AMERIGROUP District of Columbia
CONTRACT No: POHC-2002-D-0003
CORE CONTRACT
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SECTION AA
A.l SOLICITATION OFFER AND AWARD
A.1.1 With regard to this contract:
(a) References to the Child and Adolescent Supplemental Security Income
Plan (CASSIP) and Supplemental Security Income-Related Plan are not
applicable to this contract.
(b) The Health Care Financing Administration (HCFA) has changed its name
to the Centers for Medicare and Medicaid Services (CMS). Any
requirement related to HCFA is still in effect and is now a
requirement to CMS.
A.2 DOCUMENTS ATTACHED AND INCORPORATED BY REFERENCE
A.2.1 The following documents are attached to and incorporated by reference
into this contract:
Attachment 1 - U.S. Wage Determination Number: 1994-2103,
Revision Number: 24 - dated May 31, 2001.
Attachment 2 - Request For Proposal Number POHC-2001-R-2002
Attachment 3 - Amendments Number 0015 to 0001 (highest to lowest)
Attachment 4 - Proposal dated December 27,2000 (Technical only)
Attachment 5 - First Best And Final Offer dated May 21, 2001(Technical
only)
Attachment 6 - Second Best And Final Offer dated July 2,2001
(Technical only)
Attachment 7 - Minimum Covered Services for Minimum Covered Services
for Medicaid Managed Care Program (MMCP)
Attachment 8 - Managed Care Disclosure compliance Package under
Physician Incentive Regulation, Physician Incentive
Disclosure Form, HCFA Physician Incentive Plan
Worksheet, Stop-Loss Information (These documents may
be obtained by opening the website located at
hht://www.hcfa.gov/medicare/physincp/disclose.htm)
Attachment 9 - Newborn Notification Report
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CONTRACT NO.: P0HC-2002-D-0003 1
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A.3 ORDER OF PRIORITY
A conflict in language shall be resolved by giving precedence to the
document in the highest order of priority that contains language
addressing the issue in question, as follows:
Sections A through I of this contract
U.S. Wage Determination Number: 1994-2103, Revision Number: 24, dated
May 31, 2001.
(c) Minimum Covered Services for Minimum Covered Services for Medicaid
Managed Care Program (MMCP)
Managed Care Disclosure compliance Package under Physician Incentive
Regulation, Physician Incentive Disclosure Form, HCFA Physician
Incentive Plan Worksheet, Stop-Loss Information
(These documents may be obtained by opening the website located at
hht://www.hcfa.gov/medicare/physincp/disclose.htm)
(e) Amendments Number 0015 (highest priority) through 0001 (lowest
Priority)
(f) Request For Proposal Number POHC-2001-R-2002
(g) Second Technical Best And Final Offer dated July 2, 2001
(h) First Technical Best And Final Offer dated May 21, 2001
(i) Technical Proposal dated December 27, 2000
(j) Newborn Notification Report
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CONTRACT NO.: P0HC-2002-D-0003 2
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SECTION B - SUPPLIES OR SERVICES AND PRICE/COST
B. Supplies or Services and Price/Cost.......................................4
The Contractor shall provide all resources (except as may be expressly
stated in the contract as furnished by the District of Columbia Government)
necessary to furnish the items below in accordance with the
Description/Specification/Work Statement set forth in Section C...........4
B.2 The Government of the District of Columbia ("District") Department of
Health (DOH) Medical Assistance Administration (MAA) has a requirement to
contract for health care programs:........................................4
Indefinite Delivery Indefinite Quantity (IDIQ) Contract (DCHFP)...........4
RESERVED..................................................................4
Rate Adjustment...........................................................4
Rate Categories...........................................................5
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CONTRACT NO.: P0HC-2002-D-0003 3
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SECTION B
B. SUPPLIES OR SERVICES AND PRICE
B.1 The Contractor Shall Provide All Resources (Except as May be Expressly
Stated In The Contract As Furnished By The District Of Columbia Government)
Necessary To Furnish The Items Below In Accordance With The
Description/specification/work Statement Set Forth in Section C.
B.2 The Government of the District of Columbia ("District") Department of
Health (DOH) Medical Assistance Administration (MAA) Has a Requirement to
Contract for Health Care Programs:
a) District of Columbia Healthy Families Plans (DCHFP). DCHFPs will serve
individuals in Temporary Assistance to Needy Families (TANF) or
TANF-related Medicaid eligibility categories, and the
b) RESERVED.
B.3 Indefinite Delivery Indefinite Quantity (IDIQ) Contract (DCHFP)
B.3.1 DCHFP contractors will be paid the negotiated monthly capitation rate
for each eligible member enrolled in their health plan.
B.3.2 The guaranteed minimum for each DCHFP contract is $150,000 per year.
B.3.3 The maximum for each DCHFP contract is 75,000 enrollees per year.
RESERVED
Rate Adjustment
B.5.1 For DCHFP, Offerors shall propose a capitation rate to be effective
for the base period of the contract. For the option periods of the
contract, the capitation rate in effect will be the capitation rate for the
base period, as adjusted in accordance with this Section B.5.1.
No later than twelve (12) months after the date of contract award and
annually thereafter, the District will conduct an actuarial review of the
capitation rates in effect to determine the actuarial soundness of the
rates paid to the Contractors. The actuarial review will take into account
factors such as inflation, significant changes in the demographic
characteristics of the member population, or the disproportionate
enrollment selection of Contractor by members in certain rate cohorts.
This actuarial review of the capitation rates may result in an annual
adjustment, either increase or decrease, to the capitation rates. The
District and Contractor shall negotiate the actual amount of the
adjustment; however, the negotiated
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CONTRACT NO.: P0HC-2002-D-0003 4
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adjustment shall not exceed the upper payment limits as defined in 42 CFR
447.361.
The annual adjustment shall be effective as of the first day of the
option period to which the adjusted capitation rate applies. If the
District and Contractor have not completed negotiations for the
adjusted capitation rate by the first day of the affected option
period, the Contractor shall continue to perform under the contract at
the rates in effect for the preceding contract period. All
negotiations shall be concluded by the end of the third month of the
option period.
B.5.2 RESERVED.
B.6 Rate Categories
B.6.1 For DCHFP, capitation payments will be calculated based upon the
monthly enrollment in each of the following enrollment categories and the
capitation rate for that category:
B.6.1.1 Infants Under 1 year of age
. Delivery month
. Birth month
B.6.1.2 Children of 1 year through 12 years of age
B.6.1.4 Females and ages 13 through 18 years of age
B.6.1.4 Males ages 13 through 18 years of age
B.6.1.5 Females ages 19 through 36 years of age
B.6.1.6 Males ages 19 through 36 years of age
B.6.1.7 Males and 37 years of age and older
B.6.1.8 Females 37 years of age and older
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CONTRACT NO.: P0HC-2002-D-0003 5
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CONTRACT NO.: POHC-2002-D-OOO3 6
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B.6.2 Supplies/Services
AMERICAID Community Care
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CONTRACT NO.: POHC-2002-D-0003 Page 7
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LINE
ITEM
NUMBER SUPPLIES/SERVICES TOTAL PMPM*
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0001 DC HEALTHY FAMILIES PROGRAM (DCHFP)
PAGE
0001AA Infants Under 1 year of age
Delivery month (projected delivery)
Birth month (actual month of birth)
0001AB Children of 1 year of age through 12 years of age
0001AC Females ages 13 through 18 years of age
0001AD Males ages 13 through 18 years of age
0001AE Females age 19 through 36 years of age
0001AF Males ages 19 through 36 years of age
0001AG Females 37 years of age and older
0001AH Males 37 years of age and older
*PMPM = per member per month
The associated price is retrieved from
Attachment J.1.
FOR DISTRICT USE ONLY
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Line AGY YR Index PCA OBJ AOBJ Grant Proj AG1 AG2 AG3 Percent
PH PH
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Revenue Category: Infants Under 1 year of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-2003 PAGE 8
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1.000 - Calculated by
taking the total utilization multiplied by
12,000 divided by the annualized member
months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the total
dollars divided by the annualized member
months.
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Revenue Category: Delivery Month(projected delivery)
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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Contract NO.: POHC-2002-D-2003 PAGE 9
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Vlsits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1.000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the total
dollars divided by the annualized member
months.
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Revenue Category: Birth month (actual month of birth)
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 10
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000-Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking
the total dollars divided by the total
utilization
(3) PMPM - Calculated try taking the
total dollars divided by the annualized
member months.
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Revenue Category: Children of 1 year of age through 12 years of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: P0HC-2002-D-0003 PAGE 11
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking
the total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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Revenue Category: Females ages 13 through 18 years of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 12
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking
the total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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Revenue Category: Males ages 13 through 18 years of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 13
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
O001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking
the total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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Revenue Category: Females age 19 through 36 years of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 14
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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Revenue Category: Males ages 19 through 36 years of age
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 15
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000-
Calculated by taking the total
utilization multiplied by 12,000
divided by the annualized member months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the
annualized member months.
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Revenue Category: Females 37 years of age and older
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 16
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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Revenue Category: Males 37 years of age and older
Section B - Supplies/Services
RATE CALCULATION
Contractor: Americaid Community Care
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CONTRACT NO.: POHC-2002-D-0003 PAGE 17
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ITEM UNIT OF UTILIZATION
NUMBER SUPPLIES/SERVICES SERVICE PER 1000 UNIT PRICE PMPM
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0001 The Contractor shall provide covered services
for Category of Aid" DCHFP Less Than 1 year
Old Males and Females
0001AA Hospital Inpatient Days
0001AB Skilled Nursing Facility Days
0001AC Hospital Outpatient Visits
0001AD Physician Visits
0001AE Pharmacy Prescriptions
0001AF Transportation Trips
0001AG Durable Medical Equipment Units
0001AH Home Health Visits
0001AI EPSDT Services
0001AJ Dental Services N/A
0001AK Vision Visits/Services N/A
0001AL Mental Health Services Visits/Services N/A
0001AM Other Services Claims
TOTAL CAPITATION
ADMINISTRATIVE COST
TOTAL PMPM
AVERAGE HOSPITAL LENGTH OF STAY
NOTE: (1) Utilization per 1,000 - Calculated
by taking the total utilization
multiplied by 12,000 divided by the
annualized member months
(2) Unit Cost - Calculated by taking the
total dollars divided by the total
utilization
(3) PMPM - Calculated by taking the
total dollars divided by the annualized
member months.
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SECTION C
C. Description/Specifications/Work Statement.............................. 19
C.1 Scope.................................................................. 19
C.2 Background............................................................. 36
C.3 Requirements........................................................... 38
C.4 Place of Business and Hours of Operation............................... 42
C.5 Marketing.............................................................. 42
C.6 Enrollment, Education and Outreach..................................... 46
C.7 Member Services........................................................ 52
C.8 Coverage of Services and Benefits...................................... 55
C.9 Network................................................................ 69
C.10 Utilization Management and Care Coordination Capabilities.............. 84
C.11 Financial Functions.................................................... 104
C.12 Management Information System.......................................... 106
C.13 Quality Improvement.................................................... 109
C.14 Complaints, Grievances and Fair Hearings............................... 113
C.15 Implementation Plan.................................................... 120
C.16 Performance and Outcome Measures....................................... 121
C.17 Specific Requirements and Responsibilities for DCHFP Contractors Only.. 121
C.18 RESERVED............................................................... 133
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CONTRACT NO.: P0HC-2002-D-0003 18
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Section C
C. DESCRIPTION/SPECIFICATIONS/WORK STATEMENT
C.1 Scope
C.1.1 The District of Columbia, Department of Health, Medical Assistance
Program is seeking Contractors to provide healthcare services to its
Medicaid eligible population enrolled in the District of Columbia
Healthy Families Program (DCHFP).
C.1.1.1 DCHFP: The DCHFP program is a capitated program that
consists of an array of comprehensive healthcare and
mental health services. Services will be provided to
approximately 75,000 primarily low-income pregnant
women, children and adults who are enrolled in the
DCHFP managed care program on a mandatory basis.
Effective April 1,2001 it is anticipated that
approximately 11,000 additional eligible Medicaid
recipients will be enrolled in the DCHFP program as a
result of expanded coverage.
C.1.1.2 RESERVED.
C.1.2 Applicable Documents
The Contractors shall comply with the most recent versions and future
revisions to all federal and District of Columbia laws, Court Orders
including Salazar v. The District of Columbia et al., regulations,
policies, and subsequent amendments in the operation of its program,
including, but not limited to, those barring discrimination in
enrollment, access to health services, provision of health care and
coverage. The following documents are applicable.
Court Orders pertaining to Salazar v. The District of Columbia et
al.
DC Civil Action No. 93-452 (GK)(Salazar Court Order);
Medicaid Managed Care Amendment Act 1992, DC Law 9-247,DC Code,
sec 1-359./(d);
Mayor's Order No. 93-219;
. 42 CFR Part 434 subpart C, E, and F;
. Conditions of participation applicable to providers of services
described in Section 1903(m) and 1932 of the Social Security Act,
42 U.S.C. Section 1396b(m);
Implementing federal regulations including 42 CFR 434 et seq.;
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CONTRACT NO.: P0HC-2002-D-0003 19
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Terms and provisions of the waiver of federal law granted to the
District by the Secretary of Health and Human Services under
Section 1915(b) of the Social Security Act (42 U.S.C. Section
1396n(b));
. Title XIX, the Medicaid Act;
. Conditions of participation applicable to providers of managed
care services under the-District Code Section 1-359, and District
of Columbia Municipal Regulation, Title 29, Chapters 53, 54, and
55; and
. Memorandum of Agreement (MOA) Between MAA, and the Office of the
Dixon Transitional Receiver, DC Commission on Mental Health.
. The Balanced Budget Act of 1997 .
C.1.3 Definitions
ACEDS:Automated Client Eligibility Determination System. The information
system maintained by the District to document Medicaid claims
payment and service provisions.
Actuarially equivalent: Costs the same
Addictions, Prevention, Recovery Administration (APRA): The District of
Columbia's agency, responsible for alcohol and drug abuse
treatment and prevention services, under the auspices of the
Department of Health.
Administrative Cost: All operating costs of the Contractor, including care
coordination, but excluding medical costs.
Adjudicated Claim: A claim that has been processed to payment or denial.
Affiliate: Any individual, corporation, partnership, joint venture, trust,
unincorporated organization or association, or other similar
organization (hereinafter "Person"), controlling, controlled by
or under common control with Contractor or its parent(s), whether
such common control be direct or indirect. Without limitation,
all officers, or persons, holding five percent (5%) or more of
the outstanding ownership interests of Contractor or its
parent(s), directors or subsidiaries of Contractor or parent(s)
shall be presumed to be affiliates for purposes of the RFP and
Agreement. For purposes of this definition, "control" means the
possession, directly or indirectly, of the power (whether or not
exercised) to direct or cause the direction of the management or
policies of a Person, whether through the ownership of voting
securities, other ownership interests, or by contract or
otherwise including but not limited to the power to elect a
majority of the directors of a corporation or trustees of a
trust, as the case may be.
Alcohol and Drug Abuse Treatment Services: Care and services which are
covered under the District of Columbia Medicaid plan or that are
otherwise furnished to District residents pursuant to any other
funded
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CONTRACT NO.: P0HC-2002-D-0003 20
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program and which are required for the diagnosis and treatment of
an illness or condition which is classified as an
addiction-related disorder under the ICD-9 or DSM-IV.
Alternate Payment Name: The person to whom benefits are issued on behalf of
a consumer.
American Accreditation HealthCare Commission/URAC: Commission that
establishes accreditation standards for managed care
organizations.
Appeals: A request from an Enrollee for a reversal of a denial by the
managed care organization of authorization to provide a service
prescribed by an in-plan, appropriately qualified practitioner
(see also "Grievances").
Authorization: see Prior Authorization, Service Authorization
Automatic Enrollment: The process for assigning Enrollees to a health plan
if they have not exercised their right to choose for themselves
within the allowed timeframe.
Business Days: A business day includes Monday through Friday except for
those days recognized as federal holidays and/or District
holidays.
Cancellation/termination: Discontinuation of the contract for any reason
prior to the expiration date.
Capitation Rate: The monthly rate per Enrollee, fixed annually in advance,
paid by the MAA to a contracted managed care plan for managing
the services described in the contracted Evidence of Coverage,
whether or not the Enrollee receives services during the period
covered by the rate.
Care Coordination: Refers to the activities of assisting Enrollees and
service providers to coordinate care for Enrollees with multiple,
complex, and/or intensive treatment needs, including
participating in assessments, treatment planning, making
referrals, providing health education, facilitating exchange of
information, monitoring implementation of treatment plans,
discharge planning and coordination. It also includes cooperating
with other District agencies or entities serving Enrollees, such
as, but not limited to, the Commission on Mental Health Services,
Public Schools, and the District's Children and Family Services.
Care Management System: In this document, refers to an organized system for
managing the medical and/or mental health and alcohol and drug
abuse care of Enrollees with complex care needs, including
Primary Care Physicians' responsibility for providing and
managing primary care, an EPSDT tracking system, a utilization
management system with special procedures for high cost/high-risk
cases, and care coordination.
Case Management Services: Services which will assist individuals in
gaining access to necessary medical, social, educational and
other services.
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Case Payment Name: The person in whose name benefits are issued.
CASSIP: Reserved.
Certified Nurse Midwife: An individual licensed under the laws within the
scope of the Act of April 04, 1929 [P.L. 160, NO.155].
Certified Registered Nurse Practitioner (CRNP): A registered nurse licensed
in the District of Columbia who is certified by the Boards in a
particular clinical specialty area and who, while functioning in
the expanded role as a professional nurse, performs acts of
medical diagnosis or prescription of medical therapeutic or
corrective measures in collaboration with and under the direction
of a physician licensed to practice medicine in the District of
Columbia.
Child: In this document, refers to children and adolescents ages 0
through 21 eligible for Medicaid and/or enrolled in a Medicaid
Managed Care Program.
Children's Health Insurance Program (SCHIP): Passed as part of the Balanced
Budget Act of 1997, the Children's Health Insurance Program
provides health insurance for children who come from working
families with incomes too high to qualify for Medicaid, but too
low to afford private health insurance.
Children with Special Health Care Needs: Those children who have, or are at
increased risk for, chronic physical, developmental, behavioral,
or emotional conditions and who also require health and related
services of a type or amount beyond those required by children
generally. This definition includes children on SSI or who are
SSI-related eligibles.
Claim: A bill from a provider of a medical service or product that is
assigned a unique identifier (i.e. claim reference number). A
claim does not include an encounter form for which no payment is
made or only a nominal payment is made.
Clean claim: Claim submitted on an approved claim form, and containing
complete and accurate information for all data fields required by
the Contractor and MAA for final adjudication of the claim. If
information that is not included on the claim form is necessary
for adjudication of a claim, then such additional information
shall be submitted as required in order for the claim to be
considered "clean".
Commission Accreditation Rehabilitation Facilities (CARF): An accreditation
organization that develops and maintains practical and relevant
standards of quality for programs and services.
Complaint: An issue an Enrollee or provider presents to the managed care
organization, either in written or oral form, which is subject to
resolution by the Contractor, their designee and/or MAA.
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Concurrent Review: A review conducted by the Contractor or MAA during a
course of treatment to determine whether or not services should
continue as prescribed or should be terminated, changed, or
altered.
Consumer Satisfaction Surveys: Valid and reliable surveys to measure
Enrollees' overall satisfaction with Medicaid services and with
specific aspects of those services, in order to identify problems
and opportunities for improvement.
Continuity of Care: Care provided to an Enrollee that is coordinated by a
designated primary care provider or specialty provider to the
greatest degree possible, so that the delivery of care to the
Enrollee remains stable, services are consistent and
unduplicated, and persons involved in the care and treatment of
the Enrollee understand and support the plan of care.
Contractor: A managed care organization participating in the District's
Medicaid Managed Care Program authorized under DC Code sec.
1-359(d).
Covered Services: Health care services that the Contractor shall provide
to Enrollees, including all services required by this contract
and state and federal law, and all additional services described
by the Contractor in its response to the RFP for this contract.
Credentialing: A review process to approve a provider or professional who
applies to provide care in a hospital, clinic, medical group or
in a health plan, based upon specific criteria, standards and
prerequisites, including federal health care program requirements
(see also "Primary Source Verification").
Crisis Plan: A plan developed by the Enrollee, the Enrollee's family (when
relevant) and the Enrollee's medical or mental health and alcohol
or drug abuse providers to guide the management of medical or
mental health/alcohol and drug abuse crises for which the
Enrollee is at risk. In addition conditions which meet the
definition of emergency, mental health conditions which severely
compromise an individual's ability to maintain his or her
customary level of functioning, or which put him or her at risk
for harming self or others are also considered to be crisis
situations.
Cultural Competence: A set of skills that allow service providers and
medical organizations to respond sensitively and respectfully to
people of various cultures, races, ethnic backgrounds and
religions, and sexual preferences and to communicate with them
accurately and effectively to identify and diagnose
health-related problems and to jointly develop culturally
appropriate plans for treatment and self-care.
Day: calendar day unless otherwise specified.
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Deliverables: Those documents, records and reports required to be furnished
to the MAA for review and/or approval pursuant to the terms of
the RFP and Agreement.
Denial of Services: Any determination made by the Contractor in response to
a provider's request for approval to provide MAA-covered services
of a specific duration and scope which: disapproves the request
completely; approves provision of the requested service(s), but
for a lesser scope or duration than requested by the provider; or
disapproves provision of the requested service(s), but approves
provision of an alternative service(s). An approval of a
requested service which includes a requirement for a concurrent
review by the Contractor during the authorized period does not
constitute a denial.
Denied Claim: An adjudicated claim that does not result in a payment
obligation to a provider.
Disease Management: An integrated treatment approach that includes the
collaboration and coordination of patient care delivery systems
and that focuses on measurably improving clinical outcomes for a
particular medical condition through the use of appropriate
clinical resources such as preventive care, treatment guidelines,
patient counseling, education and outpatient care; and that
includes evaluation of the appropriateness of the scope, setting
and level of care in relation to clinical outcomes and cost of a
particular condition.
Disenrollment: Action taken by the MAA to remove a member's name from the
monthly Enrollment Report following the MAA's receipt of a
determination that the member is no longer eligible for
enrollment.
District of Columbia Healthy Families Program (DCHFP): District of
Columbia Healthy Families Program is the District's combination
of the Medicaid program and the State Children's Health Insurance
Program (SCHIP).
Developmental Disability: A severe, chronic disability that is (or is
suspected of being):
a) Attributable to a mental or physical impairment or
combination of mental and physical impairments;
b) Manifested before the individual attains age 22;
c) Likely to continue indefinitely; and that
d) Results in functional limitations or impairment of normal
growth and development (if not treated); and
e) When applied to infants and young children with substantial
developmental delay or specific congenital or acquired
conditions, either results, or, if not treated, could result
in developmental disabilities.
District: Refers to the Government of the District of Columbia.
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Dixon Transitional Receiver: The court designated administrator and its
successors of the DC Commission on Mental Health Services (CMHS),
responsible for assuring that individuals with mental health
needs receive care through an integrated, community-based system
of care, responsible for administering the mental health services
provided directly by the CMHS and through its contractors, and
responsible for monitoring the provision of all mental health
care under the Medicaid Managed Care Program.
DSM-IV: the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, which is the American Psychiatric Association's official
classification of mental health and alcohol and drug abuse
disorders.
Dual Eligibles: An individual who is eligible to receive services through
both Medicare and Medicaid.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT): The
pediatric component of the Medicaid program created and
implemented by federal statute and regulations. This program
establishes standards of care for children and adolescents under
age 21, calling for regular screening and for the services needed
to prevent, diagnose, correct or ameliorate a physical or mental
illness, including alcohol and drug abuse, or condition
identified through screening. Medicaid services for children are
required as a matter of law to meet these standards, which may
require that services outside traditional Medicaid benefits be
provided when needed to treat such conditions.
Eligibility Period: A period of time during which a consumer is eligible to
receive MAA benefits. An eligibility period is indicated by the
eligibility start and end date.
Eligibility Verification System (EVS): The information system maintained by
the District of Columbia Income Maintenance Administration that
allows providers to verify eligibility status of Medicaid
recipients.
Emergency Medical Condition: A medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average knowledge
of health and medicine, could reasonably expect the absence of
immediate medical attention to result in:
a) 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;
b) Serious impairment to bodily functions; and/or
c) Serious dysfunction of any body organ or part.
Emergency Member Issue: A problem of a member (including problems related
to whether an individual is a member), the resolution of which
should occur immediately or before the beginning of the next
business day in order to prevent a denial or medically
significant delay in care to the
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member that could precipitate a medical emergency condition or
need for urgent care.
Emergency Services: Covered inpatient or outpatient services that
a) Are furnished by an appropriate source;
b) Are needed immediately because of an injury or sudden
illness; and
c) Cannot be delayed for the time required to reach the
Contractor without risk of permanent damage to the
Enrollee's health.
Encounter Data: An encounter is defined as any health care service provided
to a member. Encounters whether reimbursed through capitation,
fee-for-service, or another method of compensation shall result
in the creation and submission of an encounter record to the MAA.
The information provided on these records represents the
encounter data provided by the Contractor.
Enrollee: A person eligible for the District's Medicaid program who is
enrolled in a Medicaid Managed Care Program contracted health
plan.
Enrollment: The process by which a member's entitlement to receive services
from a Contractor are initiated.
Enrollment Broker: The Contractor that provides assistance to Medicaid
eligibles in the selection of a health plan. The same Contractor
will offer a 24-hour Helpline to answer Medicaid recipients'
questions about participating in their health plans.
Evidence of Coverage: Any certificate, agreement, contract or notification
issued to an Enrollee that sets forth the responsibilities of the
Enrollee and services available to the Enrollee.
Experimental Treatment: A course of treatment, procedure, device or other
medical intervention that is not yet recognized by the
professional medical community as an effective, safe and proven
treatment for the condition for which it is being used.
External Quality Review (EQR): A requirement under Title XIX of the Social
Security Act, Section 1902(a), (30), (c) for states to obtain an
independent, external review body to perform an annual review of
the quality of services furnished under state contracts with
managed care organizations, including the evaluation of quality
outcomes, timeliness and access to services.
Fair Hearing: The process adopted and implemented by the District
Department of Health in compliance with federal regulations and
state rules relating to Medicaid Fair Hearings found at 42 CFR
Part 431, Subpart E.
Family: In this document, parents, foster parents, legal guardians or
relatives who serve as a child's primary caregiver.
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Family-Centered Care: Best practice principles for provision of medical,
therapeutic and mental health care for children with special
health care or developmental needs. Family-centered care
establishes parents as the central members of a team of
professionals that plan and implement services needed to address
a child's needs; builds upon the strengths of the family;
recognizes and addresses the impact of a child with special
health care needs on caregivers, siblings and other family
members; and arranges for services to be provided in the home or
other natural settings whenever possible.
Family Planning Services: Any medically approved diagnostic procedure,
treatment, counseling, drug, supply, or device which is
prescribed or furnished by a provider to individuals of
childbearing age for the purpose of enabling such individuals to
freely determine the number and spacing of their children.
Federally Qualified Health Center (FQHC): A health center as defined in 42
C.F.R. 405.2430 - 2470.
Federally Recognized Services: Services refers to medically necessary
services that must be made available to children and adolescents
under the EPSDT program including the services listed in
Attachment J.8.
Fee-for-Service (FFS): Payment to providers on a per-service basis for
health care services.
Formulary: An exclusive list of drug products for which the Contractor will
provide coverage to its members, as approved by the Medicaid
Program.
Fraud: An intentional deception or misrepresentation or concealment of
the facts made by a person with the knowledge that the deception
could result in some unauthorized benefit to himself/herself or
another person. It includes any act that constitutes fraud
under applicable federal or state law.
General Accepted Accounting Principles (GAAP): A technical term in
financial accounting. It encompasses the conventions, rules, and
procedures necessary to define accepted accounting practice at a
particular time. This includes not only broad guidelines of
general application, but also detailed practices and procedures.
Grievances: A complaint which cannot be resolved to the Enrollee's
satisfaction or an issue presented by the Enrollee to the
Contractor or MAA in writing for formal consideration.
Health Care Financing Administration (HCFA): The federal agency within
the Department of Health and Human Services responsible for
oversight of Medicaid programs.
Health Care Professional: Physician or other health care
provider/practitioner if coverage for the professional's
services, provided for under the
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professional scope of practice, and included under the contract
for the services of the professional. This term includes, but is
not limited to: podiatrist, optometrist, chiropractor,
psychologist, dentist, physician assistant, physical or
occupational therapist and therapy assistant, speech-language
pathologist, audiologist, registered or licensed practical nurse
(including nurse practitioner, clinical nurse specialist,
certified registered nurse anesthetist and certified
nurse-midwife), licensed certified social worker, registered
respiratory therapist and certified respiratory therapy
technician.
Health Maintenance Organization (HMO): A District of Columbia licensed
risk-bearing entity which combines delivery and financing of
health care and which provides basic health services to enrolled
members for a fixed, prepaid fee.
High Cost/High-Risk Case Management: Policies and procedures for
effectively managing the authorization of treatment services for
Enrollees with high cost and/or high-risk conditions to ensure
efficient use of resources and high quality health outcomes.
Immediate Need: A situation in which, in the professional judgment of the
dispensing registered pharmacist, the dispensing of the drug at
the time when the prescription is presented is necessary to
reduce or prevent the occurrence or persistence of a serious
adverse health condition.
In-Plan Services: Services which are the payment responsibility of the
Contractor.
Income Maintenance Administration (IMA): District agency responsible for
determining eligibility for Medicaid through TANF and
TANF-related categories, and for administering determinations for
SSI eligibility made by the Social Security Administration.
Individuals with Disabilities Education Act (IDEA): Federal law governing
the rights of infants and toddlers to receive early intervention
and children with disabilities to receive educational services.
Inquiry: Any member's request for administrative service, information or
to express an opinion. Whenever specific corrective action is
requested by the member, or determined to be necessary by the
Contractor, it should be classified as a complaint.
Involuntary Disenrollment: The termination of membership of an Enrollee
under conditions permitted in this agreement.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO):
National organization that sets standards for hospitals and other
health care organizations and conducts reviews to determine
whether they meet those standards in order to accredit them.
LaShawn Receiver: Court designated administrator of the District Child
and Family Services Agency responsible for investigating
children's
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protective issues, exercising custodial responsibility for
children who are removed from the custody of their families, and
administering foster care and other services needed to care for
children while they are in the custody of the District.
Managed Care Eligibles: District of Columbia residents who have been
determined eligible for Medicaid in an eligibility category that
requires them to participate in Medicaid Managed Care Program by
enrolling in a health plan.
Managed Care Organization (MCO): An entity which manages the purchase and
provision of physical or behavioral health services.
Management Information System (MIS): Computerized or other system for
collection, analysis and reporting of information needed to
support management activities.
Medicaid: A program established by Title XIX of the Social Security Act
which provides payment of medical expenses for eligible persons
who meet income and/or other criteria.
Medicaid Managed Care Program (MMCP): A program for the provision and
management of specified Medicaid services through contracted
Health Maintenance Organizations. MMCP was established pursuant
to the Medicaid Managed Care Amendment Act of 1992, effective
March 17, 1992 (DC Law 9-247, DC Code Section 1-359) as amended.
Medical Assistance Administration (MAA): The Administration within the
District of Columbia Department of Health responsible for
administering all Medicaid services under Title XIX (Medicaid)
for eligible recipients, including the Medicaid Managed Care
Program and oversight of its managed care contractors.
Medical Cost: All Third Party claims paid for medical services covered
under Medicaid, excluding those services not covered under the
contract as identified in Section C.8.
Medical Necessity Criteria: Clinical determinations to establish a
service or benefit that will, or is reasonably expected to:
. Prevent the onset of an illness, condition or disability;
. Reduce or ameliorate the physical, mental behavioral, or
developmental effects of an illness, condition, injury or
disability;
. Assist the individual to achieve or maintain maximum
functional capacity in performing daily activities, taking
into account both the functional capacity of the individual
and those functional capacities appropriate for individuals
of the same age.
Medically Appropriate Transfer: A transfer from a hospital, which complies
with the requirement of 42 U.S.C. Section 1395dd(c).
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Medically Necessary Services: Services that are included in the District's
Medicaid programs and meet medical necessity criteria established
in this Request for Proposals.
Member Month: One Enrollee who is enrolled in the MMCP for one month.
Member Record: A record contained on the Daily Membership File or the
Monthly Membership File that contains information on
eligibility, managed care coverage, and the category of
assistance, which help establish the covered services for which a
consumer is eligible.
Mental Health and Alcohol and Drug Abuse Services: Medicaid services for
the treatment of mental or emotional disorders and treatment of
chemical dependency disorders.
National Committee on Quality Assurance (NCQA): An organization that sets
standards, evaluates and accredits health plans and other managed
health care organizations.
Net Worth (Equity): The residual interest in the assets of an entity
that remains after deducting its liabilities.
Network: Means all contracted or employed providers in the health plan who
are providing covered services to members.
Network Provider: Health and mental health services provider who is an
individual or organization selected and under contract with a
specific contractor.
Notice of Action: Written notice of a decision by a contractor to
authorize, deny, terminate, suspend, or delay requested services
for a specific Enrollee; approve or deny a grievance; approve or
deny an appeal; or report on actions taken to resolve a
complaint.
Ombudsman: Entity that engages in impartial and independent investigation
of individual complaints, advocates on behalf of consumers and
issues recommendations. This function may be operated by an
organization independent of the Contractor, or by a designated
and appropriately delineated and empowered unit in a government
agency.
Out-of-Network Provider: A health or mental health and alcohol and drug
abuse individual or organization who does not have a written
provider agreement with a Contractor and therefore not included
or identified as being the Contractor's network.
Out of Plan Services: Services that are not included as covered
services.
Outreach: Activities performed by the Contractor or its designee to
contact its Enrollees and their families, and to communicate
information, monitor the effectiveness of care, encourage use of
Medicaid resources and treatment compliance, and provide
education.
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Primary Care Provider (PCP): A board-certified or board-eligible provider
who has a contract with a managed care plan to provide necessary
well care, diagnostic, and primary care services, and to manage
covered benefits for Enrollees in his or her caseload. A
physician with a specialty of pediatrics, obstetrics/gynecology,
internal medicine, family medicine or any other specialty the
Contractor designates from time to time may serve as a PCP.
Primary Source Verification: Credentialing procedures for the review and
verification of original documents submitted for credentialing,
including confirmation of references, appointments, and licensure
from licensing authorities. (See also "Credentialing")
Prior Authorization: A determination made by a Contractor to approve or
deny a provider's or Enrollee's request to provide a service or
course of treatment of a specific duration and scope to an
Enrollee prior to the provision of the service. (See also
"Service Authorization")
Provider: An individual or organization that delivers medical, dental,
rehabilitation, or mental health services.
Provider Agreement: Any MAA-approved written agreement between the
Contractor and a provider to provide medical or professional
services to MAA consumers to fulfill the requirements of the
contract.
Qualified Family Planning Provider (QFPP): Any public or not-for-profit
health care provider that complies with Title X
guidelines/standards and receives Title X funding.
Quality Improvement: Methods to identify opportunities for improving
organizational performance, identify causes of poor performance,
design and test interventions, and implement demonstrably
successful interventions system-wide.
Quality Management: An ongoing, objective and systematic process of
monitoring, evaluating and improving the quality, appropriateness
and effectiveness of care.
Recipient: A person eligible to receive medical and/or behavioral health
services.
Recipient Month: One MA consumer covered for one (1) month.
Rejected Claim: A claim that has erroneously been assigned a unique
identifier and is removed from the claims processing system prior
to adjudication.
Remittance Advice: A written explanation accompanying payment to a provider
indicating how the payment is to be applied.
Residential Treatment Facility: 24-hour treatment facility primarily for
children with significant behavioral problems who need long-term
treatment.
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Respite: A Service provided in order to offer a period of relief for a
family member or other non-paid caregiver of a person who has
needs requiring constant monitoring, assistance with activities
of daily living, and/or treatment. Respite may be provided in the
home setting by alternative caretakers, or out of home in a
non-acute residential, nursing or hospital setting.
Retrospective Review: Determination of the appropriateness or necessity of
services after they have been delivered, generally through the
review of the medical or treatment record.
Risk Assessment: Assessment process based on medical records, phone
contact, and when needed, an office visit or outreach to the
home, to determine which Enrollees are most in need of medical
and related services to improve their condition.
Risk Pool: Deleted.
Routine: Describes a level of health needs which is neither urgent nor
emergent, but for which medical services can improve functioning
and/or reduce symptoms.
Salazar Monitor: Court monitor appointed to report, record, evaluate,
observe, and provider recommendations to the United States
District Court on the District's Medicaid program including
processing of Medicaid applications and re-certification,
eligibility verification, and arranging for, providing, and
reporting on EPSDT services.
School-Based Health Center: A health care site located on school building
premises which provides, at a minimum, on-site, age-appropriate
primary and preventive health services with parental consent, to
children in need of primary health care.
Section 1915(b) Waiver: A statutory provision of Medicaid that allows a
state to partially limit the freedom of choice by consumers of
Medicaid eligible services or that waives the requirements under
Title XIX, the Medicaid Act, for statewideness of a plan or
comparability of benefits.
Senior Manager: A Contractor's staff member who has decision-making
authority, and is accountable, for the performance of a major
function and/or department.
Service Authorization: A determination made by a Contractor to approve or
deny a provider's or Enrollees' request to provide a service or
course of treatment of a specific duration and scope to an
Enrollee. (See also "Prior Authorization")
SOBRA: Sixth Omnibus Budget Reconciliation Act, it allows states to expand
coverage to pregnant women and children.
Special Health Care Needs: See Children with Special Health Care Needs.
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Spend-down: A process of establishing eligibility by allowing consumers to
spend their excess net income on certain incurred or paid medical
expenses. Eligibility may need to be redetermined monthly.
Stabilize: The provision of treatment necessary to assure, within
reasonable medical probability, that no material deterioration of
an Enrollee's medical condition is likely to result.
Start Date: The first date which consumers are eligible for medical
services under the operational contract, and on which the
Contractors are operationally responsible and financially liable
for providing medically necessary services to consumers.
Subcapitation: A provider in the Contractor's network paid on a per
member/per month basis to cover some or all of its services. This
method passes on a portion of risk to providers.
Subcontract: Any written agreement between the Contractor and another party
that requires the other party to provide services or benefits
that the Contractor shall make available.
Supplemental Security Income (SSI): A Medicaid category of assistance for
blind or disabled individuals who are eligible for federal
Supplemental Security Income benefits and Medicaid.
SSI-Related: A Medicaid category, which includes, but is not limited to the
same requirements as the corresponding category of SSI. Persons
who receive Medicaid in SSI-Related categories may include, but
are not limited to aged, blind or disabled and people determined
to be Medically Needy.
Sui Juris: Having full legal rights or capacity as in the case of
emancipated minors.
Temporary Assistance for Needy Families (TANF): Federally funded program
that provides assistance to single-parent families with children
who meet the categorical requirements for aid. TANF eligibles
also qualify for Medicaid coverage.
TANF-related Individuals: Persons who qualify for Medicaid and whose family
incomes do not exceed 200% of FPL. TANF-related eligibility is
determined by the District's State Medicaid Plan or federal law
(including medically needy and transitional Medicaid).
Third Party Liability: Insurance policy or other form of coverage with
responsibility to pay for certain health services for a Medicaid
eligible in addition to Medicaid. Includes commercial health
insurance, worker's compensation, casualty, torts, and estates.
These sources shall be used to offset the costs of Medicaid
services.
Third Party Resource (TPR):A third party resource is any individual, entity
or program that is liable to pay all or part of the medical cost
of injury,
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disease or disability of a consumer. Examples of third party
resources would include government insurance programs such as
Medicare or CHAMPUS (Civilian Health and Medical Program of the
Uniformed Services); private health insurance companies, or
carriers; liability or casualty insurance; and court-ordered
medical support. Such resources, or insurance, shall be billed
prior to billing the MA Program, but a TPR should never interfere
with an MA consumer's receipt of service.
Title XVIII (Medicare): A federally-financed health insurance program
administered by the Health Care Financing Administration (HCFA),
covering almost all Americans sixty-five (65) years old and older
and certain individuals under sixty-five (65) who are disabled or
have chronic kidney disease. The program provides protection with
an acute care focus under two parts: (1) Part A covers inpatient
hospital services, post-hospital care in skilled nursing
facilities and care in patients' homes; and (2) Part B covers
primarily physician and other outpatient services.
Transportation Services: Mode of transportation that can suitably meet
Enrollee's medical needs. Acceptable forms of providing
transportation include, but are not limited to, provision of bus,
subway, or taxi vouchers; wheel chair vans; and ambulances.
Triage: The process of determining the degree of urgency of the needs of an
individual Enrollee, and then referring and/or further arranging
for that Enrollee to receive the appropriate level of care.
TTD/TTY: A telecommunications instrument enabling those with communication
disorders to communicate over the telephone by using a keyboard.
Also known as Teletype (TTY) or TTD.
Urban: Consists of territory, persons and housing units in places, which
are designated as 2,501 persons or more. These places shall be in
close proximity to one another.
Urgent Medical Condition: A condition, including a mental health and/or
alcohol and drug abuse condition, less serious than an emergency
medical condition, which is severe and/or painful enough to cause
a prudent layperson, possessing an average knowledge of medicine,
to believe that his or her condition requires medical evaluation
or treatment within 24 hours in order to prevent serious
deterioration of the individual's condition or health.
Utilization Management: An objective and systematic process for planning,
organizing, directing and coordinating health care resources to
provide medically necessary, timely and quality health care
services in the most cost-effective manner.
Utilization Review Criteria: Detailed standards, guidelines, decision
algorithms, models, or informational tools that describe the
clinical factors to be considered relevant to making
determinations of medical necessity
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including, but not limited to, level of care, place of service,
scope of service, and duration of service.
Waiver: A process by which a state may obtain an approval from HCFA for an
exception to a federal Medicaid requirement(s).
Youth Services Administration (YSA): District agency responsible for
administering services for youth who are in the custody of the
District as a result of criminal activities.
Acronyms
ADA Americans with Disabilities Act
AMBHA American Managed Behavioral Healthcare Association
APRA Addictions, Prevention, Recovery Administration
CAHPS Consumer Assessment of Health Plans Studies
CARF Commission on Accreditation of Rehabilitation Facilities
CASSIP Child and Adolescent SSI or SSI-Related Plans
CLIA Clinical Laboratory Improvement Amendment
CMHS Commission on Mental Health Services
CO Contracting Officer
COTR Contracting Officer Technical Representative
DBE Disadvantaged Business Enterprise
DCHFP District of Columbia Healthy Families Program
DCPS D.C. Public Schools
DME Durable Medical Equipment
DOES District of Columbia Department of Employment Services
DOH Department of Health
D-U-N-S Data-Universal-Numbering-System
DUR Drug Utilization Review
EOB Explanation of Benefits
EPSDT Early and Periodic Screening, Diagnosis, and Treatment
ESA Employment Standards Administration
EVS Eligibility Verification System
FFS Fee-For-Service
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FTE Full Time Equivalent Employees
HCFA Health Care Finance Administration
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
ICF/MR Intermediate Care Facilities for Mental Retardation
IDEA Individuals with Disabilities Education Act
IDIQ Indefinite Delivery Indefinite Quantity
IEP Individualized Education Plan
IFB Invitation for Offers
IFSP Individualized Family Services Plan
IMA Income Maintenance Administration
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JCAHO Joint Commission on Accreditation of Healthcare Organizations
LBE Local Business Enterprise
LBOC Local Business Opportunity Commission
MAA Medical Assistance Administration
MH Mental Health
MIS Management Information System
MMCP Medicaid Managed Care Program
MOU Memorandum of Understanding
NAIC National Association of Insurance Commissioners
NCQA National Committee on Quality Assurance
OHRLBD Office of Human Rights and Local Business Development
OIG Office of Inspector General, U.S. Department of Health and Human
Services
OMC Office of Managed Care
OTMP Outreach and Transition Monitoring Plan
PBC Public Benefits Corporation
PBM Pharmacy Benefits Manager
PCP Primary Care Physician
PMPM Per Member Per Month
QFPP Qualified Family Planning Provider
QI Quality Improvement
QISMC Quality Improvement System for Managed Care
RFP Request for Proposal
SA Substance Abuse
SCHIP State Children's Health Insurance Program
SOBRA Sixth Omnibus Budget Reconciliation Act
SSI Supplemental Security Income
TANF Temporary Assistance to Needy Families
TDL Technical Direction Letter
TPL Third Party Liability
TTY Teletype
UPL Upper Payment Limit
URAC Utilization Review Accreditation Commission
VFC Vaccines for Children
WIC Special Supplemental Food Program for Women, Infants and Children
YSA Youth Services Administration
C.2 Background
The Government of the District of Columbia, Department of Health Medical
Assistance Administration is the single state agency with the
responsibility for implementation and administration of the District of
Columbia's Medicaid (i.e., Title XIX) and Children's Health Insurance
(i.e., Title XXI - SCHIP) programs. Through these programs, approximately
125,000 eligible low-income family members and disabled and elderly
individuals receive health insurance coverage. Of the 125,000 eligibles,
approximately 50,000 are enrolled in the Fee for Service
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program and are not the responsibility of the Contractor. The two
components of the Medicaid system that are subject to this contract are as
follows:
DCHFP operates as a capitated waiver program under Section 1915(b) of
the Social Security Act. The DCHFP serves approximately 75,000
primarily low-income pregnant women, children and adults (e.g., TANF,
SOBRA and SCHIP eligibles) who are enrolled on a mandatory basis in
health maintenance organizations (HMOs). The HMOs are required to
provide a comprehensive array of medically necessary health care and
mental health services to DCHFP enrollees. Beginning April 1, 2001,
MAA anticipates expanding DCHFP coverage to include individuals up to
200% of the Federal Poverty Level (FPL). The expanded coverage to 200%
FPL is anticipated to include 11,000 new Enrollees.
C.2.1.1 In addition, MAA is submitting an amendment to the
District's Medicaid State Plan to the Health Care
Finance Agency (HCFA) requesting to provide outpatient
drug and alcohol rehabilitation services. Contingent
upon HCFA approval, these services will be available
to DCHFP Enrollees on a FFS reimbursement basis through
a specialized provider network. DCHFP contractors are
not financially responsible for the delivery of
outpatient and rehabilitation services.
RESERVED.
