the health care services it provides or arranged to
provide;
b. stresses health outcomes;
c. provides review by Physicians licensed to practice medicine in all
its branches and other health professionals of the process followed
in the provision of health services;
d. includes fraud control provisions;
e. establishes and monitors access standards;
f. uses systematic data collection of performance and patient results,
provides interpretation of these data to its practitioners, and
institutes needed changes; and
g. includes written procedures for taking appropriate remedial action
whenever, as determined under the quality assurance program,
inappropriate or substandard services have been furnished or
services that should have been furnished have not been provided.
3. The Contractor shall provide to the Department a written description of
its Quality Assurance Plan (QAP) for the provision of clinical services
(e.g., medical, medically related, and behavioral health services). This
written description must meet federal and State requirements:
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a. Goals and objectives - The written description shall contain a
detailed set of QA objectives that are developed annually and
include a timetable for implementation and accomplishment.
b. Scope - The scope of the QAP shall be comprehensive, addressing both
the quality of clinical care and the quality of non-clinical aspects
of service, such as and including: availability, accessibility,
coordination, and continuity of care.
c. Methodology - The QAP methodology shall provide for review of the
entire range of care provided, by assuring that all demographic
groups, care settings, (e.g., inpatient, ambulatory, and home care),
and types of services (e.g., preventive, primary, specialty care,
behavioral health, and ancillary services) are included in the scope
of the review. Documentation of the monitoring and evaluation plan
shall be provided to Department.
d. Activities - The written description shall specify quality of care
studies and other activities to be undertaken over a prescribed
period of time, and methodologies and organizational arrangements to
be used to accomplish them. Individuals responsible for the studies
and other activities shall be clearly identified and shall be
appropriate. The written description shall provide for continuous
performance of the activities, including tracking of issues over
time.
e. Provider review - The written description shall document how
Physicians licensed to practice medicine in all its branches and
other health professionals will be involved in reviewing quality of
care and the provision of health services and how feedback to health
professionals and the Contractor staff regarding performance and
patient results will be provided.
f. Focus on health outcomes - The QAP methodology shall address health
outcomes; a complete description of the methodology shall be fully
documented and provided to Department.
g. Systematic process of quality assessment and improvement - The QAP
shall objectively and systematically monitor and evaluate the
quality and appropriateness of care and service to members, and
pursue opportunities for improvement on an ongoing basis.
Documentation of the monitoring activities and evaluation plan shall
be provided to the Department.
4. The Contractor shall provide the Department with the QAP written
guidelines which delineate the QA process, specifying:
a. Clinical areas to be monitored:
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i. The monitoring and evaluation of clinical care shall reflect the
population served by the Contractor in terms of age groups, disease
categories, and special risk status.
ii. The QAP shall, at a minimum, monitor and evaluate care and services
in certain priority clinical areas of interest specified by the
Department.
iii At its discretion and/or as required by the Department, the
Contractor's QAP must monitor and evaluate other important aspects
of care and service.
iv. At a minimum, the following areas shall be monitored:
(a) for pregnant women:
(1) number of prenatal visits;
(2) provision of ACOG recommended prenatal screening tests;
(3) neonatal deaths;
(4) length of hospitalization for the mother; and
(5) length of newborn hospital stay for the infant.
(b) for children:
(1) number of well-child visits appropriate for age;
(2) immunization status;
(3) number of hospitalizations;
(4) length of hospitalizations; and
(5) medical management for a limited number of medically
complicated conditions as agreed to by the Contractor
and Department.
(c) for adults:
(1) preventive health care (e.g., initial health history and
physical exam; mammography; papanicolaou smear).
