Exhibit 10.31
STATE OF FLORIDA
DEPARTMENT OF ELDER AFFAIRS
AGENCY FOR HEALTH CARE ADMINISTRATION
CONTRACT No. 2002-2003-02
This contract is entered into between the State of Florida. Department of Elder
Affairs hereinafter referred to as the "department, " the Agency for Health Care
Administration hereinafter referred to as the "agency:" and Physicians
Healthcare Plans, Inc. hereinafter referred to as the "Contractor."
THE PARTIES AGREE:
THE CONTRACTOR AGREES:
A. To provide services according to the conditions specified in Attachment
I.
B. FEDERAL LAWS AND REGULATIONS
If this contract contains federal funds, the Contractor shall
comply with the provisions of 45 CFR. Part 74. and/or 45 CFR,
Part 92, and other applicable regulations.
If this contract contains federal funding, the Contractor must,
prior to contract execution, complete the Certification
Regarding Lobbying form, Attachment II. If a Disclosure of
Lobbying Activities form, Standard Form LLL, is required, it may
be obtained from the department. All disclosure forms as
required by the Certification Regarding Lobbying form must be
completed and returned to the department no more than 10 days
after contract execution.
3. If this contract contains federal funding in excess of $100,000,
the Contractor shall comply with all applicable standards,
orders, or regulations issued under Section 306 of the Clean Air
Act, as amended (42 U.S.C. 1857(h) et seq.). Section 508 of the
Clean Water Act. as amended (33 U.S.C. 1368 et seq.), Executive
Order 11738, and Environmental Protection agency regulations (40
CFR Part 15). The Contractor shall report any violations of the
above to the department within ten (10) days of the discovery of
any such violation.
4. To comply with the provisions of the U.S. Department of Labor,
Occupational Safety and Health Administration (OSHA) code, 29
CFR, Part 1910.1030.
5. If this contract contains federal funding in excess of $100,000,
the Contractor must, prior to contract execution, complete the
Debarment, Suspension. Ineligibility and Voluntary Exclusion
Certification form Attachment III.
6. To comply with the Department of Health and Human Services
Privacy Regulations in the Code of Federal Regulations, Title
45, sections 160 and 164, regarding disclosure of protected
health information and as specified in Attachment VI.
C. EMPLOYMENT
If the Contractor is a non-governmental organization, it is expressly
understood and agreed that the Contractor will not knowingly employ
unauthorized alien workers. Such employment constitutes a violation of
the employment provisions as determined pursuant to section 274A(e) of
the Immigration & Naturalization Act (INA), 8 U.S.C. s.1324 a (e)
(section 274A(e)"). Violation of the employment provisions as determined
pursuant to section 274A(e) shall be grounds for unilateral cancellation
of this contract.
D. AUDITS AND RECORDS
To maintain books, records, and documents (including electronic
storage media) in accordance with generally accepted accounting
procedures and practices, which sufficiently and properly
reflect all revenues and expenditures of funds, provided under
this contract.
To assure that these records shall be subject at all reasonable
times to inspection, review, or audit by state personnel and
other personnel duly authorized by the department or agency as
well as by federal personnel.
3. To maintain and file with the department such progress, fiscal
and inventory reports as specified, in Attachment I and other
reports as the department may require within the period of this
contract.
4. To provide a financial and compliance audit as specified in
Attachment V, and to ensure that all related party transactions
are disclosed to the auditor.
5. To include these aforementioned audit and record keeping
requirements in all approved subcontracts and assignments.
6. To respond to requests for client information and statistical
data for research and evaluative purposes when requested by the
department or agency.
E. RETENTION OF RECORDS
Unless otherwise expressly set forth in this contract, the
Contractor agrees to retain all client records, financial
records, supporting documents, statistical records, and any
other documents (including electronic storage media) pertinent
to this contract for a period of five (5) years after
termination of this contract, or if an audit has been initiated
and audit findings have not been resolved, the records shall be
retained until resolution of the audit findings. Any special
provisions regarding retention of records must be in accord with
applicable state or federal law or regulation.
2. Persons duly authorized by the department or agency and federal
auditors, pursuant to 45 CFR, Parts 92.36(i)(10), 92.42(e)(1)
and (2), and 74.53(e), shall have full access to and the right
to examine any of said records and documents during said
retention period.