C.2.3 DCHFP responsibility for Proposed Alcohol and Drug Abuse Services
Contingent upon HCFA approval of the District's waiver request, the
District MAA will select a network(s) of alcohol and drug abuse
treatment providers to provide outpatient, day treatment, methadone,
residential and detoxification services to DCHFP Enrollees. The
contracted alcohol and drug abuse treatment provider network will be
paid by MAA on a for fee-for-service (FFS) basis for Enrollees of the
DCHFPs. Although the DCHFPs will not be responsible for paying
providers for these services, the DCHFP Contractors shall have a role
with regard to alcohol and drug abuse treatment, including: (1)
assisting MAA in the selection of the alcohol and drug abuse treatment
provider network(s); (2) assisting MAA in the development of
protocols, policies and procedures that govern referral and
coordination of care; (3) establishing protocols, policies and
procedures that govern the delivery of dual diagnosis services (mental
health and alcohol and drug abuse); (4) referring Enrollees suspected
of needing alcohol and drug abuse treatment; and(5) participating in
multidisciplinary staffing to ensure coordination of alcohol and drug
abuse treatment and mental health and/or physical health care needs.
DCHFP Contractors' capitation will include costs associated with the
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administrative functions of referral and care coordination for
Enrollees needing alcohol and drug abuse treatment.
C.2.4 The MAA's principal objective in the development of this solicitation
is to ensure the selection of Contractors who can provide high quality
health care services and supports to all enrollees. The MAA has also
identified the following desired outcomes and guiding principles for
each specific program.
C.2.4.1 For DCHFP:
. Improve access to and coordination of Individuals
with Disabilities Education Act (IDEA) health
related services for IDEA eligible children;
. Improve health outcomes for children through
increased compliance with Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT);
. Improve birth outcomes through earlier and
increased participation in prenatal care;
. Improve coordination of care for individuals with
serious and complex conditions including children
with special health care needs;
. Improve access to mental health and alcohol and
drug abuse treatment, and improve coordination
between primary care and mental health/alcohol and
drug abuse treatment;
. Improve access for individuals to appropriate
services and supports; and
. Utilize public resources in the most efficient
manner possible.
C.2.4.2 RESERVED.
C.3 Requirements
The requirements in this section pertain to DCHFP program the contractor(s)
shall:
C.3.1 Network
C.3.1.1. Maintain an adequate network of health service
providers and agencies that is of sufficient size and
scope to meet the health and mental health care needs
of Medicaid Enrollees and the specifications of this
contract;
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C.3.1.2 Maintain accurate and current information regarding the
membership of its provider network and the capacity of
each primary care provider within the network to accept
new patients;
C.3.l.3 Provide complete, accurate and current written
information about its network, services, and procedures
to any prospective or current Enrollee, the
representatives of such Enrollees and organizations
that counsel Medicaid-eligible persons regarding their
choice of plans.
C.3.2 Organizational Requirements
C.3.2.1 Organizational Structure
The Contractors shall have a well-defined
organizational structure with clearly assigned
responsibility and accountability for major managed
care functions. The Contractor may combine functions or
assign responsibility for a function across multiple
departments, as long as the staffing, duties and
functions are carried out as required in the following
subsections.
C.3.2.2 The Contractors shall identify key personnel for
functions specified in Sections C.3.2.3 through
C.3.2.12 below that are considered to be essential to
the work being performed.
C.3.2.3 The Contractors shall have a Chief Executive Officer
with clear authority over the entire operation and
designate a Senior Manager with overall responsibility
for fulfilling the terms for each of its Medicaid
Managed Care Program contracted plan(s).
C.3.2.4 The Contractors shall have a Chief Financial Officer to
oversee the budget and accounting system.
C.3.2.5 The Contractors shall designate a board-certified
physician licensed in the District with at least five
years experience to serve as Medical Director for its
Medicaid Managed Care Program contracted plan(s). The
responsibilities of the Medical Director pertain to
physical health care and include the following
functions:
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C.3.2.5.1 Development of clinical practice standards,
policies, procedures, and performance
standards;
C.3.2.5.2 Review and resolution of quality of care
problems;
C.3.2.5.3 Participation in grievance and appeal
processes related to service denials and
clinical practice;
C.3.2.5.4 Development, implementation, and review of
the internal quality assurance and
utilization management programs;
C.3.2.5.5 Oversight of the referral process for
specialty and out-of-plan services;
C.3.2.5.6 Leadership and direction for the Contractor's
clinical staff recruitment, credentialing and
privileging activities;
C.3.2.5.7 Leadership and direction for the Contractor's
prior authorization and utilization review
process;
C.3.2.5.8 Leadership and direction of policies and
procedures relating to confidentiality of
clinical records; and
C.3.2.5.9 Participation in meetings called by MAA
C.3.2.6 The Contractors shall designate a single Senior
Manager, which mayor may not be the contracted
Psychiatric Medical Director, with overall
responsibility for performance of the Contractor's
obligations to provide mental health services and to
coordinate with the Commission on Mental Health
Services and the Dixon Transitional Receiver.
C.3.2.7 The Contractors shall designate a Senior Manager with
overall responsibility for a Quality Improvement
Program
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to assess ongoing quality and to develop and implement
the Contractor's Quality Improvement Plan.
C.3.2.8 The Contractors shall designate a Senior Manager with
overall responsibility for a Care Coordination Program
to coordinate care for Enrollees with multiple,
complex, and/or intensive treatment needs including
individuals in need of alcohol and drug abuse
treatment.
C.3.2.9 The Contractors shall designate a Senior Manager with
overall responsibility for a Member Services Program to
communicate with Enrollees on a twenty-four (24) hours
per day, seven (7) days per week basis, act as member
advocates, and coordinate members' use of the
complaint, grievance, and appeals process.
C.3.2.10 The Contractors shall designate a Senior Manager with
overall responsibility for a Provider Services Program
to coordinate communications between the MCO and its
providers and oversee provider network management.
C.3.2.11 The Contractors shall designate a Senior Manager with
overall responsibility for Management Information
Services to support the operations of computerized
system for collection, analysis and reporting of
information.
C.3.2.12 Medicaid Advisory Committee
C.3.2.12.1 The Contractors shall establish an Advisory
Committee within sixty (60) days of contract
award. The Contractor shall ensure that this
committee meets at least quarterly to advise
the Contractors on matters relating to
services to enrollees.
C.3.2.12.2 The Advisory Committee shall also include
network providers, Enrollees, and sufficient
other stakeholders, representative of
relevant advocacy groups, trade associations,
and the District agencies that serve Medicaid
managed care Enrollees to provide
comprehensive feedback on the Contractor's
operations and planned changes. At a minimum,
the Advisory Committee shall include a
representative of the Commission
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CONTRACT N).: POHC-2002-D-OOO3 41
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on Mental Health Services/Dixon Transitional
Receiver, the DC Public Schools, the
District's Court System, Child and Family
Services Agency/LaShawn Receiver, the Use
Your Power Parent Advisory Council, the
Department of Human Services Youth Services
Administration, the Chief Executive Officer
of his/her designee of the MAA contracted
alcohol and drug abuse provider network(s),
and the Department of Human Services Early
Intervention Program.
C.3.2.12.3 MAA will approve the overall representation
on this Committee and the scope of its
jurisdiction.
C.3.2.12.4 The Contractors shall generate and maintain
minutes and records of the agendas of the
meetings, issues raised and any
recommendations made to resolve identified
issues or to improve the Contractor's
operations. These records shall be available
within three (3) working days of each
meeting, and may be reviewed by MAA or its
representative, upon request.
Place of Business and Hours of Operation
The Contractor shall maintain a business office in the District which shall
operate Monday through Friday between 8:00 a.m. and 5:00 p.m. and which
shall be adequately staffed to ensure prompt and accurate responses to
inquiries from current or prospective Enrollees, providers of the
Contractor's network and officials of the District or federal governments.
The Contractor shall provide live access twenty-four (24) hours per day,
seven (7) days per week to its Member Services program and other key
functions that support care coordination and utilization.
Marketing
The Contractor shall comply with the Balanced Budget Act of 1997.
C.5.1 Permissible Marketing Activities
In addition to the requirements of the Balanced Budget Act of 1997,
the Contractor shall be responsible for distributing all permissible
marketing materials throughout the District of Columbia. The
Contractor shall be permitted to perform the following marketing
activities under this contract:
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C.5.1.1 General information distributed through mass media
(i.e., newspapers, magazines and other periodicals,
radio, television the Internet, and other media
outlets);
C.5.l.2 Telephone calls, mailings and home visits are
permissible only to individuals who are current
Enrollees of the Contractor for the sole purpose of
educating current Enrollees about services offered by
or available through the Contractor;
C.5.1.3 General activities which benefit the entire community
such as health fairs, school contributions or activity
sponsorships, and health education and promotion
programs; and
C.5.l.4 Materials as requested and/or required by the District
to be distributed by its enrollment agent.
Prior Approval of all Marketing Activities and Materials
C.5.2.1 The Contractor shall submit a detailed description of
its marketing plan and all materials that it intends to
use to MAA sixty (60) days prior to implementation of
the marketing plan.
Content of Marketing Materials and Information
C.5.3.1 Written brochures and materials which are intended to
encourage eligibles to select the Contractor and are
distributed through the permissible marketing
activities described Section 0 shall be written at the
---------
fifth (5th) grade reading level and shall at a minimum
contain the following information:
C.5.3.1.1 A statement that Medicaid beneficiaries can
choose to enroll in any plan that is offered;
C.5.3.1.2 A listing of covered services and cost
sharing requirements if applicable;
C.5.3.1.3 An explanation of beneficiaries' rights to
select a primary care provider and to obtain
family planning services from any qualified
family planning provider, including the
qualified family planning agencies that may
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not be providers of the Contractor's network;
C.5.3.1.4 An explanation of the importance of selecting
a primary care provider from whom or through
whom all care will be obtained;
C.5.3.1.5 An explanation of the right of an Enrollee
needing mental health or alcohol and drug
abuse services to receive such care and have
a choice of network providers.
C.5.3.1.6 An explanation of the availability of
assistance from the District or its agent in
selecting a health plan; and
C.5.3.1.7 Where and how to obtain easy, userfriendly,
yet detailed and specific information on
available providers in the Contractor's
network prior to making a final plan
selection.
C.5.3.2 The Contractor shall furnish the following information
through the permissible marketing activities described
in Section C.5.1:
C.5.3.2.1 An explanation of services available through
the Contractor;
C.5.3.2.2 A description of the service network offered
by the Contractor (including types of
providers, locations of providers, and
hours);
C.5.3.2.3 The availability of services for persons
whose primary language is not English or who
have a disability; and
C.5.3.2.4 The availability of transportation services.
C.5.4 Permissible Marketing Activities of Network Providers
C.5.4.1 The Contractor shall ensure that its network providers
comply with Sections C.5 in performing any marketing
activities on the Contractor's behalf.
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C.5.4.2 Marketing information distributed by a provider in the
Contractor's network that is directed to the provider's
current patients shall be limited to general
information about their health plan and notification of
the provider's inclusion in the Contractor's network.
C.5.4.3 The Contractors shall provide the District's Enrollment
Broker with listing of its network providers. When a
listed provider serves other health plans as well, the
names of those health plans shall be disclosed.
C.5.4.4 All such information shall include a statement that
Medicaid beneficiaries can choose to enroll in any MMCP
plan that is offered for their eligibility group.
C.5.5 Prohibited Information and Activities
The Contractor and their Subcontractors are prohibited from
distributing the following information or conducting the
following activities:
C.5.5.1 Materials which mislead or falsely describe covered or
available services;
C.5.5.2 Materials which mislead or falsely describe the
Contractor's provider participation network, the
participation or availability of network providers, the
qualifications and skills of network providers
(including their bilingual skills), or the hours and
locations of network services;
C.5.5.3 Offering gifts of more than the minimums value cash
promotions, and/or other insurance products which are
designed to induce enrollment by individual
beneficiaries;
C.5.5.4 Compensation arrangements with marketing personnel that
utilize any type of payment structure in which
compensation is tied to the number (or classes) of
persons who enroll;
C.5.5.5 Direct soliciting of members, either by mail,
door-to-door or telephonic, of prospective Enrollees;
and
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C.5.5.6 Engaging in any marketing activity or using any
marketing material not approved in advance by the
District.
C.6 Enrollment, Education and Outreach
The Contractor shall develop procedures and materials to assist new
Enrollees in selecting a PCP; inform them of covered services, benefits and
procedures; and inform them of their rights as Plan Enrollees and Medicaid
recipients and how to exercise their rights. All such material shall be
submitted to MAA for approval prior to distribution.
C.6.1 Coordination with the District's Agent/Enrollment Broker
The Contractor shall coordinate enrollment, education, and
outreach activities with the District, or its Agent/Enrollment
Broker.
C.6.2 Acceptance of all Enrollees
The Contractor shall accept each individual who is enrolled in or
assigned to the Contractor by the District or its agent.
C.6.3 Evidence of Coverage
Within ten (10) business days of the date on which the District
or its agent notifies the Contractor that an individual has been
enrolled with the Contractor, the Contractor shall provide each
Enrollee with written evidence of coverage and a Member Handbook
written equivalent to a fifth grade reading level that shall
include the following orientation and education materials:
C.6.3.1 A plan membership card which contains the effective
date of enrollment, the individual's Enrollee
identification number (including the DC Medicaid ID
number), the Contractor's general information and
emergency telephone numbers, and other general
information;
C.6.3.2 Conditions of enrollment, the scope, content, duration
and limitation of coverage in the plan;
C.6.3.3 Explanation of the procedure for obtaining benefits,
including the address and telephone number of the
Contractor's office or facility and the days that the
office or facility is open and services are available;
C.6.3.4 Explanation of how and where to access emergency
medical care availability to Enrollees twenty-four (24)
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hours a day, seven (7) day a week; a description of the
process for using either in network or out-of-network
providers for emergency services; and an explanation of
out-of-plan coverage;
C.6.3.5 A confirmation of the Enrollee's selection of a primary
care provider if a PCP was designated at the time of
enrollment;
C.6.3.6 For Enrollees who have not selected a PCP, an
explanation of the auto-assignment process; the
Enrollee's right to select and change their PCP; and
instructions on how to select a PCP. The instructions
shall include a process for selection by telephone and
an explanation that an Enrollee may remain with his or
her current PCP if the PCP is a member of the
Contractor's network;
C.6.3.7 Information on prescription coverage and co-pay
schedules as applicable;
C.6.3.8 A list of all current network primary care providers
with open practices, with their board certification
status, addresses, telephone numbers, availability of
evening or weekend hours, and all languages spoken;
C.6.3.9 An explanation of how the Enrollee may obtain an
initial assessment with a network outpatient mental
health or contracted alcohol and drug abuse network
provider, and how to obtain assistance in locating a
provider;
C.6.3.10 An explanation of how the Enrollee may obtain specialty
care and the costs, if any, associated with specialty
care;
C.6.3.11 An explanation of the Enrollee's opportunity to obtain
family planning services covered under this contract
from a qualified family planning provider of their
choice regardless of the family planning provider's
membership in the Contractor's network;
C.6.3.12 A separate brochure explaining the EPSDT program which
includes a list of all of the services available to
children, a statement that services are free, and a
telephone number which Enrollees can call to receive
assistance in scheduling an appointment and obtaining
transportation;
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C.6.3.13 Information on how to request IDEA evaluation for an
enrolled child through the Contractor's network;
C.6.3.14 Notification of the Enrollee's responsibility to report
any ongoing care corresponding to a plan of care at the
time of enrollment and their rights to continue that
treatment under the Contractor on a transitional basis
as described in Section C.8.4;
C.6.3.15 Notification of the Enrollee's responsibility to report
any third party payment source to the Contractor and
the importance of doing so;
C.6.3.16 A description of the Enrollee's rights under the plans
including:
C.6.3.16.1 The right to obtain information listed in
Section C.7.4.3, upon request;
C.6.3.16.2 Notification of how to submit a grievance or
complaint and information about how to
contact the Ombudsmen for assistance in doing
so;
C.6.3.16.3 The right of an Enrollee to receive
assistance from a personal representative of
the Enrollee's choice during grievance or
complaint procedures; and
C.6.3.16.4 The Enrollee's right to request a hearing
with the Office of Fair Hearings;
C.6.3.17 Identification of the services that are covered under
the District's Medicaid plan but that are not part of
Contractor's service benefit package and that therefore
may be obtained from any participating Medicaid
provider without adhering to Contractor's procedures.
Information regarding allowable reasons and procedures
for disenrolling from the Contractor's plan;
C.6.3.18 Information on the availability of transportation and
interpretation services as required in Section C and
Attachment A.2.1(g) under this contract and the
procedures for requesting such assistance;
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C.6.3.19 As needed, the Contractor shall make the above listed
materials available to Enrollees in English, Spanish,
Vietnamese, Chinese, Braille, or audio format; and
C.6.3.20 The Contractor shall issue updates to the Member
Handbook when there are material changes that will
affect access to services and information about the
Medicaid Managed Care Program and shall provide at
least an annual mailing of the complete updated Member
Handbook.
C.6.4 Selection of Primary Care Provider
C.6.4.1 The Contractor shall allow each Enrollee the freedom to
choose from among its participating PCPs, and change
PCPs as requested. The Contractor shall notify
Enrollees of procedures for changing PCPs. The
materials used to notify Enrollees shall be approved by
MAA.
C.6.4.2 If the Enrollee desires, the Contractor shall allow him
or her to remain with his or her existing PCP if the
PCP is a member of Contractor's primary care network.
C.6.4.3 If an Enrollee does not choose a PCP, the Contractor
shall match Enrollees with PCPs by:
C.6.4.3.1 Assigning Enrollees to a provider from whom
they have previously received services, if
the information is available;
C.6.4.3.2 Designating a PCP who is geographically
accessible to the Enrollee;
C.6.4.3.3 Assigning all children within a single family
to the same PCP; and
C.6.4.3.4 Asigning a child with a significant medical
condition to a practitioner experienced in
treating that condition, if the Contractor
knows of the condition.
C.6.4.4 The Contractor shall ensure that all new Enrollees
select or are assigned to a PCP within sixty (60) days
of enrollment. The Contractor shall ensure that
Enrollees receive information about where they can
receive care during the time period between enrollment
and PCP selection/assignment. The Contractor shall
notify the
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Enrollee of his or her assigned PCP within five (5)
days of assignment.
C.6.4.5 The Contractor shall document the number of requests to
change PCPs and the reasons for such requests, and
report them to the District on a quarterly basis in
accordance with Section F.5.
C.6.5 Responsibility for Newborns
C.6.5.1 The Contractor(s) shall submit the newborn's name and
date of birth to the Enrollment Broker and MAA when
requesting enrollment of the newborn to the mother's
health plan ten (10) days after the birth of the child.
A newborn shall be enrolled from its birth month
through its eligibility end date except as provided in
Section H.1.1.2. A newborn shall remain enrolled in the
health plan of birth until a Medicaid number is
assigned to the newborn. A mother can not disenroll the
newborn from the health plan of birth until a Medicaid
number has been assigned to the newborn.
C.6.5.2 As noted in Section C.6.5.1, a newborn will be enrolled
from its birth month through eligibility end date
unless specified in this section:
C.6.5.2.1 If the newborn is abandoned the newborn shall
remain in the mother's health plan until
alternative medical care is determined. The
contractor shall ensure that the newborn has
a Medicaid number before the transfer of the
newborn for alternative medical care.
C.6.5.2.2 If the newborn is placed for adoption the
newborn shall remain in the birth mother's
health plan until alternative medical care is
determined. The contractor shall ensure the
newborn has a Medicaid number before the
transfer of the newborn for alternative
medical care.
C.6.5.2.3 The contractors shall submit the Newborn
Notification Report to MAA by the tenth
(10th) day of each month in accordance with
Section F.5. The Newborn Notification Report
shall include all newborns identified
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since the submission of the last report. See
Attachment J.4 for a sample copy of the
report.
C.6.5.3 The Contractor shall assure that each high-risk newborn
receives a home visit conducted by a registered nurse
within forty-eight (48) hours of discharge from the
birthing hospital or birthing center. The visit shall
be in compliance with established home visit protocol.
During the home visit the nurse will conduct an
assessment of the home environment; parent-child
attachment; family resources, supports, and linkages;
as well as family and parent risk factors. The nurse
will also review with the parent(s) and/or guardian(s)
the infant health care information materials provided
by the hospital and/or birthing center to assure that
parent(s) and/or guardian(s) understand the infant's
health and wellness needs. The nurse will provide
referrals for any needed services to link the family to
the most convenient and appropriate sources of on-going
support. The nurse will provide post-visit follow-up
either in person or by telephone to assure that the
family is linked to referral sources. The contractor's
response to this solicitation shall include proposed
newborn home visiting protocol. The contractors shall
comply with any relevant data reporting requirements.
C.6.6 Disenrollment of Enrollees
C.6.6.1 The Contractor shall not disenroll any Enrollee.
C.6.6.2 The Contractor may request that MAA disenroll an
Enrollee who demonstrates a pattern of disruptive or
abusive behavior or obtaining services in a fraudulent
or deceptive manner.
C.6.6.2.1 In addressing the pattern and in requesting
disenrollment, neither the Contractor nor the
network providers may in any way discriminate
against the Enrollee.
C.6.6.2.2 The Contractor shall make the request in
writing in accordance with the process set
forth in Section H.1.1.3. The Contractor
shall include supporting documentation of the
documentation of the conduct of the enrollee
who
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demonstrates a pattern of disruptive, abusive
behavior, obtaining services in a fraudulent
or deceptive manner.
C.6.6.2.3 The Contractor shall not request a
disenrollment of an enrollee solely because
of an adverse change in mental health status.
C.7 Member Services
The Contractor shall maintain a Member Services Department that is
adequately staffed with qualified individuals who shall assist Enrollees,
Enrollees' family members, or other interested parties (consistent with
laws on confidentiality and privacy) in obtaining information and services
under this plan.
C.7.1 New Enrollee Orientation
The Contractor shall offer culturally appropriate orientation
sessions for new Enrollees conducted in, at a minimum, Spanish,
English, Vietnamese, Chinese and American Sign Language as
appropriate to the audience. Orientation sessions can be either
in a group setting or in individual meetings and shall, at a
minimum, cover the following topics:
C.7.1.1 Explanation of EPSDT services;
C.7.1.2 The availability and scheduling of transportation
services;
C.7.1.3 Promotion of family-centered care and family
involvement in care and treatment planning;
C.7.1.4 Procedures for accessing care including mental health
and alcohol and drug abuse services and services
received outside the Contractor's network;
C.7.1.5 The types of assistance that can be provided by the
Ombudsman and how to contact the Ombudsman;
C.7.1.6 Enrollee rights in Medicaid Managed Care Program
contracted plans and with the Office of Fair Hearings;
and
C.7.l.7 Enrollee's responsibility for reporting any third party
payment source to the Contractor.
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C.7.2 Member Services Telephone Line
The Contractor shall operate a live access toll-free Member
Services telephone line twenty-four (24) hours per day, seven (7)
days per week. The Member Services telephone line shall:
C.7.2.1 Have procedures effective in promptly identifying
special language needs and routing them to staff and/or
services capable of meeting those needs;
C.7.2.2 Maintain TTY or comparable services for people who are
hearing impaired;
C.7.2.3 Provide a system that allows non-English speaking
callers to talk to a bilingual staff person or an
interpreter accessed through the AT&T language line or
an equivalent service, who can translate to an English
speaking staff person; and
C.7.2.4 Be monitored to measure performance such as, but not
limited to, abandonment rate and average response time
to live interaction.
C.7.3 Member Assistance
C.7.3.1 The Contractor shall ensure that Member Services staff
is also available to assist Enrollees in person when
needed during regular business hours.
C.7.3.2 Member Services staff shall:
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C.7.3.2.1 Provide information related to covered
services, accessing care, and enrollment
status;
C.7.3.2.2 Provide information on how to assist
Enrollees with accessing mental health and
alcohol and drug abuse care;
C.7.3.2.3 Assist any Enrollee to file a complaint or
grievance if the member services staff cannot
resolve the issue;
C.7.3.2.4 Provide information on contacting the
Ombudsman for assistance with filing a
complaint or grievance;
C.7.3.2.5 Assist Enrollees in selecting a PCP, or
locating another network provider; and
C.7.3.2.6 Schedule appointments and arrange
transportation for services if requested and
necessary. The Contractor shall not establish
a requirement that such requests be made more
than five (5) calendar days in advance.
C.7.3.3 The Contractor shall ensure that Member Services
Department staff has access to current information
about all providers in the network, including mental
health providers, and all providers in the MAA
contracted alcohol and drug abuse network (and also
including, but not limited to: specialty; board
certification status; geographic location, including
address and telephone number; office hours; open or
closed panels; handicap accessibility; and cultural and
linguistic abilities.
C.7.4 Member Information
C.7.4.1 All materials furnished to prospective and current
Enrollees shall be available in English, Spanish,
Vietnamese, Chinese and Braille as well as other
languages that the District may designate if speakers
of that language comprise of the Contractor's Medicaid
enrollment. Additionally the information shall meet
threshold comprehension equivalent to a grade five (5)
reading level.
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C.7.4.2 The Contractor shall have a protocol for communicating
member information accurately and completely to
Enrollees who speak languages other than those made
available or those who cannot read.
C.7.4.3 The Contractor shall provide within five working days
the following information to any Medicaid client, upon
request:
C.7.4.3.1 Procedures for authorization of services;
C.7.4.3.2 The Contractor's financial condition;
C.7.4.3.3 Description of any provider incentive plans
per 42 C.F.R. 417.479(h)(3);
C.7.4.3.4 Summaries of any Enrollee satisfaction
surveys; and
C.7.4.3.5 Formularies, if any.
C.7.4.4 If a subcontractor providing direct services to
Enrollees terminates his/her subcontract, the
Contractor shall ensure that all Enrollees in the
subcontractor's caseload are notified of the
termination thirty (30) days in advance, or as soon as
possible after a termination made with less than thirty
(30) days prior notice. The notice shall specify how
Enrollees can get needed services after the termination
C.8 Coverage of Services and Benefits
The Contractor shall develop, contract, arrange and provide for all
medically necessary covered services to Enrollees in each of the plans as
specified in Attachment J.8, and as specified in the Medicare
post-stabilization requirements, which are available in the Reference
Library.
C.8.l Medical Necessity
C.8.1.1 The District defines medical necessity as services,
equipment, or pharmaceutical supplies that are:
C.8.1.1.1 Reasonably expected to prevent the onset of
an illness, condition or disability; reduce
or ameliorate the physical, behavioral, or
developmental effects of an illness,
condition, injury or disability, and assist
the individual to achieve or maintain maximum
functional capacity in performing daily
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activities, taking into account both the
functional capacity of the individual and
those functional capacities appropriate for
individuals of the same age;
C.8.1.1.2 Reasonably expected to provide an accessible
and cost-effective course of treatment or
site of service that is equally effective in
comparison to other available, appropriate
and suitable alternatives, and is no more
intrusive or restrictive than necessary;
C.8.1.1.3 Sufficient in amount, duration and scope to
reasonably achieve their purpose as defined
in federal law; and
C.8.1.1.4 Of a quality that meets standards of medical
practice and/or health care generally
accepted at the time services are rendered.
C.8.1.2 The Contractor shall authorize mental health services
according to level of care criteria that reflect
standards of care promulgated by professional
organizations such as the American Academy of Child and
Adolescent Psychiatry, the American Psychiatric
Association, AMBHA, and other relevant standard setting
groups, and that reflect current evidence of treatment
efficacy from peer reviewed publications, medical
community acceptance and expert medical opinion. These
criteria shall be submitted to MAA for review and
approval by the Dixon Transitional Receiver.
C.8.1.2.1 These criteria shall allow authorizers to
consider treatment needs for Enrollees who
may become homeless, living at home or living
in group residential settings, and for
children in foster care.
C.8.1.2.2 The Contractor shall ensure that a Board
certified child psychiatrist reviews criteria
applicable to children and adolescents and a
Board certified psychiatrist specializing in
treatment of adults reviews criteria
applicable to adults and updates them to
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reflect new research findings and best
practices.
C.8.1.2.3 The Contractor shall disseminate Level of
Care Criteria for mental health services to
network mental health providers and to other
network providers as needed to guide
treatment and ensure consistency, and shall
be available to them upon request.
C.8.1.3 The Contractor shall cover all medically necessary
covered services, including those services that are:
C.8.1.3.1 Court-ordered. If the Contractor determines
that Court-ordered services are not medically
necessary the Contractor shall recommend an
alternative level of care to the Court. In
the event that the Court does not accept the
alternative level of care recommended by the
Contractor, the Contractor shall provide the
court-ordered level of service.
C.8.1.3.2 Required to be furnished in a work, school,
childcare, home or other settings in order to
be appropriate for the Enrollee.
C.8.1.4 If a covered EPSDT service is requested to assess a
child's eligibility for IDEA services, or as part of a
child's IDEA Individual Education Program or Early
Intervention Individual Family Services Plan, the
Contractor maydeny coverage only if it finds,
consistent with the requirements of this section, that
such service is not medically necessary. The
Contractor's Medical Director shall review all denials.
The Contractor shall report all denials and the reasons
for such denials to MAA on a quarterly basis.
C.8.1.5 In the event the Contractor denies coverage of mental
health care otherwise covered under EPSDT requirements,
and otherwise included as part of a child's IDEA plan,
the Contractor shall seek prior approval of the denial
from MAA.
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C.8.2 Service Determination Requirements
C.8.2.1 In making determinations of medical necessity, the
Contractor shall take into account all available
clinical information about the Enrollee, as well as the
recommendations of the Enrollee's PCP and other health,
educational and social service professionals caring for
the Enrollee.
C.8.2.2 In making determinations regarding the minimum amount
of services to be authorized, duration and scope of
coverage with respect to any service identified in
Attachment J.8, the Contractor shall be bound by the
same service definitions and coverage requirements
which apply to the District Medicaid program under
federal and District law, 42 U.S.C. Section 1396 et.
seq.; 42 C.F.R. Section 431 et. seq., any additional
federal and District regulations relating to coverage
of Medicaid benefits, and the specific coverage
criteria and procedures set forth in this contract.
C.8.2.3 The Contractor shall not arbitrarily deny or reduce the
amount, duration or scope of a benefit covered under
this contract solely because of the diagnosis, type of
illness, or condition.
C.8.3 Service Specific Requirements
C.8.3.1 Early and Periodic Screening, Diagnosis and Treatment
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C.8.3.1.1 The Contractor shall be responsible for
coverage and provision of all medically
necessary health care, diagnostic services,
treatment, and other items and services
described in Section 1905 of the Social
Security Act to correct or ameliorate defects
and physical and mental health illnesses and
conditions discovered by the periodic or
interperiodic screening services in children
and adolescents through age 20 other than
those services specifically excluded in the
EPSDT Periodicity Schedule.
C.8.3.1.2 The Contractor shall cover all federally
recognized services regardless of whether or
not such services are available to MMCP
Enrollees age 21 and older.
C.8.3.1.3 In the case of services specifically excluded
by MAA from a Plan's benefit and covered
under fee-for-service Medicaid, the
Contractor shall arrange for such treatment
services and is responsible for coordinating
care for the Enrollee, but is not responsible
for the cost of providing such treatment
services.
C.8.3.1.4 The Contractor shall ensure that new
Enrollees receive comprehensive, periodic
well-child exams, referred to as "EPSDT
screens" within ninety (90) days of
enrollment and that current Enrollees receive
an EPSDT screen within sixty (60) days after
identification of probable need for EPSDT
services.
C.8.3.1.5 At a minimum, these screening tools shall be
submitted to MAA for approval and shall
include:
1) A comprehensive health and developmental
history (including evaluation of both
physical and mental health development as
well as substance use);
2) A comprehensive unclothed physical exam;
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3) Immunizations appropriate to age and
health history in accordance with the
immunization schedule of the Centers for
Disease Control Advisory Committee on
Immunization Practices;
4) Laboratory tests set forth in the District
of Columbia Periodicity Schedule (included in
the Reference Library, Attachment J.9),
including blood lead level for children at
twelve (12) months and twenty four (24)
months of age, and at other times where
appropriate for risk assessment appropriate
to age and risk;
5) A mental health/alcohol and drug abuse
screen;
6) Vision services, including eyeglasses;
7) Dental services, including both preventive
and restorative services; and
8) Hearing services, including hearing aids.
C.8.3.1.6 The Contractor shall be responsible for
coverage and provision of all services
required for diagnosing a condition.
C.8.3.1.7 The Contractor shall be responsible for
provision of pediatric immunizations in
accordance with the standards established by
the Advisory Committee on Immunization
Practices. All providers of Contractor's
network who immunize children shall
participate in the Vaccines for Children
Program (VFC) as a condition of this contract
The Contractor shall comply with all of the
reporting requirements and procedures for
provider participants in the VFC as described
in the District's Medicaid State Plan
Amendment.
C.8.3.1.8 The Contractor shall be responsible for the
provision of scheduling and transportation
for medically necessary services requested by
an adolescent or by a child's family or
caregiver.
C.8.3.2 Emergency Services
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In accordance with Section 1932(b)(2)(B) of the
Balanced Budget Act of 1997, the Contractor shall
provide access to and coverage of emergency services
for its Enrollees. Emergency services are covered
inpatient or outpatient services as specified in
Attachment J.8, needed to evaluate or stabilize an
emergency medical condition and furnished by a
qualified provider.
C.8.3.2.1 The Contractor shall adhere to the following
definition of emergency medical condition,
including a mental health/alcohol and drug
abuse condition when determining coverage for
Enrollees: a medical condition manifesting
itself by acute symptoms of sufficient
severity (including severe pain) that a
prudent layperson, who possesses an average
knowledge of health and medicine, could
reasonably expect the absence of immediate
medical attention to result in placing the
health of the individual (or with respect to
a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy,
serious impairment to body functions, and/or
serious dysfunction of any bodily organ or
part.
C.8.3.2.2 The Contractor shall be responsible for
covering triage services to determine whether
an emergency exists and facilitate emergency
treatment if needed. Triage services shall be
available twenty-four (24) hours per day,
seven (7) days per week.
C.8.3.2.3 The Contractor shall be responsible for
covering emergency services, as defined
above, provided to Enrollees at either
in-network or out-of-network providers,
without regard to prior authorization.
C.8.3.2.4 The Contractor shall provide coverage for
severity of the symptoms at the time of
presentation under the prudent layperson
standard (as defined in Section C.8.3.2.1
above) even when the condition, which
appeared to be an emergency medical
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condition at the time of presentation, turned
out to be non-emergency in nature.
C.8.3.3 Prescription Drug Services
The Contractor shall provide pharmacy services either
directly or through a subcontractor.
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C.8.3.3.1 The Contractor may use a Pharmacy Benefit
Manager (PBM) to process prescription claims
if the proposed PBM subcontractor has
received advance written approval from MAA.
The PBM subcontract shall meet the
requirements of this contract. If the
Contractor elects to use a PBM, the
administration of all denials, grievances,
and appeals shall not be delegated to the
PBM, but shall be handled by the Contractor.
C.8.3.3.2 The Contractor may use a restricted formulary
as long as it allows access to other drug
products not on the formulary through some
process such as prior authorization, complies
with 42 U.S.C. Section 1396r-8(d) with
respect to formularies, prior authorization,
and other permissible limitations, and has
been formally approved by MAA.
C.8.3.3.3 The Contractor shall submit its formulary,
including drugs subject to prior
authorization or dispensing limitations, if
any, for approval by MAA and shall notify MAA
of any changes to the formulary on a
quarterly basis. Approval will be provided by
MAA within thirty (30) days of formulary
submission. MAA may elect to use the Drug
Utilization Review (DUR) Board for formulary
reviews if it deems appropriate. The
Contractor shall provide all medically
necessary legend and non-legend drugs covered
by the District of Columbia Medicaid Program.
Plans may adopt a prescription formulary as
long as it includes all items on the DC
Medicaid formulary or their generic or
therapeutic equivalents. A formulary shall
not be used to deny coverage of any
Medicaid-covered drug deemed medically
necessary.
C.8.3.3.4 If prior approval is used for certain drug
categories, the Contractor shall provide MAA
with a written protocol that describes how
and when the prior approval process will be
applied to formulary drug products.
C.8.3.3.5 If the Contractor chooses to require prior
authorization (either medical necessity or
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non-formulary) as a condition of coverage or
payment for an outpatient prescription drug,
it shall provide a response within
twenty-four (24) hours from the time that the
request for authorization is made, and shall
provide at least a seventy-two (72) hour
supply of the drug immediately. If an
Enrollee presents a prescription for a
medication that is part of the member's
ongoing treatment regimen, whether subject to
prior authorization for medical necessity or
non-formulary, the Contractor shall allow the
pharmacy to dispense the prescription for a
period of at least fifteen (15) days or the
length of the prescription, whichever is
less.
C.8.3.4 Pregnancy Related Services
In accordance with federa1 law, 42 U.S.C. 1396A(a)(10)
concerning pregnancy-related services, the Contractor
shall cover and provide the following care and
services:
C.8.3.4.1 Prenatal care;
C.8.3.4.2 Delivery services;
C.8.3.4.3 Post-partum care which continues until the
last day of the month in which the Enrollee's
sixtieth (60th) post-partum day occurs; and
C.8.3.4.4 Services related to any condition, including
HIV/AIDS that may complicate pregnancy, other
than transplant services and services
excluded from the Plan's covered benefits.
C.8.3.5 Mental Health Services
The Contractor shall be responsible for providing
mental health services under its capitation as
indicated in Attachment J.8. Services shall be provided
through an integrated, community based mental health
treatment network.
C.8.3.6 Family Planning Services and Supplies
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C.8.3.6.1 The Contractor shall be responsible for
coverage of family planning services and
supplies identified in Attachment AA.
C.8.3.6.2 The Contractor shall be responsible for
payment of covered family planning services
and supplies furnished by a Qualified Family
Planning Provider regardless of whether
Provider is a member of Provider's network.
Such-payment shall be made in accordance with
federal requirements governing payment of
claims made by participating providers and
shall utilize the District's fee schedule in
the case of Qualified Family Planning
Providers that are not members of Provider's
network.
C.8.3.7 Services for Persons with HIV or AIDS
C.8.3.7.1 The Contractor shall cover and provide
services necessary to the diagnosis and
treatment of persons with HIV and AIDS.
C.8.3.7.2 The Contractor shall ensure that PCPs for all
Enrollees with HIV or AIDS assess whether the
Enrollee meets criteria for Team Treatment
Planning or Care Coordination and shall refer
the eligible Enrollees for such services as
necessary.
C.8.3.8 Services of Advanced Nurse Practitioners and Nurse
Midwives
The Contractor shall ensure access to and pay for
necessary and appropriate advanced nurse practitioner
and certified nurse midwife services (in accordance
with the Health Occupation Revision Act of 1985 as
amended).
C.8.3.9 Employment Related Testing
The Contractor shall cover medical testing required in
relation to determining eligibility for childcare,
restaurant, and certain other types of employment.
C.8.3.10 Transplant Surgery Responsibilities and Exclusion
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C.8.3.10.1 The Contractor shall be responsible for
arranging for the transplant surgery and
obtaining authorization for the transplant
surgery under the District's fee for service
program.. The Contractor shall be responsible
for transplant surgeries when the Contractor
fails to seek District authorization for the
transplant surgery.
C.8.3.10.2 The Contractor shall cover all transplant
services, except for those services provided
during the inpatient stay in which the
transplant surgery takes place.
C.8.3.10.3 If the Contractor arranges for transplant
surgery and fails to seek District
authorization for the transplant surgery, the
Contractor shall be responsible for the cost
of the surgery.
C.8.3.11 Transportation
C.8.3.11.1 The Contractor shall be responsible for the
provision of the following transportation for
Enrollees:
a) All transportation for emergency
services;
b) Transportation requested and necessary
to and from EPSDT-related services as
indicated in Section 0. The Contractor
shall not require that requests for
routine services be made more than five
(5) days in advance;
c) All medically necessary transportation
for non-emergency situations;
d) Roundtrip transportation shall be
provided from the Enrollees' home to the
point of service. Transportation shall
be provided in accordance with the
requirements outlined in the DC Medicaid
State Plan of the MAA; and
C.8.3.11.2 The Contractor or its agent shall verify
that transportation personnel have a valid
driver's license and shall conduct a criminal
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background check of all employees and shall
not allow individuals who pose a risk to
Enrollees to provide transportation. Further,
the Contractor, or its agent shall conduct
initial and regular unannounced drug testing
of all transportation personnel. The
Contractor or its agent shall not allow
individuals who test positive for drugs
and/or alcohol to transport Enrollees. The
Contractor or its agent shall maintain
personnel records with the results of
criminal background checks, alcohol and drug
testing.
C.8.3.11.3 The Contractor shall be responsible for
services that are identified in the IEP.
C.8.4 Coverage of Services at the Time of Enrollment
The Contractor shall notify new Enrollees how they may exercise
their right to use out-of-network services on a transitional
basis for up to sixty (60) days after enrollment into the
Contractor's Plan, with the exception of enrollees that are
undergoing treatment for chronic illness, serious, potentially
terminal illness and mental illness. Contractors shall allow
Enrollees and/or their out-of-network providers sixty (60) days
from the time of enrollment to report any ongoing services
corresponding to a plan of care in place at the time of
enrollment. The Contractor may require that the out-of-network
provider contact the Contractor for authorization of such
services.
C.8.4.1 The Contractor shall be responsible for authorization
and payment of covered services included in any
treatment plan in effect at the time of enrollment
until the Enrollee is evaluated by his or her network
PCP and the treatment plan is modified, or for up to
sixty (60) days from enrollment, whichever comes first.
C.8.4.2 The Contractor may cease payment for such care and
services under the following circumstances:
C.8.4.2.1 The Enrollee has either selected or been
assigned to a network PCP and an appointment
has occurred and the PCP has modified the
treatment plan, or
C.8.4.2.2 The Enrollee has either selected or been
assigned to a network PCP and the Enrollee
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fails to meet with his or her PCP after three
(3) documented efforts. These efforts shall
include a written record of an attempt to
make a phone call indicating the name of the
person calling, the date and time of the
call, the number attempted, and the outcome
of the call; copies of letters mailed to the
Enrollee's address; and written records of an
attempt to visit the Enrollee indicating the
person making the visit, the date and time of
the visit, the address sought, and the
outcome of the visit. If the phone and
address listed on the enrollment file do not
reach the Enrollee, the Contractor shall make
other efforts such as consulting public
telephone listings and other sources for
alternative phone numbers and/or addresses to
attempt to reach the Enrollee.
C.8.4.3 The Contractor shall not be responsible for the payment
of claims for covered services provided during a
hospital stay if the date of admission precedes the
date of enrollment with the Contractor. The Contractor
shall be responsible for the payment of claims for
covered services provided during the entire hospital
stay if the date of discharge is after the date of
disenrollment from the Contractor.
C.8.4.4 Notwithstanding the prior provisions of sections C.8.4,
C.8.4.1, C.8.4.2 and C.8.4.3, the Contractor shall take
into consideration special situations such as those
involving members with serious, potentia1ly terminal
illnesses, mental illness and chronic illness who have
an existing provider relationship they do not wish to
change. In such situations, the Contractor will be
expected to respect the members wishes and continue
payment to that provider without regard to the sixty
(60) day limit for such individuals until the member
and Contractor agree the service from that provider is
not longer needed or desired.
C.8.4.5 Out-of-Network
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C.8.4.5.1 The Contractor shall be responsible for
contacting out-of-network providers to
explain how to bill for services rendered.
C.8.4.5.2 The Contractor shall provide five (5) days
prior notice of denials of out-of-network
services to the Enrollee and the
out-of-network providers, if known to the
Contractor, and instructions to the Enrollee
on how to contact the Contractor in order to
arrange for continued care with a network
provider.
C.9 Network
C.9.1 Network Composition and Capabilities
The Contractor shall maintain a network of physicians, hospitals,
and other health providers through whom it provides the items and
services included in covered benefits in a manner that complies
with the requirements of this section and meets access standards
described in Section C.9.2. The Contractor shall ensure that its
network providers are appropriately credentialed and well
coordinated with other network services and Medicaid services
available outside of the health plan network. This network shall
include an adequate number of PCPs and specialists appropriately
credentialed as health professionals located in geographically
and physically accessible locations to meet the access standards
specified in the Contract.
C.9.1.1 This network shall include PCPs in sufficient numbers
so that no PCP has more than two thousand (2,000)
Medicaid Managed Care Program Enrollees in total across
all Contractors participating in the Medicaid Managed
Care Program. In evaluating the capacity of PCPs, the
Contractor shall take into consideration both a PCP's
existing Medicaid patient load as well as its total
patient load. Notwithstanding the fact that a PCP shall
not have more than two thousand (2,000) Medicaid
Managed Care Program patients, the Contractor shall not
assign additional patients to the PCP unless it
determines that the PCP can accept additional Enrollees
and continue to furnish care of reasonable quality and
accessibility as required under this contract.
C.9.1.2 The Contractor may request to MAA that this standard be
relaxed. Any such request shall include relevant
documentation that demonstrates that the requested
level of
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PCP coverage will be effective in meeting the standards
delineated below.
C.9.1.3 With regards to the determination of the sufficient
number of PCPs, the following shall apply:
C.9.1.3.1 The Contractor shall establish procedures for
Primary Care Physicians to notify the
Contractor when they reach maximum capacity
at least thirty (30) days in advance, and
shall otherwise monitor PCPs' compliance with
capacity standards.
C.9.1.3.2 The Contractor shall notify the District in
writing at any time that there is no further
capacity under the standards of Section
C.9.1.1 in its network to accept additional
Enrollees as patients.
C.9.1.3.3 The Contractor understands and agrees that
the District, upon receipt of such
notification, may suspend new enrollment into
the Contractor's Plan until additional
primary care capacity becomes available.
C.9.1.3.4 If the District determines that the
Contractor has exceeded the permissible
patient load for PCPs or assigns to a PCP
more Enrollees than the PCP is capable of
managing in light of its total patient load,
the District may freeze Contractor's
enrollment.
C.9.1.4 The network shall include a sufficient number of
hospitals located in the District of Columbia so that
the Contractor can ensure that Enrollees are admitted
only to hospitals located in the District that can
provide them with the treatment they need. Out of
District hospital admissions may be made in the
following circumstances:
C.9.1.5 The Enrollee has an emergency medical condition as
defined in Section 0, and is admitted to a hospital
located outside of the District, and cannot be
transferred because the Enrollee's condition has not
been stabilized as required prior to the transfer of an
individual under Section 1867 of the Social Security
Act; or
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C.9.1.6 The patient requires one or more specialized services,
which are available only from or through a hospital,
which is located outside of the District.