(d) for behavioral health:
(1) all areas specified in Paragraph 12 of this Exhibit A.
b. Use of Quality Indicators - Quality indicators are measurable variables
relating to a specified clinical area, which are reviewed over a period of
time to monitor the process of outcomes of care delivered in that clinical
area:
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i. The Contractor shall identify and use quality indicators that
are objective, measurable, and based on current knowledge and
clinical experience.
ii. The Contractor shall document that methods and frequency of
data collected are appropriate and sufficient to detect need
for program change.
iii. For the priority clinical areas specified by Department, the
Contractor shall monitor and evaluate quality of care through
studies which address, but are not limited to, the quality
indicators also specified by Department.
c. Analysis of clinical care and related services, including behavioral
health services:
i. Appropriate clinicians shall monitor and evaluate quality
through review of individual cases where there are questions
about care, and through studies analyzing patterns of clinical
care and related service.
ii. Multi disciplinary teams shall be used, where indicated, to
analyze and address systems issues.
iii Clinical and related service areas requiring improvement shall
be identified and documented with a corrective action plan
developed and monitored.
d. Implementation of Remedial/Corrective Actions - The QAP shall
include written procedures for taking appropriate remedial action
whenever, as determined under the QAP, inappropriate or substandard
services are furnished, including in the area of behavioral health,
or services that should have been furnished were not. Quality
assurance actions that result in remedial or corrective actions
shall be forwarded by the Contractor to the Department on a timely
basis.
Written remedial/corrective action procedures shall include:
i. specification of the types of problems requiring
remedial/corrective action;
ii. specification of the person(s) or body responsible for making
the final determinations regarding quality problems;
iii. specific actions to be taken;
iv. a provision for feedback to appropriate health professionals,
providers and staff;
v. the schedule and accountability for implementing corrective
actions;
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vi. the approach to modifying the corrective action if
improvements do not occur; and
vii. procedures for notifying a Primary Care Provider group that a
particular Physician licensed to practice medicine in all its
branches is no longer eligible to provide services to
Beneficiaries.
e. Assessment of Effectiveness of Corrective Actions - The Contractor
shall monitor and evaluate corrective actions taken to assure that
appropriate changes have been made. The Contractor shall assure
follow-up on identified issues to ensure that actions for
improvement have been effective and provide documentation of same.
f. Evaluation of Continuity and Effectiveness of the QAP:
i. The Contractor shall conduct a regular (minimum annual)
examination of the scope and content of the QAP to ensure that
it covers all types of services, including behavioral health
services, in all settings, as required.
ii. At the end of each year, a written report on the QAP shall be
prepared by the Contractor and submitted to the Department as
a component part of the QA/UR/PR Report identified in Exhibit
C, which report addresses:
(a) QA studies, including quality indicators and
methodology, and other activities completed;
(b) peer review (e.g., results of the medical records and
credentialing/recredentialing activities);
(c) utilization data including progress toward meeting
preventive care participation goals and selected HEDIS
measures;
(d) Beneficiary Satisfaction Survey analysis;
(e) trending of clinical and service indicators and other
performance data;
(f) demonstrated improvements in quality;
(g) areas of deficiency and recommendations for corrective
action;
(h) an evaluation of the overall effectiveness of the QAP;
and
(i) changes implemented or to be implemented over the next
year.
5. The Contractor shall have a governing body to which the QAP shall be held
accountable ("Governing Body"). The Governing Body of the Contractor shall
be the Board of Directors or, where the Board's participation with quality
improvement issues is not direct, a designated committee of the senior
management of the Contractor. This Board of Directors or Governing Body
shall be ultimately responsible for the execution of the QAP. However,
changes to the medical quality assurance program shall be by the chair of
the QA Committee.
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Responsibilities of the Governing Body include:
a. Oversight of QAP - The Contractor shall document that the Governing
Body has approved the overall QAP and an annual QA plan.
b. Oversight Entity - The Governing Body shall document that it has
formally designated an accountable entity or entities within the
organization to provide oversight of QA, or has formally decided to
provide such oversight as a committee of the whole. Behavioral
health shall be included in the QAP Report.
c. QAP Progress Reports - The Governing Body shall routinely receive
written reports from the QAP describing actions taken, progress in
meeting QA objectives, and improvements made.
d. Annual QAP Review - The Governing Body shall formally review on a
periodic basis (but no less frequently than annually) a written
report on the QAP which includes: studies undertaken, results,
subsequent actions, and aggregate data on utilization and quantity
of services rendered, to assess the QAP's continuity, effectiveness
and current acceptability. Behavioral health shall be included in
the Annual QAP Review.
e. Program Modification - Upon receipt of regular written reports from
the QAP delineating actions taken and improvements made, the
Governing Body shall take action when appropriate and direct that
the operational QAP be modified on an ongoing basis to accommodate
review findings and issues of concern within the Contractor. This
activity shall be documented in the minutes of the meetings of the
Governing Board in sufficient detail to demonstrate that it has
directed and followed up on necessary actions pertaining to Quality
Assurance.
6. The QAP shall delineate an identifiable structure responsible for
performing QA functions within the Contractor. This committee or other
structure shall have:
a. Regular Meetings - The structure/committee shall meet on a regular
basis with specified frequency to oversee QAP activities. This
frequency shall be sufficient to demonstrate that the
structure/committee is following-up on all findings and required
actions, but in no case shall such meetings be held less frequently
than quarterly. A copy of the meeting summaries/minutes shall be
submitted to the Department no later than thirty (30) days after the
close of the quarterly reporting period.
b. Established Parameters for Operating - The role, structure and
function of the structure/committee shall be specified.
c. Documentation - There shall be records kept documenting the
structure's/committee's activities, findings, recommendations and
actions.
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d. Accountability - The QAP committee shall be accountable to the
Governing Body and report to it (or its designee) on a scheduled
basis on activities, findings, recommendations and actions.
e. Membership - There shall be active participation in the QA committee
from Plan Providers, who are representative of the composition of
the Plan's Providers. There shall be a majority of
Contractor-Affiliated practicing Physicians licensed to practice
medicine in all its branches.
7. There shall be a designated senior executive who will be responsible for
program implementation. The Contractor's Medical Director shall have
substantial involvement in QA activities and shall be responsible for the
required reports.
a. Adequate Resources - The QAP shall have sufficient material
resources, and staff with the necessary education, experience, or
training, to effectively carry out its specified activities.
b. Provider Participation in the QAP --
i. Participating Physicians licensed to practice medicine in all
its branches and other Providers shall be kept informed about
the written QA plan.
ii. The Contractor shall include in all its Provider subcontracts
and employment agreements a requirement securing cooperation
with the QAP for both Physicians licensed to practice medicine
in all its branches and non-physician Providers.
iii. Contracts shall specify that hospitals and other
subcontractors will allow access to the medical records of its
Beneficiaries to the Contractor.
8. The Contractor shall remain accountable for all QAP functions, even if
certain functions are delegated to other entities. If the Contractor
delegates any QA activities to subcontractors:
a. There shall be a written description of the following: the delegated
activities; the delegate's accountability for these activities; and
the frequency of reporting to the Contractor.
b. The Contractor shall have written procedures for monitoring and
evaluating the implementation of the delegated functions and for
verifying the actual quality of care being provided.
c. There shall be evidence of continuous and ongoing evaluation of
delegated
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activities, including approval of quality improvement plans and
regular specified reports.
9. The QAP shall contain provisions to assure that Physicians licensed to
practice medicine in all its branches and other health care professionals,
who are licensed by the State and who are under contract with the
Contractor, are qualified to perform their services and credentialed by
the Contractor. Recredentialing shall occur at least once every two (2)
years.
10. The Contractor shall put a basic system in place which promotes continuity
of care and case management. The Contractor shall provide documentation
on:
a. Monitoring the quality of care across all services and all treatment
modalities.
b. Studies, reports, protocols, standards, worksheets, minutes, or such
other documentation as may be appropriate, concerning its QA
activities and corrective actions and make such documentation
available to the Department upon request.