C.9.1.7 The network shall include licensed pharmacies.
C.9.1.8 All laboratories in the network shall be certified
under the provisions of the Clinical Laboratory
Improvement Amendments of 1988 (CLIA). Contractors are
responsible for ensuring that laboratories in their
network maintain current CLIA certification.
C.9.1.9 The Contractor's network shall include facilities
providing integrated care for Enrollees with complex
conditions that require multi-disciplinary assessment,
diagnosis, and/or treatment. Such facilities may
include multi-disciplinary teams practicing at a common
location such as specialty outpatient departments,
specialty clinics, and developmental centers.
C.9.1.10 The Contractor shall have and implement procedures and
protocols for ensuring access to specialty care centers
outside of the District when needed for the diagnosis
and treatment of rare disorders.
C.9.1.11 The Contractor's network shall include certified early
intervention providers for health related IDEA services
to children under age three (3), and providers
qualified to perform evaluations for IDEA eligibility
and provide health related IDEA services for children
age three (3) and older, unless and until these
services are provided by DCPS. Such providers shall
include rehabilitation services for improvement,
maintenance, or restoration of functioning, including
respiratory (including home-based), occupational,
speech and physical therapies. The current list of
certified early intervention providers is included in
the Reference Library.
C.9.1.12 The Contractor's network shall include sufficient
numbers of the following practitioners to meet the
needs of the Enrollees:
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C.9.1.12.1 Home health nurses,
C.9.1.12.2 Home health providers,
C.9.1.12.3 Registered dieticians,
C.9.1.12.4 Speech, physical, occupational, and
respiratory therapists,
C.9.1.12.5 Audiologists,
C.9.1.12.6 Providers of genetic screening and
counseling, and
C.9.1.12.7 Dentists and orthodontists.
C.9.1.13 The Contractor's network shall include Durable Medical
Equipment (DME) providers, including those that have
the capacity to individualize and customize equipment
for both children and adults, and to provide preventive
maintenance and repairs for such equipment. All DME
Services shall be provided in accordance with the
District's Medicaid policies, rules, and regulations.
C.9.1.14 The Contractor's network for mental health shall
include providers who offer integrated, community-based
mental health care. The mental health network shall
include all the DC Commission on Mental Health Services
and its designated certified providers.
C.9.1.14.1 The mental health services network shall
include sufficient numbers of appropriately
skilled practitioners - either as independent
practitioners and/or as employees of a
network clinic or program - and programs to
provide comprehensive mental health services
for Enrollees, including:
. Psychiatrists,
. Specialists in developmental/behavioral
medicine,
. Psychologists,
. Social workers for mental health and
alcohol and drug abuse,
. Inpatient psychiatric units,
. Residential treatment facilities, and
. Psychiatric day treatment programs.
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C.9.1.15 The Contractor shall ensure that its network has the
capacity to effectively treat individuals dually
diagnosed with both mental health and alcohol and drug
abuse disorders.
C.9.1.16 The network shall include providers capable of
screening, assessing and treating individual with
mental health disorders who are also developmentally
disabled.
C.9.1.17 Capacity to Serve Enrollees with Diverse Cultures and
Languages
C.9.1.17.1 The Contractor shall include in its network
providers who understand and are respectful
of health-related beliefs, cultural values,
and communication styles, attitudes and
behaviors of the cultures represented in the
target population.
C.9.1.17.2 The Contractor shall ensure that its
non-English speaking Enrollees have access to
interpreters, if needed, in the following
situations:
a) During emergencies, twenty-four (24)
hours a day, seven (7) days a week;
b) During appointments with their providers
and when talking to their health plan;
and
c) When technical, medical, or treatment
information is to be discussed.
C.9.1.17.3 Family members, especially minor children,
shall not be used as interpreters in
assessments, therapy, or other medical
situations in which impartiality and
confidentiality are critical, unless
specifically requested by the Enrollee. Every
attempt should be made to help the Enrollee
understand the availability of non-familial
interpreters and practitioner concerns with
utilizing minor children as interpreters even
at the Enrollee's request.
C.9.1.17.4 A family member or friend may be used as an
interpreter if they can be relied upon to
provide a complete and accurate translation
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of information between provider and the
Enrollee, provided that the Enrollee is
advised that there is a free interpreter
available and the member expresses a
preference to rely on the family member or
friend.
C.9.1.17.5 The Contractor shall ensure that effective
communication is provided for hearing
impaired persons in its administrative and
medical services, in accordance with Section
504 of the Rehabilitation Act of 1973, and
Title II of the Americans with Disabilities
Act of 1990 42 USC Section 1212-14, including
the availability of qualified sign language
interpreters.
C.9.1.17.6 The Contractor shall ensure that its network
includes providers who are capable of
communicating effectively about health
related issues with children and families
that have special communication needs
including limited cognitive capacity or
speech limitations.
C.9.1.17.7 Written materials provided to Enrollees for
instruction or education on health matters
shall be made available in English, Spanish,
Vietnamese, Chinese and Braille.
C.9.1.17.8The Contractor shall ensure that alternative
forms of instruction or education are
provided for Enrollees who speak other
languages and those who are unable to read.
C.9.2 Access Standards
C.9.2.1 Service Timeliness
C.9.2.1.1 Appointments shall be available for Enrollees
in accordance with the normal practice
standards and hours of operations in the
network. Maximum expected waiting times for
appointments shall be as follows:
C.9.2.1.2 Emergency care, as defined in Section
C.8.3.2.1, shall be provided immediately and
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without prior authorization. In general,
emergency care shall be provided in
accordance to the time frame dictated by the
nature of the emergency, at the nearest
available facility, twenty-four (24) hours a
day, seven (7) days a week.
C.9.2.1.3 The Contractor shall ensure access to urgent
care services from PCPs and from outpatient
mental health programs and practitioners
within twenty-four (24) hours of request; and
from other specialists within forty-eight
(48) hours of referral.
C.9.2.1.4 The Contractor shall ensure that services for
assessment and/or stabilization of
psychiatric crises, including those
experienced by children or adolescents, are
available on a twenty-four (24) hour basis.
These services shall be provided by
practitioners with appropriate expertise in
mental health with on-call access to an adult
or child and adolescent psychiatrist. When
direct services are indicated, they shall be
provided as flexibly as possible, including
at the Enrollee's home or at another
appropriate community site.
a) Phone based assessment shall be provided
within fifteen (15) minutes of request.
Intervention or face-to-face assessment shall
be provided within ninety (90) minutes of
completion of phone assessment, when needed.
C.9.2.1.5 Initial appointments for pregnant women or
persons desiring family planning services
shall be provided within ten (10) days of
request.
C.9.2.1.6 Appointments for initial EPSDT screens shall
be offered to new Enrollees within thirty
(30) days of the Enrollee's enrollment date
with the Contractor or at an earlier time if
an earlier exam is needed to comply with the
periodicity schedule. The initial screen
shall be completed within three (3) months
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of the Enrollee's enrollment date with the
Contractor, unless the Contractor determines
that the new Enrollee is up-to-date with the
EPSDT periodicity schedule.
C.9.2.1.7 IDEA multidisciplinary assessments for
infants and toddlers at risk of disability
shall be completed within thirty (30) days of
request, and any needed treatment shall begin
within fifteen (15) days of the completed
assessment.
C.9.2.1.8 Unless the Contractor has documented that the
enrollee is up to date with a physical exam
or regimen of treatment, the Contractor shall
ensure that its PCPs shall offer new
Enrollees ages twenty one (21) and over an
initial appointment within ninety (90) days
of their date of enrollment with the PCP or
within thirty (30) days of request, whichever
is sooner.
C.9.2.1.9 The following routine appointments shall take
place within thirty (30) days of the request:
a) Diagnosis and treatment of health
conditions and problems that are not urgent;
b) Asymptotic health assessments of adults
ages twenty one (21) and older;
c) Periodic EPSDT screening examinations;
d) Non-urgent EPSDT vision screening,
preventive dental services, and hearing
evaluation services; and
e) Non-urgent referral appointments with
specialists.
C.9.2.1.10 To be considered timely, all EPSDT screens,
laboratory tests, and immunizations shall
take place within 30 (30 days of their
scheduled due dates for children under the
age of two (2) and within sixty (60) days of
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their due dates for children over the age of
two (2).
C.9.2.1.11 Contractors and/or their network providers
shall furnish evaluations and/or reports as
required by the Court within timeframes
specified by the Court
C.9.2.1.12 The average waiting time in a PCP's office
for a scheduled appointment, computed on a
monthly basis for each PCP, shall be no
greater than one (1) hour.
C.9.2.2 After Hours Access
To promote sufficient access for individuals who cannot
easily get leave from their employment, the Contractor
shall include in its network providers who offer
evening and weekend access to appointments. The
Contractor shall monitor whether evening and weekend
access is adequate to meet the requests of Enrollees
and adjust the network as needed.
C.9.2.3 Geographic and Physical Access Requirements
C.9.2.3.1 All individuals shall have the option to
select between at least two PCPs located
within thirty (30) minutes travel time of
their place of residence by public
transportation.
C.9.2.3.2 Contractor shall ensure access to pharmacies
based on the following criteria:
a) At least one (1) pharmacy is located
within two (2) miles of Enrollee's
residence;
b) Does not exceed the travel time limit of
fifteen (15) minutes by public
transportation from the Enrollee's place
of residence; and
c) Pharmacy network shall include at least
one twenty-four (24) hour/seven (7)
day/week pharmacy. The network shall
also include a pharmacy that provides
home delivery service (excluding
mail-order entities) within four (4)
hours.
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C.9.2.3.3. The Contractor shall require that all
network providers are in compliance with the
requirements of the Americans with
Disabilities Act, (ADA) 42 U.S.C. Section
12101 et seq., and Section 504 of the
Rehabilitation Act of 1973,29 U.S.C. Section
794 or have plans for meeting ADA
requirements.
C.9.2.4 The Contractor shall subcontract with sufficient
outpatient mental health practitioners, as well as
clinics, and/or hospital outpatient departments that
Enrollees have at least one clinic or hospital
department or two independent practitioners for their
age group within thirty (30) minutes travel time of
their place of residence by public transportation. If
no providers meeting the Contractor's selection
criteria are available in some areas of the District,
the Contractor shall develop a plan for procuring
accessible services and submit it to MAA for review and
approval by the Dixon Transitional Receiver.
C.9.2.5 Access to Out-of-Network Providers
C.9.2.5.1 The: Contractor shall authorize that services
be provided by out-of-network providers who
meet the Contractor's standards for quality
and data reporting under the circumstances
listed below:
a) For specialty care called for in the
Enrollee's treatment plan, an
Individualized Education Plan (IEP) or
an Individualized Family Services Plan
(IFSP) and not available in the
Contractor's network;
b) To provide an extended period of
transition from existing care providers
not included in the Contractor's
network, or to allow for the provider to
complete the process of application to
participate in the Contractor's network;
c) To complete a course of treatment begun
with an out-of-network provider when
notification of such treatment is
received within the timeframes
delineated in Section C.8.4;
d) Other as defined by the Contractor.
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C.9.2.5.2 The Contractor shall define criteria for such
referrals, and shall include information in
their Member handbook and provider manual
indicating when such referrals will be
approved and how PCPs and Enrollees may
request such referrals.
C.9.2.5.3 The Contractor shall establish procedures and
requirements for authorizing and paying
out-of-network providers that comply with the
provisions of Section 0.
C.9.2.5.4 All out-of-network providers shall be paid at
the current Medicaid fee for service schedule
for comparable services, or the Contractor's
rates for these or comparable network
services, whichever is lower.
C.9.2.5.5 Contractors shall follow protocols, policies
and procedures established by MAA with input
from the Contractor to refer and coordinate
care for Enrollees in need of alcohol and
drug abuse treatment services.
C.9.3 Network Development
The Contractor shall recruit, credential, evaluate, and monitor
selected providers with an appropriate combination of skills,
experience, and specialties to constitute a network to provide
covered benefits to MMCP Enrollees within the acceptable
geographic access standards.
C.9.3.1 Credentialing and Selection
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C.9.3.1.1. The Contractor's
credentialing/recredentialing process shall
conform to industry standards. As part of its
credentialing and selection process, the
Contractor shall request information from the
DC Office of Consumer and Regulatory Affairs
and from MAA on the standing of DC licensed
practitioners, from the HHS website listing
of disbarred providers and relevant licensing
and Medicaid agencies for providers licensed
in other states.
C.9.3.1.2 The Contractor shall include facilities that
are JCAHO, CARF, or other equivalent
accreditation and necessary state or District
licenses in its network. In the event the
Contractor wishes to contract with a facility
that does not have accreditation, the
Contractor shall review the facility's
standards of care and qualifications to
ensure that these standards are consistent
with facilities having accreditation and
shall submit documentation of that review to
MAA for its approval prior to entering into a
contract for MAA-covered services with that
facility.
C.9.3.1.3 The Contractor shall not use criteria for
selection of participants in its network that
discriminate against providers that
specialize in conditions that requires costly
treatment.
C.9.3.1.4 The Contractor shall analyze the composition
of its provider network quarterly to identify
any gaps or areas requiring expansion
including provision of primary care and
mental health services on evenings and
weekends, and recruit providers needed to
provide comprehensive and accessible care on
an ongoing basis. Any material change in the
provider network that affects the
Contractor's ability to meet network
standards shall be reported to MAA
immediately, along with a plan of correction.
C.9.4 Network Management
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C.9.4.1 Provider Manual
C.9.4.1.1 Contractor shall maintain and distribute to
network providers a Provider Manual that
comprehensively documents the policies and
procedures pertaining to the Contractor's
providers. The Contractor shall issue updates
to the Provider Manual prior to implementing
significant changes in policy or procedure.
Contractor shall notify provider(s) thirty
(30) days in advance of change.
C.9.4.1.2 The Provider Manual shall address
authorization of services, the contractual
definition of medical necessity, medical
necessity criteria necessary to guide
provider management of treatment, prior
authorization requirements, EPSDT
requirements, protocols for fulfilling
responsibilities to provide health related
IDEA services, grievance and appeals
procedures for reconsideration of
authorization decisions, procedures for
provider and Enrollee complaint resolutions;
claims submission procedures, rights of
Medicaid Enrollees (including those with
limited English and those who are hearing
impaired), process and timeliness for
submitting and resolving complaints, mandated
reporting requirements of the District, and a
description of the Contractor's Quality
Improvement program and goals. The manual
should also include medical record
requirements and advance directive
procedures.
C.9.4.1.3 The Provider Manual shall contain information
provided by MAA addressing access to mental
health care and the role of the Dixon
Transitional Receiver in ensuring that
community-based services are provided to all
Enrollees as needed.
C.9.4.1.4 The Provider Manual shall contain information
on how to access substance
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abuse services through Medicaid Fee For
Services.
C.9.4.2 Provider Management
The Contractor shall assign responsibility and
establish procedures to monitor, manage and
continuously improve the performance of its provider
network. These procedures shall ensure that:
C.9.4.2.1 Each hospital participating in the
Contractor's network complies with the
requirements of Section 1867 of the Social
Security Act, 42 U.S.C. Section 1395dd
(Anti-dumping);
C.9.4.2.2 The network provides services of acceptable
quality, accessibility, and efficiency;
C.9.4.2.3 Each physician providing EPSDT services is
evaluated annually to determine whether he or
she has the necessary equipment and knowledge
to perform such services in accordance with
standard medical practice;
C.9.4.2.4 Advances in medical practice are implemented
promptly and consistently in accordance with
industry standard;
C.9.4.2.5 Providers receive information (provider
profiles) on their performance on key aspects
of their practice in comparison to
benchmarks. The Contractor shall specify in
its Quality Management Plan its goals for
profiling providers and establishing
benchmarks and shall comply with reporting
requirements specified in Section F; and
C.9.4.2.6 Unacceptable provider performance or
indications of fraud and abuse are promptly
identified, addressed, documented and
reported to MAA Offices of Program Integrity,
Managed Care and District OIG Office of
Medicaid Fraud and Abuse.
C.9.4.3 Management of Mental Health and Alcohol and Drug Abuse
Providers
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C.9.4.3.1 The Contractor shall profile, on a
semi-annual basis, utilization of mental
health services for the Contractor's service
population. The profile elements shall
include a review of the following data
stratified for children and adults: member
satisfaction, complaints and grievances,
treatment records, audit findings, quality
indicators, and utilization statistics.
Required profile elements and report format
is included in Section F.
C.9.4.3.2 DCHFP Contractors shall profile, on a
semi-annual basis, the number of referrals
for alcohol and drug abuse treatment as well
as efforts to coordinate care of Enrollees in
need of alcohol and drug abuse treatment.
C.9.4.4 Provider Training
The Contractor shall have an organized training program
for network providers based upon the Contractor's
annual assessment of training needs.
This program shall include training on current EPSDT
and IDEA requirements as follows: within three (3)
months of a new physician entering the network; within
twelve (12) months of the start date of this contract
for any current network physician who has not received
such training in the prior year; and every two years
for physicians who have received an initial training.
C.9.4.4.1 In the first contract year, the Contractor
shall also provide training, at a minimum, on
the following topics:
a) Policies and procedures on advance
directives;
b) The availability and protocols for use
of interpreters with Enrollees who speak
limited English, and other skills for
effective health related cross-cultural
communication;
c) An overview of IDEA and the relative
roles and responsibilities of schools,
the Early Intervention Program, and
Contractors; and
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d) Manifestations of mental illness and
alcohol and drug abuse, use of the MAA
selected screening tool to identify such
problems, and how to make appropriate
referrals for treatment services.
C.10 Utilization Management and Care Coordination Capabilities
The Contractor shall maintain a care management system, including
utilization management and care coordination that ensures that all
Enrollees are regularly examined to identify potential or actual health
problems requiring prevention, treatment, rehabilitation, and/or education
in self-care. This system shall be operated in accordance with applicable
standards for high quality provision of services, including EPSDT, IDEA,
standards for prenatal care, guidelines of the Office of Maternal and Child
Health, and relevant professional standards for the provision of health
care to adults. In addition, the Contractor shall identify children and
adults with special health care needs and determine which cases warrant
additional management and coordination. The Contractor shall establish
procedures to ensure that their medical and adjunct care is comprehensively
planned with the involvement of the Enrollee, family, and/or caretaker and
appropriately qualified practitioners, the Enrollee is assisted to
coordinate services when needed, and health care resources are used
efficiently.
C.10.l Utilization Management
The Contractor shall operate a system for managing service
utilization that both ensures adequate control over high cost and
high-risk services and procedures and promotes timely access to
preventive and needed treatment and rehabilitation services in
accordance with current medical best practices. These procedures
shall have the flexibility to efficiently authorize services for
complex treatment plans and for medically necessary services in
approved IDEA, IFSPs and IEPs.
C.10.1.1 The Contractor's Medical Director shall be responsible
for overseeing utilization management so that
authorization decisions are based on all relevant
medical information available about the individual
Enrollees and in accordance with best medical practice.
C.10.1.2 The Contractor's Medical Director shall review all
denials of care for EPSDT services pertaining to
physical health care and the Contractor's Psychiatric
Medical Director shall review all denials of care for
mental health treatment services.
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C.10.1.3 The Contractor shall operate a well-defined utilization
management system that clearly specifies: services that
are available upon direct request; services that
require Primary Care Physician authorization; services
that require additional review and prior approval;
services that require concurrent review; circumstances
that warrant retrospective review; and special
procedures for management of high cost and high-risk
cases.
C.10.1.4 The Contractor shall instruct and assist network
providers to verify an Enrollee's plan membership and
eligibility prior to providing any service. The only
exception to this requirement is when a person requests
services for an emergency medical condition. In the
event of an emergency medical condition, network
providers shall provide immediate medical services.
C.10.1.5 The Contractor shall have established procedures that
ensure that authorization decisions are made within
established time standards by professionals with
appropriate credentials and experience who have been
trained in the application of criteria for the
determination of medical necessity, as defined in
Section 0.
---------
C.10.1.5.1 The Contractor shall implement a system for
authorization of ongoing mental health
treatment that includes authorization by
experienced mental health professionals who
function within their scope of practice.
C.10.1.6 The Contractor shall ensure twenty-four (24) hour
access to a qualified health professional that is able
to assess patient need and authorize services.
C.10.1.7 Authorization decisions shall be communicated to the
provider of care being authorized within forty-eight
(48) hours of the decision.
C.10.1.8 Authorization procedures shall be coordinated with IDEA
service planning procedures to facilitate authorization
of medically necessary IDEA services upon receipt of an
approved IEP or IFSP.
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C.10.l.9 The Contractor shall authorize medical and
rehabilitative care according to written medical
necessity criteria, which accurately reflect the
definition of medical necessity in Section C.8.1, are
based on best available medical evidence, and are
updated on an annual basis. Criteria applicable to
children ages birth through twenty (20) shall reflect
EPSDT standards.
C.10.1.9.1 The Contractor shall communicate its medical
necessity criteria along with any practice
guidelines or other criteria the Contractor
will use in making medical necessity
determinations to its network physicians and
utilization reviewers as needed to provide
effective guidance and ensure consistency in
authorization decisions. At no time shall any
covered service be denied based upon cost.
C.10.1.9.2 The Contractor shall provide medical
necessity criteria to its network providers.
C.10.1.9.3 Criteria and guidelines shall allow
physicians and utilization reviewers to
consider the nature of the Enrollee's home
environment in determining what services to
authorize.
C.10.1.9.4 The Contractor shall ensure that its PCPs
and utilization reviewers authorize services
consistent with these medical necessity
criteria.
C.10.1.9.5 The Contractor, prior to the enrollment of
recipients, shall provide its medical
necessity criteria for MAA review on its own
premises, and shall provide specific criteria
to MAA upon MAA request.
C.10.l.10 The Contractor shall submit to MAA and implement
clinical care standards and practice guidelines that
are based on national guidelines or promulgated by
professional medical associations or other expert
committees.
C.10.1.11 Management of High Cost and High-Risk Cases
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C.10.1.11.1 The Contractor shall establish a system to
effectively manage the authorization of
treatment for Enrollees with high cost and/or
high-risk conditions. This function may be
integrated with the care coordination
function. The Contractor's model of case
management shall clearly define the
relationship of this function to care
coordination.
C.10.l.ll.2 The Contractor shall establish criteria
consistent with industry standards for cases
that warrant case management and procedures
for identifying Enrollees that meet these
criteria. These criteria shall be submitted
to MAA.
C.10.l.ll.3 The Contractor shall establish procedures
for the operation of this function that:
a) Assign each case to an appropriately
qualified staff member;
b) Define the role and responsibilities of
staff responsible for high cost case
management in working with PCPs,
specialists, and care coordinators that
also have responsibility for the case;
c) Require active involvement of the
Enrollee and/or the Enrollee's
caregivers as much as possible;
d) Provide appropriate supervision,
oversight, and expert consultation to
staff performing high cost case
management; and
e) Regularly review the effectiveness of
the high cost/high-risk case management
function in containing costs and in
promoting positive health outcomes.
C.10.1.12 The Contractor shall inform children and adolescents
for whom residential treatment is being considered and
their parents or guardians, and adults for whom
inpatient treatment is being considered of all their
options for residential and/or inpatient placement, and
alternatives to residential and/or inpatient treatment
and the benefits, risks and limitations of each in
order that they can provide informed consent.
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C.10.1.13 The Contractor shall inform Enrollees being considered
for prescription of psychotropic medications of the
benefits, risks, and side effects of the medication,
alternate medications, and other forms of treatment.
C.10.1.14 Second Opinions
C.10.1.14.1 The Contractor shall provide for a second
opinion in any situation when there is a
question concerning a diagnosis or the
options for surgery or other treatment of a
health condition when requested by any member
of the health care team, an Enrollee,
parent(s) and/or guardian(s), or a social
worker exercising custodial responsibility
the right to request a second opinion.
C.10.l.15 Authorization of Experimental Treatment
The Contractor shall establish guidelines and
procedures for considering an Enrollee's participation
in experimental treatment for rare disorders, and shall
ensure consistency and coordination with MAA's
procedures for review of proposed experimental
treatment.
C.10.1.16 Denials
The Contractor shall ensure that any denial
determinations made by a member of the utilization
review staff or network providers, including PBMs, are
reviewed by a the Medical Director or Psychiatric
Medical Director prior to notifying the provider and
Enrollee in writing.
C.10.1.17 Grievance and Appeals
C.10.1.17.1 The Contractor shall administer a formal
grievance and appeals process that will
assure reconsideration of care decisions in
accordance with the requirements of
delineated in Section C.l4.
C.10.2 Planning and Monitoring Treatment
The Contractor shall ensure that each Enrollee's care is
appropriately planned with active involvement and informed
consent of the Enrollee and his or her caregiver, is well
coordinated with other needed
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Medicaid and non-Medicaid treatment services, and the Enrollee is
assisted in accessing any supports needed to maintain the
treatment plan.
C.10.2.1 The Contractor shall define the relative
responsibilities of the PCP and other staff in
fulfilling the following diagnostic, planning and
treatment tasks, and shall monitor treatment planning
and provision of treatment to ensure that these
responsibilities are carried out.
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C.10.2.1.1 The Contractor shall forward to the PCP any
information about Enrollees' health history
or health conditions received upon enrollment
from MAA, the Enrollment Broker, Enrollees,
or other sources, in a manner that protects
the Enrollee's confidentiality within thirty
(30) days of receipt so that it can be
considered in the Enrollee's initial
evaluation.
C.10.2.1.2 An Enrollee's initial visit with a new PCP
who has not previously cared for the Enrollee
shall include a comprehensive initial
examination, screening for mental health and
alcohol and drug abuse problems using a
validated screening tool approved by MAA, and
referrals for any additional tests or
examinations needed in order to complete a
comprehensive assessment of the Enrollee's
health condition.
C.10.2.1.3 During the initial examination and
assessment of a child, the PCP shall perform
EPSDT screening and any additional assessment
needed to determine whether a child meets the
definition of a child with special health
care needs and shall report this
determination to the Contractor according to
the Contractor's defined procedure.
C.10.2.1.4 Treatment planning shall be based upon a
comprehensive assessment of each Enrollee's
condition and needs.
C.10.2.1.5 The Enrollee and the Enrollee's family (as
clinically appropriate) shall be actively
involved in developing a treatment plan for
any identified health conditions.
C.10.2.1.6 Enrollees and their families shall be fully
informed of all appropriate treatment
options, their expected effects, and any
risks or side effects of each option in order
to make treatment decisions and give informed
consent.
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C.10.2.1.7 The treatment plan shall specify mutually
agreed upon goals, medically necessary
medical services, mental health and alcohol
and drug abuse services if the Enrollee has
consented to share this information with the
PCP and/or treatment team, any support
services necessary to carry out or maintain
the treatment plan, and, for children with
more complex needs, planned care coordinator
activities. The plan shall take into account
the cultural values and any special
communication needs of the family or the
child.
C.10.2.1.8 The Contractor shall establish an effective
system for PCPs to make referrals to other
network services needed by Enrollees and for
authorization of services that the PCP cannot
authorize him or herself. The Contractor
shall monitor timeliness of referrals and
access to specialists.
C.102.1.9 The Contractor shall establish effective
methods for referring Enrollees to
non-network Medicaid services specified in
the treatment plan.
C.102.1.10 When an Enrollee's treatment plan includes
multiple services inside or outside the
Contractor's network, the Contractor shall
ensure effective communication and
collaboration between network providers and
other Medicaid providers inside or outside of
the Contractor's network, the Contractor's
Care Coordinators, and non-Medicaid
providers. This shall include establishing
effective methods to coordinate with the DC
Commission on Mental Health Services, DCPS
and its providers of healthrelated IDEA
services for children receiving such services
under approved Individual Education Plans or
Individual Family Service Plans, and, for
DCHFP Contractors, the MAA contracted alcohol
and drug abuse provider network(s).
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C.10.2.1.11 If not provided by DCPS or its providers,
the Contractor shall ensure that medically
necessary IDEA services continue during
summer and school vacation periods.
C.10.2.1.12 The Contractor shall ensure that healthy
Enrollee examinations are performed for
children as required by EPSDT standards.
C.10.2.1.13 The Contractor shall ensure that healthy
Enrollee examinations are performed for
adults at a frequency determined by their age
and risk factors. These examinations shall
include routine preventive health screening
for cancer following American Cancer Society
guidelines, screening for diabetes for adults
over forty (40) with risk factors, and annual
lipid profiles and hypertension screenings
for adult Enrollees. The Contractor may
request that MAA approve the use of
equivalent preventive screening guidelines,
providing documentation demonstrating
equivalent efficacy.
C.10.2.1.14 The Contractor shall provide influenza and
pneumococcal vaccinations for appropriate
high-risk individuals.
C.10.2.1.15 The Contractor shall establish procedures
to monitor the provision of planned
treatment, evaluate its effectiveness in
meeting treatment goals, and revise and
update treatment plans when needed.
C.10.2.1.16 The Contractor shall develop written
policies and procedures that ensure that its
staff and network providers comply with the
requirements of 42 C.F.R. Ch. IV, Subpart I
of part 489 regarding advance directives.
a) The Contractor shall educate its staff
about its policies and procedures on
advance directives, situations in which
advance directives may be of benefit to
Enrollees,and their responsibility to
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educate Enrollees about this tool and
assist them to make use of it.
b) The Contractor shall educate Enrollees
about their ability to direct their care
using this mechanism and shall
specifically designate which staff
members and/or network providers are
responsible for providing this
education.
c) The Contractor shall inform Enrollees
that complaints concerning the advance
directive requirements may be filed with
the state survey and certification
agency.
C.10.2.1.17 The contractor shall establish procedures
for arranging for transplant surgery that
specify who is responsible for obtaining
consent, following MAA prior approval
procedures to request and document the need
for these services, arranging for the surgery
and managing the Enrollee's aftercare.
C.10.3 Coordination of Care
The Contractor shall coordinate care. Coordination of care
activities shall include EPSDT Outreach, IDEA, Care Coordination,
Health Education, and, for DCHFP Contractors, coordination with
the MAA approved alcohol and drug abuse provider network(s).
C.10.3.1 EPSDT Outreach Activities
C.10.3.1.1. The Contractor shall track the compliance
of children's treatment with EPSDT
periodicity schedules and shall conduct
outreach activities to assist Enrollees
through age twenty one (21) to make and keep
EPSDT appointments.
C.10.3.1.2 The outreach activities shall include every
reasonable effort, including a telephone call
or mailed reminder prior to the date of each
visit; in the case of a first missed
appointment, a telephone call or mailed
reminder; and, if there is still no response,
a personal appointment urge the parent(s)
and/or guardian(s) to bring the child for his
or her EPSDT appointment,
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or personal visit where feasible. When
appropriate such contacts should also be
directed to sui juris teenagers.
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C.10.3.1.3 The Contractor shall offer scheduling and
transportation assistance prior to the due
date of each enrolled child's periodic
examination, and shall provide this
assistance when requested and necessary.
C.1O.3.1.4 The Contractor shall track compliance with
IDEA and shall provide appropriate staff to
attend IEP and IFSP planning meetings.
C.10.4 Care Coordination
C.10.4.1.1. The Contractor shall establish a care
coordination department directed by a Senior
Manager with a RN, MD, or the equivalent and
staffed by care coordinators with appropriate
clinical/medical training and experience.
C.10.4.1.2 The Contractor shall define criteria for the
identification of Enrollees who are eligible
for service from care coordinators. These
criteria shall be submitted to MAA for review
and approval, and shall include, at a
minimum:
a) People with severe disabilities - Adults
or children with HIV / AIDS or other
disabling conditions with a cognitive,
biological, or psychological basis that
result in, but are not limited to, the
following:
b) The need for medical care or special
services at home, place of employment or
school;
c) Dependency on daily medical care,
special diet, medical technology,
assistive devices, or personal
assistance in order to function; or
d) Complex conditions requiring coordinated
services from multiple treatment
providers on a frequent basis;
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e) Adolescents or women with high-risk
pregnancies including, but not limited
to, those with:
f) Young maternal age;
g) Short inter-conceptional period;
h) Late onset of prenatal care;
i) Alcohol and drug abuse or domestic
violence in the home;
j) Documented barriers to accessing health
care; or
k) Maternal illness that may affect the
birth of the fetus;
1) Enrollees with complex disease
management issues or complex
psychosocial needs which could adversely
affect their health status;
m) People with or at risk of serious life
threatening conditions;
n) Children with mental health care needs;
and
o) IDEA.
C.10.4.1.3 The Contractor shall review the cases of
Enrollees referred by PCPs or otherwise
identified as potentially eligible for care
coordinator assistance and shall contact
Enrollees determined to be eligible to offer
assistance by care coordinators.
C.10.4.1.4 The care coordinator shall work with the
family and the PCP or treatment team to plan
care-coordinator activities. These activities
shall be included in the treatment plan.
C.10.4.1.5 Care coordinators are responsible for
assisting providers to coordinate treatment
with the family and other practitioners by
performing the following functions:
a) Facilitating development of a
multidisciplinary treatment plan, when
necessary;
b) Communicating relevant information and
participating in development of an IEP
or IFSP;
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c) Coordination of the treatment plan
including facilitation of transfer of
medical information from one provider to
another;
d) Coordination between network providers,
out-of-network providers, schools, and
district agencies that are involved with
the Enrollee;
e) Monitoring the treatment plan to be sure
that it is being followed and that it is
effective in reaching treatment goals;
and
f) Arranging periodic reassessments of
Enrollee progress.
C.10.4.1.6 The care coordinator shall provide the
following forms of assistance, when needed,
to Enrollees and their caregivers, to ensure
comprehensive and well-coordinated care. Care
coordination assistance provided to Enrollees
and their caregivers shall encourage
empowerment and independence of the family.
a) In accordance with care coordinator's
scope of practice, educating Enrollees
and caregivers about their conditions,
techniques for self-management, and
administration of medication or other
treatments.
b) Assisting Enrollees to gain access to
and/or schedule medical, social,
educational and other services, both
within and outside the Contractor's
plan.
c) Assisting Enrollees to arrange for
services to be provided, when necessary,
in non-traditional sites, including
home, work or school; or outside of
working hours.
d) Assisting Enrollees to arrange for
medically necessary IDEA services.
e) Providing linkage with staff in other
agencies and/or community service
organizations involved with or providing
services to an Enrollee.
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f) Assisting in planning for and arranging
the services called for by a discharge
plan after hospital treatment.
g) Assisting in planning for termination
when the Enrollee is being disenrolled
and facilitating communication of
medical information to new providers,
when the Enrollee gives consent.
C.10.4.1.7 The Contractor shall maintain a tracking
system for its treatment plans that
facilitates care coordinators'
responsibilities for care planning,
authorization of care and monitoring of
receipt of planned services; meets the
requirements for EPSDT tracking; and allows
the Contractor to track and monitor other
aspects of treatment planning and delivery.
The system shall control online access to
confidential information so that only
authorized staff can use it. Further, the
Contractor should monitor satisfaction with
these services.
C.10.4.2 Health Education
C.10.4.2.1 The Contractor shall ensure that its PCPs
provide a written and oral explanation of
EPSDT services to Enrollees including
pregnant women, parent(s) and/or guardian(s),
child custodians and sui juris teenagers.
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This explanation shall occur on the first
visit, and annually thereafter, and include
distribution of a pocketsize card with the
schedule for screens, laboratory tests and
immunizations. The importance of the
preventive aspects of the service and the
benefits of early developmental and
anticipatory guidance services should be
emphasized for children under age three (3)
and their caregivers.
C.10.4.2.2 The Contractor shall encourage and support
its PCPs to provide Enrollees with education
and information about health maintenance, the
appropriate use of urgent care and emergency
services and how to access care; how to
access mental health care; self-
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management of health conditions; and selfcare
strategies relevant to their age, culture and
conditions.
C.l0.4.2.3 The Contractor shall provide an organized
health education program including the
following required elements:
a) The importance and availability of
testing for HIV/AIDS and the services
available for treatment of HIV/AIDS;
b) The importance and availability of early
intervention for infants, toddlers and
school-age children who either have been
diagnosed as having, or who are
suspected of having, a developmental
disability or delay;
c) Proper nutrition for pregnant women and
children and the WIC program and how to
obtain benefits; and
d) Sexuality education for teenagers which
addresses prevention of pregnancy,
protection from sexually transmitted
diseases, and issues of homosexuality
and gender identification.
C.l0.4.2.4 The Contractor shall maintain up-to-date
listings of available community health
education programs and self-help
organizations relevant to the needs of its
Enrollees, and ensure that Enrollees are
offered referrals to these organizations
whenever relevant.
C.10.4.2.5 The Contractor shall provide MAA with a
summary of health education activities on a
quarterly basis including participation
levels, curriculum, locations, and a schedule
of sessions, in accordance with Section F.
C.10.5 Collaboration with Other Service Systems
C.10.5.1 Required Reporting
a) The Contractor shall ensure compliance with
reporting requirements as specified in Section F.4
and consistent with confidentiality requirements;
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b) Persons that meet the District's definition of
developmental delay;
c) Children and adults with vaccine-preventable
diseases; and
d) Persons with sexually transmitted and other
communicable diseases.
C.10.5.1.1 The Contractor shall report Enrollees
diagnosed with or suspected as being infected
with tuberculosis to the DC Tuberculosis
Control Program within forty-eight (48)
hours, provide periodic reports on Enrollees
in treatment, and notify the Program of
Enrollees absent from treatment more than
thirty (30) days.
C.10.5.1.2 The Contractor shall report any child with
an elevated blood lead level (greater than 15
ug/dl) to the District of Columbia Department
of Health Childhood Lead Poisoning Prevention
Program within seventy-two (72) hours after
identification, shall refer such child for
assessment of developmental delay, and shall
coordinate services required to treat the
exposed child with the lead inspection and
abatement services furnished by the District.
C.10.5.1.3 The Contractor shall be responsible for
referring pregnant and post-partum women and
children up to age five (5) who have been or
are at risk for nutritional deficiencies or
have nutrition-related medical conditions to
the Special Supplemental Food Program for
Women, Infants and Children (WIC) and for
furnishing the WIC agency with the results of
tests conducted to ascertain nutritional
status. The Contractor shall also direct all
eligible members to the WIC program (Medicaid
recipients are automatically income-eligible)
and coordinate with existing WIC providers to
ensure members have access to the special
supplemental nutrition program for women,
infants and children or the Contractor shall
provide these services. The Contractor may
use the
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nutrition education provided by WIC to
satisfy related health education and
promotion requirements.
C.10.5.2 Court Ordered Evaluations and Services
C.10.5.2.1 The Contractor shall respond to direct
referrals from the court system for
court-ordered evaluation. Such referrals
shall be forwarded to appropriately qualified
providers who are able to promptly and fully
respond to the needs of the court. The
Contractor shall be responsible for oversight
of the evaluation and for providing the
evaluation results to the court.
C.10.5.2.2 The Contractor shall respond promptly to
direct referrals from the court system for
court-ordered services and ensure that
appointments for medically necessary services
are offered promptly. If the Contractor
determines that court-ordered services are
not medically necessary, the Contractor shall
recommend to the court alternative services
to address the Enrollee's needs.
C.10.5.3 Coordination with Other District Agencies
C.10.5.3.1 The Contractor shall be responsible for
designating a senior contact person for each
of the following District agencies:
a) District of Columbia Public Schools
Special Education;
b) Department of Human Services Early
Intervention Program;
c) Department of Human Services, Youth
Services Administration;
d) Child and Family Services Agency/LaShawn
Receiver;
e) Commission on Mental Health
Services/Dixon Transitional Receiver;
f) Department of Health Office of Maternal
and Child Health;
g) DC Courts; and
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h) Department of Health Addiction,
Prevention, Recovery Administration
(APRA).
C.10.5.4 Coordination of Health-related IDEA Services
C.10.5.4.1 The Contractor shall ensure that appropriate
staff members attend an MAA-sponsored
training session to inform them about the
requirements, services, and procedures of
IDEA, and will communicate this information
to its PCPs and other staff through
appropriate and effective means.
C.10.5.4.2 The Contractor shall ensure that its
designated contact person for DCPS and the
Early Intervention Program regularly attends
a working group sponsored by MAA that will
develop protocols to implement MAA's
Interagency Agreements with DCPS and with
Early Intervention Program. The protocols
shall specify procedures and performance
expectations for coordination and
communication concerning the medical and
behavioral care of Enrollees served in
common. Protocols shall include:
a) Procedures for accessing assessments,
for collaborative service planning, and
for authorization of services;
b) Procedures consistent with
confidentia1ity laws for communication
among service providers on progress in
treatment and significant developments
in the Enrollee's condition or
treatment;
c) Where applicable, procedures for billing
and payment of services whose cost is
shared, or services provided by one
party and paid for by another;
d) Designation of a point of contact from
each system, responsible for
coordinating resolution of case or
system issues;
e) Regular meetings for ongoing planning,
resolution of systems problems, and
resolution of problems with specific
cases;
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f) Procedures for resolving conflicts that
cannot be resolved in the established
meetings;
g) If applicable, procedures for arranging
and paying for court-ordered services
that are not medically necessary; and
h) If applicable, procedures for responding
to court orders concerning Enrollees.
C.10.5.5 Coordination with Custodial Agencies
The contact people designated by each Contractor for
the Child and Family Services Agency and for the Youth
Services Administration shall meet with representatives
of each agency to develop any policies and procedures
needed to coordinate health care for wards of the
District who are enrolled in a health plan. Such
policies and procedures shall be documented in
memoranda between the Contractor and the agencies as
appropriate. If a system-wide approach is necessary,
MAA will facilitate meetings between all health plans
and the agencies involved.
C.10.5.6 Coordination with Mental Health and Alcohol and Drug
Abuse Services
The Contractor shall establish a system that provides
Enrollees' access to covered mental health and alcohol
and drug abuse treatment. The Contractor's system shall
be subject to review and approval by the Commission on
Mental Health Services/Dixon Transitional Receiver.
This system shall also ensure effective coordination
between medical service providers and network mental
health and alcohol and drug abuse providers, to the
extent that the Enrollee consents to sharing
information about his or her mental health and alcohol
and drug abuse treatment. This system shall:
a) Disseminate and train PCPs in the use of
a validated tool or tools designated by
MAA for screening children and adults
for mental health and alcohol and drug
abuse problems;
b) Ensure that PCPs administer MAA-approved
screening tools for mental health and
alcohol and drug abuse needs as a
routine part of every child and adult
preventive health examination;
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c) Identify Enrollees who are in need of
mental health and alcohol and drug abuse
treatment and assist Enrollees in
selecting a mental health and alcohol
and drug abuse provider and making an
appointment, when requested and
necessary;
d) Prepare a directory of all network
mental health and alcohol and drug abuse
providers. Distribute this directory to
all PCPs in the network and ensure that
they offer an appropriate directory to
all Enrollees whose screening indicates
possible mental health and alcohol and
drug abuse problems;
e) Ensure that PCPs coordinate care with
any mental health and alcohol and drug
abuse treatment providers in or outside
of the network serving their Enrollees,
in accordance with the Enrollee's
consent to share information about such
treatment;
f) Assign appropriate staff to coordinate
among primary care providers and network
and non-network mental health and
alcohol and drug abuse providers; and
designate a single Senior Manager to
oversee this function;
g) Establish procedures to identify
problems that arise in specific cases or
in mental health or alcohol and drug
abuse treatment systems generally and
bring them to the attention of the
designated staff person on a timely
basis; and
h) Develop and implement procedures to
monitor compliance with these protocols
and to improve compliance, if necessary.
C.10.5.7 Memorandum of Agreements
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C.10.5.7.1 The Contractor shall develop Memorandum of
Agreements with the following agencies within
sixty (60) days of contract award to ensure
effective coordination of treatment.
C.10.5.7.2 District of Columbia Public Schools, Special
Education;
C.10.5.7.3 Department of Human Services Early
Intervention Program;
C.10.5.7.4 Child and Family Services Agency/LaShawn
Receiver;
C.10.5.7.5 Department of Human Services Youth Services
Administration;
C.10.5.7.6 Commission on Mental Health Services/Dixon
Transitional Receiver; and
C.10.5.8 Coordination with Other MMCP Health Plans The
Contractor shall establish procedures for transfer of
medical information, continuity of care and for linkage
of medical information of Enrollees who transfer
between the DCHFP plan.
C.11 Financial Functions
C.11.1 Claims Payment Capacity
The Contractor shall be responsible for paying all claims for
properly accessed and, if necessary, authorized Medicaid services
provided to Enrollees on dates of service when they were eligible
for Medicaid unless the services are excluded under the Plan.
C.11.1.1 The Contractor shall have written policies and
procedures for processing claims submitted for payment
from any source and shall monitor its compliance with
these procedures. The procedures shall specify time
frames for:
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C.11.1.1.1 Date stamping claims when received;
C.ll.1.l.2 Determining, within a specific number of
days from receipt, whether a claim is clean
or not;
C.11.1.1.3 Follow-up of pended claims to obtain
additional information;
C.11.1.1.4 Reaching a determination following receipt
of additional information; and
C.11.1.1.5 Sending notice of the provider's appeal
rights when a determination is made to deny
the claim.
C.11.1.2 The Contractor shall allow network and non-network
providers to submit an initial claim for covered and,
if required, prior authorized services for a maximum
period of ninety (90) days following the provision of
such services.
C.11.1.3 The Contractor's claims payment system shall use
standard claims forms wherever possible. In addition,
the Contractor shall have the capability to
electronically accept and adjudicate claims.
C.11.1.4 The Contractor's claims processing system shall ensure
that duplicate claims are denied.
C.11.1.5 The Contractor shall pay or deny at least ninety
percent (90%) of "clean claims" (claims for which no
further written information or substantiation is
required) within thirty (30) calendar days of receipt
and at least ninety-nine percent (99%) of clean claims
within ninety (90) calendar days of receipt consistent
with the claims payment procedures described in Section
1902(a)(37)(A) of the Social Security Act. The
Contractor shall adhere to these claims payment
procedures unless the health care provider and the
Contractor agree to an alternative payment schedule.
C.11.1.6 The Contractor shall verify that reimbursed services
were actually provided to Enrollees by providers and
subcontractors.
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C.11.1.7 The Contractor shall provide MAA with information prior
to implementation of any changes to the software system
to be used to support the claims processing function as
described in the Contractor's proposal and incorporated
by reference in the contract.
C.ll.2 Provider Relations
The Contractor shall maintain staff to perform provider relation
functions to include; training providers in the Contractor's
procedures for authorization and claims payments, assisting
providers to resolve billing and other administrative problems
and responding to provider complaints about administrative
processes.