11. The findings, conclusions, recommendations, actions taken, and results of
the actions taken as a result of QA activity, shall be documented and
reported to appropriate individuals within the organization and through
the established QA channels. The Contractor shall document coordination of
QA activities and other management activities.
a. QA information shall be used in recredentialing, recontracting
and/or annual performance evaluations.
b. QA activities shall be coordinated with other performance monitoring
activities, including utilization management, risk management, and
resolution and monitoring of member complaints and grievances.
c. There shall be a linkage between QA and the other management
functions of the Plan such as:
i. network changes;
ii. benefits redesign;
iii. medical management systems (e.g., pre-certification);
iv. practice feedback to Physicians licensed to practice medicine
in all its branches; and
v. patient education.
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d. In the aggregate, without reference to individual Physicians
licensed to practice medicine in all its branches or Beneficiary
identifying information, all Quality Assurance findings,
conclusions, recommendations, actions taken, results or other
documentation relative to QA shall be reported to Department on a
quarterly basis or as requested by the Department. The Department
shall be notified of any Physician licensed to practice medicine in
all its branches terminated from a subcontract with the Contractor
for a quality of care issue.
12. The Contractor shall, through its behavioral health subcontractor and its
internal QAP, monitor the quality of behavioral health services its
subcontractor provides. Areas to be monitored include:
a. behavioral health network adequacy;
b. Beneficiary access to timely behavioral health services through
self-referral, PCP/specialist referral, MCO referral, CBHP referral,
or referral by other entities;
c. an individual plan or treatment and provision of appropriate level
of care;
d. coordination of care between the CBHPs, MCO behavioral health
subcontractor, and the Primary Care Provider;
e. provision of follow-up services and continuity of care;
f. involvement of the Primary Care Provider in aftercare to the extent
possible, ensuring client confidentiality protections provided under
law;
g. member satisfaction with access to and quality of behavioral health
services; and
h. behavioral health service utilization, as set forth in the following
chart.
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The following behavioral health care utilization statistics shall be determined
and reported quarterly to the Department in a format agreed to by the MCOs and
Department:
SUBSTANCE ABUSE/CHEMICAL DEPENDENCY: MENTAL HEALTH:
------------------------------------ --------------
Inpatient (Rehab): Acute Inpatient Psychiatric Admission:
------------------ --------------------------------------
Number of Admits Number of Admits
Admits/1000 Beneficiaries Admits/1000 Beneficiaries
Number of Days of Care Number of Days of Care
Days/1000 Beneficiaries Days/1000 Beneficiaries
Average Length of Stay ("ALOS") ALOS
Inpatient (Detox):
------------------
Number of Admits
Admits/1000 Beneficiaries
Number of Days of Care
Days/1000 Beneficiaries
ALOS
Partial (Day/Night) Treatment: Partial (Day/Night) Treatment:
------------------------------ ------------------------------
Number of Admits Number of Admits
Admits/1000 Beneficiaries Admits/1000 Beneficiaries
Number of Days of Care Number of Days of Care
Days/1000 Beneficiaries Days/1000 Beneficiaries
ALOS ALOS
Intensive Outpatient Program: Intensive Outpatient Program:
----------------------------- -----------------------------
Number of Outpatients Number of Outpatients
Outpatients/1000 Beneficiaries Outpatients/1000 Beneficiaries
Number of Days of Care Number of Days of Care
Days/1000 Beneficiaries Days/1000 Beneficiaries
ALOS ALOS
Outpatient: Outpatient:
----------- -----------
Number of Outpatients Number of Outpatients
Outpatients/1000 Beneficiaries Outpatients/1000 Beneficiaries
Number of Outpatient Sessions Number of Outpatient Sessions
Average Number of Sessions Average Number of Sessions
Follow-up: Follow-up:
---------- ----------
Number of Discharges with Number of Discharges with
Follow-up Care Plan and Treatment Follow-up Care Plan and Treatment
The provision of behavioral health services and appropriate risk assessment and
referral shall be
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included in the Contractor's medical record review processes and considered for
a clinical evaluation study as further described in Exhibit B, Utilization
Review/Peer Review, under (4).