C.12 Management Information System
C.12.1 Minimum MIS Requirements
The Contractor shall operate an MIS capable of maintaining,
providing and documenting information sufficient to document
contractor's compliance with the contract requirements that will
include but not be limited to the following functions:
. Enrollee eligibility data - current and historical;
. Encounter and claim payment records - current and
historical;
. Authorization and care coordination data;
. Utilization management;
. Provider network information, i.e., provider affiliations,
credentialing information;
. EPSDT tracking;
. Outcome reports;
. Financial accounting data;
. Grievance and complaints statistics;
. Internal operations data, e.g., telephone response time;
. Clinical information;
. Serious incidents;
. Client satisfaction;
. Provider profiling; and
. Outcome measurements.
C.12.1.1 The Contractor shall have an MIS capable of documenting
administrative and clinical procedures while
maintaining confidentiality of individual medical
information, including special confidentiality
provisions related to people with HIV/AIDS, mental
illness, and alcohol and drug abuse disorders. The
encounter data reporting system should be designed to
assure aggregated, unduplicated service counts
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provided across service categories, provider types, and
treatment facilities.
C.12.1.2 The Contractor shall have internal procedures to ensure
that data reported to the District are valid and to
test validity and consistency on a regular basis. The
Contractor shall also agree to cooperate in data
validation activities that may be conducted by the
District, at its discretion, by making available
medical records, claims records, and a sample of other
data according to specifications developed by the
District.
C.12.1.3 The Contractor shall develop and implement required
corrective action plans to correct data validity
problems.
C.12.1.4 The Contractor shall provide the District with
aggregate performance and outcome data, as well as its
policies for transmission of data from network
providers. The Contractor shall submit its work plan or
readiness survey assessing its ability to comply with
Health Insurance Portability and Accountability Act
(HIPAA) mandates in preparation for the standards and
regulations.
C.12.2 Eligibility Data
C.12.2.1 The Contractor's enrollment system shall be capable of
linking records for the same Enrollee that are
associated with different Medicaid identification
numbers, e.g., Enrollees who are re-enrolled and
assigned new numbers.
C.12.2.2 A Contractor operating a District of Columbia DCHFP and
a CASSIP shall have a method linking the records of an
Enrollee who is disenrolled from the DCHFP and enrolled
in the CASSIP or vice versa.
C.12.2.3 At the time of service, the Contractor or its
subcontractors shall verify every Enrollee's
eligibility through the Eligibility Verification System
(EVS) operated by the District.
C.12.2.4 The Contractor shall update its eligibility database
whenever Enrollees change names, phone numbers, and/or
addresses, and shall notify the District of such
changes.
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C.12.2.5 The Contractor shall notify the MAA of any Enrollees
for whom accurate addresses or current locations cannot
be determined and shall document the action that has
been taken to locate the Enrollees. The Contractor
shall notify the MAA of the known deaths of any
Enrollees within two (2) business days.
C.12.3 Encounter and Claims Records
C.12.3.1 The Contractor shall use a standardized methodology
capable of supporting HCFA reporting categories for
collecting service event data and costs associated with
each category of service.
C.12.3.2 The Contractor shall collect and submit service
specific encounter data in the appropriate HCFA 1500 or
UB92 format or an alternative format if approved by
MAA. The data shall be submitted electronically within
seventy-five (75) days of the end of the month in which
the service occurs, or as needed. The data shall
include all services reimbursed by Medicaid.
C.12.4 EPSDT Tracking System
C.12.4.1 The Contractor shall operate a system that tracks EPSDT
activities for each enrolled child by name and Medicaid
identification number and allows the Contractor to
complete HCFA form 416 to report the timeliness of the
performance of scheduled activities. This system shall
be enhanced, if needed, to meet any other reporting
requirements instituted by HCFA for the District in the
future;
C.12.4.2 The system shall also track the status of the child
with respect to WIC referrals; and
C.12.4.3 The status of the child with respect to mental health
referra1s.
C.l2.5 Authorization and Care Coordination Data
C.12.5.1 The Contractor's system shall include all data
necessary to coordinate care, including, but not
limited to: client ID number, provider number,
treatment plan and treatment goals, progress toward
goals, referrals made, services requested and services
authorized, period of service
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authorization, number of units authorized, diagnosis -
all axis, any applicable assessment information,
eligibility and legal status, reviewer ID, date of
request and date of review. The Contractor's MIS shall
support care coordination functions, including, but not
limited to, EPSDT compliance, treatment planning,
comments from service providers, and resources
available from the provider.
C.12.5.2 Records in an electronic or digital on-line format
shall be easy to access and to transport in a
non-proprietary format.
C.12.5.3 The system shall ensure flexibility to record and
easily access text describing clinical issues.
C.12.6 Additional Clinical Information
The Contractor shall extract clinical data from electronic
databases, through chart reviews, or through other special data
collection methods when needed for analyses to inform quality
improvement, provider management, or development of clinical
protocols.
C.12.7 Provider Network
C.12.7.1 In accordance with Section 1932(d)(4) of the Balanced
Budget Act of 1997, the Contractor shall require its
physicians who provide Medicaid services to have a
unique identifier in accordance with the system
established under Section 1173(b).
C.12.7.2 The Contractor's provider database shall include but
not be limited to licensure status, professional
affiliations, hospital admitting privileges, languages
spoken, education and training and board eligibility/
certification. Basic demographic information, hours of
operations, office locations, languages spoken by
office staff, status of panel (open, closed),
satisfaction survey responses malpractice coverage, and
reported incidents shall also be available.
C.12.8 Outcome Reporting
The Contractor's MIS shall have the capacity to report on the
measures outlined in Section C.17.7.
C.13 Quality Improvement
The Contractor shall establish quality management functions to monitor its
compliance with Quality Improvement System for Managed Care (QISMC)
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Interim Standards and Guidelines and industry standards for care planning,
authorization, and provision, and to investigate serious incidents. In
addition, the Contractor shall implement a structured process for
continuously improving quality that addresses aspects of its performance
that are of significance for its MMCP Enrollees and that meet QISMC
standards.
C.13.1 Chart Reviews
The Contractor shall establish a system for periodic review of
medical records, care coordination records, and claims records
using explicit criteria to establish whether:
C.13.1.1 Treatment is consistent with diagnosis;
C.13.1.2 High-risk chronic or acute conditions receive
appropriate treatment and achieve appropriate outcomes;
C.13.1.3 Services emphasize preventive care and result in early
detection;
C.13.1.4 Treatment is provided in accordance with quality of
care guidelines;
C.13.1.5 Enrollees are appropriately referred to specialty care;
C.13.1.6 Enrollees are offered needed support services; and
C.13.1.7 Barriers to appropriate care are identified and
patients are offered assistance in addressing them.
The results of such chart reviews will be provided to
MAA on an annual basis in accordance with Section F.4.
C.13.2 Critical Incidents
The Contractor shall adopt definitions for critical and serious
incidents from a national accrediting body and adopt that body's
procedures for reporting, investigating, addressing, and
documenting them, including who is responsible for each activity.
These policies shall be included in the Contractor's Provider
Manual, which shall be reviewed for approval by MAA.
C.13.2.1 The Contractor shall report all critical incidents to
MAA's Medical Director within twenty-four (24) hours of
their occurrence, along with measures taken to address
the situation and/or prevent additional occurrences.
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C.13.2.2 The Contractor shall summarize and report quarterly to
MAA in accordance with Section F.4 serious incidents
and the Contractor's actions taken.
C.13.2.3 In order to prevent and better manage such incidents,
the Contractor shall designate a multi-disciplinary
committee under the leadership of the Medical Director
to review critical incidents as they happen, as well as
to review summary reports on a quarterly and annual
basis.
C.13.2.4 The Contractor's committee shall order and monitor
needed corrective actions and shall issue protocols
designed to guide practitioners in preventing or
providing appropriate responses to commonly experienced
incidents, and shall identify commonly experienced
incidents warranting development of improved approaches
to prevention or management.
C.13.3 Quality Improvement (QI) Program
C.13.3.1 The Contractor shall operate a Quality Improvement
Program. The Contractor shall develop a written QI Plan
annually that details plans, tasks, initiatives, and
staff responsible for improving quality and meeting the
requirements incorporated in this Contract.
C.13.3.1.1 The Contractor's QI Plan shall specify
measures of effectiveness from such domains
as observable health outcomes, provision of
efficacious services, adherence to
professional guidelines, family satisfaction,
patient satisfaction and access to or
utilization of services that will provide a
basis for evaluation of effectiveness.
C.13.3.1.2 All initiatives shall set measurable
improvement targets for health outcomes or
for structures or processes that have been
demonstrated by best practice or industry
standards to be linked to positive outcomes.
C.13.3.1.3 The Contractor's QI Plan shall set
measurable goals for reducing racial or
ethnic disparities indicated by baseline data
for health plan performance, either within
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the Plan or between the Plan and national
benchmarks.
C.13.3.1.4 The Contractor shall include provisions for
measuring the effectiveness of its proposed
interventions, using a baseline and a
post-intervention measurement and the
relevant health outcomes that will also be
measured.
C.13.3.1.5 When a measure is based on a sample rather
than on all Enrollees, a sampling methodology
shall be used which ensures that the results
are representative of the enrolled
population. The Contractor shall report on
functional and health outcome measures as
needed in connection with Plan or MAA Quality
Improvement Initiatives.
C.13.3.1.6 The Contractor shall include an
implementation schedule for quality
improvement tasks outlined in the QI Plan.
C.13.3.1.7 The Contractor shall submit an annual
Quality Improvement Report 30 days prior to
the expiration of each year of the contract
The QI Report shall summarize the findings
from initiatives described in the annual QI
Plan.
C.13.3.2 The Contractor shall participate in MAA quality
improvement initiatives for managed care plans. This
shall involve sending appropriate staff with an
appropriate level of decision-making authority to
participate in planning meetings that may involve MAA,
other contracted managed care plans, the other District
agencies, the MAA Advisory Group, and other
stakeholders.
C.13.3.3 The Contractor shall make available minutes from the
Contractors' internal Quality Improvement Committee
meetings upon request by the District for review at the
Contractor's site. All such minutes shall be kept
confidential by reviewing parties as required under the
District's Health Maintenance Organization Act of 1996.
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C.13.4 Consumer and Family Surveys
The Contractor shall conduct at least two surveys per year of its
Enrollees.
C.13.4.1 One survey shall assess the satisfaction of its
Enrollees and families at least once per year, using
appropriate nationally validated and normative tools
appropriate for Medicaid populations, such as the
Consumer Assessment of Health Plans Studies (CAHPS).
C.13.4.2 The Contractor shall include in such surveys any
specific questions requested by MAA.
C.13.4.3 The Contractor shall conduct one additional survey of
its Enrollees, or a subpopulation of Enrollees, at
least once per year to collect self-reported data
relevant to analysis of outcomes or quality improvement
initiatives.
C.13.5 Provider Satisfaction
The Contractor shall assess the satisfaction of the Enrollees of
its Provider network at least once per year, using a provider
satisfaction tool that addresses concerns of importance to
providers treating its Enrollees.
C.14 Complaints, Grievances And Fair Hearings
The Contractor shall maintain adequate staff to receive Enrollee complaints
submitted by phone or in writing and meet by phone or in person with
Enrollees to answer questions and attempt to resolve complaints. If the
complaint cannot be resolved at this level, the staff shall submit
complaints to the formal complaints and grievance process. The Contractor
shall document all communications, written and verbal, with Enrollees and
shall maintain written policies and procedures for the receipt and prompt
resolution of complaints and grievances. This system shall comply with the
requirements of 42 CFR 434.32. All reports and documentation shall be
subject to review by the District as deemed necessary.
C.14.1 General Requirements
C.14.1.1 The Contractor shall establish a complaint and
grievance process that adheres to the following
requirements:
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C.14.1.1.1 The Contractor shall inform enrollees of
their right to file a grievance with the
Office of Fair Hearing at any time during the
process.
C.14.1.1.2 The Contractor shall offer to assist the
enrollee with the filing of a complaint to
the Office of Fair Hearing
C.14.1.1.3 The Contractor shall establish a reasonable
time frame that allows Enrollees ninety (90)
days from the date the Contractor mails a
notice of action to file a complaint,
grievance, or request a fair hearing.
C.14.1.1.4 After ninety (90) days, Enrollees or their
designees shall have the right to file a
grievance with "good cause".
C.14.1.1.5 The Contractor shall in no way penalize any
Enrollee who files a complaint or grievance,
or requests a fair hearing.
C.14.2 Complaint Procedure
C.14.2.1 The Contractor shall establish and maintain a defined
process for members, providers, or others to resolve
disputes regarding any aspect of service provision or
administration, other than a request for
reconsideration of an authorization decision. This
process shall specify timeframes for the completion of
each step in order to ensure timely response to the
complainant.
C.14.2.2 The Contractor shall ensure that complaints are
investigated and resolved in a timely manner by an
individual who was not directly or indirectly involved
in the situation which gave rise to the complaint.
C.14.3 Grievances and Appeals
The Contractor shall reconsider a decision to deny, reduce,
terminate, or delay authorization of a requested covered service
or payment denial in response to an a grievance to request
submitted by an Enrollee or a provider on behalf of an Enrollee.
Should the Enrollee disagree with the Contractor's response to a
grievance, the Enrollee or a provider on the Enrollee's behalf,
may appeal the Contractor's decision.
C.14.3.1 Levels of Reconsideration
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C.14.3.1.1. Immediate Reconsideration (InformalReview)
The Contractor shall establish a process for
immediate reconsideration of the denial,
termination, or reduction of services when
there is a dispute about whether the Enrollee
has an urgent or emergency medical condition
or there is a delay in the furnishing of an
emergency or urgent service. A physician not
involved in the original decision shall
perform the review and reconsideration of the
matter and a decision shall be issued within
one (1) hour.
C.14.3.1.2 The Contractor shall utilize the immediate
reconsideration process under the following
circumstances:
a) An Enrollee submits a grievance and
taking the time for a standard
resolution could seriously jeopardize
the Enrollee's life or health;
b) A physician submits a grievance or
supports an Enrollee's request and
indicates that taking the time for a
standard resolution could seriously
jeopardize the Enrollee's life, health,
or functioning; or
c) An Enrollee submits a grievance while
accessing services for urgent or
emergency care.
C.14.3.1.3 Expedited Grievance (First Level Review)
The Contractor shall establish an expedited
grievance process for making a first level
reconsideration determination of an acute
care denial within a seventy-two (72) hour
period. The reviewer shall be an appropriate
specialist who was not involved in the
initial coverage determination. Aggrieved
individuals shall have the right to submit
additional data and meet with the reviewer
prior to final determination.
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C.14.3.1.4 The Contractor shall ensure that, at a
minimum, the expedited grievance process is
utilized for:
a) Persons dissatisfied with the response
to a request for urgent care;
b) Persons with HIV/AIDS dissatisfied with
a Contractor's determination of
coverage;
c) Other persons as designated by the
Contractor based on stated criteria; and
d) Persons who are dissatisfied with an
MCO's determination of coverage for
acute services, or for services that may
be authorized as alternatives to acute
inpatient services.
e) Persons dissatisfied with decisions
regarding denial of surgical procedures,
including but not limited to
circumcisions.
C.l4.3.1.5 Standard Grievance (First Level Review)
The Contractor shall establish and maintain a
standard grievance process for first level
reconsideration of authorization decisions
that resulted in the denial, termination,
delay or reduction of a covered item or
service. This process may also serve as a
first level reconsideration of an unresolved
complaint. The Contractor shall be
responsible for the following activities
regarding the grievance process:
a) The Contractor shall inform providers
and Enrollees of procedures for grieving
denials or reductions of requested
services.
b) The Contractor shall inform Enrollees of
their rights in the grievance process,
including the right to appear in person
before the Contractor's personnel
responsible for resolving the grievance,
the timing in which the review will be
completed, and their rights to Fair
Hearings at any point in the process.
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c) The Contractor shall ensure that all
grievances regarding services for adults
are reviewed by appropriate specialists
and sub- specialists and that all
grievances regarding services for
children are reviewed by appropriate
pediatric specialists and
subspecialists.
d) The Contractor shall appoint a Grievance
Committee to review all standard
grievances. At a minimum, the Grievance
Committee shall include the Medical
Director or his/her designee, the
Clinical Director or his/her designee,
and a Supervising Care Coordinator
representing a discipline other than the
Clinical Director's. Other medical and
clinical staff shall participate to
substitute for a staff member involved
in the matter being grieved, or to
provide needed specialty expertise.
e) The Contractor shall resolve the
grievance and notify the member or the
member's designee in writing of the
decision no later than thirty (30)
working days from the date the grievance
was received except in cases involving
an expedited grievance. The Contractor
may extend the thirty (30) day time
frame by up to fourteen (14) calendar
days if the Enrollee or the Enrollee's
representative requests the extension.
C.14.3.1.6 Appeals (Second Level Review)
The Contractor shall establish and maintain
an appeals process to review and resolve
disputes involving adverse decisions
resulting from the standard grievance
process. Contractors shall be responsible for
ensuring:
a) The same resolution and notification
timeframes described above for the
standard grievance process are adhered
to throughout the appeals process.
b) The appeals committee responsible for
the review and reconsideration of the
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dispute includes a physician who was not
involved in any previous decision
regarding the dispute.
C.14.3.2 Requirements for Notice of Action
The Contractor shall notify an Enrollee in writing and
in a timely manner of any intention to deny, limit,
reduce, delay or terminate a service or deny payment.
This notice shall clearly explain the following:
C.14.3.2.1 The action the Contractor intends to take
and the supporting reasons, laws or rules for
the action;
C.14.3.2.2 The Enrollee's right to file a complaint or
grievance with the Contractor and the right
to request a Fair Hearing at any time;
C.14.3.2.3 The Enrollee's right to appear in person in
front of the Contractor's personnel if the
Enrollee files a grievance;
C.14.3.2.4 The Enrollee's right to have a
representative involved in the process;
C.14.3.2.5 The assistance that can be provided by the
Ombudsman and how to contact the Ombudsman;
C.14.3.2.6 The Enrollee's right to obtain free copies
of the documents, including the Enrollee's
medical records, used to make the decision
and the medical necessity criteria referenced
in the decision; and
C.14.3.2.7 The circumstances under which benefits will
continue pending resolution of the grievance
or issuance of a District Fair Hearing
decision.
C.14.3.3 Written Notification of Receipt
The Contractor shall, within two (2) working days, send
to the member or the member's designee a letter of
notification of receipt of the complaint or grievance.
C.14.3.4 Continuation of Coverage
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C.14.3.4.1 The Contractor shall continue to furnish the
item or service at the level and in the
amount, scope, and duration that item or
service was provided to the Enrollee prior to
notification of the Contractor's
determination pending resolution of the
grievance or appeal.
C.14.3.4.2 This provision for continued coverage
applies only to Enrollees or an Enrollee's
designee who filed a standard grievance
within ten (10) days of the date on which the
Enrollee was notified of the Contractor's
determination to terminate or reduce an item
or service.
C.14.3.4.3 The Contractor shall provide continued
coverage until the date that:
a) The grievance is resolved; and
b) The Enrollee has not requested a fair
hearing.
C.14.3.4.4 The Contractor shall issue an authorization
for any services authorized as a result of
the grievance or fair hearing process within
two (2) working days of a grievance or notice
of a fair hearing decision.
C.14.4 Fair Hearings
C.14.4.1 The Contractor shall notify the Enrollee or the
Enrollee's designee of the right to a fair hearing with
a District hearing officer, each time notification of
an adverse decision on a complaint, grievance, or
appeal is sent to an Enrollee or the Enrollee's
designee.
C.14.4.2 The Contractor shall submit all documents regarding the
Plan's action and the Enrollee's dispute to MAA no
later than five (5) working days from the date the
Contractor receives notice from the District that a
fair hearing request has been filed if an Enrollee
requests a fair hearing.
C.14.4.3 An Enrollee may request a fair hearing before, during,
or after a Contractor's grievance process. However, an
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Enrollee is allowed no more than ninety (90) days from
the date notice of action is mailed to request a
hearing.
C.14.4.4 Pending the decision from the fair hearing, the
Contractor shall continue to furnish the item or
service at the level and in the amount, scope, and
duration that item or service was provided to the
Enrollee prior to notification of the Contractor's
determination.
C.14.4.5 The Contractor shall assist the enrollee with filing of
any request for a fair hearing and send a copy of the
request filed to the enrollee's home address.
C.14.5 Grievance and Fair Hearing Resolutions
If the Contractor reverses or modifies an authorized decision
through the grievance resolution process or is notified of the
District's fair hearing decision to reverse a decision, the
service shall be authorized or provided no later than two (2)
working days after reversal or notification of reversal from the
District. In the case of an expedited grievance, services must
begin within twenty-four (24) hours of the reversal.
C.14.6 Tracking Log
The Contractor shall maintain a log to document all complaints
and grievances. The log shall document the type and nature of
each dispute, the Plan in which the complainant is enrolled, how
the matter was addressed and what, if any, corrective action was
taken.
C.15 Implementation Plan
C.15.1 Implementation Requirements
C.15.1.1 Organizational
C.15.1.2 The Contractor shall designate a group composed of
individuals who are qualified to direct the
implementation of all required functions of the health
plan and to be responsible for developing the
Implementation Plan and carrying it out.
C.15.1.2.1 This group shall include individuals with
experience with managed care, Medicaid
managed care, mental health care, the
District of Columbia's health system, and
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with the functions they will be implementing.
C.15.1.3 The Contractor shall allocate sufficient resources to
carry out the Implementation Plan in accordance with
the Contract.
Performance and Outcome Measures
The Contractor shall generate and track the performance measures as
described in Section C.17, and Section C.18 for evaluation of the
Contractor's performance. MAA reserves the right to specify additional or
change perfonnance measures or criteria within sixty (60) days of prior
notification to the Contractor. Nothing in this Section precludes the
requirement of the Contractor to fulfill reporting requirements specified
in Section F or reports that are mandated by the Health Care Finance
Administration (HCFA) or other federal or District governmental entities.
C.16.1 Sample Based Reporting
When a measure is based on a sample rather than on all Enrollees,
the Contractor shall use a sampling methodology which ensures
that the results are representative of the enrolled population of
concern. The Contractor shall report on functional and health
outcome measures as needed in connection with Plan or MAA Quality
Improvement Initiatives.
Specific Requirements and Responsibilities for DCHFP Contractors Only
C.17.1 Authority to Operate
C.17.1.1 The Contractor shall comply with the Medical Assistance
State Plan, Section 2.1, and health plan requirements,
which are incorporated herein by reference.
C.17.1.2 The Contractor shall maintain a certificate of
authority to operate a health maintenance organization
in the District of Columbia from the Department of
Insurance and Securities Regulations.
C.17.2 Additional Provision for Disenrollment of Enrollees
The Contractor may request that MAA disenroll an individual from
its DCHFP who has been admitted to a long term care facility
other than a Residential Treatment Facility, and who is expected
to remain in the facility for thirty (30) consecutive days. If
approved by the MAA, disenrollment is effective the first day of
the first full month following the date of MAA approval.
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C.17.3 Coverage of Services and Benefits
C.17.3.1 Contractors shall provide medically necessary health
care, diagnostic services, treatment, and other items
and services described in Section 1905 of the Social
Security Act to correct or ameliorate substance abuse
illnesses.
C.17.3.2 In addition to those covered services listed in
Attachment J.8 and described in Section 0, the
---------
Contractor shall develop, contract, and arrange for the
following medically necessary services for its
Enrollees.
C.17.3.3 Mental lllness Treatment Services
C.17.3.3.1 The DCHFP Contractor shall be responsible
for providing services for Enrollees who are
dually diagnosed (mental illness and alcohol
and drug abuse) as prescribed in protocols,
policies and procedures developed by MAA with
input from the Contractor.
C.17.3.4 Alcohol and Drug Abuse Referral and Care Coordination
C.17.3.4.1 DCHFP contractors are responsible for
facilitating access to emergency services
related to alcohol and drug abuse even though
treatment services are available through the
MAA contracted network(s).
C.17.3.4.2 The DCHFP Contractor shall be responsible
for referring and coordinating care for
Enrollees in need of alcohol and drug abuse
treatment.
C.17.3.5 Long Term Care
C.17.3.5.1 The Contractor shall arrange for long term
treatment services for its Enrollees who need
them. These services shall be arranged in
Medicaid-certified facilities.
C.17.3.5.2 The Contractor may submit a written request
that MAA disenroll any such member from
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its DCHFP. In order to do so the Contractor
shall:
a) Notify MAA that a physician has
certified that an Enrollee who is
receiving such treatment will continue
to need such treatment for longer than
thirty (30) consecutive days
b) Submit the Enrollee's medical record to
document the need for long term
treatment and submit a plan for
transition from the Contractor's DCHFP
to fee-for-service providers; and
c) Request that the Enrollee be disenrolled
at the end of the thirty (30) days.
C.17.3.5.3 The Contractor shall not be responsible for
the cost of providing such treatment
beginning on the first day of the month
following the month during which the Enrollee
is disenrolled from the Contractor's Plan.
C.17.3.5.4 The Contractor shall include an explanation
of the right of an Enrollee needing alcohol
and drug abuse treatment to self-refer to any
provider in the MAA network(s);
C.17.3.5.5 The Contractor shall include an explanation
of alcohol and drug abuse treatment services
available through the MAA contracted
network(s).
C.17.4 Network
C.17.4.1 In establishing a DCHFP network that meets the
requirement in Section O, the Contractor shall have
sufficient providers in each listed category with
specialized training and/or experience in pediatrics to
meet the needs of enrolled children in accessible
locations on a timely basis, and sufficient providers
in each category with training and experience in adult
medicine to meet the needs of adult Enrollees in
accessible locations on a timely basis.
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C.17.5 Utilization Management and Care Coordination Capabilities
C.17.5.1 DCHFP Contractors shall disseminate Level of Care
Criteria for alcohol and drug abuse treatment available
through the MAA contracted network to network providers
to guide treatment and ensure consistency and
coordination, and shall be available to them upon
request.
C.17.5.2 Additional Requirements for Health Education
In addition to the health education programs required
in Section C.17.4.2, The Contractor shall provide DCHFP
health education programs that include, but are not
limited to the following topics:
C.17.5.2.1 Preventive services for adults, in
particular cervical cancer screens and
mammograms for women;
C.17.5.2.2 Routine family planning services, early
pregnancy testing, and early and continuous
prenatal care; and
C.17.5.2.3 Treatment for mental health, alcohol and
alcohol and drug abuse.
C.17.5.2.4 For DCHFP plans, the Contractor shall
designate a Senior Manager with overall
responsibility for a Utilization Management
Program to assess and substantiate the need
for physical health and mental health
services and to assure the Enrollee receives
the appropriate level of care.
C.17.4.3 Additional Requirements for Care Coordination
In addition to the requirements in Section C.10.4, the
Contractor shall establish methods to identify and
refer children with special health care needs according
to the process described in Section C.17.5.3.3.
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C.17.5.3.1 DCHFP Contractors shall refer Enrollees in
need of alcohol and drug abuse treatment to
the MAA contracted provider network(s).
C.17.5.3.2 The Contractor shall promptly forward any
information that is relevant to the
determination that a child has special health
care needs to the child's PCP. This
information includes but is not limited to
information it receives from MAA, the
Enrollment Broker, from the child or family,
or that the Contractor produces from its own
database.
C.17.5.3.3 The Contractor shall require PCPs to
determine whether a child meets the
definition of a child with special health
care needs during initial examination and
assessment, and to report any child
determined to have special health care needs
to the Contractor.
C.17.5.3.4 The Contractor shall contract for a board
certified psychiatrist with combined
experience in mental health and alcohol and
drug abuse services, licensed in the
District, to serve as contracted Psychiatric
Medical Director of the Medicaid Managed Care
Program contracted plans. The
responsibilities of the contracted
Psychiatric Medical Director for DCHFP plans
pertain to the mental health delivery system
and coordination with the alcohol and drug
abuse treatment delivery system and include:
C.17.5.3.5 Development of mental health clinical
practice standards, policies, procedures, and
performance standards;
C.17.5.3.6 Implementation and review of quality of care
programs for mental health services;
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C.17.5.3.7 Participation in grievance and appeal
processes related to mental health service
denials and clinical practice;
C.17.5.3.8 Development, implementation and review of
the internal quality assurance and
utilization management programs for mental
health services;
C.17.5.3.9 Oversight of the referral process for
specialty and out-of-plan mental health
services;
C.17.5.3.10 Leadership and direction to the
Contractor's clinical staff in areas of
recruitment, credentialing and privileging
activities of mental health professionals;
C.17.5.3.11 Leadership and direction in the
Contractor's prior authorization and
utilization review process of mental health
services;
C.17.5.3.12 Leadership and direction of policies and
procedures relating to confidentiality of
mental health clinical records;
C.17.5.3.13 Participation in meetings called by MAA and
participation in meetings with the Commission
on Mental Health Services/Dixon Transitional
Receiver;
C.17.45.3.14 Ensuring the appropriate staffing levels
of Board Certified child and adolescent
psychiatrists.
C.17.5.3.15 For DCHFP plans, the Contractor shall
designate a single Senior Manager, which may
or may not be the contracted Psychiatric
Medical Director, with overall responsibility
for coordinating with MAA on the delivery of
alcohol and drug abuse treatment services.
C.17.5.4 Children with Special Health Care Needs
C.17.5.4.1 The Contractor shall have methods for
producing and disseminating information
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relevant to this determination to PCPs or
other staff capable of making a
determination. This shall include information
supplied by the Enrollment Broker about new
pediatric Enrollees, analysis of claims data
on Enrollees continuing with the Contractor
from the previous contract period, use of
other screening tools, or other valid and
reliable methods.
C.17.5.4.2 The Contractor shall have a method for
entering this designation on its clinical
information system to facilitate analysis of
the needs and care patterns of such children.
C.17.5.4.3 The Contractor shall participate with MAA
and other plans in collaborative efforts to
identify and adopt best practices for serving
children with special health care needs.
C.17.6 Quality Improvement
C.17.6.1 Clinical Initiatives
As part of its Quality Improvement program, the
Contractor shall undertake clinical initiatives as
follows:
C.17.6.2 The Contractor(s) that have not received an
accreditation by the NCQA shall conduct focused quality
of care studies in the following clinical areas:
a) Childhood immunizations;
b) Obesity in Children and Adults;
c) Prenatal care and birth outcomes;
d) Pediatric asthma and asthma related disease;
e) Hypertension;
f) Diabetes; and
g) One other area determined by Contractor and
approved by MAA.
C.17.6.3 The Contractor(s) that have received an accreditation
by NCQA shall submit their focused quality of care
study plans to be conducted during the contract term to
the MAA
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for review and approval. MAA has the authority to
request the specific areas of study.
C.17.6.4 Any clinical initiatives targeted to areas identified
by the United States Department of Health and Human
Services in which significant disparities in outcomes
of care between ethnic and racial groups have been
shown shall evaluate the presence of racial and ethnic
differences, analyze their root causes, and develop
targeted interventions. Areas for the clinical
initiatives include:
a) Infant mortality;
b) Childhood immunizations;
c) HIV disease;
d) Cardiovascular disease;
e) Diabetes; and
f) Cancer screening and management.
C.17.6.5 The Contractor shall consult with the District of
Columbia Department of Health in undertaking these
clinical initiatives.
C.17.6.6 Health Outcomes of Children with Special Health Care
Needs
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C.17.6.6.1 The Contractor shall analyze the utilization
and health outcomes of the children
identified with special health care needs
during the first six months of the second
year of operation of the health care plan, in
order to identify and propose to MAA
opportunities for improvement of children
with special health care needs.
C.17.6.6.2 The clinical quality improvement initiative
for children with special health care needs
shall begin during the second six (6) months
of the second contract year.
C.17.6.6.3 During its first year of operation, the
Contractor shall have a method for measuring
the effectiveness of its implementation of
the requirements for coordinating primary and
mental health and alcohol and drug abuse
care.
C.17.6.6.4 Based upon initial measurements of
effectiveness of coordinating primary care
and mental health and alcohol and drug abuse
care, the Contractor shall develop
improvement goals, develop interventions,
implement them, and measure their
effectiveness.
C.17.6.6.5 The Contractor shall establish a contact
person responsible for communicating with the
MAA designee about the QI initiative to
improve local network capacity for children
in or at risk of residential treatment.
C.17.6.6.6 The Contractor shall adopt the practices and
policies developed by this QI initiative in
conducting treatment planning for children in
or at risk of residential treatment and in
making residential treatment placements, or
shall implement equivalent practices and
policies.
C.17.7 Table of Measures for DCHFP
The Contractor shall report quarterly on the measures listed below
in Tables 1 and 2.
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Table 1
DCHFP Physical Health Care Performance Measures
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Reporting Goal Corrective Action
MEASURE Eligible Population Description Frequency Progression Sanctions
- --------------------------------------------------------------------------------------------------------------------
Early Women who had a % of women who Quarterly 1st Year 65% Corrective action
Identification delivery and were began prenatal care 2nd Year plan and sanctions in
of Pregnancy enrolled 280 days during first 13 weeks 75% the 1st year if
prior to delivery of pregnancy and 3rd Year measures is less than
delivered during the 85% 65% based on the
Objective: Early reporting quarter aggregate MCO
identification of score; in the 2nd year
pregnant women if measure is less
using multiple data than 75% based on
sources to increase the aggregate MCO
prenatal services in score; in the 3rd year
the 1st trimester. if measure is less
than 85% based on
the aggregate MCO
score.
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DIABETES
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1. Eye Exam Refer to HEDIS % of enrollees age 32 Annual Meet and/or Corrective action
2000 Specifications, years and older with HEDIS exceed plan and sanctions if
page 91 diabetes who received Report National the measure is less
a retinal eye exam in Measures and/or than the National
the reporting year Commercial HEDIS standard for
HEDIS the most recent years
measures reported data.
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2. HbA 1c Refer to HEDIS % of enrollees age 32 Annual Meet and/or Corrective action
Testing 2000 Specifications, years and older with HEDIS exceed plan and sanctions if
page 91 diabetes who received Report National the measure is less
a at least 1 test in the Measures and/or than the National
reporting year Commercial HEDIS standard for
HEDIS the most recent years
measures reported data.
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BETA Refer to HEDIS % of enrollees age 35 Annual Meet and/or Corrective action
BLOCKERS 2000 Specifications, and older hospitalized HEDIS exceed plan and sanctions if
page 84 and discharged with Report National the measure is less
the diagnosis of acute Measures and/or than the National
myocardial infarction Commercial HEDIS standard for
who received a HEDIS the most recent years
prescription for beta measures reported data.
blockers
- --------------------------------------------------------------------------------------------------------------------
EPSDT* Medicaid eligible % of EPSDT Enrollees Quarterly 85% Establish benchmarks
children age 0-21 receiving EPSDT in the first 90 days of
screen operation. Establish
corrective action plan
and assess financial
penalties in fast year
if performance is less
than 85% of
benchmark.
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* The Contractor shall comply with all EPSDT requirements as per the Salazar
court order.
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Table 2
DCHFP Mental Health Care Performance Measures
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**Quarterly Goal,
Measure Description Progression Corrective Action/Sanctions
- -------------------------------------------------------------------------------------------------------
Prenatal Care % of women who began 1st year 65% Corrective action plan and
prenatal care during first 2nd year 75% sanctions in the first year if
13 weeks of pregnancy 3rd year 85% measure is less than 65%
based on the aggregate
MCO score; in the second
year if measure is less than
75% based on the aggregate MCO
score, in the third year if
measure is less than 85% based
on the aggregate MCO score.
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Eye exam for diabetes % of Enrollees age 32 1st year 65% same
years and older with 2nd year 75%
diabetes who received a 3rd year 85%
retinal eye exam in the
reporting year
- -------------------------------------------------------------------------------------------------------
Beta blockers % of Enrollees age 35 and 1st year 65% same
older hospitalized and 2nd year 75%
discharged with the 3rd year 85%
diagnosis of acute
myocardial infarction who
received a prescription for
beta blockers
- -------------------------------------------------------------------------------------------------------
**The progressive percentage goals are based on the DC MAA's belief that a
continuous level of improvement towards 100% compliance best serves the managed
care Medicaid population in providing quality service. Sanctions will be
implemented based on the MCO's rating as compared to the aggregate average of
all MCO's for the category. DC MAA reserves that right to evaluate each MCO's
incremental progress in meeting the Physical Health Care Performance Measures
weighing the totally of performance and efforts to enhance compliance.
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CONTRACT NO.: P0HC-2002-D-0003 132
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C.17.7.1 Quality Improvement Reports
C.17.7.1.1 The Contractor shall submit to the MAA the
following information relating to the quality
assurance activities described in this
section as they occur during the term of the
contract:
a) Descriptions of, and results obtained
from, clinical studies and analyses of
the quality and appropriateness of care;
and
b) Copies of the questionnaires used by the
Contractor to conduct consumer and
provider satisfaction studies and
memoranda and analyses regarding the
results of such studies in accordance
with Section F.4.
C.18 RESERVED.
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SECTION D - PACKAGING AND MARKING
D. Packaging and Marking ..................................................135
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CONTRACT NO.: P0HC-2002-D-0003 134
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Section D
D. PACKAGING AND MARKING
D.1.1 Packing and Marking
D.1.1.1 The Contractor shall package and mark all deliverables
in such a manner that will ensure acceptance by common
carrier and safe delivery at the destination.
D.1.2 Address
D.1.2.1 Unless otherwise specified, all deliverables under this
contract will be shipped prepaid, FOB Destination, to
the following address:
Department of Health
Medical Assistance Administration
Managed Care Administration
Fifth Floor
825 North Capitol Street, NE
Washington, DC 20002
D.1.3 All reports shall prominently show on the cover of the report:
(1) name and business address of the contractor
(2) contract number
(3) contract dollar amount
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SECTION E - INSPECTION AND ACCEPTANCE
E. Inspection and Acceptance....................................
E.l Inspection of Work Performed.................................
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Section E
E. INSPECTION AND ACCEPTANCE
E.l Inspection of Work Performed
E.1.1 Right to Enter Premises
The Medical Assistance Administration or any authorized representative
of the District of Columbia, the U.S. Department of Health and Human
Services, the U.S. Comptroller General, the U.S. General Accounting
Office, or their authorized representative shall, at all reasonable
times, have the right to enter the Contractor's premises or such other
places where duties under this contract are being performed to
inspect, monitor, or otherwise evaluate (including periodic systems
testing) the work being performed. The Contractor and all
subcontractors shall provide reasonable access to all facilities and
assistance to the District and federal representatives. All
inspections and evaluations shall be performed in such a manner as
will not unduly delay work.
E.l.2 Inspection of Supplies: See Section I.4 regarding the requirements
related to Inspection of Supplies.
E.l.3 Inspection of Services: See Section I.5 regarding the requirements
related to Inspection of Services.
E.l.4 Inspection and Acceptance-Destination: Inspection and acceptance of
the supplies/services to be furnished hereunder shall be made at
destination by the Contracting Officer Technical Representative (COTR) or
his/her duly authorized representative.
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CONTRACT NO.: P0HC-2002-D-0003 137
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SECTION F - DELIVERIES OR PERFORMANCE
F. Term of Contract ................................................... 139
F.l Base Period ........................................................ 139
F.2 The Per Member Per Month (PMPM) rate for the option period
shall be as specified in the contract .............................. 139
F.3 Implementation Plan Deliverables ................................... 139
F.4 Comprehensive Reporting Requirements ............................... 141
F.5 Deliverables - Submission and Acceptance ........................... 149
F.6 Notice of Disapproval .............................................. 149
F.7 Resubmission with Corrections ...................................... 149
F.8 Notice of Approval/Disapproval of Resubmission ..................... 149
F.9 MAA Fails to Respond ............................................... 149
F.10 Representations .................................................... 149
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Section F
F. TERM OF CONTRACT
F.l BASE PERIOD
F.1.1 The period of performance of this contract shall be from date of
award through October 31, 2002.
F.l.l.l The District may extend the terms of this contract by
exercising up to four (4) one year options periods.
F.l.l.2 The exercise of an option is subject to the
availability of funds at the time of the option period.
F.l.2 Option to Extend the Term of the Contract
F.l.2.1 The District may extend the term of this contract for a
period of one (1) year or multiple successive fractions
thereof, by written notice to the Contractor before the
expiration date of the contract. The District will give
the Contractor a preliminary written notice of its
intent to extend at least thirty (30) days before the
contract expires. The preliminary notice does not
commit the District to an extension. The Contractor may
waive the thirty (30) day notice requirements by
providing a written notice to the Contracting Officer
prior to expiration of the contract.
F.2 The Per Member Per Month (PMPM) Rate for the Option Period Shall be as
Specified in the Contract.
F.2.1 If the District exercises this option, the extended contract shall be
considered to include this option provision.
F.2.2 Maximum Duration of Contract Option
F.2.2.1 The total duration of the contract including the
exercise of the exercise of any options, shall not
exceed five (5) years.
F.3 Implementation Plan Deliverables
The Offeror shall submit the following deliverables for the DCHFP
initiative.
The table below indicates the deliverables that are required.
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Table 4
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[Illegible] [Illegible] [Illegible]
- ----------------------------------------------------------------------------------------------
Member Handbook/other X Final 30 days after contract signing
Enrollment Materials (i.e., provider date.
directory)
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EPSDT description for Enrollees X Final 30 days after contract signing
date.
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Network Refinements Plan 60 days after contract signing date.
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Provider Manual including provider X Final 10 days after contract signing
policies and medical necessity date.
criteria
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List of designated contacts and X 60 days after contract signing date.
MOU for the following agencies:
... DC Public Schools, Special
Education
... Dept. of Human Services Early
Intervention Program,
... Child and Family Services
Agency/LaShawn Receiver
... Dept. of Human Services Youth
Services Administration
... Commission on Mental Health
Services/Dixon Transitional Receiver
- ----------------------------------------------------------------------------------------------
Quality Improvement Plan X Final 45 days after contract signing.
Updates annually 30 days after start
of each contract year
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Standards for identification of X Final 15 days after contract signing
children with special health care
needs
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Reports on Performance Measures X Quarterly
as specified in Sections C. 17.7 and
Section C. 18.7
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Reporting Requirements specified X Per schedule in Section F.4
in Section F.4
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F.4 Comprehensive Reporting Requirements
F.4.1 The Contractor shall submit the deliverables cited below for MAA
acceptance and approval. Table 5 indicates which reports are required for
the DCHFPs.
F.4.2. The Contractor shall submit reports to the COTR according to the
following timelines, unless other wise indicated below:
F.4.2.1 Annual reports shall be submitted within thirty (30)
days following the twelfth month after the contract
start date;
F.4.2.2 Bi-annual reports shall be submitted thirty (30) days
following each six month interval following the
contract start date;
F.4.2.3 Quarterly Reports shall be submitted within thirty (30)
days following the end of the preceding quarter by
April 30, July 30, October 30, and January 30;
F.4.2.4 Monthly reports shall be submitted within thirty (30)
days following the end of each month; and
F.4.2.5 Failure to submit timely, accurate reports may result
in sanctions and liquidated damages described in
Section G.7 and Section G.8.
F.4.3. The Contractor shall ensure that any reports that contain
information about individuals which are protected by privacy laws shall be
prominently marked as confidential and submitted to MAA in a fashion that
ensures that unauthorized individuals do not have access to the
information. No such reports shall be made public by the Contractor.