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EXHIBIT B
UTILIZATION REVIEW/PEER REVIEW
1. The Contractor shall have a utilization review and peer review
committee(s) whose purpose will be to review data gathered and the
appropriateness and quality of care. The committee(s) shall review and
make recommendations for changes when problem areas are identified and
report suspected Fraud and Abuse in the Medical Assistance Program or
KidCare to the Department's Office of Inspector General. The committees
shall keep minutes of all meetings, the results of each review and any
appropriate action taken. A copy of the minutes shall be submitted to the
Department no later than thirty (30) days after the close of the quarterly
reporting period. At a minimum, these programs must meet all applicable
federal and State requirements for utilization review. The Contractor and
Department may further define these programs.
2. The Contractor shall implement a Utilization Review Plan, including peer
review. The Contractor shall provide the Department with documentation of
its utilization review process. The process shall include:
a. Written program description - The Contractor shall have a written
utilization management program description which includes, at a
minimum, procedures to evaluate medical necessity criteria used and
the process used to review and approve the provision of medical
services.
b. Scope - The program shall have mechanisms to detect
under-utilization as well as over-utilization.
c. Preauthorization and concurrent review requirements For
organizations with preauthorization and concurrent review programs:
i. review decisions shall be supervised by qualified medical
professionals;
ii efforts shall be made to obtain all necessary information,
including pertinent clinical information, and consultation
with the treating Physician licensed to practice medicine in
all its branches as appropriate;
iii. the reasons for decisions shall be clearly documented and
available to the member;
iv. there shall be written well-publicized and readily available
appeals mechanisms for both Providers and patients;
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v. decisions and appeals shall be made in a timely manner as
required by the circumstances of the situation;
vi. there shall be mechanisms to evaluate the effects of the
program using data on member satisfaction, provider
satisfaction or other appropriate measures;
vii. if the organization delegates responsibility for utilization
management, it shall have mechanisms to ensure that these
standards are met by the delegate.
3. The Contractor further agrees to review the utilization review procedures,
at reasonable intervals, for the purpose of amending same, as necessary in
order to improve said procedures. All amendments must be approved by the
Department. The Contractor further agrees to supply the Department and/or
its designee with the utilization information and data, and reports
prescribed in its approved utilization review system or the status of such
system. This information shall be furnished upon request by the
Department.
4. The Contractor shall establish and maintain a peer review program approved
by the Department to review the quality of care being offered by the
Contractor, employees and subcontractors. This program shall provide, at a
minimum, the following:
a. A peer review committee comprised of Physicians licensed to practice
medicine in all its branches, formed to organize and proceed with
the required reviews for both the health professionals of the
Contractor's staff and any contracted Providers which include:
i. A regular schedule for review;
ii. A system to evaluate the process and methods by which care is
given; and
iii. A medical record review process.
b. The Contractor shall maintain records of the actions taken by the
peer review committee with respect to providers and those records
shall be available to the Department upon request.
c. A system of internal medical review, including behavioral health
services, medical evaluation studies, peer review, a system for
evaluating the processes and outcomes of care, health education,
systems for correcting deficiencies, and utilization review.
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112
d. At least two medical evaluation studies must be completed yearly
that analyze pressing problems identified by the Contractor, the
results of such studies and appropriate action taken. One of the
studies may address an administrative problem noted by the
Contractor and one may address a clinical problem or diagnostic
category. One brief follow-up study shall take place for each
medical evaluation study in order to assess the actual effect of any
action taken.
5. The Contractor further agrees to review the peer review procedures, at
reasonable intervals, for the purpose of amending same in order to improve
said procedures. All amendments must be approved by the Department. The
Contractor further agrees to supply the Department and/or its designee
with the information and reports related to its peer review program upon
request.
6. The Department may request that peer review be initiated on specific
providers.
7. The Department will conduct its own peer reviews at its discretion.
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113
EXHIBIT C
Summary of Required Reports
Report names and reporting frequencies are listed herein. These shall be due to
the Department no later than thirty (30) days after the close of the reporting
period unless otherwise stated. Reports include hard copy reports and/or any
electronic medium as designated by the Department.