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Table 5
Reporting Requirements Summary
- ---------------------------------------------------------------------------------------
Reporting
Aspect Of Care And Report DCHFP Schedule Source
- ---------------------------------------------------------------------------------------
I. MCO's Capacity To Provide Services
- ---------------------------------------------------------------------------------------
Number of Medicaid PCPs and Dentists X Quarterly Contractor database
... With fully open panels NCQA
... With partially restricted panels
... Who are Specialists authorized to serve
as PCPs
- ---------------------------------------------------------------------------------------
PCPs by zip code of office locations X Quarterly Contractor database
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New Enrollee assignments to PCPs X Quarterly Contractor database
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Number of mental health practitioners X Quarterly Contractor database
... With open panels
... With partially restricted panels
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II. Access to Care
- ---------------------------------------------------------------------------------------
Penetration: number of Enrollees receiving X Quarterly Claims data
any health service per 1,000 member and
months Annually
- ---------------------------------------------------------------------------------------
Reserved
- ---------------------------------------------------------------------------------------
Time between request for service and X Bi-annually Survey Data
scheduling of appointment for:
... Physical health care
... Specialty health care
Mental health
... Within 7 days
... Within 14 days
... Within 21 days
... Beyond 30 days
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Availability and utilization of language X Bi-annually Contractor database
interpretation services. Current HEDIS
Requirement
- ---------------------------------------------------------------------------------------
Mental Health Care Benefit Expenditures X Quarterly Claims data
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III. Process of Care
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Preventive and Ambulatory Services
- ---------------------------------------------------------------------------------------
Health Education Activities Summary X Quarterly Contractor
documentation
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Reporting
Aspect Of Care And Report DCHFP Schedule Source
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... Number of Enrollees due for an EPSDT X Quarterly Encounter Data and
service EPSDT tracking
... Number of Enrollees who received all system
scheduled EPSDT services Number who HCFA
received any dental service
... Number who completed dental treatment
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Percentage of enrolled children screened X Quarterly EPSDT tracking
for mental health/alcohol and drug abuse system and
needs encounter data
- ---------------------------------------------------------------------------------------
... Childhood immunization status X Quarterly EPSDT tracking
... Adolescent immunization status system and
encounter data
Current HEDIS
Requirement NCQA
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Number and rate of lead screening X Quarterly Claims data
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Percentage of adults screened for mental X Annually Chart reviews
health/alcohol and drug abuse needs Contractor database
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Cancer screening X Annually Encounter data
... Breast cancer Current HEDIS
... Cervical cancer Requirement
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Prenatal, Perinatal and Newborns
- ---------------------------------------------------------------------------------------
Prenatal care visit for each trimester of X Quarterly Claims data
pregnancy Current HEDIS
Requirement NCQA
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First prenatal care visit within six weeks X Quarterly Claims data
of enrollment NCQA
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Check-ups after delivery X Quarterly Claims data
Current HEDIS
Requirement NCQA
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Number of live births and average length X Quarterly Claims data
of stay for all, well and complex newborns Current HEDIS
Requirement NCQA
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Cesarean section rate, VBAC, days and X Quarterly Claims data
ALOS for deliveries Current HEDIS
Requirement NCQA
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Time from birth to first outpatient visit X Monthly Claims data
for newborn
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Specialty Care
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Reporting
Aspect Of Care And Report DCHFP Schedule Source
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Number of encounters by age group and X Quarterly Claims data
specialty-Unduplicated Enrollees
- ---------------------------------------------------------------------------------------
Diabetes Care
- ---------------------------------------------------------------------------------------
Eye exams for people with diabetes X Quarterly Encounter data
NCQA
- ---------------------------------------------------------------------------------------
Comprehensive diabetes care X Annually Encounter data
Voluntary Current
HEDIS
Requirement
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Asthma Care
- ---------------------------------------------------------------------------------------
ER visits for asthma per 1,000 Enrollees X Monthly Encounter data
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Cardiac Care
- ---------------------------------------------------------------------------------------
Beta Blocker treatment after heart attack X Bi-Annually Encounter data
Current HEDIS
Requirement
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Cholesterol management after acute X Quarterly Encounter data
cardiovascular events Current HEDIS
Requirement
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Hospital Care
- ---------------------------------------------------------------------------------------
Hospital discharges and days/1,000 X Quarterly Claims data
member months NCQA
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Number of hospital admissions for: X Annual Encounter data
Ambulatory care
Sensitive conditions
- ---------------------------------------------------------------------------------------
Emergency Room
- ---------------------------------------------------------------------------------------
Number of ER denials/1,000 member X Monthly Encounter data
months NCQA
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Number of ER approvals/ 1,000 member X Bi Annually Encounter Data
months NCQA
- ---------------------------------------------------------------------------------------
Injury related admissions X Bi Annually Encounter data
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Inpatient Mental Health/Substance Abuse
- ---------------------------------------------------------------------------------------
Psychiatric Inpatient re-admissions within X Quarterly Claims data
30 days
- ---------------------------------------------------------------------------------------
Number of denied inpatient psychiatric X Monthly Claims data
days/1,000 member months by reason
- ---------------------------------------------------------------------------------------
Outpatient Mental Health
- ---------------------------------------------------------------------------------------
Number of outpatient mental health visits X Quarterly Encounter data
by provider type, number of unduplicated and Current HEDIS
clients by age, and average visits per client Annually Requirement
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Reporting
Aspect Of Care And Report DCHFP Schedule Source
- ---------------------------------------------------------------------------------------
Follow-up after hospitalization for mental X Annually Claims data,
illness Current HEDIS
Requirement
- ---------------------------------------------------------------------------------------
Residential Treatment
- ---------------------------------------------------------------------------------------
Number of admissions to residential X Quarterly Claims data
treatment/1,000 member months
... Number of in-area admissions
... Number of admissions out-of-area
- ---------------------------------------------------------------------------------------
Number of days in residential treatment per X Quarterly Claims data
1,000 member months and average length
of stay per discharge
... Distribution and average length of stay
for all current placements
... Disposition of discharges
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Percentage of requests for residential care X Quarterly Authorization data
diverted
... Disposition of diversion
- ---------------------------------------------------------------------------------------
Readmission within 30 days of adolescents X Quarterly Claims data
discharged from residential care
... To residential only
... To residential or psychiatric inpatient
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Other Institutional Care
- ---------------------------------------------------------------------------------------
Log of children in institutional care during X Monthly Contractor database
the month indicating name, ID, facility
(other than acute hospitals and residential
treatment facilities), primary treatment
need, date of admission, total days to date,
discharge potential, target discharge date,
date of discharge, discharge disposition
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Pharmacy
- ---------------------------------------------------------------------------------------
Summary Statistics to include the X Monthly Contractor
following, provided by Category of Aid: pharmacy claims
... # Prescriptions per 1,000 members database
... # Utilizing Members
... % Single source drugs (based on number
of prescriptions)
... Average cost per generic prescription
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Reporting
Aspect of Care And Report DCHFP Schedule Source
- ---------------------------------------------------------------------------------------
Number of Drug Claims Rejected (due to X Monthly Contractor
Prior Authorization and/or non-formulary pharmacy claims
status) database
Number of rejected claims for which Prior
Authorization was immediately secured
- ---------------------------------------------------------------------------------------
Top 100 drugs (by drug name, not NDC) X Quarterly Contractor
based on total cost pharmacy claims
Includes drug cost, amount paid, # database
prescriptions, average cost per prescription
and PMPM cost)
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Top 100 drugs (by drug name, not NDC) X Quarterly Contractor
based on number of prescriptions pharmacy claims
Includes drug cost, amount paid, # ease
prescriptions, average cost per prescription
and PMPM cost)
- ---------------------------------------------------------------------------------------
Therapeutic Class Summary Report X Quarterly Contractor
Includes drug cost, amount paid, # pharmacy claims
prescriptions, average cost per prescription database
and PMPM cost in descending cost order.
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IV. Quality Management
- ---------------------------------------------------------------------------------------
Provider Profiling Reports X Annually Contractor database
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Medical Necessity Criteria X As Contractor database
requested by
MAA
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Formulary (if any) X Annually/ Contractor database
Changes
submitted
Quarterly
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Serious incident summary X Quarterly Contractor database
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Summary of chart reviews X Quarterly Chart reviews
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Comprehensive identification of enrolled X Monthly Contractor database
children with special healthcare needs
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Report on clinical initiatives X Annually Contractor database
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V.Administrative Reports
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Reporting
Aspect of Care And Report DCHFP Schedule Source
- ---------------------------------------------------------------------------------------------
Changes made to policies and procedures X Annually, Contractor database
... Marketing plans/marketing materials except
... Utilization review activities material
... Provider procedure manuals changes to
... Quality improvement program be reported
... Claims payment prior to
implementation
of
policy
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Percentage of new Enrollees who attended X Bi-annually Contractor database
an orientation or received a telephone or at-
home orientation
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... Claims processing X Quarterly Contractor database
... Claims aging report
... Claims paid
... Claims denied
... Claims pended
... Average days from receipt to
adjudication
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Third party liability reports X Quarterly, Contractor database
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Independent Audit of Physician Incentive X Annually 30 Independent Audit
Plan days prior to
renewal of
contract
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Total Contractor enrollment, all lines of Quarterly Contractor database
business
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VI.MCO Financial Status
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Medicaid-only financial statements, X Quarterly Contractor database
including balance sheets and Income
Statements by Category of Aid
... Total revenues
... Medical expenses
... Incurred but not reported medical
expense estimate
... Administrative expenses
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Independent audited financial statements X Annually Contractor database
plan-wide and DC Medicaid members
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VII: Member Satisfaction
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Reporting
Aspect of Care And Report DCHFP Schedule Source
- --------------------------------------------------------------------------------------------
Number and rate of Enrollees who change X Quarterly Contractor
PCPs Database
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Number of complaints by type X Monthly Contractor
Database
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Number of grievances and appeals filed by X Monthly Contractor
type and disposition Database
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Number of expedited grievances requested X Monthly Contractor
Database
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Average length of time required to process Monthly Contractor
expedited grievances in days) Database
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Health plan member services telephone X Quarterly Contractor
abandonment rate Database
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Health plan member services telephone X Quarterly Contractor
average speed of answer Database
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Enrollee satisfaction survey results X Annually Survey Data
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VIII. Provider Satisfaction
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Rate of PCP turnover X Annually Contractor database
Current HEDIS
Requirement
- --------------------------------------------------------------------------------------------
Summary of Provider Satisfaction Survey X Annually Survey data
Results
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Deliverables - Submission and Acceptance
F.5.l Due Dates
F.5.l.l The Contractor shall perform its tasks and produce the
required Deliverables by the due dates presented in
Section F.3. and Section F.4.
F.6 Notice of Disapproval
F.6.1 MAA shall provide written notice of disapproval of a Deliverable to
the Contractor within thirty (30) days of submission if it is disapproved.
The notice of disapproval shall state the reasons for disapproval as
specifically as is reasonably necessary and the nature and extent of the
corrections required for meeting the Contract requirements.
Resubmission With Corrections
F.7.1 Within fourteen (14) business days after receipt of a notice of
disapproval, the Contractor shall make the corrections and resubmit the
Deliverable.
Notice of Approval/Disapproval of Resubmission
F.8.1 Within thirty (30) business days following resubmission of any
disapproved Deliverable, the MAA Contract Administrator shall give written
notice to the Contractor of the Medical Assistance Administration's
approval, conditional approval or disapproval.
MAA Fails to Respond
In the event that MAA fails to respond to a Contractor's resubmission
within the applicable time period, the Contractor may elect either of the
following two (2) courses:
F.9.1.1 Notify MAA in writing that it intends to proceed with
subsequent work unless MAA provides written notice of
disapproval within fourteen (14) days from the date MAA
receives the Contractor's notice.
F.9.1.2 Notify MAA that it intends to delay subsequent work
until MAA responds in writing to the resubmission.
Representations
F.10.1 By submitting a Deliverable, the Contractor represents that to the
best of its knowledge, it has performed the associated tasks in a manner
that will, in concert with other tasks, meet the objectives stated or
referred to in the Contract. By approving a Deliverable, the MAA represents
only that it has reviewed the Deliverable and detected no errors or
omissions of sufficient gravity to defeat or substantially threaten the
attainment of those objectives and to warrant the
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CONTRACT NO.:P0HC-2002-D-0003 149
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withholding or denial of payment for the work completed. MAA's acceptance
of a Deliverable does not discharge any of the Contractor's contractual
obligations with respect to that Deliverable, or to the quality,
comprehensiveness, functionality, effectiveness or certification of the
District of Columbia MAA as a whole.
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CONTRACT NO.:P0HC-2002-D-0003 150
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SECTION G - CONTRACT ADMINISTRATION DATA
G. Contract Administration Data........................................ 152
G.1 Capitation Rate..................................................... 152
G.2 Other Payment Provisions............................................ 152
G.3 Reserved ........................................................... 153
G.4 Upper Payment Limit ................................................ 153
G.5 Provision for Adjustment of Rate ................................... 153
G.6 Right to Withhold Payment .......................................... 153
G.7 Sanctions........................................................... 153
G.8 Liquidated Damage Amounts:.......................................... 153
G.9 Co-Payment Prohibition ............................................. 155
G.10 Authority of Contracting Officer.................................... 155
G.11 Authorized Changes Only by the Contracting Officer ................. 156
G.12 Contracting Officer Technical Representative (COTR)................. 156
G.13 Continuity of Services ............................................. 157
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CONTRACT NO.:P0HC-2002-D-0003 151
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Section G
G. CONTRACT ADMINISTRATION DATA
The District will pay the Contractor in accordance with its 1915 (b)
waiver, a prospective monthly capitation rate for each Medicaid Managed
Care Program Enrollee that is enrolled with the Contractor on the first day
of each month.
G.1 Capitation Rate
G.1.1 Monthly Payments
G.1.1.1 The District will make monthly capitation payments to
the selected Contractors as compensation for covered
services provided to DCHFP Enrollees in each contracted
DCHFP and Enrollment for each month is finalized by the
fifteenth (15th) of the prior month, and a final
enrollment list for the designated month, including all
continuing Enrollees and those whose enrollment will
begin on the first of that month is submitted to each
Contractor by the 20th of the prior month. The monthly
capitation payment will be based on this final
enrollment list and the applicable PMPM rate. The
Contractor shall reconcile each month's final
enrollment list submitted by MAA with its own records,
and shall report any discrepancies to MAA within thirty
(30) days of receipt.
G.1.2 If an Enrollee reaches a birthday that results in a change in rate
cell or ends coverage under this agreement, or is disenrolled for any
reason, the District will terminate payments to the Contractor for
that Enrollee effective the last day of the month in which the
disenrollment becomes effective. New rates shall begin in the month
following the birthday.
G.1.3 Because the capitation payment will be calculated based on the number
of Enrollees on the first day of each month, no adjustments will be
made for members who are enrolled after the beginning of the month's
payment or disenrolled after the beginning of the month's payment
cycle.
G.2 Other Payment Provisions
G.2.1 Basis for Payment
G.2.1.1 The District will provide a remittance advice to the
Contractor on or before the first of the month that
shall serve as the basis for determining payment for
the month.
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Reserved
Upper Payment Limit
Payments to Contractor shall not exceed the upper payment limits as defined
in 42 C.F.R.447.36l.
Provision for Adjustment of Rate
G.5.1 In the event that the District, pursuant to the Changes Clause of the
Standard Contract Provisions, adds, deletes or changes any services to
be covered by the Contractor under a DCHFP, the District will review
the effect of the change and equitably adjust the capitation rate
(either upwards or downwards) if appropriate. In the event a
capitation rate adjustment needs to be made prospectively, an
actuarial calculation will be made by the District to determine the
increase or decrease in the total cost of care from the instituted
change. If required, the adjusted rate will be applied by the
District. The Contractor may request a review of the program with
assumptions discussed with Contractor's change if it believes the
program change is not equitable; the District will not unreasonably
withhold such a review.
Right to Withhold Payment
G.6.1 The District reserves the right to withhold and/or recoup funds from
the Contractor in accordance with any remedies allowed under the
Contract or any policies and procedures.
G.6.2 The District may withhold portions of capitation payments from health
plans as provided in Section G.8, and elsewhere in the contract. When
the Medical Assistance Administration has determined that the health
plan has failed to provide one or more medically necessary services as
defined in Section C.8.1, the District may withhold an estimated
portion of the health plan's capitation payment in subsequent months.
Sanctions
G.7.1 In addition to any other remedies available to the District, the
District may impose sanctions against the Contractor for poor
performance or noncompliance with contract terms by the Contractor or
its subcontracted providers.
G.7.2 Any recoup or. sanctions imposed by the federal government to the
District, that is related to the Contractor's non-compliance of any
part of the Contract, may be passed to the Contractor.
G.7.3 The Contractor shall be responsible for any fines of sanctions
imposed upon the District by the courts in which the Contractors
failure to meet the requirements of Salazar v. The District of
Columbia et al, or the contract.
Liquidated Damage Amounts
G.8.1 Liquidated damages are set forth in the following table:
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Table 6
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Contract Provision Violated Liquidated Damages
- ----------------------------------------------------------------------------
Medically Necessary Services, Section C.8.1 4*
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Contract provisions related to administrative
responsibilities 1*
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Contract provisions related to other access and quality
of care requirements. 2*
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Failure to submit reports and late reporting 3*
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Denial of services based upon cost of services,
Section C.10.1.11 2*
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1* Up to 1% of one monthly capitation payment for each month or fraction
thereof in which the violation occurs.
2* Up to 2% of one monthly capitation payment for each month or fraction
thereof in which the violation occurs.
3* Up to .5% of one monthly capitation payment for each month or fraction
thereof in which the violation occurs.
4* Up to 3% of one monthly capitation payment for each month or fraction
thereof in which the violation occurs.
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G.8.2 Written notice shall be provided by the Contracting Officer to the
Contractor specifying the sanctions proposed, the grounds for the
liquidated damage, identification of any subcontracted providers
involved in the violation, the amount of funds to be withheld from
payments to the Contractor and steps necessary to avoid future
sanctions.
G.8.3 The Contractor shall complete all steps necessary to correct the
violation and to avoid future sanctions within the time frame
established by the District in the notice of sanctions. Following the
notice of sanctions, a full month's sanctions are due for the first
month or any portion of a month during which the Contractor, or its
subcontracted provider, is in violation. For any subsequent month, or
portion of month, during which the Contractor, or its subcontracted
providers, remains in violation, the District will impose additional
sanctions.
G.8.4 The District will have the right to offset against any payments due
the Contractor until the full sanctions amount is paid. The Contractor
has the right to appeal such adverse action in accordance with the
dispute clause of the contract.
Co-Payment Prohibition
Contractor shall not impose co-payment requirements or other fees on
Enrollees except as directed to do so by MAA, in accordance with the
District's approved Medicaid waiver.
Authority of Contracting Officer
G.10.1 Contracting Officer
G.10.l.l Authority and responsibility to contract for authorized
supplies and services are vested in the Director,
Office of the Contracting and Procurement, who
establishes contracting activities and delegates to
heads of such contracting activities broad authority to
manage the agency's contracting functions. Contracts
may be entered into and signed on behalf of the
District Government only by contracting officers. The
address and telephone number of the Contracting Officer
for this contract is:
Ms. Esther Scarborough, Agency Chief
Contracting Officer
Department of Health
Office of Contracting and Procurement
441- 4th Street, NW
Suite 800 South
Washington, DC 20001
(202) 724-2144
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Authorized Changes Only by the Contracting Officer
G.11.1 The Contracting Officer is the only person authorized to approve
changes elsewhere in this contract.
G.11.2 The Contractor shall not comply with any order, directive or request
that changes or modifies the requirements of this contract, unless
issued in writing and signed by the Contracting Officer, or pursuant
to specific authority otherwise included as part of this contract.
G.11.3 In the event the Contractor effects any change at the direction of
any person other than the Contracting Officer, the change will be
considered to have been made without authority and no adjustment will
be made in the contract price to cover any cost increase incurred as a
result thereof.
Contracting Officer Technical Representative (COTR)
G.12.1 The Contracting Officer Technical Representative (COTR) will have
the responsibility of ensuring the work conforms to the requirements
of this contract and such other responsibilities and authorities as
may be specified in the contract. These may include:
G.12.2 Keeping the Contracting Officer (CO) fully informed of any technical
or contractual difficulties encountered during the performance
period and advising the CO of any potential problem areas under the
contract;
G.12.3 Coordinating site entry for Contractor personnel, if applicable;
G.12.4 Reviewing vouchers for cost-reimbursement type work and recommend
approval by the CO if the Contractor's cost are consistent with the
negotiated amounts and progress is satisfactory and commensurate with
the rate of expenditure;
G.12.5 Reviewing and approving invoices for deliverables to ensure receipt
of goods and services. This includes the timely processing of invoices
and vouchers in accordance with the District's Payment provisions; and
G.12.6 Maintaining a file that includes all contract correspondence,
modifications, records of inspections (site, data, equipment) and
invoices/vouchers.
G.12.7 It is understood and agreed, in particular, that the COTR shall not
have the authority to:
G.12.8 Award, agree to, or sign any contract, delivery order or task order.
Only the CO shall make contractual agreements, commitments, or
modifications;
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G.12.9 Grant deviations from or waive any of the terms and conditions of
the contract;
G.12.10 Increase the dollar limit of the contract or authorize work beyond
the dollar limit of the contract, or authorize the expenditure of
funds by the Contractor;
G.12.11 Change the period of performance; and
G.12.12 Authorize the furnishing of District property, except as specified
under the contract.
G.12.13 The address and telephone number of the Contracting Officer
Technical Representative for this contract is:
Maude Holt
Administrator, Office of Managed Care
Medical Assistance Administration
825 North Capitol Street, NE
Washington, DC 20002
Telephone: (202) 442-9074
Technical Direction
G.13 Continuity of Services
G.13.1 The Contractor recognizes that the services provided under this
contract are vital to the District of Columbia and shall be continued
without interruption and that, upon contract expiration or
termination, a successor, either the District Government or another
contractor, at the District's option, may continue to provide these
services. To that end, the Contractor agrees to:
G.13.1.1 Furnish phase-out, phase-in (transition) training; and
G.14.1.2 Exercise its best efforts and cooperation to effect an
orderly and efficient transition to a successor.
G.13.2 The Contractor shall, upon the Contracting Officer's written notice,
furnish transition services for up to one hundred twenty (120) days
after this contract expires and negotiate in good faith a plan with a
successor that identifies the nature and extent of transition services
required.
G.13.3 The Contractor shall provide, during the said transition period,
sufficient experienced personnel to ensure that the services provided
under this contract are maintained at the required level of
effectiveness and efficiency.
G.13.4 To facilitate a smooth transition, the Contractor shall allow as
many personnel as practicable to remain on the job to help the
successor maintain the continuity and consistency of the services
required by this
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CONTRACT NO.: P0HC-2002-D-0003 157
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contract. The Contractor also shall disclose, with the consent of the
employees, necessary personnel records and allow the successor to
conduct onsite interviews with those employees. For those personnel
who are interested in accepting a position with the successor and are
selected by the successor, the Contractor shall release them at a
mutually agreeable date.
G.13.5 If authorized in writing by the Contracting Officer, the Contractor
shall be reimbursed for all reasonable transition costs (i.e., costs
incurred within the agreed period after contract
expiration/termination that result from transition operations)
specified under this contract.
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SECTION H - SPECIAL CONTRACT REQUIREMENTS
H. Special Contract Requirements ..................................... 160
H.1 Medical Assistance Administration Role and Responsibilities ....... 160
H.2 Medicaid Program and Recipients Held Harmless ..................... 168
H.3 Responsibility for Prescription Drug Services ..................... 168
H.4 Sanctions for Non-Compliance ...................................... 169
H.5 Readiness Assessment .............................................. 170
H.6 Review and Approval of Subcontracts ............................... 171
H.7 General Subcontract Requirements .................................. 173
H.8 Fraud and Abuse Provisions and Protections ........................ 174
H.9 Physician Incentive Plan .......................................... 177
H.10 Insurance ......................................................... 177
H.11 Financial Requirements ............................................ 178
H.12 Equity Balance, Solvency, and Financial Reserves .................. 179
H.13 Fiduciary Relationship ............................................ 179
H.14 Provider Payment Arrangement ...................................... 179
H.15 Special Provider Payment Arrangements ............................. 179
H.16 Management Information System ..................................... 183
H.17 Wage Rates ........................................................ 185
H.18 Conflict of Interest .............................................. 186
H.19 Security Requirements ............................................. 186
H.20 Key Personnel ..................................................... 187
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Section H
H. SPECIAL CONTRACT REQUIREMENTS
H.1 Medical Assistance Administration Role and Responsibilities
H.1.1 Eligibility, Enrollment and Discharge
The District is responsible for notifying eligibles of their
choices of managed care organizations, assisting them to make a
choice, processing their enrollment, notifying the plans, and
notifying each Enrollee of the opportunity to change enrollment
sixty (60) days before each anniversary of the enrollment. In
order to carry out these responsibilities, the District will
procure the services of an Enrollment Broker. The Enrollment
Broker is responsible for enrolling the DCHFP-related eligibles
into contracted health plan, including administration of default
enrollment procedures. The Enrollment Broker will also be
responsible for maintaining, transmitting, and verifying
enrollment data. In addition, the Enrollment Broker will maintain
a consumer information telephone line to address consumer
questions.
H.1.1.1 Overall Enrollment Process
The notification and enrollment process for DCHFP
eligibles will be as follows: For TANF eligibles, MAA's
Enrollment Broker will send a notification letter to
the family or representative of each eligible
individual designated for notification, advising the
family or representative of the requirement to select a
plan. The letter will also inform each family or
representative that in the event the family or
representatives do not exercise the right to choose,
MAA will assign the individual to a plan. In addition,
the Enrollment Broker will distribute a reminder notice
(by mail or in person) ten (10) days before the
deadline for selecting a plan.
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H.1.1.1.1 In the event that the eligible individual or
representative of an eligible individual does
not exercise the right to choose within
thirty (30) days of the date of the
notification letter, the Enrollment Broker
will automatically assign the individual to a
Contractor according to assignment rules set
forth in this section, applicable to DCHFP.
H.l.1.1.2 By the fifteenth (15th) of the month, MAA
will notify each Contractor of all automatic
enrollments made to its DCHFP. These
enrollments shall have an effective date for
enrollment of the first day of the following
month.
H.l.l.l.3 MAA will provide the Contractor with a
preliminary hard copy listing and a computer
readable file containing information on
eligible Enrollees who are either voluntarily
enrolled in or auto-assigned to the
Contractor. MAA will send the listing to the
Contractor by the thirtieth (30th) day of the
month.
H.l.l.l.4 The database shall include the following
information:
a) Enrollee's name, recipient
identification number, phone, address
and birth date;
b) Enrollee's Medicaid eligibility code;
c) Method of enrollment - voluntary or
auto-enrollment;
d) Current PCP or provider; and
e) Indication of designated high-risk
conditions, if any are known to the
Enrollment Broker.
H.l.l.l.5 The effective date of enrollment for
individuals who are voluntarily enrolled or
are auto-assigned to the Contractor will be
the first (1st) day of the second (2nd) month
following the District's notification letter.
H.l.l.l.6 An eligible individual or a representative
for the individual may choose to disenroll
from a Contractor during the individual's
first
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ninety (90) days of enrollment or during the
ninety (90) day period beginning upon every
anniversary of the Enrollee's date of
enrollment. In such a case, the individual or
his or her representative shall select and
enroll in another plan.
H.1.1.1.7 An individual who has been enrolled with a
Contractor for ninety (90) days from the date
of enrollment is locked in with that
Contractor's plan and may disenroll from the
plan between the ninety-first (91st) day and
the three-hundred-sixty-fifth (365th) day of
enrollment, only upon showing good cause as
determined by the Medical Assistance
Administration.
H.1.1.1.8 A family or representative of an eligible
child that seeks disenrollment of the child
from the Contractor shall notify the
Contractor or MAA of the disenrollment
request. If the request is approved by the
District on or before the fifteenth (15th)
day of the month then the child will be
disenrolled effective the first (1st) day of
the next month. If the request is approved
after the fifteenth (15th) day of the month,
then the child will be disenrolled no later
than the first (1st) day of the second (2nd)
month.
H.l.l.l.9 The Dixon Transitional Receiver/CMHS will
review ail instances where the precipitating
factors for the disenrollment request pertain
to mental illness or alcohol and drug abuse,
and advise MAA on a course of action. MAA
shall make the final decision to disenroll
any Enrollee.
H.l.l.2 Newborn Enrollment
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H.l.l.2.1 The Contractor shall notify MAA and Income
Maintenance (IMA) of the birth of a newborn
no later than ten (10) business days after
the birth.
H.l.l.2.2 If the mother changes enrollment to another
health plan the newborn will stay with the
health plan of record on the date of birth
until the newborn receives a Medicaid number.
H.l.l.2.3 If the Contractor fails to notify IMA and MAA
of the birth of a newborn via the newborn
notification form in Attachment AA, within
ten (10) business working days of the birth,
MAA will not reimburse the Contractor for
services rendered to the newborn.
H.l.l.2.4 If the mother wants to select a health plan
for the newborn other than the health plan of
record on the newborn's date of birth, the
Contractor shall inform the mother that she
shall first receive a Medicaid number from
the Income Maintenance Administration for the
newborn. Upon receipt of the Medicaid number,
the mother may select another health plan for
her newborn.
H.l.l.2.5 When the Medicaid number for the newborn is
received, the newborn will be enrolled in the
health plan requested.
H.l.l.2.6 If the OMC has failed to notify the health
plan of the newborn's Medicaid number by the
fifteenth (15th) day of the sixth (6th)
month, the health plan shall disenroll the
child from the health plan at the end of the
sixth (6th) month.
H.l.l.3 Disenrollment of Enrollees
H.1.1.3.1 Prior to a request for disenrollment, the
Contractor shall provide a written notice to
the Enrollee and afford the Enrollee the
opportunity to describe the circumstances of
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the dispute. MAA will reach a decision on
Contractor's request within five (5) working
days of receipt of the request. The Enrollee
has the right to appeal the District's
determination to the Office of Fair Hearing
as described in Section C.14.
H.l.l.3.2 Involuntary disenrollment under this section
shall be effective not later than the first
(1st) day of the second (2nd) month following
the approval of the involuntary disenrollment
by the District.
H.1.1.3.3 Except as provided in Section C.17.2, no
Enrollee shall be disenrolled solely because
of an adverse change in health status.
H.l.l.4 Provider Training
H.l.l.4.1 MAA has the right to restrict the assignment
of new Enrollees to any Contractor, which has
not met the provider training requirements in
Section C.9.4.4.
H.l.l.5 Effective Date of Enrollment for non Medicaid Immigrant
Eligible Children
H.1.1.5.1 Non-Medicaid eligible immigrant children will
be enrolled or auto assigned upon the date
they are deemed eligible by the Income
Maintenance Administration. Children who are
deemed eligible on or after the sixteenth
(16th) of the month will be assigned to the
Contractor effective the first of the
following month.
H.l.l.5.2 Children that are deemed eligible prior to
the sixteenth (16th) of the month will be
assigned to a Contractor, effective
immediately.
H.l.l.6 Notification of the Opportunity to Change Enrollment
H.l.l.6.1 MMA's Enrollment Broker will send a
notification letter (by mail or in person)
sixty (60) days prior to the annual
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enrollment date to the individual, family or
representative of each eligible individual
designated for notification, advising of the
opportunity to change enrollment.
H.1.1.7 DCHFP Enrollment Process
The following describes the schedule for notification
and enrollment into the Contractors selected under this
requirement for DCHFP and DCHFP-related individuals.
H.1.1.7.1 One month after the date of contract signing,
the District's Enrollment Broker will send a
notification letter to all eligible
individuals. The letter will advise the
following two groups regarding the steps in
the enrollment and selection process.
H.1.1.7.2 Current Enrollees of plans not selected to
continue in MMCP will be notified by the
District that they must choose a new plan
from one of the Contractors selected as a
result of this procurement. As outlined in
Section 0, Enrollees will have thirty (30)
days to select a new plan and those Enrollees
who do not make a selection will be
automatically assigned to a Contractor.
H.1.1.7.3 Current Enrollees of plans that will be
continuing as DCHFPs will be notified that
they may remain in the current plan or select
a new plan. These Enrollees will also be
notified of the lock-in provision as
described in Section H.1.1.1.7. Enrollees who
fail to communicate a choice by the selection
deadline will continue to be enrolled with
their current plan.
H.l.l.7.4 Individuals who do not voluntarily select a
plan within thirty (30) days will be
automatically assigned, except as been
provided in Section H.l.l.7.3. Each of the
selected contractors will receive an equal
share of the default.
H.1.1.8 RESERVED
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H.l.l.9 An individual who has been enrolled in one Plan, and
disenrolled within ninety (90) days to enroll in the
other Plan, will have the right to disenroll from the
second plan within ninety (90) days. However, if the
individual re-enrolls in the first plan, he or she
shall only be disenrolled for cause during the first
three hundred sixty-five (365) days of re-enrollment.
H.1.1.10 An Enrollee shall be disenrolled due to loss of
eligibility under the following circumstances:
H.1.1.10.1 If the Enrollee is no longer eligible for
SSI benefits or Medicaid, disenrollment shall
be effective no later than the first (1st)
day of the first (1st) full month following
the loss of eligibility; or
H.l.l.10.2 If the Enrollee reaches his or her
twenty-second (22nd) birthday the
disenrollment shall be effective not later
than the first (1st) day of the first (1st)
full month following the date of the
Enrollee's twenty-second (22nd) birthday.
H.1.1.11 RESERVED
H.l.2 Network Composition Requirements
H.l.2.1 The Contractors shall contract for the provision of
primary care services, preventive care services, and/or
specialty/referral services with Federally Qualified
Health Centers (FQHCs) or FQHC look-alike if an FQHC or
FQHC look alike is not selected to be a Contractor. The
Contractors shall ensure Enrollees currently using FQHC
services shall be offered the opportunity to continue
receiving services from the FQHC. Additionally, if an
FQHC or FQHC look alike is not selected to be a
Contractor as a result of this then all selected
Contractors shall negotiate a formal agreement that
specifies the services and value of the contract with
the FQHC.
H.l.2.2 The Public Benefits Corporation (PBC) is an important
safety-net provider for Medicaid eligible and uninsured
individuals. The Contractor shall include the PBC in
its network and shall contract with the PBC for the
provision
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of hospital, primary care services, emergency services,
preventive care services, and/or specialty/referral.
Enrollees who currently use the services of PBC shall
be encouraged to continue their care through the PBC.
The Contractor shall negotiate a formal agreement that
specifies the services and value of the contract it
will enter into with the PBC.
H.l.3 Coordination with Other Medicaid Services
H.1.3.1 Medicaid Mental Health and Alcohol and Drug Abuse
Services.
H.l.3.1.1 MAA will furnish each contracted DCHFP with
copies of a Mental Health/ Alcohol and Drug
Abuse Directory listing the names, services
and locations of the mental health and
alcohol and drug abuse treatment providers
certified as Medicaid providers by the
District of Columbia.
H.l.3.1.2 MAA will review validated screening tools for
identification of mental health and alcohol
and drug abuse problems in primary care
settings, and shall select a tool or tools
for implementation by all Primary Care
Providers in MMCP networks.
H.l.3.1.3 MAA may update procedures and protocols for
referral and coordination between DCHFPs and
certified Medicaid mental health and alcohol
and drug abuse providers in the
fee-for-service system.
H.l.3.1.4 MAA will develop, with input from contracted
DCHFP, protocols, policies and procedures for
the referral and care coordination of
Enrollees in need of alcohol and drug abuse
treatment.
H.l.3.2 Transplant Surgery
H.l.3.2.1 Transplant surgery services provided during
the inpatient stay in which the transplant
surgery takes place will not be covered by
the Contractor but will be covered by the
Medicaid program and reimbursed by MAA
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on a fee-for-service basis in accordance with
the rate or methodology described in the
State Plan of Medical Assistance.
H.l.3.3 Periodic Review of Claims Files and Medical Audits
MAA or its agent will periodically review claims files
and audit medical records, in conformance with HCFA
requirements.
H.l.3.4 Evaluation
The terms of HCFA's waiver approval requires that the
Medicaid waiver program as operated by the selected
health plans, including DCHFP, shall be evaluated over
the two-year wavier period.
Medicaid Program and Recipients Held Harmless
H.2.1 Parties held Harmless
H.2.2.1 In addition to the obligations set forth in Clause 10,
of the Standard Contract Provisions, the Contractor
shall hold harmless the District government, the
Department of Health and the Enrollee against any loss,
damage, expense and liability of any kind that arises
from any action of the organization or its
subcontractors in the performance of this contract.
H.2.2 Subcontracts Look Solely to Contractors
H.2.2.1 Each subcontract shall contain a provision that
requires the subcontractor to look solely to Contractor
for payment for services rendered.
Responsibility for Prescription Drug Services
H.3.1 The Contractor shall be responsible for the payment of all medically
necessary prescription drugs written for its Enrollees including
prescribed drugs required for the treatment of mental illness and
addiction disorders and the treatment related to organ transplants
prescribed outside the hospital inpatient stay in which the transplant
occurred. The Contractor shall also be responsible for the payment of
durable medical equipment related to diagnosis issues, such as glucose
monitors and test strips for the treatment of diabetes.
H.3.2 The Contractor is responsible for providing the MAA Office of Managed
Care a copy in writing of all denials of prescription drugs within
seventy
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two (72) hours of such denial. MAA reserves the right to access all
denials and grievances to ensure the Contractor is providing
appropriate care and adhering to all legal requirements.
H.3.3 MAA reserves the right to require the Contractor to provide detailed
pharmacy claims on a regular basis in order to develop a coordinated
prospective drug utilization review program.
H.3.4 The Contractor's formulary shall be approved by MAA before being
implemented. MAA shall consult the Commission on Mental Health
Services/Dixon Transitional Receiver for review and approval of the
formulary with respect to psychotropic medications.
H.3.5 MAA shall consult with the Commission on Mental Health Services/Dixon
Transitional Receiver for review and approval of the Contractor's
prior approval process for psychotropic medications.
H.4 Sanctions for Non-Compliance
H.4.1 Written Notice to Contractor
H.4.1.1 In addition to its rights under the Default Clause of
the Standard Contract Provisions, if the District
determines that the Contractor has failed to comply
with terms of this contract or has violated applicable
federal or District law or regulation or court orders
including but not limited to Salazar v. the District of
Columbia et al., the District may after 30 days written
notice of intent to the Contractor:
H.4.1.2 Require submission of a corrective action plan before
exercising the right to impose any other sanctions for
non-compliance authorized by this section;
H.4.1.3 Freeze enrollment;
H.4.1.4 Withhold part of the Contractor's payment;
H.4.1.5 Forfeit all or part of the deposit identified in
Section H.16.1;
H.4.1.6 Deny payments for new Enrollees under 42 C.F.R. 434.42;
H.4.1.7 Impose a financial sanction as approved by HCFA; and/or
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H.4.1.8 Utilize any other sanctions set forth in 29 DCM.R.
5320, et seq., as may be amended from time to time.
H.4.2 Denial of Payment by the Health Care Financing Administration
H.4.2.1 Payments provided for under this contract, shall be
denied for new Enrollees when and for so long as,
payment for those Enrollees is denied by the Health
Care Financing Administration under 42 C.F.R.
434.67(e).
Content of Notice
H.4.3.1. Before taking any action described in Section 0, the
District will provide written notice which shall
include at least the following:
a) A citation to the law or regulation or
contract provision that has been
violated;
b) The sanction to be applied and the date
the sanction will be imposed;
c) The basis for the District's
determination that the sanction should
be imposed; and
d) The time frame and procedure for the
Contractor to appeal the District's
determination.
H.4.4 Effective Date
H.4.4.1 A Contractor's appeal of an action pursuant to Section
0 shall not stay the effective date of the proposed
action.
H.5 Readiness Assessment
H.5.1 Contractors to be Reviewed
H.5.1.1 MAA will conduct a readiness assessment of all new
Contractors for DCHFP and any existing Contractors that
MAA determines require review. The Dixon Transitional
Receiver will participate in MAA's Readiness Review.
Timing
H.5.2.1 Readiness assessments will be conducted in the start-up
period, during the second and/or third month after
awards are announced and prior to the enrollment of any
recipients.
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H.5.3 Content of Readiness Assessment
H.5.3.1 The readiness assessment will include site visits and
review of documentation and deliverables that are
required prior to enrollment. Areas of special emphasis
for the readiness assessment may include, but are not
limited to, EPSDT, mental health care and care
coordination capacity, financial capacity, utilization
and quality management, network adequacy, enrollment
activities, provisions for monitoring the transition of
high-risk Enrollees, claims payment procedures and
reporting.
H.5.4 Corrective Action Plan
H.5.4.1 If MAA determines that any potential Contractor has not
met the criteria for readiness, the Contractor will be
notified and required to develop a corrective action
plan acceptable to MAA. Following the implementation of
the corrective action plan, MAA has the right to
conduct a site visit to the Contractor's office, to
verify implementation of the corrective actions. MAA
will approve the Contractor for enrollment once MAA
verifies that the corrective action plan has been
implemented to its satisfaction.
H.5.5 Commencement of Enrollment
H.5.5.l MAA will not delay enrollment procedures eligibles
because a Contractor is not ready for enrollment.
Enrollment procedures will commence in accordance with
this Contract, but eligibles will be offered enrollment
choices only into plans that have been determined to
meet critical criteria for readiness.
H.5.5.2 The effective date of the awarded capitation rate shall
be on date of contract award.
H.6 Review and Approval of Subcontracts
H.6.1 Review and Approval of Subcontract(s).
H.6.1.1 The Contracting Officer will notify the Contractor, in
writing, of its approval or disapproval of a proposed
model subcontract for service providers within fifteen
(15) business days of receipt of the proposed
subcontract and supporting documentation required by
the District. The District will specify the reasons for
any disapproval, which shall be based upon review of
the provisions of this
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contract, the Contractor's proposal, and District or
federal law or regulations.
H.6.1.1.1 A proposed subcontract may be awarded by the
Contractor if MAA fails to notify the
Contractor within the fifteen (15) business
day time limit.
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H.6.1.1.2 The District may delay enrollment or utilize
any other remedy which it deems appropriate
if a Contractor executes a subcontract for
services furnished under this contract that
is materially different from the model
subcontract approved by the District.
H.6.1.1.3 The District may require the Contractor to
furnish additional information relating to
the ownership of the subcontractor, the
subcontractor's ability to carry out the
proposed obligations under the subcontract,
and the procedures to be followed by the
Contractor to monitor the execution of the
subcontract.
H.6.1.1.4 The District may terminate its relationship
with the Contractor if the District
determines that the termination or expiration
of a subcontract materially affects the
ability of the Contractor to carry out its
responsibility under this contract.
H.6.1.1.5 MAA staff will conduct site visits to the
Plan's offices periodically, or as needed,
and may review data on file there. MAA will
provide the Contractor with a copy of the
site visit results. The Contractor shall
submit a plan to correct all deficiencies
identified within fifteen (15) days of
written notification of deficiencies. The
District may terminate this contract for
failure to correct identified deficiencies.
H.7 General Subcontract Requirements
H.71 Allowable Subcontracting
H.7.1.1 The Contractor shall ensure that all activities carried
out by any subcontractor conform to the provisions of
this contract. The terms of any subcontracts involving
the provision or administration of medical services
shall be subject to MAA approval via the Contracting
Officer.
H.7.1.1.1 It is the responsibility of the Contractor to
insure its subcontractors are capable of
meeting the reporting requirements under
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this contract and, if they cannot, the
Contractor is not relieved of the reporting
requirements.
H.7.2 Termination of Subcontract
H.7.2.1 The Contractor shall notify the District Contracting
Officer, in writing, of the termination of any
subcontract for the provision or administration of
medical services, including the arrangements made to
ensure continuation of the services covered by the
terminated subcontract, not less than forty-five (45)
days prior to the effective date of the termination,
unless immediate termination of the contract is
necessary to protect the health and safety of Enrollees
or prevent fraud and abuse. In such an event, the
Contractor shall notify MAA immediately upon taking
such action.
H.7.2.2 If the District determines that the termination or
expiration of a subcontract materially affects the
ability of the Contractor to carry out its
responsibility under this contract, the District may
terminate this contract.
H.8 Fraud and Abuse Provisions and Protections
H.8.1 Cooperation with the District
H.8.1.1 This contract is subject to all state and federal laws
and regulations relating to fraud and abuse in health
care and the Medicaid program. The Contractor shall
cooperate and assist the District of Columbia and any
state or federal agency charged with the duty of
identifying, investigating, or prosecuting suspected
fraud and abuse. The Contractor shall provide originals
and/or copies of all records and information requested
and allow access to premises and provide records to MAA
or its authorized agent(s), HCFA, the U.S. Department
of Health and Human Services, FBI and the District's
Medicaid Fraud Control Unit. All copies of records
shall be provided free of charge. The Contractor shall
be responsible for promptly reporting suspected fraud,
abuse, or violation of the terms of this contract to
MAA via the Contracting Officer, taking prompt
corrective actions consistent with the terms of any
subcontract, and cooperating with MAA investigations.
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H.8.2 Prohibiting Affiliations with Individuals Debarred by Federal
Agencies
H.8.2.1 In accordance with the Social Security Act (Section
1932(d) (1), as amended by the Balanced Budget Act of
1997) or Executive Order, the Contractor may not
knowingly have a director, officer, partner, or person,
who has been debarred or suspended by the federal
government, with more than 5% equity, or have an
employment, consulting, or other agreement with such a
person for the provision of items and services that are
significant and material to the entity's contractual
obligation with the District. The Contractor shall
notify MAA within three (3) days of the time it
receives notice that action is being taken against
Contractor or any person defined under the provisions
of section 1128(a) or (b) of the Social Security Act
(42 USC 1320 a-7) or any subcontractor which could
result in exclusion, debarment, or suspension of the
Contractor or a subcontractor from the Medicaid
program, or any program listed in Executive Order
12549.
H.8.3 Fraud and Abuse Compliance Plan
H.8.3.1 The Contractor shall have a written Fraud and Abuse
Compliance Plan. The Contractor shall submit any
updates or modifications prior to making them effective
to MAA for approval.
H.8.3.1.1 The plan shall ensure that all officers,
directors, managers and employees know and
understand the provisions of Contractor's
fraud and abuse compliance plan.
H.8.3.1.2 The written plan shall contain procedures
designed to prevent and detect potential or
suspected abuse and fraud in the
administration and delivery of services under
this contract.
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H.8.3.1.3 The plan shall contain provisions for the
confidential reporting of plan violations to
the designated person, as described in
Section H.8.3.4.plan.
H.8.3.1.4 The plan shall contain provisions for the
investigation and follow-up of any compliance
plan reports.
H.8.3.1.5 The fraud and abuse compliance plan shall
ensure that the identities of individuals
reporting violations of the plan are
protected.
H.8.3.1.6 The plan shall contain specific and detailed
internal procedures for officers, directors,
managers and employees for detecting,
reporting, and investigating fraud and abuse
compliance plan violations.
H.8.3.1.7 The compliance plan shall require that
confirmed violations be reported to MAA
within 24 hours of it being confirmed.
H.8.3.1.8 The plan shall require any confirmed or
suspected fraud and abuse under state or
federal law be reported to the District of
Columbia Office of the Inspector General
Medicaid Fraud Unit, the Medicaid Program
Integrity section of MAA, and the Office of
Managed Care.
H.8.3.1.9 The written plan shall ensure that no
individual who reports plan violations or
suspected fraud and abuse is retaliated
against.
H.8.3.2 Contractors shall comply with the requirements of the
Model Compliance Plan for HMOs when this model plan is
issued by the U.S. Department of Health and Human
Services, the Office of Inspector General (OIG).
H.8.3.3 Contractors shall designate executive and essential
personnel to attend mandatory training in fraud and
abuse detection, prevention and reporting. The training
will be conducted by the District of Columbia Office of
the
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Inspector General, Medicaid Fraud Unit and will be
provided free of charge. Training shall be scheduled
not later than sixty (60) days after contract award.
H.8.3.4 Contractors shall designate an officer or director in
its organization who has the responsibility and
authority for carrying out the provisions of the fraud
and abuse compliance plan.
H.8.3.5 Contractors failure to report potential or suspected
fraud or abuse may result in sanctions, cancellation of
contract, or exclusion from participation in the
Medicaid program.
H.8.3.6 Contractors shall allow the District of Columbia
Medicaid Fraud Unit or its representatives to conduct
private interviews of Contractor's employees,
subcontractors, and their employees, witnesses, and
patients. Requests for information shall be complied
with in the form and the language requested.
Contractors employees and its subcontractors and their
employees shall cooperate fully and be available in
person for interviews, consultation grand jury
proceedings, pre-trial conference, hearings, trial and
in any other process.
H.9 Physician Incentive Plan
H.9.1 Per 42 CFR 417.479(a), no specific payment can be made directly or
indirectly under a physician incentive plan to a physician group as an
inducement reduce or limit medically necessary services furnished to
an individual Enrollee. Prior to contract award and annually ninety
(90) days prior to contract renewal thereafter, the Contractor shall
submit to the District for the District's approval the information on
provider incentive plans listed in 42 CFR 4l7 .479(h)(1) and
417.479(I) at the times indicated at 42 CFR 434.70(a)(3), in order to
determine whether the incentive plan(s) meets the requirements.
H.9.2 Per 42 CFR 417.4 79(d)-(g). The Contractor shall provide the
capitation data required under paragraph (h)(l)(vi) for previous
calendar year to the state by application/contract prior to Contract
renewal of each year. The Contractor will provide the information on
the its physician incentive plans listed in 42 CFR 417.479(h)(3) to
any Medicaid client, upon request.
H.10 Insurance
H.10.1 The successful offeror at its expense shall obtain the minimum
insurance coverage set forth below within five (5) calendar days after
being called
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upon by the District to do so and keep such insurance in force
throughout the contract period.
H.10.2 Public Liability and Property Damage Insurance: Insurance against
liability for personal and bodily injury and property damage and
machinery insurance in the amount of at least one hundred thousand
dollars ($100,000) for each individual and five hundred thousand
dollars ($500,000) in the aggregate (liability) and two hundred fifty
thousand dollars ($250,000) (property).
H.10.3 Worker's Compensation: The contractor shall carry workers
compensation insurance covering all of its employees employed upon the
premises and in connection with its other operations pertaining to
this agreement, and the contractor agrees to comply at all times with
the provisions of the workers compensation laws of the District
H.10.4 Employer's Liability: The Contractor shall carry employer's
liability of at least one hundred thousand dollars ($100,000).
H.10.5 Comprehensive Automobile Liability Insurance (applicable to owned,
non-owned and hired vehicles): The Contractor shall carry
comprehensive automobile liability insurance applicable to owned,
non-owned and hired vehicles against liability for bodily injury and
property damage and in the amount not less than that required by the
District's Compulsory/No-Fault Vehicle Insurance Act of 1982, as
amended, and in 27 DCMR 2712.6.
H.10.6 All insurance provided by the Contractor as required by this
section, except Comprehensive Automobile Liability Insurance, shall
set forth the District as an additional insured. All insurance shall
be written with responsible companies licensed by the District with a
duplicate copy to be sent to the District. The policies of insurance
shall provide for at least thirty (30) days written notice to the
District prior to their termination or material alteration.
H.11 Financial Requirements
H.11.1 Debts of Contractor
H.11.1.1 The Contractor shall ensure through its contracts,
subcontracts and in any other appropriate manner that
neither Enrollees nor the District are held liable for
Contractor's debts in the event of Contractor's
insolvency.
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Equity Balance, Solvency, and Financial Reserves
H.12.1 Consistent with the Balanced Budget Act of 1997, the Contractor
shall maintain a positive net worth, and insolvency reserves or
deposits that equal or exceed the minimum requirements established by
the District of Columbia's Department of Insurance and Securities
Regulations as a condition for maintaining a certificate of authority
to operate a health maintenance organization in the District.
H.12.2 The Contractor shall otherwise have demonstrated the ability to
maintain a strong financial position in order to provide a sound
financial foundation for its operations and to ensure the provision of
high quality medical care.
Fiduciary Relationship
H.13.1 Any director, officer, employee, or partner of a Contractor who
receives, collects, disburses, or invests funds in connection with the
activities of such Contractor shall be responsible for such funds in a
fiduciary relationship to the Contractor.
H.13.2 The Contractor shall maintain in force and provide evidence of a
fidelity bond in an amount of not less than one hundred thousand
dollars ($100,000) per person for each officer and employee who has a
fiduciary responsibility or duty to the organization.
Provider Payment Arrangement
H.14.1 The Contractor shall make its provider rate agreements available to
MAA.
Special Provider Payment Arrangements
H.15.1 Contractors that subcontract with a Federally Qualified Health
Center (FQHC), shall reimburse the FQHC with a negotiated rate on the
same payment terms as other providers of similar services. Under the
Balanced Budget Act of 1997, FQHCs are entitled to. reasonable
cost-based reimbursement as subcontractors of Medicaid health plans.
The District will be responsible for the excess of reasonable cost, as
defined under federal law, over the amount paid to the FQHC by
Contractor. The reimbursement to FQHCs is not a payment under this
contract.
H.15.2 The Contractor shall pay all network emergency facilities at the
contracted rate and non-network facilities at the current Medicaid
rates for the following services:
H.15.2.1 The screening examination and the services required to
stabilize an Enrollee determined by the examining
physician to have an emergency medical condition as
defined in Section 0.
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H.l5.2.2 The screening examination for Enrollees determined by
the examining physician not to have an emergency
medical condition, if the Contractor's review of the
presenting symptoms of the Enrollee finds that the
symptoms were of sufficient severity to have warranted
emergency attention under the prudent layperson
standard.
H.l5.2.3 The screening examination and any medically necessary
emergency services for Enrollees instructed by a PCP or
other representative of the Contractor to seek
emergency treatment in-network or out-of-network,
without regard to whether the Enrollee's symptoms meet
the prudent layperson standard.
H.15.2.4 A triage fee for screening services provided when
Enrollee's symptoms did not meet the prudent layperson
standard and no PCP or other Contractor employee
instructed the Enrollee to seek emergency treatment.
H.15.2.5 The emergency services and ambulance services provided
by the District Fire and Emergency Medical Services
Department.
H.15.2.6 Emergency services are considered to be medically
necessary in order to ensure, within reasonable medical
probability, that no material deterioration of the
Enrollee's condition is likely to result from or occur
during, discharge of the Enrollee or transfer of the
Enrollee to another facility.
H.l5.2.7 If there is a disagreement between a hospital and the
Contractor concerning whether the Enrollee is stable
enough for discharge or transfer, or whether the
medical benefits of an unstabilized transfer outweigh
the risks, the judgment of the attending physician(s)
actually caring for the Enrollee at the treating
facility prevails.
H.l5.2.8 The Contractor may establish arrangements with
hospitals whereby it may send one of its own physicians
with appropriate emergency room privileges to assume
the attending physician's responsibilities to
stabilize, treat, and transfer the Enrollee.
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H.15.2.9 The Contractor shall be responsible for payment of
services provided to Enrollee as defined under the
Balanced Budget Act of 1997 and medically appropriate
transfers as defined under the Emergency Medical and
Treatment Labor Act.
H.l5.3 Third Party Liability (TPL) and Coordination of Benefits
H.15.3.1 The Contractor shall comply with all applicable federal
statutes and regulations including Section 1902(a)(25)
of the Social Security Act and the Health Care
Assistance Reimbursement Act of 1984 (DC Law 5-86: DC,
Code Section 3-501 et seq.).
H.15.3.2 The Contractor shall be responsible for the
identification and collection of all health insurance
benefits available for payment of covered services
described in this contract and rendered to Enrollees
including court-ordered medical support available from
an absent parent.
H.15.3.3 Recovery from all third party payers, other than Health
Insurance, is the responsibility of MAA's Third Party
Liability Section. This includes but is not limited to
the following types of resources: casualty, torts and
worker's compensation.
H.l5.3.4 The Contractor shall not release copies of itemized
medical bills directly to an Enrollee or his/her
designee. Instead, such requests (including copies of
the requested documentation) shall be directed to the
TPL section of MAA within thirty (30) days from the
date the request is received by the Contractor.
H.15.3.5 Contractors are responsible for obtaining from
Enrollees any third party payment source to the
Contractor pursuant to notification of this
responsibility in the Enrollees' written Evidence of
Coverage.
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H.15.3.6 The Contractor shall not consider an enrolled child
with an IEP or an IFSP to be an Enrollee with third
party coverage.
H.15.3.7 The Contractor shall submit third party liability
reports as defined by MAA on a quarterly basis by the
tenth (10th) day of the month following the end of each
quarter in accordance with Section F.4.
H.15.3.8 The Contractor shall forward all information relating
to a potential third party resource available to an
Enrollee to the TPL section within thirty (30) days of
learning of the existence of the third party in a
format to be prescribed by MAA.
H.15.4 Financial Statements
H.15.4.1 The Contractor shall submit audited calendar year
financial statements in compliance with NAIC guidelines
audited by an independent certified public accountant
to the District by June 1 of each year. The financial
statements shall clearly show both total expenses and
revenues and the expenses and revenues attributable to
DCHFP Enrollees, including all direct medical expenses
and administrative costs charged to the Plan.
H.15.4.2 The Contractor shall submit all reports that are
submitted to the Department of Insurance to MAA within
thirty (30) days that such reports are submitted to the
Department of Insurance, and security regulations.
H.15.4.3 The District is considering the implementation of a
Financial Reporting Guide that will separately account
for funds received pursuant to this Contract on an
annual, quarterly, and if needed, monthly basis. This
Financial Reporting Guide will assist the District in
monitoring the financial viability of the Contractors
and will assist in the tracking of medical expenditures
as compared to the revenues received. If implemented,
the Contractor shall have ninety (90) days after the
date of implementation to
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commence reporting under the guidelines of the
Financial Reporting Guide.
H.l5.4.4 Upon the District's written request, the Contractor
shall permit, and shall assist the federal government,
its agents or the District in the inspection and audit
of any financial records of the Contractor or its
subcontractors. The records of the Contractor and its
subcontractors shall be available for inspection and
audit by the District.
H.15.4.5 The Contractor shall retain annual audit reports and
records for at least five (5) years.
H.15.4.6 If any litigation, claim, negotiation, audit, or other
action involving the records described in this section
is initiated before the expiration of the five (5) year
period, the records shall be retained until completion
of the action and final resolution of all issues that
arise from the litigation, claim, negotiation, audit,
or other action, including any appeal and the
expiration of any right of appeal, or until the end of
the five (5) year period, whichever is later.
H.16 Management Information System
H.16.1 Confidentiality
H.16.1.1 Client eligibility information from MAA's Enrollment
Broker will be supplied to the Contractor on a periodic
basis through a taped exchange. File specifications
will be available in the Reference Library.
H.16.2 Use of Information and Data
H.16.2.1 The District agrees to maintain, and to cause its
employees, agents or representatives to maintain on a
confidential basis information concerning the
Contractor's relations and operations as well as any
other information compiled or created by Contractor
which is proprietary to Contractor and which Contractor
identifies as proprietary to the District in writing.
If the District receives a request pursuant to the
Freedom of Information Act, the District will determine
what information is required by law to be
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released and retain authority over the release of that
information.
H.16.3 Year 2000 Certification
H.16.3.1 Each signature on the offer is considered to be a
certification by the signatory that:
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H.16.3.1.1 The Contractor warrants that each hardware,
software, and firm product delivered under
this contract and listed in this contract
shall be able to process accurately date/time
data (including, but not limited to
calculating, comparing, and sequencing) from,
into, and between the twentieth and
twenty-first centuries, and the years 1999
and 2000 and leap year calculations to the
extent that other information technology,
used in combination with the information
technology being acquired, properly exchanges
date/time data with it. If the contract
requires that specific listed products shall
perform as a system in accordance with the
foregoing warranty and the remedies available
to the District of Columbia for breach of
this warranty shall be defined in, and
subject to, the terms and limitations of the
Contractor's standard commercial warranty or
warranties contained in this contract,
provided that notwithstanding any provision
to the contrary in such commercial warranty
or warranties, the remedies available to the
District of Columbia under this warranty
shall include repair or replacement of any
listed product whose non-compliance is
discovered and made known to the Contractor
in writing within ninety (90) days after
acceptance. Nothing in this warranty shall be
construed to limit any rights or remedies the
District of Columbia may otherwise have under
this contract with respect to defects other
than Year 2000 performance.
H.17 Wage Rates
H.17.1 The contractor is bound by Wage Determination No. 1994-2103,
Revision No. 24, dated May 31, 2001, incorporated herein as Attachment
J.1, issued by the U.S. Department of Labor in accordance with the
Service Contract Act of 1965, as amended (41 U.S.C. 351). The
Contractor shall be bound by the wage rates for the term of the
contract. If an option is exercised, the Contractor shall be bound by
the applicable wage rate at the time of the option. If the option is
exercised and the Contracting Officer for the option obtains a revised
wage determination, that determination is
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applicable for the option periods; the Contractor may be entitled to
an equitable adjustment.
H.18 Conflict of Interest
H.18.1 No official or employee of the District of Columbia or the Federal
government who exercises any functions or responsibilities in the
review of approval of the undertaking or carrying out of this contract
shall, prior to the completion of the project, voluntarily acquire any
personal interest, direct or indirect, in the contract or proposed
contract. (DC Procurement Practices Act of 1985, DC Law 6-85 and
Chapter 18 of the DC Personnel Regulations).
H.18.2 The Contractor represents and covenants that it presently has no
interest and shall not acquire any interest, direct or indirect, which
would conflict in any manner or degree with the performance of its
services hereunder. The Contractor further covenants that, in the
performance of the contract, no person having any such known
interests shall be employed.
H.19 Security Requirements
H.19.1 The Contractor shall conduct routine pre-employment criminal record
background checks of all Contractor's staff that will provide services
under this contract to the extent permitted under D.C. law. The
Contractor shall not employ any staff in the fulfillment of the work
under this contract unless said person has successfully cleared a
background check, to include a National Criminal Information Center
report. The Contractor shall provide the results of the background
checks to the Contract Administrator prior to Contractor's staff
providing services under this contract. The Contractor shall conduct
the criminal record background checks on an annual basis and for all
newly acquired staff.
H.19.2 The Contractor's staff and administrative personnel that will visit
or supervise the clients at the designated facility site shall
complete a DOH background check except for licensed professionals
pursuant to D.C. Code, Chapter 33. No personnel employed by the
Contractor in the fulfillment of the work included in this
solicitation shall have a criminal conviction, for any offenses
enumerated in D.C. Code Sec.32-1352(e).
H.19.3 Employees of the Contractor shall disclosure to DOH through the
Contractor, any arrests or convictions that may occur subsequent to
employment. Any conviction or arrest of the Contractor's employees
after DOH/Office of Inspection and Compliance, which will determine
the employee's suitability for continued employment.
H.19.4 The Contractor's employees shall not bring into the facility any
form of weapons or contraband; shall be subject to search; shall
conduct themselves in a professional manner at all times; and shall
not cause any disturbance in the facility; and shall be subject to all
other rules and regulations of the facility and DOH. The Contractor
shall be provided a copy of all applicable rules and regulations of
the facility. The Contractor
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shall ascertain that each civilian employee is issued a copy of said
rules and signs a statement acknowledging the receipt of said rules.
The Contractor shall maintain the acknowledgement of receipt in the
individual employee's personnel folder.
H.20 Key Personnel
H.20.1 The key personnel specified below are considered to be essential to
the work being performed hereunder. Prior to diverting any of the
specified key personnel for any reason, the Contractor shall notify
the Contracting Officer at least thirty (30) calendar days in advance
and shall submit justification (including proposed substitutions) in
sufficient detail to permit evaluation of the impact on the contract.
The Contractor shall not reassign these key personnel or appoint
replacements, without written permission from the Contracting Officer.
The Contractor shall identify Key Personnel in the spaces below:
----------------------------------------------------------------------
NAME POSITION
----------------------------------------------------------------------
Jane Thompson Chief Executive Officer
----------------------------------------------------------------------
Scott Tabakin, CPA Chief Financial Officer
----------------------------------------------------------------------
Shirley Grant, M.D. Medical Director - Physical Health
----------------------------------------------------------------------
Conway McDanald, M.D. Medical Director - Behavioral Health
----------------------------------------------------------------------
Gerald B. Niewenhous, MSW Senior Manager - Mental Health
----------------------------------------------------------------------
Kathleen M. Scelzo, RN, MSN Senior Manager - Quality Assurance
----------------------------------------------------------------------
Dorothy Johnson, RN Senior Manager - Care Coordination
----------------------------------------------------------------------
Paul A. Richardson Senior Manager - Member Services
----------------------------------------------------------------------
Paul A. Richardson Senior Manager - Provider Services
----------------------------------------------------------------------
Scott Pickens Senior Manager - MIS
----------------------------------------------------------------------
Stanley Baldwin, Esq., JD Officer - Compliance and Fraud
----------------------------------------------------------------------
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SECTION I - CONTRACT CLAUSES
I. Standard Contract Clauses..........................................................189
I.1 Covenant Against Contingent Fees...................................................189
I.2 Patents............................................................................189
I.3 Quality............................................................................189
I.4 Inspection of Supplies.............................................................189
I.5 Inspection of Services.............................................................193
I.6 Waiver.............................................................................193
I.7 Default.........:..................................................................193
I.8 Indemnification....................................................................195
I.9 Transfer...........................................................................195
I.10 Taxes..............................................................................196
I.11 Payments...........................................................................196
I.12 Evaluation of Prompt Payment Discount..............................................196
I.13 Responsibility for Supplies Tendered...............................................196
I.14 Appointment of Attorney............................................................197
I.15 Officers Not to Benefit............................................................197
I.16 Disputes...........................................................................198
I.17 Claims by the District Against a Contractor........................................199
I.18 Changes............................................................................200
I.19 Termination for Convenience of the District........................................201
I.20 Recovery of Debts Owed the District................................................208
I.21 Examination of Books, etc. by the Office of Inspector General and the District
of Columbia Auditor................................................................208
I.22 Non-Discrimination Clause..........................................................208
I.23 Definitions........................................................................210
I.24 Health and Safety Standards........................................................210
I.25 Appropriation of Funds.............................................................210
I.26 Hiring of District Residents.......................................................211
I.27 Buy American Act...................................................................211
I.28 Service Contract Act of 1965.......................................................212
I.29 Cost and Pricing Data..............................................................218
I.30 Cost-Reimbursement Contracts - CLIN 0002 Only......................................220
I.31 Termination of Contracts for Certain Crimes and Violations.........................220
I.32 Additional Standard Clauses........................................................220
I.33 Contract Type and Price............................................................229
I.34 Accounting and Audits for CLIN 0002................................................229
I.35 Assignment of Funds................................................................229
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I. STANDARD CONTRACT CLAUSES
I.1 Covenant Against Contingent Fees
I.1.1 The Contractor warrants that no person or selling agency has been
employed or retained to solicit or secure the contract upon an
agreement or understanding for a commission, percentage, brokerage, or
contingent fee, excepting bona fide employees or bona fide established
commercial or selling agencies maintained by the Contractor for the
purpose of securing business. For breach or violation of this
warranty, the District government shall have the right to terminate
the contract without liability or in its discretion to deduct from the
contract price or consideration or otherwise recover, the full amount
of the commission, percentage, brokerage, or contingent fee.
I.2 Patents
I.2.1 The Contractor shall hold and save the District, its officers,
agents, servants, and employees harmless from liability of any nature
or kind, including costs, expenses, for or on account of any patented
or un-patented invention, article process, or appliance, manufactured
or used in the performance of this contract, including their use by
the District, unless otherwise specifically stipulated in this
contract.
I.3 Quality
I.3.1 Unless otherwise specified, all materials used for the manufacture or
construction of any supplies covered by this bid/proposal shall be new
and of the best quality and the workmanship shall be of the highest
grade. The use of the name of a manufacturer or of any special brand
or make in describing any item in this bid/proposal does not restrict
Offeror to that manufacturer, or specific brand or make; the reference
thereto indicates the character or quality of article desired, but
articles on which bids/proposals are submitted shall be equal to those
referred to. Offerors offering any article other than the specific
make, brand or manufacture named in this solicitation shall so state
in each instance, otherwise the bid/proposal will be considered as
being based upon furnishing the specific make, brand or manufacture
named in the solicitation.
I.4 Inspection of Supplies
I.4.1 Definition. "Supplies," as used in this clause, includes, but is not
limited to raw materials, components, intermediate assemblies, end
products, and lots of supplies.
I.4.2 The Contractor shall provide and maintain an inspection system
acceptable to the District covering supplies under this contract and
shall tender to the District for acceptance only supplies that have
been inspected in accordance with the inspection system and have been
found by the
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Contractor to be in conformity with contract requirements. As part of
the system, the Contractor shall prepare records evidencing all
inspections made under the system and the outcome. These records shall
be kept complete and made available to the District during contract
performance and for as long afterwards as the contract requires. The
District may perform reviews and evaluations as reasonably necessary
to ascertain compliance with this paragraph. These reviews and
evaluations shall be conducted in a manner that will not unduly delay
the contract work. The right of review, whether exercised or not, does
not relieve the Contractor of the obligations under this contract.
I.4.3 The District has the right to inspect and test all supplies called
for by the contract, to the extent practicable, at all places and
times, including the period of manufacture, and in any event before
acceptance. The District will perform inspections and tests in a
manner that will not unduly delay the work. The District assumes no
contractual obligation to perform any inspection and test for the
benefit of the Contractor unless specifically set forth elsewhere in
the contract.
If the District performs inspection or test on the premises of the
Contractor or subcontractor, the Contractor shall furnish, and shall
require subcontractors to furnish, without additional charge, all
reasonable facilities and assistance for the safe and convenient
performance of these duties. Except as otherwise provided in the
contract, the District shall bear the expense of District inspections
or tests made at other than Contractor's or subcontractor's premise;
provided, that in case of rejection, the District shall not be liable
for any reduction in the value of inspection or test samples.
I.4.4.1 When supplies are not ready at the time specified by
the Contractor for inspection or test, the Contracting
Officer may charge to the Contractor the additiona1
cost of inspection or test.
I.4.4.2 The Contracting Officer may also charge the Contractor
for any additional cost of inspection or test when
prior rejection makes re-inspection or retest
necessary.
The District has the right either to reject or to require correction
of nonconforming supplies. Supplies are nonconforming when they are
defective in material or workmanship or otherwise not in conformity
with contract requirements. The District may reject nonconforming
supplies with or without disposition instructions.
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I.4.5.1 The Contractor shall remove supplies rejected or
required to be corrected. However, the Contracting
Officer may require or permit correction in place,
promptly after notice, by and at the expense of the
Contractor. The Contractor shall not tender for
acceptance corrected or rejected supplies without
disclosing the former rejection or requirement for
correction, and when required, shall disclose the
corrective action taken.
I.4.5.2 If the Contractor fails to promptly remove, replace, or
correct rejected supplies that are required to be
replaced or corrected, the District may either (1) by
contract or otherwise, remove, replace or correct the
supplies and charge the cost to the Contractor or (2)
terminate the contract for default. Unless the
Contractor corrects or replaces the supplies within the
delivery schedule, the Contracting Officer may require
their delivery and make an equitable price reduction.
Failure to agree to a price reduction shall be a
dispute.
I.4.5.2.1 If this contract provides for the performance
of District quality assurance at source, and
if requested by the District, the Contractor
shall furnish advance notification of the
time (i) when Contractor inspection or tests
will be performed in accordance with the
terms and conditions of the contract and (ii)
when the supplies will be ready for District
inspection.
I.4.5.2.2 The District request shall specify the period
and method of the advance notification and
the District representative to whom it shall
be furnished. Requests shall not require more
than two (2) workdays of advance notification
if the District representative is in
residence in the Contractor's plant, nor more
than seven (7) workdays in other instances.
I.4.5.3 The District shall accept or reject supplies as
promptly as practicable after delivery, unless
otherwise provided in the contract. District failure to
inspect and accept or reject the supplies shall not
relieve the Contractor from
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responsibility, nor impose liability upon the District,
for non-conforming supplies.
I.4.5.4 Inspections and tests by the District do not relieve
the Contractor of responsibility for defects or other
failures to meet contract requirements discovered
before acceptance. Acceptance shall be conclusive,
except for latent defects, fraud, gross mistakes
amounting to fraud, or as otherwise provided in the
contract.
I.4.5.5 If acceptance is not conclusive for any of the reasons
in Section I.6.11 hereof, the District, in addition to
any other rights and remedies provided by law, or under
provisions of this contract, shall have the right to
require the Contractor (1) at no increase in contract
price, to correct or replace the defective or
nonconforming supplies at the original point of
delivery or at the Contractor's plant at the
Contracting Officer's election, and in accordance with
a reasonable delivery schedule as may be agreed upon
between the Contractor and the Contracting Officer;
provided, that the Contracting Officer may require a
reduction in contract price if the Contractor fails to
meet such delivery schedule, or (2) within a reasonable
time after receipt by the Contractor of notice of
defects or noncompliance, to repay such portion of the
contract as is equitable under the circumstances if the
Contracting Officer elects not to require correction or
replacement. When supplies are returned to the
Contractor, the Contractor shall bear the
transportation cost from the original point of delivery
to the Contractor's plant and return to the original
point when that point is not the Contractor's plant. If
the Contractor fails to perform or act as required in
(1) or (2) above and does not cure such failure within
a period of 10 days (or such longer period as the
Contracting Officer may authorize in writing) after
receipt of notice from the Contracting Officer
specifying such failure, the District shall have the
right to contract or otherwise to replace or correct
such supplies and charge to the Contractor the cost
occasioned the District thereby.
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I.5 Inspection of Services
I.5.1 Definition. "Services" as used in this clause includes services
performed, workmanship, and material furnished or utilized in the
performance of services.
I.5.2 The Contractor shall provide and maintain an inspection system
acceptable to the District covering the services under this contract.
Complete records of all inspection work performed by the Contractor
shall be maintained and made available to the District during contract
performance and for as long afterwards as the contract requires.
I.5.3 The District has the right to inspect and test all services called
for by the contract, to the extent practicable at all times and places
during the term of the contract. The District shall perform
inspections and tests in a manner that will not unduly delay the work.
I.5.4 If the District performs inspections or tests on the premises of the
Contractor or subcontractor, the Contractor shall furnish, without
additional charge, all reasonable facilities and assistance for the
safety and convenient performance of these duties.
I.5.5 If any of the services do not conform to the contract requirements,
the District may require the Contractor to perform these services
again in conformity with contract requirements, at not increase in
contract amount. When the defects in services cannot be corrected by
performance, the District may (1) require the Contractor to take
necessary action to ensure that future performance conforms to
contract requirements and reduce the contract price to reflect value
of services performed.
I.5.6 If the Contractor fails to promptly perform the services again or
take the necessary action to ensure future performance in conformity
to contract requirements, the District may (1) by contract or
otherwise, perform the services and charge the Contractor any cost
incurred by the District that is directly related to the performance
of such services, or (2) terminate the contract for default. The
waiver of any breach of the contract will not constitute a waiver of
any subsequent breach thereof, nor a waiver of the contract.
I.6 Waiver
I.6.1 The waiver of any breach of this contract will not constitute a
waiver of any subsequent breach thereof, nor a waiver of the contract.
I.7 Default
I.7.1 The District may, subject to the provisions of Section I.7.3 below,
by written notice of default to the Contractor, terminate the whole or
any part of this contract in any one of the following circumstances:
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I.7.1.1 If the Contractor fails to make delivery of the
supplies or to perform the services within the time
specified herein or any extension thereof; or
I.7.1.2 If the Contractor fails to perform any of the other
provisions of this contract, or so fails to make
progress as to endanger performance of this contract in
accordance with its terms, and in either of these two
circumstances does not cure such failure within a
period of ten (10) days (or such longer period as the
Contracting Officer may authorize in writing) after
receipt of notice from the Contracting Officer
specifying such failure.
In the event the District terminates this contract in whole or in part
as provided in Section I.7.1 of this clause, the District may procure,
upon such terms and in such manner as the Contracting Officer may deem
appropriate, supplies or service similar to those so terminated, and
the Contractor shall be liable to the District for any excess costs
for similar supplies or services; provided, that the Contractor shall
continue the performance of this contract to the extent not terminated
under the provisions of this clause.
Except with respect to defaults of subcontractors, the Contractor
shall not be liable for any excess costs if the failure to perform the
contract arises out of causes beyond the control and without the fault
or negligence of the Contractor. Such causes may include, but are not
restricted to, acts of God or of the public enemy, acts of the
District or Federal Government in either their sovereign or
contractual capacity, fires, floods, epidemics, quarantine
restrictions, strikes, freight embargoes, and unusually severe
weather; but in every case the failure to perform shall be beyond the
control and without fault or negligence of the Contractor. If the
failure to perform is caused by the default of the subcontractor, and
if such default arises out of causes beyond the control of both the
Contractor and the subcontractor, and without the fault or negligence
of either of them, the Contractor shall not be liable for any excess
cost for failure to perform, unless the supplies or services to be
furnished by the subcontractor were obtainable from other sources in
sufficient time to permit the Contractor to meet the required delivery
schedule.
If this contract is terminated as provided in paragraph (a) of this
clause, the District, in addition to any other rights provided in this
clause, may require the Contractor to transfer title and deliver to
the District, in the manner and to the extent directed by the
Contracting Officer, (i) completed supplies, and (ii) such partially
completed supplies and
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materials, parts, tools, dies, jigs, fixtures plans, drawing
information, and contract rights (hereinafter called "manufacturing
materials") as the Contractor has specifically produced or
specifically acquired for the performance of such part of this
contract as has been terminated; and the Contractor shall, upon
direction of the Contracting Officer, protect and preserve property in
possession of the Contractor in which the District has an interest.
Payment for completed supplies delivered to and accepted by the
District shall be at the contract price. Payment for manufacturing
materials delivered to and accepted by the District shall be at the
contract price. Payment for manufacturing materials delivered to and
accepted by the District and for the protection and preservation of
property shall be in an amount agreed upon by the Contractor and
Contracting Officer; failure to agree to such amount shall be a
dispute concerning a question of fact within the meaning of the clause
of this contract entitled "Disputes." The District may withhold from
amounts otherwise due the Contractor for such completed supplies or
manufacturing materials such sum as the Contracting Officer determines
to be necessary to protect the District against loss because of
outstanding liens or claims of former lien holders.
If, after notice of termination of this contract under the provisions
of this clause, it is determined for any reason that the Contractor
was not in default under the provisions of this clause, or that the
default was excusable under the provisions of this clause, the rights
and obligations of the parties shall, if the contract contains a
clause providing for termination of convenience of the Government, be
the same as if the notice of termination had been issued pursuant to
such clause. See Section I.19 for Termination for Convenience of the
District.
The rights and remedies of the District provided in this clause shall
not be exclusive and are in addition to any other rights and remedies
provided by law or under this contract.
As used in Section I.7.3 of this clause, the term "subcontractor(s)"
means subcontractor(s) at any tier.
I.8 Indemnification
I.8.1 The Contractor shall indemnify and hold harmless the District and all
its officers, agents and servants against any and all claims or
liability arising from or based on, or as consequence of or result of,
any act, omission or default of the Contractor, its employees, or its
subcontractors, in the performance of this contract. Monies due or to
become due the Contractor under the contract may be retained by the
District as necessary to satisfy any outstanding claim which the
District may have against the Contractor.
I.9 Transfer
No contract or any interest therein shall be transferred by the
parties to whom the award is made; such transfer will be null and void
and will be cause to annul the contract.
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Taxes
I.10.1 The Government of the District of Columbia is exempt from and will
not pay Federal Excise Tax, Transportation Tax, and the District of
Columbia Sales and Use.
I.10.2 Tax exemption certificates no longer issued by the District for
Federal Excise Tax. The following statement may be used by the
supplier when claiming tax deductions for Federal Excise Tax exempt
items sold to the District.
I.10.2.1 "The District of Columbia Government Is Exempt From
Federal Excise Tax - Registration No. 52-73-0206-K
Internal Revenue Service, Baltimore, Maryland."
I.l0.2.2 Exempt From Maryland Sales Tax, Registered With The
Comptroller Of The Treasury As Follows:
I.10.2.3 Deliveries to Children's Center-Exemption No. 4648
I.10.2.4 Deliveries to other District Departments or Agencies -
Exemption No. 09339
Payments
I.11.1 Unless otherwise specified in this contract, payments will be made
only after performance of the contract in accordance with all
provisions thereof.
Evaluation of Prompt Payment Discount
I.12.1 Prompt payment discounts shall not be considered in the evaluation
of offers. However, any discount offered will form a part of the
award and will be taken by the District if payment is made within the
discount period specified by the Offeror.
I.12.2 In connection with any discount offered, time will be computed from
the date of delivery of the supplies to carrier when delivery and
acceptance are at point of origin, or from date of delivery at
destination when delivery, installation and acceptance are at that, or
from the date correct invoice or voucher is received in the office
specified by the District, if the latter date is later than date of
delivery. Payment is deemed to be made for the purpose of earning the
discount on the date of mailing of the Government check.
Responsibility for Supplies Tendered
I.13.1 The Contractor shall be responsible for the materials or supplies
covered by this contract until they are delivered at the designated
point, but the Contractor shall bear all risk on rejected materials or
supplies after
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notification of rejection. Upon failure to do so within ten(10) days
after date of notification, the District may return the rejected
materials or supplies to the Contractor at his risk and expense.
Appointment of Attorney
I.14.1 The Offeror or Contractor (whichever the case may be) does hereby
irrevocably designate and appoint the Clerk of the District of
Columbia Superior Court and his successor in office as the true and
lawful attorney of the Contractor for the purpose of receiving service
of all notices and processes issued by any court in the District of
Columbia, as well as service all pleadings and other papers, in
relation to any action or legal proceeding arising out of or
pertaining to this contract or the work required or performed
hereunder.
I.14.2 The Offeror or Contractor (whichever the case may be) expressly
agrees that the validity of any service upon the said Clerk as herein
authorized shall not be affected either by the fact that the
Contractor was personally within the District of Columbia and
otherwise subject to personal service at the time of such service upon
the said Clerk or by the fact that the Contractor failed to receive a
copy of such process, notice or other paper so served upon the said
Clerk provided the said Clerk shall have deposited in the United
States mail, registered and postage prepaid, a copy of such process,
notice pleading or other paper addressed to the Offeror or Contractor
at the address stated in this contract.
Officers Not to Benefit
No member of or delegate to Congress, or officer or employee of the
District shall be admitted to any share or part of this contract or to any
benefit that may arise therefrom, and any contract made by the Contracting
Officer of any District employee authorized to execute contract which they
or the employee of the District shall be personally interested shall be
void, and no payment shall be made thereon by the District or any officer
thereof, but this provision shall not be construed to extend to this
contract if made with a corporation for its general benefit. However,
should a federal or District employee submit a bid for his personal
benefit, the Contracting Officer reserves the right to waive the
aforementioned restriction; providing that said employee furnishes a
Notarized Affidavit prior to the time set for opening of bids or submission
of proposal, setting forth intention to resign his/her federal or District
employment in the event said employee shall be considered for an award of
contract. Failure to submit such affidavit shall automatically render
his/her bid/proposal non-responsive and no further consideration shall be
given thereto. (See Representations, Certifications and Acknowledgements.)
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I.16 Disputes
I.16.1 All disputes arising under or relating to this contract shall be
resolved as provided herein.
I.16.2 Claims by a Contractor against the District.
I.16.2.1 Claim, as used in Section B of this clause, means a
written assertion by the Contractor seeking, as a
matter of right, the payment of money in a sum certain,
the adjustment or interpretation of contract terms, or
other relief arising under or relating to this
contract. A claim arising under a contract, unlike a
claim relating to that contract, is a claim that can be
resolved under a contract clause that provides for the
relief sought by the claimant.
I.16.2.2 All claims by a Contractor against the District arising
under or relating to a contract shall be in writing and
shall be submitted to the Contracting Officer for a
decision
I.16.2.3 For any claim of $50,000 or less, the Contracting
Officer shall issue a decision within sixty (60) days
from receipt of a written request from a Contractor
that a decision be rendered within that period.
I.16.2.4 For any claim over $50,000, the Contracting Officer
shall issue a decision within ninety (90) days of
receipt of the claim. Whenever possible, the
Contracting Officer shall take into account factors
such as the size and complexity of the claim and the
adequacy of the information in support of the claim
provided by the Contractor.
I.16.2.5 Any failure by the Contracting Officer to issue a
decision on a contract claim within the required time
period will be deemed to be a denial of the claim. The
Contractor may appeal denial of the claim as provided
herein.
I.16.2.6 If a Contractor is unable to support any part of his or
her claim and it is determined that the inability is
attributable to a material misrepresentation of fact or
fraud on the part of the Contractor, the Contractor
shall be liable to the District for an amount equal to
the unsupported part of the claim in addition to all
costs to the District attributable to the cost of
reviewing that part of the Contractor's claim.
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I.16.2.7 Liability under Section I.16.2.6 shall be determined
within six (6) years of the commission of the
misrepresentation of fact or fraud
I.16.3 Interest on amounts found due to a Contractor on claims shall be
payable at a rate set in DC Code Section 28-3302(b) applicable to
judgments against the District and shall begin accruing from the date
the Contracting Officer receives the claim until payment of the claim.
I.16.4 The decision of the Contracting Officer shall be final and not
subject to review unless an administrative appeal or action for
judicial review is timely commenced by the Contractor as authorized by
DC Code Section 1-1189.4.
I.16.5 Pending final decision of an appeal, action, or final settlement, a
Contractor shall proceed diligently with performance of the contract
in accordance with the decision of the Contracting Officer.
I.17 Claims by the District Against a Contractor
I.17.1 Claim as used in Section I.17.1.3 of this clause, means a written
demand or written assertion by the District seeking, as a matter of
right, the payment of money in a sum certain, the adjustment of
contract terms, or other relief arising under or relating to this
contract. A claim arising under a contract, unlike a claim relating to
that contract, is a claim that can be resolved under a contract clause
that provides for the relief sought by the claimant.
I.17.1.1 All claims by the District against a Contractor arising
under or relating to a contract shall be decided by the
Contracting Officer.
I.17.1.2 The Contracting Officer shall send written notice of
the claim to the Contractor. The Contractor may respond
to the claim within thirty (30) days from the date the
Contractor receives the claim.
I.17.1.3 After the expiration of sixty (60) days from the date
the Contractor receives the claim, the Contracting
Officer shall issue a decision in writing, and furnish
a copy of the decision to the Contractor.
I.17.1.4 The decision shall be supported by reasons and shall
inform the Contractor of his or her rights as provided
herein. Specific findings of fact are not required,
but, if made, shall not be binding in any subsequent
proceeding.
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I.17.1.5 The authority contained in this clause shall not apply
to a claim or dispute for penalties or forfeitures
prescribed by statute or regulation which another
District agency is specifically authorized to
administer, settle, or determine.
I.17.1.6 This clause shall not authorize the Contracting Officer
to settle, compromise, pay, or otherwise adjust any
claim involving fraud.
I.17.2 Interest on amounts found due to the District from a Contractor on
claims shall be payable at the rate set in DC Code Section 28-3302(b)
applicable to judgments against the District, and shall begin accruing
from the date the Contractor receives a Contracting Officer's written
decision on behalf of the District until payment of the claim.
I.17.3 The decision of the Contracting Officer shall be final and not
subject to review unless an administrative appeal or action for
judicial review is timely commenced by the District as authorized by
DC Code Section 1-1189.4.
I.17.4 Pending final decision of an appeal, action, or final settlement,
the Contractor shall proceed diligently with performance of the
contract in accordance with the decision of the Contracting Officer.
I.18 Changes
I.18.1 The Contracting Officer may, at any time, by written order, and
without notice to the surety, if any, make changes in the contract
within the general scope hereof. If such change causes an increase or
decrease in the cost of performance of this contract, or in the time
required for performance, an equitable adjustment shall be made. Any
claim for adjustment under this paragraph shall be asserted within ten
(10) days from the date the change is offered, provided, however, that
the Contracting Officer, if he or she determines that the facts
justify such action, may receive, consider and adjust any such claim
asserted at any time prior to the date of final settlement of the
contract. If the parties fail to agree upon the adjustment to be made,
the dispute shall be determineed as provided in the Dispute clause
hereto. Nothing in this clause shall excuse the Contractor from
proceeding with the contract as changed.
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I.19 Termination for Convenience of the District
I.19.1 The District may terminate performance of work under this contract
in whole or, from time to time, in part if the Contracting Officer
determines that a termination is in the District's interest. The
Contracting Officer shall terminate by delivering to the Contractor a
Notice of Termination specifying the extent of termination and
effective date.
I.19.2 After receipt of a Notice of Termination, and except as directed by
the Contracting Officer, the Contractor shall immediately proceed with
the following obligations, regardless of any delay in determining or
adjusting any amounts due under this clause:
I.19.2.1 Stop work as specified in the notice
I.19.2.2 Place no further subcontracts or orders (referred to as
subcontracts in this clause) for materials, services,
or facilities, except as necessary to complete the
continued portion of the contract.
I.19.2.3 Terminate all contracts to the extent they relate to
the work terminated.
I.19.2.4 Assign to the District, as directed by the Contracting
Officer, all rights, title and interest of the
Contractor under the subcontracts terminated, in which
case the District shall have the right to settle or pay
any termination settlement proposal arising out of
those terminations.
I.19.2.5 With approval or ratification to the extent required by
the Contracting Officer, settle all outstanding
liabilities and termination settlement proposals
arising from the termination of subcontracts. The
approval or ratification will be final for purposes of
this clause.
I.19.2.6 As directed by the Contracting Officer, transfer title
and deliver to the District (i) the fabricated or
unfabricated parts, work in process, completed work,
supplies, and other materials produced or acquired for
the work terminated, and (ii) the completed or
partially completed plans, drawings, information, and
other property that, if the contract has been
completed, would be required to be furnished to the
District.
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I.19.2.7 Complete performance of the work not terminated.
I.19.2.8 Take any action that may be necessary, or that the
Contracting Officer may direct, for the protection and
preservation of the property related to this contract
that is in the possession of the Contractor and in
which the District has or may acquire an interest.
I.19.2.9 Use its best efforts to sell, as directed or authorized
by the Contracting Officer, any property of the types
referred to in Section I.19.2.6 above; provided,
however, that the Contractor (i) is not required to
extend credit to any purchaser and (ii) may acquire the
property under the conditions prescribed by, and at
prices approved by, the Contracting Officer. The
proceeds of any transfer or disposition will be applied
to reduce any payments to be made by the District under
this contract, credited to the price or cost of the
work, or paid in any other manner directed by the
Contracting Officer.
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I.19.3 After the expiration of ninety (90) days (or such longer period as
may be agreed to) after receipt by the Contracting Officer of
acceptable inventory schedules, the Contractor may submit to the
Contracting Officer a list, certified as to quantity and quality of
termination inventory not previously disposed of excluding items
authorized for disposition by the Contracting Officer. The Contractor
may request the District to remove those items or enter into an
agreement for their storage. Within fifteen (15) days, the District
will accept title to those items and remove them or enter into a
storage agreement. The Contracting Officer may verify the list upon
removal of the items, or if stored, within forty-five (45) days from
submission of the list, and shall correct the list, as necessary,
before final settlement.
I.19.4 After termination, the Contractor shall submit a final termination
Settlement proposal to the Contracting Officer in the form and with
the certification prescribed by the Contracting Officer. The
Contractor shall submit the proposal promptly, but no later than six
(6) months from the effective date of termination, unless extended in
writing by the Contracting Officer upon written request of the
Contractor within this six (6) month period. However, if the
Contracting Officer determines that the facts justify it, a
termination settlement proposal may be received and acted on after six
(6) months or any extension. If the Contractor fails to submit the
proposal within the time allowed, the Contracting Officer may
determine, on the basis of information available, the amount, if any,
due to the Contractor because of the termination and shall pay the
amount determined.
I.19.5 Subject to Section I.19.4 above, the Contractor and the Contracting
Officer may agree upon the whole or any part of the amount to be paid
because of the termination. The amount may include a reasonable
allowance for profit on work done. However, the agreed amount, whether
under this Section I.19.5 or Section I.16.6 below, exclusive of costs
shown in Section I.19.6.3 below, may not exceed the total contract
price as reduced by (1) the amount of payment previously made and (2)
the contract price of work not terminated. The contract shall be
amended, and the Contractor paid the agreed amount. Section I.19.6
below shall not limit, restrict, or affect the amount that may be
agreed upon to be paid under this paragraph.
I.19.6 If the Contractor and the Contracting Officer fail to agree on the
whole amount to be paid because of the termination work, the
Contracting Officer shall pay the Contractor the amounts determined by
the Contracting Officer as follows, but without duplication of any
amounts agreed on under Section I.19.5 above:
I.19.6.1 The contract price for completed supplies or Services
accepted by the District (or sold or
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acquired under Section I.19.5 (above) not previously
paid for, adjusted for any saving of freight and other
charges.
I.19.6.2 The total of:
I.19.6.2.1 The costs incurred in the performance of the
work terminated, including initial costs and
preparatory expense allocable thereto, but
excluding any costs attributable to supplies
or services paid or to be paid under Section
I.19.2.9 above;
I.19.6.2.2 The cost of settling and paying termination
settlement proposals under terminated
subcontracts that are properly chargeable to
the terminated portion of the contract if not
included in subparagraph above; and
I.19.6.2.3 A sum, as profit on subparagraph above,
determined by the Contracting Officer to be
fair and reasonable; however, if it appears
that the Contractor would have sustained a
loss on the entire contract had it been
completed, the Contracting Officer shall
allow no profit under this subparagraph and
shall reduce the settlement to reflect the
indicated rate of loss.
I.19.6.3 The reasonable cost of settlement of the work
terminated, including:
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I.19.6.3.1 Accounting, legal, clerical, and other
expenses reasonably necessary for the
preparation of termination settlement
proposals and supporting data;
I.19.6.3.2 The termination and settlement of
subcontractors (excluding the amounts of such
settlements) and
I.19.6.3.3 Storage, transportation, and other costs
incurred, reasonably necessary for the
preservation, protection, or disposition of
the termination inventory.
I.19.6.4 Except for normal spoilage, and except to the extent
that the District expressly assumed the risk of loss,
the Contracting Officer shall exclude from the amounts
payable to the Contractor under Section I.19.2.9 above,
the fair value as determined by the Contracting
Officer, of property that is destroyed, lost, stolen,
or damaged so as to become undeliverable to the
Government or to a buyer.
I.19.6.5 The Contractor shall have the right of appeal, under
the Disputes clause, from any determination made by the
Contracting Officer under paragraphs (d), (f) or (j),
except that if the Contractor failed to submit the
termination settlement proposal within the time
provided in paragraph (d) or (j), and failed to request
a time extension, there is no right of appeal. If the
Contracting Officer has made a determination of the
amount due under paragraph (d), (f) or (j), the
District shall pay the Contractor (1) the amount
determined by the Contracting Officer if there is no
right of appeal or if no timely appeal has been taken,
or (2) the amount finally determined on an appeal.
I.19.6.6 In arriving at the amount due the Contractor under this
clause, there shall be deducted:
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I.19.6.6.1 All unliquidated advance or other payments
to the Contractor under the termination
portion of the contract;
I.19.6.6.2 Any claim which the District has against the
Contractor under this contract; and
I.19.6.6.3 The agreed price for, or the proceeds of
sale of, materials, supplies, or other things
acquired by the Contractor or sold under the
provisions of this clause and not recovered
by or credited to the District.
I.19.6.7 If the termination is partial, the Contractor may file
a proposal with the Contracting Officer for an
equitable adjustment of the price(s) of the continued
portion of the contract. The Contracting Officer shall
make any equitable adjustment agreed upon. Any proposal
by the Contractor for an equitable adjustment under
this clause shall be requested within ninety (90) days
from the effective date of termination unless extended
in writing by the Contracting Officer.