Report frequencies are defined as follows:
Annually- The State fiscal year of July 1 - June 30.
Quarterly- The last day of the fiscal quarter grouped as:
J/A/S (1st qtr), O/N/D (2nd qtr), J/F/M
(3rd qtr), and A/M/J (4th qtr).
Monthly- The last day of a calendar month.
NAME OF REPORT FREQUENCY
QUALITY ASSURANCE/MEDICAL
QA/UR/PR Report Annually
Summary of Grievances and Quarterly
Resolutions and External Independent
Reviews and Resolutions
Behavioral Health Report Quarterly, 60 days
after end of quarter
MARKETING
Marketer Training Schedule and Agenda Quarterly, 2 weeks
prior to the
beginning of each
quarter, and as
revised
Marketing Representative Listing Monthly on the
first day of each
month for that month
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114
FRAUD/ABUSE
Fraud and Abuse Report Immediately upon
identification or
knowledge of
suspected Fraud,
Abuse, or misconduct;
or quarterly
certification, due 30
days after the close
of the quarter, that
no Fraud, Abuse, or
misconduct was
identified during the
quarter
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115
EXHIBIT D
Summary of Required Submissions
Submissions and submission frequencies are listed herein. These shall be due to
the Department no later than thirty (30) days after the close of the reporting
period unless otherwise stated. Submissions include hard copy reports and/or any
electronic medium as designated by the Department.
Submission frequencies are defined as follows:
Annually- The State fiscal year of July 1 - June 30
Quarterly- The last day of the fiscal year quarter
grouped as:
J/A/S (1st qtr), O/N/D (2nd qtr), J/F/M (3rd
qtr), and A/M/J (4th qtr).
Monthly- The last day of a calendar month.
NAME OF SUBMISSION FREQUENCY DPA PRIOR
------------------ ---------
APPROVAL
--------
ADMINISTRATIVE
--------------
Disclosure Statements Initially, No
Annually, on
request and as
changes occur
Encounter Data Report Monthly no No
later than 120
days after the
close of the
reporting
period
BENEFICIARY MATERIALS
---------------------
Certificate or Document of Initially and Yes
Coverage and Any Changes or as revised
Amendments
Beneficiary Handbook Initially and Yes
as revised
Identification Card Initially and Yes
as revised
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SUBCONTRACTS
------------
Model Subcontractor Initially and No
Agreements as revised
Linkage Agreements As executed No
and updated
Copies of Actual Executed Upon Request No
Subcontracts
PROVIDER NETWORK
----------------
New Site Provider As new Yes
Affiliation File sites/PCPs are
(electronic)* added
Site/PCP Approvals (paper As new Yes
format-A&B forms)* sites/PCPs are
added
Provider Affiliation with Monthly on the No
Site Report first day of
each month for
that month
Beneficiary Site As they occur No
Assignment/Site Transfer
Site Terminations As they occur No
MARKETING MATERIALS
-------------------
Marketing Plans and Procedures Initially and Yes
as revised
Marketing Training Manuals Initially and Yes
as revised
Marketing Materials and Initially and Yes
Information as revised
Marketing Representative As they occur No
Terminations
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117
QUALITY ASSURANCE/MEDICAL
-------------------------
Quality Assurance, Initially and Yes
Utilization Review and Peer as revised
Review Plan (includes health
education plan)
QA/UR/PR Committee Meeting Quarterly No
Minutes
Grievance Procedures Initially and as Yes
revised
*The approval of Sites/PCPs will transition from paper to electronic format
during the course of this Contract. Both versions of the submission are
listed. The electronic format will not be required until such time as the
Department provides one-hundred twenty (120) days advance notice.
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EXHIBIT E
Encounter Data Format Requirements
Illinois Medicaid UB92 Billing Specification
(Approved by the Illinois UB92 Billing Committee)
HCFA National Standard Format for non-institutional claims
IDPA Direct Tape format for pharmacy claims