I.19.6.7.1 The District may, under the terms and
conditions it prescribes, make partial
payments and payments against costs incurred
by the Contractor for the terminated portion
of the contract, if the Contracting Officer
believes the total of these payments will not
exceed the amount to which the Contractor
will be entitled
I.19.6.7.2 If the total payments exceed the amount
finally determined to be due, the Contractor
shall repay the excess to the District upon
demand together with interest computed at the
rate of 10 percent (10%) per year. Interest
shall be computed for the period from the
date the excess payment is received by the
Contractor to the date the excess payment is
repaid. Interest shall not be charged on any
excess payment due to a reduction in the
Contractor's termination settlement proposal
because of retention or other disposition of
termination inventory
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until ten (10) days after the date of the
retention or disposition, or a later date
determined by the Contracting Officer because
of the circumstances.
I.19.6.8 Unless otherwise provided in this contract or by
statue, the Contractor shall maintain all records and
documents relating to the terminated portion of this
contract for three (3) years after final settlement.
This includes all books and other evidence bearing on
the Contractor's costs and expenses under this
contract. The Contractor shall make these records and
documents available to the District, at the
Contractor's office, at all reasonable times, without
any direct charge. If approved by the Contracting
Officer, photographs, micrographs, or other authentic
reproductions may be maintained instead of original
records and documents.
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I.20 Recovery of Debts Owed the District
I.20.1 The Contractor hereby agrees that the District of Columbia may use
all or any portion of any consideration or refund due the Contractor
under the present contract to satisfy in whole or part, any debt due
the District.
I.21 Examination of Books, etc. by the Office of Inspector General and the
District of Columbia Auditor
I.21.1 The Contracting Officer, the Inspector General and the District of
Columbia Auditor, or any of their duly authorized representatives
shall, until five (5) years after final payment, have the right to
examine any directly pertinent books, documents, papers and records of
the Contractor involving transactions related to the contract.
I.22 Non-Discrimination Clause
I.22.1 The Contractor shall not discriminate in any manner against any
employee or applicant for employment that would constitute a Violation
of the District of Columbia Human Rights Act, approved December 13,
1977 (DC Law 2-38: DC Code I-2512) (1981 Ed.). The Contractor shall
include a similar clause in all subcontracts, except subcontracts for
standard commercial supplies or raw materials. In addition, Contractor
agrees and any subcontractor shall agree to post in conspicuous
places, available to employees and applicants for employment, notice
setting forth the provisions of this non-discrimination clause proved
in Section 251 of the District of Columbia Human Rights Act (DC Code
1-2522).
I.22.2 Pursuant to rules of the Department of Human Rights and Local
Business Development, published on August 15, 1986 in the DC Register,
the following clauses apply to this contract:
I.22.2.1 1103.2 - The Contractor shall not discriminate against
any employee or applicant for employment because of
race, color, religion, national origin, sex, age,
marital status, personal appearance, sexual
orientation, family responsibilities, matriculation,
political affiliation, or physical handicap.
I.22.2.2 1103.3 - The Contractor agrees to take affirmative
action to ensure that applicants are employed, and that
employees are treated during employment, without regard
to their race, color, religion, national origin, sex,
age, marital status, personal appearance, sexual
orientation, family responsibilities, matriculation,
political affiliation, or physical handicap. The
affirmative action shall include, but not be limited to
the following:
. employment, upgrading or transfer;
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. recruitment, or recruitment advertising;
. demotion, layoff, or termination;
. rates of pay, or other forms of compensation;
. and selection for training and apprenticeship.
I.22.2.3 1103.4 - The Contractor agrees to post in conspicuous
places, available to employees and applicants for
employment, notices to be provided by the Contracting
Agency, setting forth the provisions in subsections
1103.2 and 1103.3 concerning non-discrimination and
affirmative action.
I.22.2.4 1103.5 - The Contractor shall, in all solicitations or
advertisements for employees placed by or on behalf of
the Contractor, state that all qualified applicants
will receive consideration for employment pursuant to
the non-discrimination requirements set forth in
subsection 1103.2.
I.22.2.5 1103.6 - The Contractor agrees to send to each labor
union or representative of workers with which he has a
collective bargaining agreement or other contract or
understanding, a notice to be provided by the
Contracting Officer, advising the said labor union or
workers' representative of that Contractor's
commitments under this chapter, and shall post copies
of the notice in conspicuous places available to
employees and applicants for employment.
I.22.2.6 1103.7 - The Contractor agrees to permit access to his
books, records and accounts pertaining to its
employment practices, by the Chief Procurement Officer
or his/her alternates, for purposes of investigation to
ascertain compliance with this chapter, and to require
under terms of any subcontractor agreement each
subcontractor to permit access of such subcontractors'
books, records, and accounts for such purposes.
I.22.2.7 1103.8 - The Contractor agrees to comply with the
provisions of this chapter and with all guidelines for
equal employment opportunity applicable in the District
of Columbia adopted by the Chief Procurement Officer,
or any authorized official.
I.22.2.8 1103.9 - The prime Contractor shall include in every
subcontract the equal opportunity clauses, subsection
1103.2 through 1103.10 of this section, so that such
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provisions shall be binding upon each subcontractor or
vendor.
I.22.2.9 1103.10 - The prime Contractor shall take such action
with respect to any subcontract as the Contracting
Officer may direct as a means of enforcing these
provisions, including sanctions for noncompliance;
provided, however, that in the event the prime
Contractor becomes involved in, or is threatened with,
litigation with a subcontractor or vendor as a result
of such direction by the contracting agency, the prime
Contractor may request the District to enter into such
litigation to protect the interest of the District.
Definitions
I.23.1 The terms Mayor, Chief Procurement Officer, Contract Appeals Board
and District shall mean the Mayor of the District of Columbia, the
Chief Procurement Officer of the District of Columbia or his/her
alternate, the Contract Appeals Board of the District of Columbia, and
the Government of the District of Columbia respectively. If the
Contractor is an individual, the term Contractor shall mean the
Contractor, his heirs, his executive and his administrator. If the
Contractor is a corporation, the term Contractor shall mean the
Contractor and its successor.
Health and Safety Standards
I.24.1 Items delivered under this contract shall conform to all
requirements of the Occupational Safety and Health Act of 1970, as
amended, and Department of Labor Regulations under the Act, and all
Federal requirements in effect at time of bid opening/proposal
submission.
Appropriation of Funds
I.25.1 The District's liability under this contract is contingent upon the
future availability of appropriated monies with which to make payment
for the contract purposes. The legal liability on the part of the
District for the payment of any money shall not arise unless and until
such appropriation shall have been provided.
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Hiring of District Residents
I.26.1 All new employment resulting from this contract or subcontracts
hereto, as defined in Mayor's Order 83-265 and implementing
instructions, shall include the following basic goals and objectives
for utilization of bona fide residents of the District of Columbia in
each project's labor force:
I.26.1.1 At least fifty-one (51) percent of all jobs created are
to be performed by employees who are residents of the
District of Columbia.
I.26.1.2 At least fifty-one (51) percent of apprentices and
trainees employed shall be residents of the District of
Columbia registered in programs approved by the
District of Columbia Apprenticeship Council. The
Contractor shall negotiate an Employment Agreement with
the District of Columbia Department of Employment
Services for jobs created as a result of this contract.
The Department of Employment Services shall be the
Contractor's first source of referral for qualified
applicants, trainees and other workers in the
implementation of employment goals contained in this
clause.
Buy American Act
I.27.1 The Buy American Act (41 U.S.C. 10) provides that the District give
preference to domestic end products.
I.27.2 "Components," as used in this clause, means those articles,
materials, and supplies incorporated directly into the end products.
I.27.3 "Domestic end product," as used in this clause, means, (1) an
unmanufactured end product mined or produced in the United States, or
(2) an end product manufactured in the United States, if the cost of
its components mined, produced, or manufactured in the United States,
exceeds 50 percent (50%) of the cost of all its components. Components
of foreign origin of the same class or kind as the products referred
to in Sections I.27.5.3 or I.27.5.4 of this clause shall be treated as
domestic. Scrap generated, collected and prepared for processing in
the United States is considered domestic.
I.27.4 "End products," as used in this clause, means those articles,
materials, and supplies to be acquired for public use under this
contract.
I.27.5 The Contractor shall deliver only domestic end products, except
those:
I.27.5.1 For use outside the United States;
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I.27.5.2 That the District determines are not mined, produced,
or manufactured in the United States in sufficient and
reasonably available commercial quantities of a
satisfactory quality;
I.27.5.3 For which the agency determines that domestic
preference would be inconsistent with the public
interest; or
I.27.5.3 For which the agency determines the cost to be
unreasonable.
I.28 Service Contract Act of 1965
I.28.1 Definitions
I.28.1.1 "Act, as used in this clause, means the Service
Contract Act of 1965, as amended (41 U.S.C. 351-358).
I.28.1.2 "Contractor," as used in this clause, means the prime
Contractor or any subcontractor at any tier.
I.28.1.3 "Service employee," as used in this clause, means any
person (other than a person employed in a bona fide
executive, administrative, or professional capacity as
defined in 29 CFR 541) engaged in performing a
Government contract not exempted under 41 U.S.C. 356,
the principal purpose of which is to furnish services
in the United States, as defined in section 22.1001 of
the Federal Acquisition Regulation. It includes all
such persons regardless of the actual or alleged
contractual relationship between them and a contractor.
I.28.2 Applicability
I.28.2.1 To the extent that the Act applies, this contract is
subject to the following provisions and to all other
applicable provisions of the Act and regulations of the
Secretary of Labor (20 CFR 4). All interpretations of
the Act in Subpart C of 29 CFR 4 are incorporated in
this contract by reference. This clause does not apply
to contracts or subcontracts administratively exempted
by the Secretary of Labor or exempted by 41 U.S.C. 356,
as interpreted in Subpart C of 29 CFR 4.
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I.28.3 Compensation
I.28.3.1 The Contractor shall pay not less than the minimum wage
and shall furnish fringe benefits to each service
employee under this contract in accordance with the
wages and benefits determined by the Secretary of Labor
or the Secretary's authorized representative, as
specified in any attachments to this contract.
I.28.3.2 If there is an attachment, the Contractor shall
classify any class of service employees not listed in
it, but to be employed under this contract. The
classification shall provide a reasonable relationship
to those listed in the attachment. The Contractor shall
pay that class wages and fringe benefits determined by
agreement of the interested parties: The contracting
agency, the Contractor, and the employees who will
perform the contract or their representatives. If the
interested parties do not agree, the Contracting
Officer shall submit the question, with a
recommendation, for final determination by the Office
of Government Contract Wage Standards, Wage and Hour
Division, Employment Standards Administration (ESA),
Department of Labor. Failure to pay such employees the
compensation agreed upon by the interested parties or
finally determined by ESA is a contract violation.
I.28.3.3 If the term of this contract is more than one (1) year,
the minimum wages and fringe benefits required for
service employees under this contract shall be subject
to adjustment after one (1) year and not less often
than once every two (2) years, under wage
determinations issued by ESA.
I.28.3.4 The Contractor can discharge the obligation to furnish
fringe benefits specified in the attachment or
determined under Section I.28.3.1 of this clause by
furnishing any equivalent combinations of bona fide
fringe benefits, or by making equivalent or
differential cash payments, in accordance with Subpart
Band C of 29 CFR 4.
I.28.4 Minimum wage
I.28.4.1 In the absence of a minimum wage attachment for this
contract, the Contractor shall not pay any service or
other employees performing this contract less than the
minimum
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wage specified by section 6(a)(l) of the Fair Labor
Standards Act of 1938, as amended (29 U.S.C. 206).
Nothing in this clause shall relieve the Contractor of
any other legal or contractual obligation to pay a
higher wage to any employee.
I.28.5 Successor contracts
I.28.5.1 If this contract succeeds a contract subject to the Act
under which substantially the same services were
furnished and service employees were paid wages and
fringe benefits provided for in a collective bargaining
agreement, then, in the absence of a minimum wage
attachment to this contract, the Contractor may not pay
any service employee performing this contract less than
the wages and benefits, including those accrued and any
prospective increases, provided for under that
agreement. No Contractor may be relieved of this
obligation unless the limitations of 29 CFR 4.1c(b)
apply or unless the Secretary of Labor or the
Secretary's authorized representative,
I.28.5.1.1 Determines that the agreement under the
predecessor was not the result of arms-length
negotiations; or
I.28.5.1.2 Finds, after a hearing under 29 CFR 4.10.
that the wages and benefits provided for by
that agreement vary substantially from those
prevailing for similar services in the
locality.
I.28.6 Notification to employees
I.28.6.1 The Contractor shall notify each service employee
commencing work on this contract of a minimum wage and
any fringe benefits required to be paid, or shall post
a notice of these wages and benefits in a prominent and
accessible place at the worksite, using such poster as
may be provided by the Department of Labor.
I.28.7 Safe and sanitary working conditions
I.28.7.1 The Contractor shall not permit services called for by
this contract to be performed in buildings or
surroundings or under working conditions provided by or
under the control or supervision of the Contractor that
are unsanitary, hazardous, or dangerous to the health
or safety of service
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employees. The Contractor shall comply with the health
standards applied under 29 CFR Part 1925.
I.28.8 Records
I.28.8.1. The Contractor shall maintain for three (3) years from
the completion of work, and make available for
inspection and transcription by authorized ESA
representatives, a record of the following:
I.28.8.1.1 For each employee subject to the Act:
a) Name and address;
b) Work classification or classifications,
rate or rates of wages and fringe
benefits provided, rate or rates of
payments in lieu of fringe benefits, and
total daily and weekly compensation;
c) Daily and weekly hours worked; and
e) Any deductions, rebates, or refunds from
total daily or weekly compensation.
I.28.8.1.2 For those classes of service employees not
included in any wage determination attached
to this contract, wage rates or fringe
benefits determined by the interested parties
or by ESA under the terms of Section I.28.4.1
of this clause. A copy of the report required
by Section I.28.4 of this clause will fulfill
this requirement.
I.28.8.2 Withholding of payments and termination of contract
I.28.8.2.1 The Contracting Officer shall withhold from
the prime Contractor under this or any other
Government contract with the prime Contractor
any sums the Contracting Officer, or an
appropriate officer of the Labor Department,
decides may be necessary to pay underpaid
employees. Additionally, any failure to
comply with the requirements of this clause
may be grounds for termination for default.
I.28.8.3 Subcontracts
The Contractor agrees to insert this clause in all
subcontracts.
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I.28.8.4 Contractor's report
I.28.8.4.1 If there is a wage determination attachment
to this contract and any classes of service
employees not listed on it are to be employed
under the contract, the Contractor shall
report promptly to the Contracting Officer
the wages to be paid and the fringe benefits
to be provided each of these classes, when
determined under Section I.28.3.2 of this
clause.
I.28.8.4.2 If wages to be paid or fringe benefits to be
furnished any service employees under the
contract are covered in a collective
bargaining agreement effective at any time
when the contract is being performed, the
prime Contractor shall provide to the
Contracting Officer a copy of the agreement
and full information on the application and
accrual of wages and benefits (including any
prospective increases) to service employees
working on the contract. The prime Contractor
shall report when contract performance
begins, in the case of agreements then in
effect, and shall report subsequently
effective agreements, provisions, or
amendments promptly after they are
negotiated.
I.28.8.5 Variations, tolerances, and exemptions involving
employment. Notwithstanding any of the provisions in
Sections I.28.3.2 through I.28.4 of this clause, the
following employees may be employed in accordance with
the following variations, tolerances, and exemptions
authorized by the Secretary of Labor.
I.28.8.5.1 In accordance with regulations issued under
Section 14 of the Fair Labor Standards Act of
1938 by the Administrator of the Wage and
Hour Division, ESA (29 CFR 520, 521, 524, and
525), apprentices, student learners, and
workers whose earning capacity is impaired by
age or by physical or mental deficiency or
injury, may be employed at wages lower than
the minimum wages
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otherwise required by section 2(a)(1) or
2(b)(1) of the Service Contract Act, without
diminishing any fringe benefits or payments
in lieu of these benefits required under
section 2(a)(2) of the Act.
a) The Administrator will issue
certificates under the Act for employing
apprentices, student-learners,
handicapped persons, or handicapped
clients of sheltered workshops not
subject to the Fair Labor Standards Act
of 1938, or subject to different minimum
rates of pay under the two acts,
authorizing appropriate rates of minimum
wages, but without changing requirements
concerning fringe benefits or
supplementary cash payments in lieu of
these benefits.
b) The Administrator may also withdraw,
annul, or cancel such certificates under
29 CFR 525 and 528.
c) An employee engaged in an occupation in
which the employee customarily and
regularly receives more than $30 a month
in tips credited by the employer against
the minimum wage required by section
2(a)(1) or section 2(b)(1) of the Act,
in accordance with regulations in 29 CFR
531. However, the amount of credit shall
not exceed 40 percent of the minimum
rate specified in section 6(a)(1) of
the Fair Labor Standards Act of 1938 as
amended.
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I.29 Cost and Pricing Data
I.29.1 This paragraph and paragraphs b through e below shall apply to
Contractors or Offerors in regards to: (1) any procurement in excess
of $100,000, (2) any contract awarded through competitive sealed
proposals, (3) any contract awarded through sole source procurement,
or (4) any change order or contract modification. By entering into
this contract or submitting this offer, the Contractor or Offeror
certifies that, to the best of the Contractor's or Offeror's knowledge
and belief, any cost and pricing data submitted was accurate, complete
and current as of the date specified in the contract or offer.
I.29.2 Unless otherwise provided in the solicitation, the Offeror or
Contractor shall, before entering into any contract awarded through
competitive sealed proposals or through sole source procurement or
before negotiating any price adjustments pursuant to a change order or
modification, submit cost or pricing data and certification that, to
the best of the Contractor's knowledge and belief, the cost or pricing
data submitted was accurate, complete, and current as of the date of
award of this contract or as of the date of negotiation of the change
order or modification.
I.29.3 If any price, including profit or fee, negotiated in connection with
this contract, or any cost reimbursable under this contract, was
increased by any significant amount because (1) the Contractor or a
subcontractor furnished cost or pricing data that were not complete,
accurate, and current as certified by the Contractor, (2) a
subcontractor or prospective subcontractor furnished the Contractor
cost or pricing data that were not complete, accurate, and current as
certified by the Contractor, or (3) any of these parties furnished
data of any description that were not accurate, the price or cost
shall be reduced accordingly and the contract shall be modified to
reflect the reduction.
I.29.4 Any reduction in the contract price under paragraph c above due to
defective data from a prospective subcontractor that was not
subsequently awarded the subcontract shall be limited to the amount,
plus applicable overhead and profit markup, by which (1) the actual
subcontract or (2) the actual cost to the Contractor, if there was no
subcontract, was less than the prospective subcontract cost estimate
submitted by the Contractor; provided that the actual subcontract
price was not itself affected by defective cost or pricing data.
I.29.5 Cost or pricing data includes all facts as of the time of price
agreement that prudent buyers and sellers would reasonably expect to
affect price negotiations significantly. Cost or pricing data are
factual, not judgmental, and are therefore verifiable. While they do
not indicate the accuracy of the prospective Contractor's judgment
about estimated future costs or projections, cost or pricing data do
include the data forming the basis for that judgment. Cost or pricing
data are more than historical accounting
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data; they are all the facts that can be reasonably expected to
contribute to the soundness of estimates of future costs and to the
validity of determinations of costs already incurred.
I.29.6 The following specific information should be included as cost or
pricing data, as applicable:
I.29.6.1 Vender quotations;
I.29.6.2 Nonrecurring costs;
I.29.6.3 Information on changes in production methods or
purchasing volume;
I.29.6.4 Data supporting projections of business prospects and
objectives and related operations costs;
I.29.6.5 Unit/cost trends such as those associated with labor
efficiency;
I.29.6.6 Make-or-buy decisions;
I.29.6.7 Estimated resources to attain business goals;
I.29.6.8 Information on management decisions that could have a
significant bearing on costs.
I.29.7 If the Offeror or Contractor is required by law to submit cost or
pricing data in connection with pricing this contract or any change
order or modification of this contract, the Contracting Officer or
representatives of the Contracting Officer shall have the right to
examine all books, records, documents and other data of the Con-
tractor (including computations and projections) related to
negotiating, pricing, or performing the contract, change order or
modification, in order to evaluate the accuracy, completeness, and
currency of the cost or pricing data. The right of examination shall
extend to all documents necessary to permit adequate evaluation of the
cost or pricing data submitted, along with the computations and
projections used. Contractor shall make available at its office at all
reasonable times the materials described above for examination, audit,
or re- production until three years after the later of:
I.29.7.1 Final payment under the contract;
I.29.7.2 Final termination settlement; or
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I.29.7.3 Final disposition of any appeals under the disputes
clause or of litigation or the settlement of claims
arising under or relating to the contract.
Cost-Reimbursement Contracts - CLIN 0002 Only
I.30.1 Contract line item number 0002 is a cost-reimbursement contract,
the only costs determined in writing to be reimbursable by the
Contracting Officer, in accordance with the cost principles set forth
in rules issued pursuant to Title VI of the Procurement Practices Act
of 1985 shall be reimbursable.
Termination of Contracts for Certain Crimes and Violations
I.31.1 The District may terminate without liability any contract and may
deduct from the contract price or otherwise recover the full amount of
any fee, commission, percentage, gift, or consideration paid in
violation of this title if:
I.31.2 The Contractor has been convicted of a crime arising out of or in
connection with the procurement of any work to be done or any payment
to be made under the contract; or
I.31.3 There has been any breach or violation of:
I.31.3.1 Any provision of the Procurement Practices Act of 1985,
as amended, or
I.31.3.2 The contract provision against contingent fees.
I.31.4 If a contract is terminated pursuant to this section, the
Contractor:
I.31.4.1 May be paid only the actual costs of the work performed
to the date of termination, plus termination costs, if
any; and
I.31.4.2 Shall refund all profits or fixed fees realized under
the Contract.
I.31.5 The rights and remedies contained in this are in addition to any
other right or remedy provided by law, and the exercise of any of them
is not a waiver of any other right or remedy provided by law.
Additional Standard Clauses
I.32.1 Contract Clauses
I.32.1.1 Disclosure of Information
I.32.1.1.1 Documents or data submitted under the
contract are subject to disclosure under the
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Freedom of Information Act, DC Code 1- 521
and other applicable disclosure statutes.
I.32.1.2 Applicability of Standard Contract Provisions The
Standard Contract Provisions for use with District of
Columbia Government Supply and Services Contracts dated
October 1999 shall be applicable to the contract
resulting from this solicitation.
I.32.1.3 Time
I.32.1.3.1 Time, if stated in a number of days, will
include Saturdays, Sundays, and holidays,
unless otherwise stated herein.
I.32.1.4 Restriction on Disclosure and Use of Information Before
Awarded
I.32.1.4 Offerors who include in their proposal data
that they do not want disclosed to the public
or used by the District Government except for
use in the procurement process shall:
I.32.1.5 Make the title page with the following legend
I.32.1.5.1 "This proposal includes data that shall not
be disclosed outside the District Government
and shall not be duplicated, used or
disclosed in whole or in part for any purpose
except for use in the procurement process."
I.32.2 Drug-Free Workplace
I.32.2.1 Definitions
I.32.2.1.1 As used in this provision "Controlled
substance" means a controlled substance in
schedules I through V of section 202 of the
Controlled Substance Act (21 U.S.C. 812) and
as further defined in regulation at 21 CFR
1308.11 - 1308.15.
I.32.2.1.2 "Conviction" means a finding of guilt
(including a plea of nolo contendere) or
imposition of sentence, or both, charged
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with the responsibility to determine
violations of the federal or state criminal
drug statutes.
I.32.2.1.3 "Criminal drug statute" means a federal or
non-federal criminal statute involving the
manufacture, distribution, dispensing,
possession or use of any controlled
substance.
I.32.2.1.4 "Drug-free workplace" means a site for the
performance of work done by the Contractor in
connection with a specific contract at which
employees of the Contractor are prohibited
from engaging in the unlawful manufacture,
distribution, dispensing, possession, or use
of a controlled substance.
I.32.2.1.5 "Directly engaged" is defined to include all
direct cost employees and any other
Contractor employee who has other than a
minimal impact or involvement in contract
performance.
I.32.2.1.6 "Employee" means an employee of a Contractor
directly engaged in the performance of work
under a Government contract.
I.32.2.1.7 "Individuals" means an Offeror/Contractor
that has no more than one employee including
the Offeror/Contractor.
I.32.2.2 The Contractor, if other than an individual, shall,
within 30 calendar days after award (unless a longer
period is agreed in writing for contracts of 30
calendar days or more performance duration) or as soon
as possible for contracts of less than 30 calendar days
performance duration:
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I.32.2.2.1 Publish a statement notifying its employees
that the unlawful manufacture, distribution,
dispensing, possession, or use of a
controlled substance is prohibited in the
Contractor's workplace and specifying the
actions that will be taken against employees
for violations of such prohibition;
I.32.2.2.2 Establish an ongoing drug-free awareness
program to inform such employees about:
a) The dangers of drug abuse in the
workplace:
b) The Contractor's policy of maintaining a
drug-free workplace;
c) Any available drug counseling,
rehabilitation, and employee assistance
programs; and
d) The penalties that may be imposed upon
employees for drug abuse violations
occurring in the workplace;
I.32.2.2.3 Provide all employees engaged in performance
of the contract with a copy of the statement
required by this clause;
I.32.2.2.4 Notify such employees in writing in the
statement required by this clause that as a
condition of continued employment on this
contract the employee will:
a) Abide by the terms of the statement; and
b) Notify the employer in writing of the
employee's conviction under a criminal
drug statue for a violation occurring in
the work place no later than five (5)
calendar days after such conviction.
c) Notify the Contracting Officer in
writing within ten (10) calendar days
after receiving notice of this clause,
from an employee or otherwise receiving
actual notice of such conviction. The
notice shall include the position title
of the employee;
I.32.2.2.5 Within thirty (30) calendar days after
receiving notice under this clause of a
conviction, take one of the following
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actions with respect to any employee who is
convicted of a drug abuse violation occurring
in the workplace:
a) Taking appropriate personnel action
against such employee, up to and
including termination; or
b) Require such employee to satisfactorily
participate in a drug abuse assistance
or rehabilitation program approved for
such purposes by a federal, state or
local health, law enforcement, or other
appropriate agency; and
c) Make a good faith effort to maintain a
drug-free workplace through
implementation of this clause.
I.32.2.3 The Contractor, if an individual, agrees by award of
the contract or acceptance of a purchase order, not to
engage in the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled
substance in performance of this contract.
I.32.2.4 In addition to other remedies available to the
Government, the Contractor's failure to comply with the
requirements of paragraphs I.7.2 or I.7.4 or this
clause may, pursuant to FAR 23.506, render the
Contractor subject to suspension of contract payments,
termination of the contract for default, and suspension
or debarment.
I.32.3 Confidentiality of Information
I.32.3.1 All information obtained by the Contractor relating to
any employee of the District shall be kept in absolute
confidence and shall not be used by the Contractor in
connection with any other matters, nor shall any such
information be disclosed to any other person, firm or
corporation, in accordance with the District and
federal laws governing the confidentiality of records.
I.32.4. Equal Employment Opportunity
I.32.4.1 In accordance with the District of Columbia
administrative Issuance System, Mayors Order 85-85
dated June 10, 1985, the forms for completion of the
Equal Employment Opportunity Information Report is
incorporated herein as Attachment J.2. An award cannot
be made to any Offeror
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who has satisfied the equal employment requirements as
set forth by the Office of Human Rights.
I.32.5 Other Contractors
I.32.5.1 The Contractor shall not commit or permit any act,
which will interfere with the performance of work by
another District Contractor or by any District
employee. If another Contractor is awarded a future
contract for performance of the required services, the
Contractor shall cooperate fully with the District and
the new Contractor in any transition activities, which
the Contracting Officer deems necessary during the term
of the contract.
I.32.6 Rights In Data
I.32.6.1 "Data," as used herein, means recorded information,
regardless of form or the media on which it may be
recorded. The term includes technical data and computer
software. The term does not include information
incidental to contract administration, such as
financial, administrative, cost or pricing, or
management information.
I.32.6.2 The term "Technical Data," as used herein, means
recorded information, regardless of form or
characteristic, of a scientific or technical nature. It
may, for example, be document research, experimental,
developmental or engineering work, or be usable or used
to define a design or process or to procure, produce,
support, maintain, or operate material. The data may be
graphic or pictorial, delineation in media such as
drawings or photographs, text in specifications or
related performance design type documents, or computer
printouts. Examples to technical data include research
and engineering data, engineering drawings and
associated list, specifications, standards, process
sheets, manuals, technical reports, catalog item
identifications and related information, and computer
software documentation. Technical data does not include
computer software or financial, administrative, cost
and pricing, and management data or other information
incidental to contract administration.
I.32.6.3 The term "Computer Software," as used herein, means
computer programs and computer databases. "Computer
programs" include operating systems, assemblers,
compilers, interpreters, data management systems,
utility
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programs, sort/merge programs such as payroll,
inventory control and engineering analysis programs.
I.32.6.3.1 Computer Programs may be either
machine-idependent or machine-independent,
and may be general-purpose in nature or
designed to satisfy the requirements of a
particular user.
I.32.6.4 The term "Computer Databases," as used herein, means a
collection of data in a form capable of being processed
and operated on by a computer.
I.32.6.5 All data first produced in the performance of this
contract shall be the sole property of the District.
The Contractor hereby acknowledges that all data
including, without limitation, computer program codes
produced by Contractor for the District under this
Contract are works made for hire and are the property
of the District; but, to the extent any such data may
not, by operation of law, be works made for hire,
Contractor hereby transfers and assigns to the District
the ownership of copyright in such works, whether
published or unpublished. The Contractor agrees to give
the District all assistance reasonably necessary to
perfect such rights including, but not limited to, the
works and supporting documentation and the execution of
any instrument required to register copyrights. The
Contractor agrees not to assert any rights at common
law or in equity in such data. The Contractor shall not
publish or reproduce such data in whole or in part or
in any manner or form, or authorize others to do so,
without written consent of the District, until such
time as the District may have released such data to the
public.
I.32.6.6. The District shall have restricted rights in computer
software and all accompanying documentation, manuals
and instructional materials listed or described in a
license or agreement made a part of the contract, which
the parties have agreed will be furnished with
restricted rights, provided however, notwithstanding
any contrary provision in any such license or
agreement, such restricted right shall include, as a
minimum, the right to:
I.32.6.7 Use the computer software and all accompanying
documentation, and manuals or instructional materials
with the computer for which or with which it was
required,
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including use at any District installation to which the
computer may be transferred by the District;
I.32.6.8 Use the computer software and all accompanying
documentation and manuals or instructional materials
with a backup computer if the computer for which or
with which it was acquired are inoperative;
I.32.6.9 Copy computer programs for safekeeping (archives) or
backup purposes; and
I.32.6.10 Modify the computer software and all accompanying
documentation and manuals or instructional materials,
or combine it with other software, subject to the
provision that modified portions shall remain subject
to these restrictions.
I.32.7 The restricted rights set forth in paragraph I.32.6 are of no effect
unless (i) the computer software is marked by the Contractor with the
following legend:
I.32.7.1 RESTRICTED RIGHTS LEGEND
I.32.7.2 Use, duplication, or disclousre is subject to
restrictions stated in Contract
No. with
--------------------- -----------------------
(Contractor's Name)
I.32.7.3 and (ii) the related computer software documentation
includes a prominent statement of the restrictions
applicable to the computer software.
I.32.7.4 The Contractor may not place any legend on computer
software indicating restrictions on the District's
rights in such software unless the restrictions are set
forth in a license or agreement made a part of the
contract prior to the delivery date of the software.
Failure of the Contractor to apply a restricted rights
legend to such computer software shall relieve the
District of liability with respect to such unmarked
software.
I.32.7.5 In addition to the rights granted in paragraph I.32.6
above, the Contractor hereby grants to the District a
nonexclusive, paid-up license throughout the world, of
the same scope as restricted rights set forth in
paragraph I.32.6 above, under
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any copyright owned by the Contractor, in any work of
authorship prepared for and acquired by the District
under the contract. Unless written approval of the
Contracting Officer is obtained, the Contractor shall
not include technical data or computer software
prepared for, or acquired by the District under the
contract any works of authorship in which copyright is
not owned by the Contractor without acquiring for the
District any rights necessary to perfect a copyright
license of the scope specified in the first sentence of
this paragraph.
I.32.7.6 Whenever any data, including computer software, are to
be obtained from a subcontractor under this contract,
the Contractor shall use this same clause in the
subcontract, without alteration, and no other clause
shall be used to enlarge or diminish the District's or
the Contractor's rights in that subcontractor data or
computer software which is required for the District.
I.32.8 For all computer software furnished to the District with the rights
specified in paragraph I.32.6, the Contractor shall furnish to the
District a copy of the source code with such rights of the scope
specified in paragraph I.32.6. For all computer software furnished to
the District with the restricted rights specified in paragraph I.32.6,
the District, if the Contractor, either directly or through a
successor or affiliate shall cease to provide the maintenance or
warranty services provided the District under this contract or any
paid-up maintenance agreement, or if Contractor should be declared
bankrupt or insolvent by a court of competent jurisdiction, shall have
the right to obtain, for its own and sole use only, a single copy of
the then current vision of the source code supplied under this
contract, and a single copy of the documentation associated therewith,
upon payment to the person in control of the source code the
reasonable cost of making each copy.
I.32.9 The Contractor shall indemnify and save and hold harmless the
District, its officers, agents and employees acting within the scope
of their official duties against any liability. Including costs and
expenses, (i) for violation of proprietary rights, copyrights, or
rights of privacy, arising out of the publication, translation,
reproduction, delivery, performance, use or disposition of any data
furnished under this contract or (ii) based upon any data furnished
under
- --------------------------------------------------------------------------------
CONTRACT NO.: P0HC-2002-D-0003 228
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
this contract, or based upon libelous other unlawful matter contained
in such data.
I.32.10 Nothing contained in this clause shall imply a license to the
District under any patent, or be construed as affecting the scope of
any license or other right otherwise granted to the District under any
patent.
I.32.11 Paragraphs I.32.6.1, I.32.6.2, I.32.6.3, I.32.6.5, and I.32.6.6
above are not applicable to material furnished to the Contractor by
the District and incorporated in the work furnished under contract,
provided that such incorporated materials is identified by the
Contractor at the time of delivery of such work.
Contract Type and Price
I.33.1 Contract line item number 0001 is based on an Indefinite Delivery/
Indefinite Quantity (IDIQ)
I.33.1.1 The price for performing this contract shall not exceed
the total specified in Section A, Block 20.
I.33.2 RESERVED.
Reserved
Assignment of Funds
I.35.1 No contract or any interest therein shall be transferred by the
party to whom the award is made; such transfer will be null and void, and
will be cause to annul the contract.
- --------------------------------------------------------------------------------
CONTRACT NO.: P0HC-2002-D-0003 229
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
SECTION J - LIST OF ATTACHMENTS
FOR ATTACHMENTS SEE SECTION AA OF THIS CONTRACT.
REMAINDER OF THIS PAGE WAS INTENTIONALLY LEFT BLANK
- --------------------------------------------------------------------------------
CONTRACT NO.: P0HC-2002-D-0003 230
- --------------------------------------------------------------------------------
ATTACHMENT 7
Minimum Covered Services for Minimum
Covered Services for Medicaid Managed Care
Program (MMCP)
Minimum Covered Services for the Medicaid Managed Care Program
(MMCP)
Services Included in the Capitation Rate
1. Inpatient hospital services (other than services in institutions for
mental diseases, as defined in federal law, 42 U.S.C. Section 1396d).
Inpatient hospital care includes cosmetic surgery, limited to services
required to correct the following conditions: (a) a condition
resulting from surgery or disease; (b) an accidental injury; (c) a
congenital deformity; and (d) correction of a functional problem, i.e.
a condition that impairs the normal function of a part of the body.
Covered dental surgery is limited to emergency repair of accidental
injury to the jaw and related structures.
2. Outpatient hospital services: surgery is limited as in 1. above.
3. Federally qualified health center services and other ambulatory
services covered by federally qualified health centers.
4. Laboratory and x-ray services.
5. Nursing facility services that are not otherwise excluded under this
agreement.
6. Physician services: preventive and non-routine care, including
medically necessary elective surgery, anesthesia; maternity care;
emergency care; family planning, except the treatment of infertility;
allergy testing and injections; radiation, chemotherapy and dialysis
treatment; plastic surgery, gastric bypass surgery, reduction
mammoplasty, intestinal bypass for morbid obesity and insertion of a
penile prosthesis. Not covered are sterilizations of patients under
21.
7. Medical and surgical services furnished by a dentist.
8. Podiatrists services excluding routine foot care for asymptomatic
individuals.
9. Optometrist services including contact lenses and special eyeglasses
and sunglasses when authorized as medically necessary. Eyeglasses or
contacts limited to one pair every 24 months except for persons under
age 21, persons experiencing a change of more than plus or minus one
half diopter and to replace broken or lost eyeglasses. In these
exception cases, eyeglasses or contacts are limited to one pair every
six months.
10. Home health services for individuals of all ages including
intermittent or part-time nursing care, home health aide services
provided by a home health agency, medical supplies, equipment, and
appliances suitable for use in the home, and physical therapy,
occupational therapy or speech pathology and audiology services.
Services for individuals with speech, language and hearing disorders
are limited to children under 21.
11. Private duty nursing services limited to individuals who require more
individual and continuous care than is routinely provided by home
health agencies, a nursing facility, or a hospital.
2
12. Physical therapy and related services including physical and
occupational therapy and services for individuals with speech,
language and hearing disorders furnished under the supervision of a
speech pathologist or audiologist. Services for speech, language and
hearing disorders are limited to children under 21 and include
services furnished by the District's school system.
13. Prescribed drugs limited to legend drugs approved as safe and
effective by the FDA and over-the-counter medications in the District
specified categories. Only those over-the-counter drugs that fall into
the following categories are covered if they are prescribed on a
written prescription by a participating health care professional:
Oral analgesics
Ferrous sulfate
Antacids
Diabetic preparations
Pediatric and prenatal vitamin formulations
Senna extract, single dose preparations when required for
diagnostic radiological procedures performed under the
supervision of a participating physician
Family planning drugs and supplies
Psychotropic medications as approved by the Dixon Transitional
Receiver
14. Durable Medical Equipment including prosthetic devices including items
listed in the program's Medical Equipment/Medical Supplies Procedure
Code and Price List as well as other devices as authorized for medical
necessity.
15. Nurse midwife services.
16. Pediatric nurse practitioner services and family nurse practitioner
services.
17. Transportation services other than those specifically excluded.
Covered transportation include emergency transportation, medially
necessary transportation for non-emergency situations, and as
requested and necessary transportation to EPSDT services.
18. Personal care services not to exceed 1,040 hours annually except as
authorized for medical necessity.
19. Abortions as permitted under federal law.
20. Adult day treatment services for persons with mental retardation to
prepare for independent living.
21. Family planning services and supplies as defined in Section B.
22. Early and periodic screening diagnosis and treatment (EPSDT) services
for persons under 21 as defined in Section C.
3
23. Mental health and alcohol and drug abuse services
Diagnostic evaluation/assessment
Psychiatric outpatient clinic services (individual, group &
family therapy)
Crisis Intervention
Medication Management
Psychological Testing
Residential Treatment Centers
Psychiatric Inpatient Hospitalization
Therapeutic Nursery
Lab
CASSIP Only:
Inpatient drug and alcohol detoxification
Inpatient/residential drug and alcohol rehabilitation
Outpatient drug and alcohol rehabilitation.
Drug and alcohol rehabilitation day treatment
NOTE: For DCHFP Enrollees, alcohol and drug abuse treatment services
will be provided through a provider network contracted by MAA. DCHFP
will be responsible for referral and care coordination for DCHFP
Enrollees. This includes screening and the provision of emergency
services.
Excluded Services for MMCP
Inpatient Transplantation Surgery and Services provided during the
inpatient stay in which the transplant surgery takes place.
2. Cosmetic surgery, except services required to correct the following
conditions: (a) a condition resulting from surgery or disease; (b) an
accidental injury; (c) a congenital deformity; and (d) correction of a
functional problem, i.e. a condition that impairs the normal function of
a part of the body.
3. Steri1izations~ if the Enrollee is under 21
4. Health related IDEA services and transportation to or from them when
provided by the District of Columbia Public Schools or one of its
Contractors.
Benefits for CASSIP Only
1. Intermediate Care Facilities for Mental Retardation.
2. Long Term Nursing Facilities.
3. Substance abuse treatment services as identified above
4
Eligibility Guidelines
Persons Eligible For The MMCP DC Healthy Families Plans.
Except as provided in Section 0 enrollment in an MMCP DC Healthy Families Plan
will be mandatory for the following individuals:
1. All children under age 19, pregnant women and the parents, legal guardians,
and relative caretakers of eligible children who are:
Citizens or qualified immigrants;
Residents of the District of Columbia;
Have family income at or below 200 percent of the federal poverty
guidelines; and
Have been determined to be eligible for Medical Assistance by the
Department of Human Services.
2. Individuals ages 19 or 20 who are
Citizens or qualified immigrants;
Residents of the District of Columbia;
Have family income at the medically needy level; and
Have been determined to be eligible for Medical Assistance by the
Department of Human Services.
3. Infants born to Medicaid-eligible women.
4. Immigrants
Up to 500 children in FY 2000 and 850 children in FY 2001 who are:
Not eligible for Medicaid;
Residents of the District of Columbia;
Have family income at or below 200 percent of the federal poverty
guidelines;
Have been determined to be eligible by the Department of Human
Services
Persons excluded from the DC Healthy Families Plans
Individuals who meet the requirements of Section 0 and are included in one or
more of the following categories are excluded from enrollment in an MMCP DC
Healthy Families Plan:
1. Individuals whose eligibility for Medicaid is retroactive, to the extent of
that period;
2. Individuals receiving supplemental security income disability or aging
benefits, or who qualify for Medicaid due to old age or disability;
3. Foster care children and other wards of the District of Columbia under
guardianship of the department of human services unless enrolled
voluntarily;
4. Individuals who have been identified by the department of human services as
homeless;
5. Individuals who have been restricted to a specific provider by the medical
assistance administration;
6. Individuals eligible for both Medicare and Medicaid;
7. Individuals who have gained eligibility through the "spend-down" process;
8. Individuals who are residing in a long-term care facility (nursing
facility, intermediate care facility for the mentally retarded, residential
treatment center, Hospital for Sick Children, or mental institution);
9. Individuals participating in services provided under a Section 1915c Home
and Community Based Waiver; or
10. Women who are twenty-six (26) weeks or more pregnant at the time they are
notified that they shall select a managed care plan and who have requested
exemption from enrollment in managed care.
5
Persons Eligible for the MMCP Child and Adolescent SSI Plans
Participation in the MMCP Child and Adolescent SSI Plan is open only to children
under age 22 who are receiving Supplemental Security Income disability benefits
except for:
1. Individuals whose eligibility for Medicaid is retroactive, to the extent of
that period;
2. Individuals who have been restricted to a specific provider by the Medical
Assistance Administration;
3. Individuals eligible for both Medicare and Medicaid; or
4. Individuals participating in services provided under a Section 1915(c)
Home and Community Based Waiver.
5. Individuals aged 20 or 21 who are placed in an Intermediate Care Facility
for Mental Retardation (ICF/MR) at the time of enrollment.
Automatic enrollment of Newborns
Infants born to (an) Enrollee(s) of a Child and Adolescent SSI or
SSI-related Plan are not automatically eligible for SSI Medicaid
themselves. Most however, will be eligible for Medicaid in the
categories defined in Section 0.
If the Contractor is operating the CASSIP in which the mother is
enrolled, the Contractor will be responsible for coordinating the care
of the infant. However if the infant is not a special needs child, the
infant will be enrolled in the fee-for-service program and care will
continue to be coordinated by the CASSIP Contractor.
Other Persons Eligible for the MMCP
The District reserves the right to expand the targeted populations to include
the following individuals:
1. Actuarially equivalent individuals that may become eligible for
Medicaid through expansions; and
2. Individuals who are not actuarially equivalent but for whom MAA will
negotiate an appropriate capitation rate with the Contractor.
Managed care services for the homeless population and other subpopulations will
be contingent upon federal approval of the District's 1115 waiver.
6
Principles and Goals
MAA has incorporated the following standards and principles into its planning
for its Medicaid Managed Care program, and has set the following goals for the
continued development of Medicaid managed care.
Family-Based Principles
MAA's Medicaid Managed Care Program for families enrolled in a DCHFP and for
children and adolescents on SSI/1/ is built on a family-based model of care and
reflects the principles listed below.
1. Every child deserves quality primary and specialty health care that is
affordable and within geographic reach.
2. Families are the core of this nation's health system, their children's most
important health providers and caregivers.
3. Quality health care is family-centered, community-based, coordinated, and
culturally competent.
4. Health benefits and services shall be flexible, guided by what children
need.
5. Strong family-professional partnerships improve decision-making, enhance
outcomes and assure quality.
6. Families practice cost-effectiveness and expect the same from health
systems.
Early and Periodic Screening Diagnosis and Treatment Services (EPSDT)
The EPSDT program is the major pediatric component of Medicaid and its
requirements for child and adolescent services are integrated throughout this
document. EPSDT requires coverage of periodic and interperiodic screens; vision,
dental, and hearing care; other diagnostic services needed to confirm the
existence of a physical or mental illness or condition; and treatment for any
illness or condition. All federally recognized (under Section 1905 of the Social
Security Act) Medicaid services shall be provided to children age 20 and under
if needed to provide the coverage described above even if some of those
federally recognized services are not offered to persons age 21 and older under
the state plan.
- ----------
Both Family Voices and a similar set of principles put forth by the Child and
Adolescent Service System Program (CASSP) stress individualization of care and
flexibility of service provision. These depend upon a continuum of care that
can provide a progression from brief community-based interventions to inpatient
hospitalization.
Source: Family Voices, http://www.familyvoices.org/survey.html, 1999.
7
ATTACHMENT 9
Newborn Notification Report
Hospital
--------------------------
Submission Date
-------------------
DHS/IMS Receipt Date
--------------
REQUEST TO ADD NEWBORNS
TO DC MEDICAID, PUBLIC ASSISTANCE AND FOOD STAMP ROLLS
To enable the D.C. Department of Human Services to add all eligible newborns to
our Medicaid and Public Assistance Program, as appropriate, please provide us
with the information requested below and forward to:
Income Maintenance Administration
645 H Street, N.E.
3rd Floor
Washington, D.C. 20002
Attention: Branch Manager
Mother's Medicaid I.D. Number: Eligibility Period:
---------------- ------------
Mother's Name Telephone:
----------------------------------- ------------------
Mother's Address:
----------------------------------
----------------------------------
Father's Name: Telephone:
---------------------------------- ------------------
Newborn's Name: Sex: Date of Birth:
------------------------ --------------
Place of Birth:
------------------------------------
I hereby request that my child, , be added to my Medicaid
-----------------------
eligibility case.
This also serves as the official report to D.C. DHS of this birth for Public
Assistance and/or Food Stamp Program purposes. If I am currently receiving these
services, I am requesting that my child be added to my PA and/or FS household
----------------------------------
Mother's Signature
----------------------------------
Date of Report
- --------------------------------------------------------------------------------
I do hereby certify that the above information is the same as reflected on our
Medical Records
- --------------------------------- -------------------------------
Utilization Reviewer HMO Medical Director
Telephone: Telephone:
----------------------- ---------------------
2
- ------------------------------------------------------------------------------------------------------------------------------------
AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. Contract Number Page of Pages
POHC-2002-D-0003 1 23
- ------------------------------------------------------------------------------------------------------------------------------------
2. Amendment/Modification Number 3. Effective Date 4. Requisition/Purchase Request No. 5. Project No. (If applicable)
'M0001 SEE BLOCK 16C BELOW HCOP2-210457
- ------------------------------------------------------------------------------------------------------------------------------------
6. Issued By Code[______________] 7. Administered By (If other than line 6)
Office of Contracting and Procurement Department of Health, Office of Managed Care
Public Safety Cluster, Department of Health Bureau Medical Assistance Administration
441 4th Street, N.W., Suite 800 South 825 North Capitol Street, N.E.
Washington, DC 20001 Attention: Ms. Maude Holt
- ------------------------------------------------------------------ Telephone: (202)442-9074
- ------------------------------------------------------------------------------------------------------------------------------------
8. Name and Address of Contractor (No. Street, city, country, state and ZIP Code) (X)9A. Amendment of Solicitation No.
---
------------------------------------------
9B. Dated (See Item 11)
AMERICAID COMMUNITY CARE
514 10TH STREET, N.W., SUITE 500 ---------------------------------------------
WASHINGTON, D. C. 20004 10A. Modification of Contract/Order No.
ATTN: MS. JANE E. THOMPSON POHC-2002-D-0003
TELEPHONE NO.: (202)783-8100 X ------------------------------------------
- -------------------------------------------------------------------------------- 10B. Dated (See Item 13)
Code Facility APRIL 1, 2002
- ------------------------------------------------------------------------------------------------------------------------------------
11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS
- ------------------------------------------------------------------------------------------------------------------------------------
[__]The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers[___]is
extended.[___]is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the
solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning [__________]copies
of the amendment: (b) By acknowledging receipt of this amendment on each copy of the offer submitted: or (c) By separate letter
or telegram which includes a reference to the solicitation and amendment number. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED
AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER.
If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or telegram,
provided each letter or telegram makes reference to the solicitation and this amendment, and is received prior to the opening
hour and date specified.
- ------------------------------------------------------------------------------------------------------------------------------------
12. Accounting and Appropriation Data (If Required)
- ------------------------------------------------------------------------------------------------------------------------------------
13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,
IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14
- ------------------------------------------------------------------------------------------------------------------------------------
(X) A. This change order is issued pursuant to: (Specify Authority)
The changes set forth in Item 14 are made in the contract/order no. in item 10A.
- ------------------------------------------------------------------------------------------------------------------------------------
B. The above numbered contract/order is modified to reflect the administrative changes (such as changes in paying office,
appropriation date, etc.) set forth in item 14, pursuant to the authority of 27 dCMR, Chapter 36, Section 3601.2.
- ------------------------------------------------------------------------------------------------------------------------------------
C. This supplemental agreement is entered into pursuant to authority of:
- ------------------------------------------------------------------------------------------------------------------------------------
X D. Other (Specify type of modification and authority)
DISTRICT OF COLUMBIA MUNICIPAL REGULATIONS 3601.2 (c) Bilateral Contract Modification and agreement between the parties
- ------------------------------------------------------------------------------------------------------------------------------------
E. IMPORTANT: Contractor[____]is not, [X] is required to sign this document and return 2 copies to the issuing office
--- --
- ------------------------------------------------------------------------------------------------------------------------------------
14. Description of amendment/modification (Organized by USC Section headings, including solicitation/contract subject matter where
feasible.)
THE CONTRACT REFERENCED IN BLOCK 10A ABOVE IS MODIFIED AS STATED ON PAGES 2 THROUGH 27 OF THIS MODIFICATION.
- ------------------------------------------------------------------------------------------------------------------------------------
Except as provided herin, all terms and conditions of the document referenced in Item (9A or 10A as heretofore changed, remains
unchanged and in full force and effect
- ------------------------------------------------------------------------------------------------------------------------------------
15A. Name and Title of Signer (Type or print) 16A. Name of Contracting Officer
JANE E. THOMPSON CEO-DC OPERATIONS ESTHER M. SCARBOROUGH
- ------------------------------------------------------------------------------------------------------------------------------------
15B. Name of Contractor 15C. Date Signed 16B. District of Columbia 16C. Date Signed
AMERIGROUP District of Columbia 4/9/02 4-9-02
/s/ Jane E. Thompson /s/ E. M. Scarborough
- -------------------- ---------------------
(Signature of person authorized to sign) (Signature of Contracting Officer)
- ------------------------------------------------------------------------------------------------------------------------------------
[LOGO] Government of the District of Columbia [LOGO] Office of Contracting & Procurement DC OCP 202 (7-99)
- ------------------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
SECTION B - Supplies / Services
- --------------------------------------------------------------------------------
Section B - Contract Line Item Number (CLIN) 0001 for DC Health Families Program
(DCHFP) The Contractor shall provide healthcare services to individuals in
Temporary Assistance to Needy Families (TANF) or TANF-related Medicaid
eligibility categories using the rate cells and total per member per month price
noted below. The period of performance shall be from April 1, 2002 through
October 31, 2002.
- ------------------------------------------------------------------------
CLIN SUPPLIES/SERVICES/RATE CELL TOTAL PMPM.
- ------------------------------------------------------------------------
0001 Infants Under 1 year of age
- ------------------------------------------------------------------------
0001AA . Delivery month (projected delivery)
- ------------------------------------------------------------------------
. Birth month (actual month of birth)
- ------------------------------------------------------------------------
0001AB Children of 1 year of age through 12 years of age
- ------------------------------------------------------------------------
0001AC Females ages 13 through 18 years of age
- ------------------------------------------------------------------------
0001AD Males ages 13 through 18 years of age
- ------------------------------------------------------------------------
0001AE Females ages 19 through 36 years of age
- ------------------------------------------------------------------------
0001AF Males ages 19 through 36 years of age
- ------------------------------------------------------------------------
0001AG Females 37 years of age and older
- ------------------------------------------------------------------------
0001AH Males 37 years of age and older
- ------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 2 OF 23
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
C.1.2 ADDITIONAL CITATIONS ADDED
Section 1932 (b)(3) of the
Social Security Act
SSA 1128B (d)(1)--BBA 4704(b)
SSA 1932(f)--BBA4708(c)
Social Security Act 1124(a)
(2)(A)--BBA 4704(c)
Social Security Act 1932 (d)
(3)--BBA 4707(a)
Social Security Act 1932(b)(6)
Social Security Act 1932(b)(7)
Section 504 of the
Rehabilitation Act
- --------------------------------------------------------------------------------
C.1.3 REPLACE THE TERM: REPLACE THE TERM WITH:
C.3.2.6
C.3.2.12.2 Commission on Mental Health Department of Mental Health
C.9.14
C.10.2.1.10
C.10.5.3.1(e)
C.10.5.6
C.10.5.7
0.17.5.3.13
0.18.8.7.2
C.18.9.1(e)
F.3, Table 4
H.3.4
H.3.5
- --------------------------------------------------------------------------------
C.1.3 DELETE DEFINITION
ACRONYM PBS - PUBLIC
BENEFITS CORPORATION
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 3 OF 23
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
C.2.3 DELETE THE FIRST SENTENCE: REPLACE WITH NEW SENTENCE:
DCHFP is responsible for
DCHFP responsibility for providing and coordinating
Proposed Alcohol and Drug inpatient substance abuse
Abuse Services Contingent upon services. The Contractor shall
HCFA approval of the coordinate the enrollee's
District's waiver request, the outpatient substance abuse
District MAA will select a services that are purchased in
network(s) of alcohol and drug the Medicaid fee-for-service
abuse treatment providers to system.
provide outpatient, day
treatment, methadone,
residential and detoxification
services to DCHFP Enrollees.
- --------------------------------------------------------------------------------
C.3.3 INSERT NEW SECTION C.3.3
Health plans must ensure that
all individually identifiable
information relating to
Medicaid enrollees is kept
confidential pursuant to
District of Columbia, 42
U.S.C. Section 1396a(a)(7)
{Section 1902(a)(7) of the
Federal Social Security Act},
42CFR Part 2 and other
regulations promulgated
thereunder. Such information
may be used by the plan or its
providers only for a purpose
directly connected with
performance of the plan's
obligations under this
program. The provisions of
this section will survive the
termination of a health plan's
participation in the Medicaid
managed care program and will
remain in effect as long as
the plan maintains any
individually identifiable
information relating to
Medicaid beneficiaries.
The Contractor must ensure
compliance with the Health
Insurance Portability and
Accountability Act of 1996
(Public Law 104-191, August
21, 1996) and all applicable
regulations promulgated
thereunder. Such regulations
include but are not limited
to, the medical privacy rule
65 Federal Regulations 82462
(December
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 4 OF 23
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
28, 2000) (codified at 45
C.F.R. Parts 160-164) and the
electronic transactions and
code set standards rule, 65
Federal Regulations 50312
(August 17, 2000) (codified at
45 C.F.R. Parts 160 and 162).
The Contractor shall maintain
written procedures for
compliance with all applicable
privacy, confidentiality, and
information security
requirements. The Contractor
shall train employees and
subcontractors on compliance
with all applicable privacy,
confidentiality, and
information security
requirements.
- --------------------------------------------------------------------------------
C.3.4 INSERT NEW SECTION C.3.4
The Contractor is responsible
to DC MAA or their designee
for complying with all
activities of the External
Quality Review (EQR) process
including:
. Submitting requested
pre-site survey documents
and/or information in
accordance with published
timelines;
. Submitting documents
and/or information
required during the
on-site reviews within
specified timelines;
. Submitting requested
member medical
records/information for
annual clinical studies
within specified
timelines;
. Adhering to HIPAA
guidelines when securing
and/or submitting
consumer related
information;
. Maintaining Quality
Improvement Programs and
Plans that focus on
meeting and/or exceeding
the Performance Standards
with Guidelines required
by the District of
Columbia Medical
Assistance Administration
or their designee.
. Submitting corrective
action plans (CAPs)
within pre-established
timelines.
. Having a representative
in attendance at all
meetings related to the
EQR process.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 5 OF 23
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
. Making available
organizational documents,
member clinical records
and/or information
requested by DC MAA or
their designee related to
any type of health care
quality review or study.
The Contractor shall ensure
that the Contractor and each
provider participating in the
Contractor's provider network
collects and reports the data
and information required by an
external quality review
organization to carry out its
responsibilities under
1902(a)(30)(C) and 1932(c)(2)
of the Social Security Act, 42
U.S.C. 1396a(a)(30)(C) and 42
U.S.C. 139u-2(c)(2).
The Contractor agrees that the
results of each annual
external independent quality
review conducted by DC MAA or
its designee shall be
available to each provider
participating in the
Contractor's provider network.
- --------------------------------------------------------------------------------
C.5.4.5 INSERT NEW SECTION C.5.4.5
C.5.4.5 Every month the
Contractor will send a current
Provider File to Benova via
FTP. The file should be sent
by the 13th of each month.
If the 13th falls on a weekend
or holiday, the file should be
sent on the previous business
day.
The file name should be in the
following format:
XXXMMDDYY.dat, where XXX is
the Contractor identifier and
the MMDDYY is the date the
file was sent.
Benova will process the
Provider File. Benova will not
be processing any mid-month
files. All errors will be
corrected with the following
months processing. Benova will
load all records from the
Provider File that have a
valid Contractor's
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 6 OF 23
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
number. Any records with an
invalid Contractor's number
will be rejected, and reported
back to the Contractor within
ten business days. These
records will not be loaded in
that month's processing, and
must be corrected by the
Contractor before the next
monthly processing in order
for the records to load
successfully at that time.
Any records from the Provider
File that do not conform to
the Provider File format will
be loaded into Benova's
system. An error log will be
produced identifying those
records that do not conform to
the Provider File format, and
the error log will be sent to
the Contractor. These records
should be corrected by the
Contractor before the next
monthly processing and sent on
the next monthly file to
Benova.
On the Provider File, Benova
collects data on the number of
active recipients per PCP, and
reports that information to
the MAA. If the PCP has more
than one location, the MCO
should only report the # of
Active Recipients for that PCP
at one location, filling in
that field with a 0 for the
remaining locations.
Benova will send the following
reports to the MAA to forward
to the Contractor based on
information collected by the
Customer Service
Representatives:
. Health Assessment Report
------------------------
- This report will
identify the individual
recipients' answers to
the Health Assessment
Questions. This is a
weekly report that will
be sent out from Benova
by the close of business
each Monday (or Tuesday,
if Monday is a holiday)
. Address/Phone Change
--------------------
Report - This report will
------
identify any changes in
address or phone number
that have been reported
to Benova during the
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previous month. This
report will be sent out
from Benova within ten
business days following
the end of each month.
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C.8.3.2 INSERT NEW SECOND PARAGRAPH IN
C.8.3.2
The Contractor is required to
follow all applicable laws,
regulations and rules
governing emergency care
including but not limited to:
C.1.2 Applicable Documents
42 C.F.R. Section 434.30
42 C.F.R. Section 434.32 as
amended
42 C.F.R. Section 431.210,
431.211, 431.213, 431.214
Section 1867 of the Social
Security Act
Section 1902 (a)(25) of the
Social Security Act, (42
U.S.C. Section 1396a(a)(25),
42 C.F.R. Part 431, Subpart F,
as amended, regarding
confidentiality of information
concerning applicants and
recipients of public
assistance,
42 C.F.R. Part 2, as amended,
regarding confidentiality of
alcohol and drug abuse patient
records,
42 C.F.R. Section 431.302,
42 C.F.R. 431,
Part C of the Individuals with
Disabilities Education Act (20
U.S.C. Section 1471 et seq.),
Early Periodic Screening,
Diagnosis, and Treatment
(EPSDT) Section 1905(r) of the
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Social Security Act, 42 USC
Section 1396 d (r),
Section 1932 (a)(4)(A) of
Title XIX.
42 C.F.R. Section 405.2401(b),
as amended,
42 C.F.R. Section 493.3, as
amended,
42 C.F.R. Section 440.230,
42 C.F.R. Section 441.150,
42 C.F.R. Section 441.152,
441.153, 441.156,
42 C.F.R. Section 447.331
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C.8.3.1.5 DELETE THE FOLLOWING WORDS:
...shall be submitted to MAA
for approval
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C.8.3.2.5 - INSERT NEW SECTIONS
C.8.3.2.17 C.8.3.2.5 - C.8.3.2.17
C.8.3.2.5 In accordance with
42 C.F.R. Section 434.30, the
Contractor shall ensure that
all covered emergency services
are available twenty-four (24)
hours a day and seven (7) days
a week through the
Contractor's network.
C.8.3.2.6 The Contractor shall
cover all emergency services
provided by out of-net-work
providers.
C.8.3.2.7 In the absence of an
agreement otherwise, all
claims for emergency services
shall be reimbursed at the
applicable Medicaid
fee-for-service rate in effect
at the time the service was
rendered.
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C.8.3.2.8 The Contractor may
not retroactively deny a claim
for a claim for an emergency
screening examination because
the condition, which appeared
to be an emergency medical
condition under the "prudent
layperson" standard, as
defined herein, was in fact
non-emergency in nature.
C.8.3.2.9 The Contractor may
not require prior
authorization for emergency
services. This applies to
out-of-network as well as to
in-network services, which an
enrollee seeks in an
emergency.
C.8.3.2.10 In accordance with
Section 1867 of the Social
Security Act, hospitals that
offer emergency services are
required to perform a medical
screening examination on all
people who come to the
hospital seeking emergency
care, regardless of their
insurance status or other
personal characteristics. If
an emergency medical condition
is found to exist, the
hospital must provide whatever
treatment is necessary to
stabilize that condition. A
hospital may not transfer a
patient in unstabilized
emergency condition to another
facility unless the medical
benefits of the transfer
outweigh the risks, and the
transfer conforms to all
applicable requirements. When
emergency services are
provided to an enrollee of the
Contractor, the organization's
liability for payment is
determined as follows:
. Presence of a Clinical
----------------------
Emergency - If the
---------
screening examination
leads to a clinical
determination by the
examining physician that
an actual emergency
medical condition exists,
the Contractor must pay
for both the services
involved in the screening
examination and the
services required to
stabilize the patient.
. Emergency Services
------------------
Continue Until the
------------------
Patient Can be Safely
---------------------
Discharged or
-------------
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Transferred - The
-----------
Contractor shall pay for
all emergency services,
which are medically
necessary until the
clinical emergency is
stabilized. This shall
include payment for all
treatment that may be
necessary to assure,
within reasonable medical
probability, that no
material deterioration of
the patient's condition
is likely to result from,
or occur during,
discharge of the patient
or transfer of the
patient of the patient or
transfer of the patient
to another facility.
If there is a
disagreement between a
hospital and the
Contractor concerning
whether the patient is
stable enough for
discharge or transfer, or
whether the medical
benefits of an
unstabilized transfer
outweigh the risks, the
judgment of the attending
physician(s) actually
caring for the enrollee
at the treating facility
prevails and is binding
on the Contractor. The
Contractor may establish
arrangements with
hospitals whereby the
Contractor may send one
of its own physicians
with appropriate ER
privileges to assume the
attending physician's
responsibilities to
stabilize, treat, and
transfer the patient.
. Post Stabilization Care -
-----------------------
Post stabilization
services are services
subsequent to an
emergency that a treating
physician views as
medically necessary AFTER
an emergency medical
condition has been
stabilized
C.8.3.2.11 In accordance with
42 C.F.R. Section 422.
100(b)(1)(iv), the Contractor
must cover the following
services without requiring
authorization, and regardless
of whether the enrollee
obtains the services within or
outside the Contractor's
network.
C.8.3.2.12 Post stabilization
care services
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that were pre-approved by the
Contractor, or were not
pre-approved by the Contractor
because the Contractor did not
respond to the provider of
post-stabilization care
services request for
pre-approval within one (1)
hour after being requested to
approve such care, or could
not be contacted for
pre-approval.
C.8.3.2.13 If the screening
examination leads to a
clinical determination by the
examining physician that an
actual emergency medical
condition does not exist, the
Contractor shall pay for all
services involved in the
screening examination if the
presenting symptoms (including
severe pain) were of
sufficient severity to have
warranted emergency attention
under the "prudent layperson"
standard, as defined herein.
If an enrollee believes that a
claim for emergency services
has been inappropriately
denied by the Contractor, the
enrollee may seek recourse
through the MCO or the
District appeal process.
C.8.3.2.14 When an enrollee's
primary care physician or
other plan representative
instructs the enrollee to seek
emergency care in-network or
out-of-network, the MCO shall
be responsible for payment for
the medical screening
examination and for other
medically necessary emergency
services, without regard to
whether the patient meets the
"prudent layperson" standard,
as defined herein.
C.8.3.2.15 The Contractor
shall cover those medical
examinations performed in
emergency departments for
enrolled children as part of a
child protective services
investigation. In absence of
an agreement otherwise, these
services shall be reimbursed
at the applicable District of
Columbia Medicaid
fee-for-service rate in effect
at the time the service was
rendered.
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C.8.3.2.16 The Contractor may
require that continuing care
following the conclusion of an
emergency, be obtained from a
network provider or another
health care provider specified
by the Contractor. An
emergency shall be deemed to
have concluded at such time as
the enrollee can, without
medically harmful
consequences, travel or be
transported to an appropriate
Contractor facility or to such
other facility as the
Contractor may designate.
C.8.3.2.17 Required payments
for emergency services are
summarized below:
. In-network provider paid
at negotiated rate for
non-emergency condition
and emergency condition.
. Out-of-network provider
paid at applicable
Medicaid fee-for-service
rate in effect at the
time the service was
rendered for
non-emergency condition
and emergency condition.
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C.8.4.5.3 INSERT NEW SECTION C.8.4.5.3
Section 1932(b)(3) of the
Social Security Act requires
that a "Medicaid managed care
organization shall not
prohibit or otherwise restrict
a covered health care
professional from advising
such an individual who is a
patient of the professional
about the health status of the
individual or medical care or
treatment for the individual's
conditions or disease,
regardless of whether benefits
for such care or treatment are
provided under the contract,
if the professional is acting
within the lawful scope of
practice." In accordance with
subsection(b) as required by
1903(m)(2)(A)(xi) of the
Social Security Act, 42 U.S.C.
1396b(m)(2)(A)(xi), the
Contractor shall comply with
prohibitions on interference
with communications between
health professionals and
patients.
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The Contractor shall comply
with provisions of
1932(b)(3)(A) of the Social
Security Act, 42 U.S.C.
1396u-2(b)(3)(A), which bar
the Contractor from
prohibiting or restricting any
physician or other health care
professional (whether or not
such provider participates in
the Contractor's provider
network) from advising an
individual about the
individual's health status or
medical care or treatment for
the individual's condition or
disease, regardless of whether
items and services for such
care or treatment are covered
under this Contract, if the
professional is acting within
the lawful scope of practice.
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C.9.1.17.9 INSERT NEW SECTION C.9.1.17.9
The Contractor must comply
with Section 1932(b)(7) of the
Social Security Act. The
Contractor shall not apply any
credentialing requirements,
measures of financial or other
performance, or any other
participation criteria to
applicants for, or
participants in, the plan's
provider network that
discriminate against
particular providers that
specialize in conditions that
require costly treatment or
are otherwise inconsistent
with the requirements of this
contract. The Contractor shall
not otherwise discriminate
with respect to participation,
reimbursement, or
indemnification as to any
provider who is acting within
the scope of the provider's
license or certification under
applicable District of
Columbia law, solely on the
basis of such license or
certification.
The Contractor may not refuse
an assignment or seek to
disenroll a member or
otherwise discriminate against
a member on the basis of
age, sex, race, gender,
physical or mental
handicap/developmental
disability, national origin,
or type of illness
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or condition, except when that
condition can better be
treated by another provider
type.
The Contractor shall notify in
writing the Contracting
Officer Technical
Representative and the Agency
Chief Contracting Officer
thirty (30) days in advance of
any change in network
composition that negatively
affect member access to
services. Such changes may be
grounds for contract
termination.
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C.9.2:5.4 DELETE SECTION C.9.2.5.4 REPLACE WITH NEW SECTION
C.9.2.5.4
The Contractor is required to
pay out of network provider
the Medicaid rate for
emergency services. Emergency
services are defined as
covered inpatient and
outpatient services furnished
by a qualified Medicaid
provider that are necessary to
evaluate or stabilize and
emergency medical condition.
In-network providers will be
paid based on the previously
negotiated rates with the
Contractor.
Any services other than
emergency services that are
not in-network will be paid at
a rate negotiated between the
provider and the Contractor.
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C.10.1.15 DELETE SECTION C.10.1.15 REPLACE WITH NEW SECTION
C.10.1.15
A contractor who receives or
identifies a request for
experimental treatment must
submit the request to the MAA
medical director for review
within 24 hours of identifying
or receiving the request.
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C.10.5.1.2 DELETE SECTION C.10.5.1.2 REPLACE WITH NEW SECTION
C.10.5.1.2:
The Contractor shall arrange
with contracted laboratories
to submit all lead screening
results to the District of
Columbia Department of Health
Childhood Lead Poisoning
Prevention Program. Any child
with an elevated blood lead
level (greater than 15 ug/dl)
must be reported within
seventy-two (72) hours after
identification to the
Department of Health Childhood
Lead Poisoning Prevention
Program. The contractor shall
refer such a child for
assessment of developmental
delay, and shall coordinate
services required to treat the
exposed child with the lead
inspection and abatement
services furnished by the
District.
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C.10.5.7.7 INSERT NEW SECTION C.10.5.7.7
Department of Health/Maternal
and Family Health
Administration
- --------------------------------------------------------------------------------
C.13.1 INSERT NEW SECTION C.13.1
MCOs are responsible for
actively conducting valid
reviews of members' medical
records as a regular,
consistent component of the
health plan's Quality
Management program.
All medical record reviews and
evaluation will be conducted
using accepted industry
standards for quality
assurance and quality
improvement related to:
. The diagnosis and
treatment of injury,
illness and disease;
. Disease prevention,
health promotion and
health education
activities;
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. The appropriate
documentation of care in
clinical records.
. Medical record reviews
and evaluations will
occur on population
samples of sufficient
size so as to yield
valid, reliable
statistical information;
. Medical record reviews
will be conducted in
compliance with HIPAA
regulations.
The Contractor is responsible
for submitting members'
medical records for review
upon request from DC MAA or
their designee.
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C.14.5 INSERT NEW SECOND PARAGRAPH
IN C.14.5
The Contractor shall comply
with the Office of Managed
Care and the Office of Fair
Hearing decision. The Office
of Managed Care and the Office
of Fair Hearing decisions in
these matters shall be final
and shall not be subject to
appeal by the Contractor. The
Contractor shall provide to
the Office of Managed Care and
or Office Fair Hearing all
information necessary for any
enrollee appeal within a time
frame established by Office of
Managed Care and or the Office
of Fair Hearing.
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C.14.6 DELETE SECTION C.14.6 REPLACE WITH NEW SECTION
C.14.6
Tracking Log Tracking Log
The Contractor shall maintain The Contractor shall maintain
a log to document all a record keeping and tracking
complaints and grievances. The system for complaints,
log shall document the type grievances and appeals that
and nature of each dispute, includes copy of the original
the Plan in which the written complaint, grievance,
complainant is or appeal, the decision, and
the nature of the
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enrolled, how the matter was decision and any corrective
addressed and what, if any, action that was taken.
corrective action was taken.
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H.1.1.2.3 DELETE SECTION H.1.1.2.3 REPLACE WITH NEW SECTION
H.1.1.2.3:
If the Contractor fails to
notify IMA and MAA of the
birth of a newborn via the
"Request to Add Newborns Form"
and "Add Newborn Log Form" in
Attachment J.23., within ten
(10) business working days of
the birth, MAA will not
process the kick payment or
reimburse the contractor for
services rendered to the
newborn. Attachment J.23
supercedes attachment J.4.
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H.1.1.2.7 INSERT NEW SECTION H.1.1.2.7
If more than one MCO is
claiming payment for a
newborn, MAA will only pay the
MCO that demonstrates services
rendered to the newborn. The
MCO must submit written
notification to MAA of the
following information:
. Newborn's name;
. Newborn's Medicaid
number;
. Newborn's Date of birth;
. Date of service;
. Diagnosis treatment;
. Provider of service; and
. Provider's address and
telephone number.
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H.1.1.2.6 DELETE SECTION H.1.1.2.6 REPLACE WITH NEW SECTION
H.1.1.2.6:
If the OMC has failed to
notify the health plan of the
newborn's Medicaid number by
the fifteenth (15th) day of
the third (3rd) month, the
health plan must submit
written notification to MAA
with the following
information:
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. Mother's name;
. Mother's Medicaid number
. Newborn's Name;
. Newborn's Date of Birth;
and
. Name of hospital newborn
was born.
Newborns who do not receive a
Medicaid number by the end of
the third month will convert
to the fee for service
Medicaid program. After a
Medicaid number is received,
the newborn will be
re-enrolled through the
provider continuity process.
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H.1.2.2 DELETE SECTION H.1.2.2
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H.93 INSERT NEW SECTION H.9.3
Any physician incentive plan
applicable to physicians
participating in the
Contractor's provider network
shall meet the requirements
applicable to physician
incentive plans under
1876(I)(8) of the Social
Security Act, 42 U.S.C.
1395mm(I)(8), 42 C.F.R.
417.479. The contractor must
submit with the Physician
Incentive Forms the following
information:
Whether services not furnished
by the physician or physician
group are covered by the
incentive plan. If only the
services furnished by the
physician or physician group
are covered by the plan,
disclosure of other aspects of
the plan need not be made.
(h)(ii) The type of incentive
arrangement; for example,
withhold, bonus, capitation.
If the incentive plan involves
a withhold or bonus, the
percent of the withhold or
bonus. (h)(iv) Proof that the
physician or physician group
has adequate stop-loss
protection, including
specification of the amount
and
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type of stop-loss protection.
The panel size and, if
patients are pooled according
to either or both of the
following permitted methods,
the method used including
commercial, Medicare, and/or
Medicaid patients in the
calculation of the panel size.
and pooling together (by the
physician groups that
contracts with more than one
HMO, CMP, health insuring
organization (HIO) or prepaid
health plan (PHP)), the
patients of each of those
HMOs, CMPs, HIOs and PHPs.
The Contractor shall submit
Physician Incentive Plans on
an annual basis thirty (30)
days prior to date of the
exercise of the following year
option.
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H.11.1 DELETE SECTION H.11.1 INSERT NEW SECTION H.11.1
Debts of Contractor Protection of Enrollees
Against Liability for Payment
- --------------------------------------------------------------------------------
H.11.1.1 DELETE SECTION H.11.1.1 INSERT NEW SECTION H.11.1.1
The Contractor shall ensure The Contractor and each
through its contracts, provider (whether or not the
subcontracts and in any other provider participates in the
appropriate manner that Contractor's provider network)
neither Enrollees nor the through which the Contractor
District are held liable for furnishes or arranges for the
Contractor's debts in the furnishing of items or
event of Contractor's services covered under the
insolvency. contract to an enrolled
individual shall comply with
the requirements of 1932(b)(6)
of the Social Security Act, 42
U.S.C. 1396u-2(b)(6), that an
enrolled individual or the
individual's family or
caregiver may not be held
liable or be subject to
collection efforts for:
. debts or other
obligations of the
Contractor or any
provider participating in
the Contractor's provider
network in the event of
insolvency;
. the cost of items and
services covered under
the contract in the event
that the
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Contractor fails to
receive payment from DC;
. the cost of items and
services covered under
the contract if a
provider participating in
the Contractor's provider
network fails to receive
payments from the
Contractor; or
. payments to a provider
that furnishes items and
services covered under
the contract to an
enrolled individual under
a contractual, referral,
or other arrangement with
the Contractor in excess
of the amount that would
be owed by the enrolled
individual if the
Contractor had furnished
such items or services
directly.
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H.11.2 INSERT NEW SECTION H.11.2
Cost Sharing
The Contractor and each
provider (whether or not the
provider participates in the
Contractor's provider network)
through which the Contractor
furnishes or arranges for the
furnishing of items or
services covered under the
contract to an enrolled
individual shall comply with
requirements of 1916(a)(2)(A)
of the Social Security Act, 42
U.S.C. 1396o(a)(2)(A),
prohibiting the imposition of
cost-sharing or similar
charges on enrolled
individuals under this
contract.
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H.14.2 INSERT NEW SECTION H.14.2
The Contractor shall provide
language in all of their
provider's contracts and
subcontracts that preclude
balance billing, except for
any outstanding co-payments.
Medicaid payment is "payment
in full". The contractor's
contract shall preclude their
providers from sending
individual Medicaid
recipient's bills to
collections agencies.
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Protection of enrollees
against balance billing
through subcontractors (Amends
SSA 1128B (d)(1) --BBA 4704(b)
Section 1128b(d)(1) of the
Act authorizes criminal
penalties to providers in the
case of services provided to
an individual enrolled with a
managed care organization
under contract under section
1903(m) of the Act which are
charged at a rate in excess of
the rate permitted under the
organization's contract.
Section 1128B(d)(1) of the Act
states that whoever knowingly
and willfully charges, for any
service provided to a patient
under a State plan approved
under Title XIX or under a
managed care organization
contract under 1903(m) of the
Act, money or other
consideration at a rate in
excess of the rates
established by the State or
contract shall be guilty of a
felony and upon conviction
shall be fined no more than
$25,000 or imprisoned for no
more than five years, or both.
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I.9.2 INSERT NEW SECTION 1.9.2
The contractor shall notify
the Agency Chief Contracting
Officer in writing of any
changes to MCO ownership and
key personnel at least thirty
days prior to any change in
ownership or key personnel.
The Contractor must provide
information concerning each
Person with Ownership or
Control Interest as defined in
this Contract. This
information includes but is
not limited to the following:
. Name, address, and
official position;
. A biographical summary;
. A statement as whether
the person with ownership
or control interest is
related to any other
person with ownership or
control interest such as
a spouse, parent, child,
or sibling;
. The name of any
organization in which the
person with ownership or
control
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 22 OF 23
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CONTRACT MODIFICATION - M0001
DCHFP
SUMMARY SHEET
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- --------------------------------------------------------------------------------
CONTRACT
SECTION CHANGED FROM CHANGED TO
- --------------------------------------------------------------------------------
interest in the
Contractor also has an
ownership or control
interest, to the extent
obtainable from the other
organization by the
Contractor through
reasonable written
request. The Contractor
must keep copies of all
written requests and
responses and provide
them to the Agency Chief
Contracting Officer when
requested;
and
The identity of any
person, principal, agent,
managing employee, or key
provider of health care
services who (1) has been
convicted of a criminal
offense related to that
individual's or entity's
involvement in any
program under Medicaid or
Medicare since the
inception of those
programs (1965) or (2)
has been excluded from
the Medicare or Medicaid
programs for any reason.
This disclosure must be
in compliance with
Section 1128, as amended,
of the Social Security
Act, 42 U.S.C. Section
1320a-7, as amended, and
42 C.F.R. Section
455.106, as amended, and
must be submitted on
behalf of the Contractor
and any subcontractor as
well as any provider of
health care services or
supplies.
Federal regulations contained
in 42 C.F.R. Section 455.104
and 42 C.F.R. Section 455.106
also require disclosure of all
entities with which a Medicaid
provider has an ownership or
control relationship. The
Contractor shall provide
information concerning each
Person with Ownership or
Control.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
POHC-2002-D-0003 PAGE 23 OF 23
- --------------------------------------------------------------------------------
CORRECTION OF INCONSISTENCIES
-----------------------------
Section Reference Correction
- ----------------- ----------
C.5.3.1 Section C.5.3.1 references Section 0; the correct reference
is Section C.5.1 in stated in the Request For Proposal (RFP)
as amended.
C.6.3.18 Section C.6.3.18 references Attachment A.2.1 (g), the
correct is reference Section A.2.1 which includes Attachment
7 - Covered Services.
C.6.5.2.3 Section C.6.5.2.3 reference Attachment J.4; the correct
reference is Attachment 9 - Newborn Notification Report.
C.8 Section C.8 references Attachment J.8; the correct reference
is Attachment 7 - Covered Services.
C.8.3.2 Section C.8.3.2 references Attachment J.8; the correct
reference is Attachment 7 - Covered Services.
C.8.3.2.4 The following language was inadvertently omitted from the
contract:
...emergency services including screening and
diagnostic services necessary to diagnose the
condition, based on the...
C.8.3.5 Section C.8.3.5 references Attachment J.8; the correct
reference is Attachment 7 - Covered Services.
C.8.3.6.1 Section C.8.3.6.1 references Attachment AA; the correct
reference is Attachment 7 - Covered Services.
C.8.3.11.1(b) Section C.8.3.11.1 (b) references Section 0; the correct
reference is Section C.8.3.1.8.
C.9.1.5 Section C.9.1.5 reference Section 0, the correct reference
is Section C.8.3.2.1.
C.9.2.5.3 Section C.9.2.5.3 reference Section 0, the correct reference
is C.8.4
C.10.1.5 Section C.10.1.5 references Section 0, the correct reference
is C.8.1.
C.17.3.2 Section C.17.3.2 references Attachment J.8 and Section 0,
the correct references are Attachment 7 - and Section C.8.
Page of 2
--
CORRECTION OF INCONSISTENCIES
-----------------------------
Section Reference Correction
- ----------------- ----------
C.17.4.1 Section C.17.4.1 reference Section 0, the correct reference
is C.9.1 as stated in the RFP.
H.1.1.2.3 Section H.1.1.2.3 reference Attachment AA, the correct
reference is Attachment 9 - Newborn Notification Report
sample.
H.1.1.7.2 Section H.1.1.7.2. reference Section 0, the correct
reference is H.1.1.1.1.
H.4.3.1 Section H.4.3.1 references Section 0, the correct reference
is H.4.
H.1.4.4.1 Section H.4.4.1 references Section 0; the correct reference
is Section H.4.
H.15.2.1 Section H.15.2.1 references Section 0; the correct reference
is Section C.8.3.2.1 as stated in the RFP.
Page 2 of 2
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AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. Contract Number Page of Pages
POHC-2002-D-0003 1 1
- ------------------------------------------------------------------------------------------------------------------------------------
2. Amendment/Modification Number 3. Effective Date 4. Requisition/Purchase Request No. 5. Project No. (If applicable)
'M0002 SEE BLOCK 16C BELOW HCOP2-210457
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6. Issued By Code[______________] 7. Administered By (If other than line 6)
Office of Contracting and Procurement Department of Health, Office of Managed Care
Public Safety Cluster, Department of Health Bureau Medical Assistance Administration
441 4th Street. N.W., Suite 800 South 825 North Capitol Street, N.E.
Washington, DC 20001 Attention: Ms. Maude Holt
- ------------------------------------------------------------------ Telephone: (202)442-9074
- ------------------------------------------------------------------------------------------------------------------------------------
8. Name and Address of Contractor (No. Street, city, country, state and ZIP Code) (X)9A. Amendment of Solicitation No.
---
----------------------------------------------
9B. Dated (See Item 11)
AMERICAID COMMUNITY CARE
514 10TH STREET, N.W., SUITE 500 -------------------------------------------------
WASHINGTON, D. C. 20004 10A. Modification of Contract/Order No.
ATTN: MS. JANE E. THOMPSON POHC-2002-D-0003
TELEPHONE NO.: (202)783-8100 X ----------------------------------------------
- -------------------------------------------------------------------------------- 10B. Dated (See Item 13)
Code Facility APRIL 1, 2002
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11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS
- ------------------------------------------------------------------------------------------------------------------------------------
[__]The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers[___]is
extended.[___]is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the
solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning [__________]copies
of the amendment: (b) By acknowledging receipt of this amendment on each copy of the offer submitted: or (c) By separate letter
or telegram which includes a reference to the solicitation and amendment number. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED
AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER.
If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or telegram,
provided each letter or telegram makes reference to the solicitation and this amendment, and is received prior to the opening
hour and date
- ------------------------------------------------------------------------------------------------------------------------------------
12. Accounting and Appropriation Data (If Required)
- ------------------------------------------------------------------------------------------------------------------------------------
13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,
IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14
- ------------------------------------------------------------------------------------------------------------------------------------
(X) A. This change order is issued pursuant to: (Specify Authority)
The changes set forth in Item 14 are made in the contract/order no. in item 10A.
- ------------------------------------------------------------------------------------------------------------------------------------
B. The above numbered contract/order is modified to reflect the administrative changes (such as changes in paying office,
appropriation date, etc.) set forth in item 14, pursuant to the authority of 27 dCMR, Chapter 36, Section 3601.2.
- ------------------------------------------------------------------------------------------------------------------------------------
C. This supplemental agreement is entered into pursuant to authority of:
DISTRICT OF COLUMBIA MUNICIPAL REGULATIONS 3601.2 (c) Bilateral Contract Modification and agreement between the parties
- ------------------------------------------------------------------------------------------------------------------------------------
X D. Other (Specify type of modification and authority)
DISTRICT OF COLUMBIA MUNICIPAL REGULATIONS 3601.2 (c) Bilateral Contract Modification and agreement between the parties
- ------------------------------------------------------------------------------------------------------------------------------------
E. IMPORTANT: Contractor[____]is not, [X] is required to sign this document and return 2 copies to the issuing office
--- --
- ------------------------------------------------------------------------------------------------------------------------------------
14. Description of amendment/modification (Organized by USC Section headings, including solicitation/contract subject matter where
feasible.)
THE CONTRACT REFERENCED IN BLOCK 10A ABOVE IS MODIFIED AS FOLLOWS:
The purpose of this modification is to correct the TERM OF THE CONTRACT Base Period as stated in SECTION F.1.1. The Term of the
Contract currently states from date of award through October 31, 2002, this is corrected to read "Date of Award through twelve
(12) months thereafter."
The District's intent was to award a contract with a based period of twelve months and four-one year options as stated in
SECTIONS B.5.1 and F.2.2.1 of the solicitation and the contract.
- ------------------------------------------------------------------------------------------------------------------------------------
Except as provided herin, all terms and conditions of the document referenced in Item (9A or 10A as heretofore changed, remains
unchanged and in full force and effect
- ------------------------------------------------------------------------------------------------------------------------------------
15A. Name and Title of Signer (Type or print) 16A. Name of Contracting Officer
JANE E. THOMPSON CEO-DC OPERATIONS ESTHER M. SCARBOROUGH
- ------------------------------------------------------------------------------------------------------------------------------------
15B. Name of Contractor 15C. Date Signed 16B. District of Columbia 16C. Date Signed
AMERIGROUP DC 4/9/02 4-9-02
/s/ Jane E. Thompson /s/ E. M. Scarborough
- -------------------- ---------------------
(Signature of person authorized to sign) (Signature of Contracting Officer)
- ------------------------------------------------------------------------------------------------------------------------------------
[LOGO] Government of the District of Columbia [LOGO] Office of Contracting & Procurement DC OCP 202 (7-99)
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. Contract Number Page of Pages
POHC-2002-D-0003 1 1
- ------------------------------------------------------------------------------------------------------------------------------------
2. Amendment/Modification Number 3. Effective Date 4. Requisition/Purchase Request No. 5. Project No. (If applicable)
'M0001 SEE BLOCK 16C BELOW POHC-2002-F-0001
- ------------------------------------------------------------------------------------------------------------------------------------
6. Issued By Code[______________] 7. Administered By (If other than line 6)
Office of Contracting and Procurement Department of Health, Office of Managed Care
Public Safety Cluster, Department of Health Bureau Medical Assistance Administration
441 4th Street, N.W., Suite 800 South 825 North Capitol Street, N.E.
Washington, DC 20001 Attention: Ms. Maude Holt
- ------------------------------------------------------------------ Telephone:(202)442-9074
- ------------------------------------------------------------------------------------------------------------------------------------
8. Name and Address of Contractor (No. Street, city, country, state and ZIP Code) (X)9A. Amendment of Solicitation No.
---
----------------------------------------------
9B. Dated (See Item 11)
AMERICAID COMMUNITY CARE
514 10TH STREET, N.W., SUITE 500 -------------------------------------------------
WASHINGTON, D. C. 20004 10A. Modification of Contract/Order No.
ATTN: MS. JANE E. THOMPSON POHC-2002-D-0003/POHC-2002-F-0001(D.O)
TELEPHONE NO.: (202) 783-8100 X ----------------------------------------------
- -------------------------------------------------------------------------------- 10B. Dated (See Item 13)
Code Facility APRIL 9, 2002
- ------------------------------------------------------------------------------------------------------------------------------------
11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS
- ------------------------------------------------------------------------------------------------------------------------------------
[__]The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers[___]is
extended.[___]is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the
solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning [__________]copies
of the amendment: (b) By acknowledging receipt of this amendment on each copy of the offer submitted: or (c) By separate letter
or telegram which includes a reference to the solicitation and amendment number. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED
AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER.
If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or telegram,
provided each letter or telegram makes reference to the solicitation and this amendment, and is received prior to the opening
hour and date specified.
- ------------------------------------------------------------------------------------------------------------------------------------
12. Accounting and Appropriation Data (If Required)
- ------------------------------------------------------------------------------------------------------------------------------------
13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,
IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14
- ------------------------------------------------------------------------------------------------------------------------------------
(X) A. This change order is issued pursuant to: (Specify Authority)
- ------- The changes set forth in Item 14 are made in the contract/order no. in item 10A.
- ------------------------------------------------------------------------------------------------------------------------------------
B. The above numbered contract/order is modified to reflect the administrative changes (such as changes in paying office,
appropriation date, etc.) set forth in item 14, pursuant to the authority of 27 dCMR, Chapter 36, Section 3601.2.
- ------------------------------------------------------------------------------------------------------------------------------------
C. This supplemental agreement is entered into pursuant to authority of:
- ------------------------------------------------------------------------------------------------------------------------------------
X D. Other (Specify type of modification and authority)
DISTRICT OF COLUMBIA MUNICIPAL REGULATIONS 3601.2 (c) Bilateral Contract Modification and agreement between the parties
- ------------------------------------------------------------------------------------------------------------------------------------
E. IMPORTANT: Contractor[____]is not, [X] is required to sign this document and return 2 copies to the issuing office.
--- --
- ------------------------------------------------------------------------------------------------------------------------------------
14. Description of amendment/modification (Organized by USC Section headings, including solicitation/contract subject matter where
feasible.)
THE DELIVERY ORDER REFERENCED IN BLOCK 10A ABOVE IS MODIFIED AS FOLLOWS:
F.3.1 IMPLEMENTATION:
The implementation date of this Delivery Order shall be one hundred and twenty (120) days after date of contract award, August 1,
2002. through October 31, 2002.
- ------------------------------------------------------------------------------------------------------------------------------------
Except as provided herin, all terms and conditions of the document referenced in Item (9A or 10A as heretofore changed, remains
unchanged and in full force and effect
- ------------------------------------------------------------------------------------------------------------------------------------
15A. Name and Title of Signer (Type or print) 16A. Name of Contracting Officer
JANE E. THOMPSON CEO-DC Operations ESTHER M. SCARBOROUGH
- ------------------------------------------------------------------------------------------------------------------------------------
15B. Name of Contractor 15C. Date Signed 168. District of Columbia 16C. Date Signed
AMERIGROUP District of Columbia 4/9/02 4-9-02
/s/ Jane E. Thompson /s/ E. M. Scarborough
- -------------------- ---------------------
(Signature of person authorized to sign) (Signature of Contracting Officer)
- ------------------------------------------------------------------------------------------------------------------------------------
[LOGO] Government of the District of Columbia [LOGO] Office of Contracting & Procurement DC OCP 202 (7-99)
- ------------------------------------------------------------------------------------------------------------------------------------