F. MONITORING
To provide reports as specified in Attachment I. These reports
will be used for monitoring progress or performance of the
contractual services.
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To permit persons duly authorized by the department or agency to
inspect any records, papers, documents, facilities, goods and
services of the Contractor which are relevant to this contract
or the mission and statutory authority of the department and
agency, and/or interview any clients and employees of the
Contractor to be assured of satisfactory performance of the
terms and conditions of this contract. Following such inspection
the department will deliver to the Contractor a list of its
concerns with regard to the manner in which said goods or
services are being provided. The Contractor will rectify all
noted deficiencies provided by the department within the time
set forth by the department or provide the department with a
reasonable and acceptable justification for the Contractor's
failure to correct the noted shortcomings. The department shall
determine whether such failure is reasonable and acceptable. The
Contractor's failure to correct or justify within a reasonable
time as specified by the department may result in the agency
taking any of the actions identified in the Suspension section,
or the department and agency deeming the provider's failure to
be a breach of contract.
G. INDEMNIFICATION
If the Contractor is a state or local governmental entity, pursuant to
subsection 768.28 (18) Florida Statutes, the provisions of this section
do not apply.
To indemnify, defend, and hold harmless the department and
agency and all of their officers, agents, and employees from any
claim, loss, damage, cost, charge, or expense arising out of any
acts, actions, neglect or omission by the Contractor, its
agents, employees, or subcontractors during the performance of
the contract, whether direct or indirect, and whether to any
person or property to which the department, agency or said
parties may be subject, except that neither Contractor nor any
of its subcontractors will be liable under this section for
damages arising out of injury or damage to persons or property
directly caused or resulting from the sole negligence of the
department, agency or any of their officers, agents, or
employees.
2. Contractor's obligation to indemnify, defend, and pay for the
defense or at the department's option, to participate and
associate with the department or agency in the defense and trial
of any claim and any related settlement negotiations, shall be
triggered by the department's notice of claim for
indemnification to Contractor. The Contractor's inability to
evaluate liability or its evaluation of liability shall not
excuse the Contractor's duty to defend and indemnify the
department or agency, upon notice by the department. Notice
shall be given by registered or certified mail, return receipt
requested. Only an adjudication or judgment after the highest
appeal is exhausted specifically finding the department or
agency solely negligent shall excuse performance of this
provision by the Contractor. The Contractor shall pay all costs
and fees related to this obligation and its enforcement by the
department. The department's failure to notify the Contractor of
a claim shall not release the Contractor of the above duty to
defend.
It is the intent and understanding of the parties that the
Contractor is not an agent of the department or agency for
purposes of application of section 768.28. F.S., and is not
entitled or subject to any of the benefits and limitations
therein. Contractor expressly agrees to and does hereby waive
any and all claims or entitlement to any and all application of
section 768.28 F.S., Contractor may have or may hereafter
acquire by reason of this agreement or by interpretation of this
agreement and applicable law by any court of law equity, or by
or through any other dispute resolution method or forum,
regarding any all claims that may directly or indirectly arise
from or otherwise involve Contractor's direct or indirect
involvement, obligations, or benefits under this agreement. Not
withstanding the foregoing provisions, nothing in this agreement
shall serve as a waiver of sovereign immunity, or any other
defense, by the department or agency. Neither the Contractor nor
any of its subcontractors are employees of the department or
agency and shall not hold themselves out as employees or agents
of the department or agency without specific authorization from
the department. It is the further intent and understanding of
the parties that the department or agency does not control the
employment practices of the Contractor and shall not be liable
for any wage and hour, employment discrimination, or other labor
and employment claims, which arise against the Contractor.
H. INSURANCE
To provide adequate liability insurance coverage on a
comprehensive basis and to hold such liability insurance at all
times during the existence of this contract. The Contractor
accepts full responsibility for identifying and determining the
type(s) and extent of liability insurance necessary to provide
reasonable financial protections for the Contractor and the
clients to be served under this contract. Upon the execution of
this contract, the Contractor shall furnish the department
written verification supporting both the determination and
existence of such insurance coverage. A self-insurance program
established and operating under the laws of the State of Florida
may provide such coverage. The department reserves the right to
require additional insurance where appropriate.
2. If the Contractor is a state agency or subdivision as defined by
section 768.28. Florida Statutes, the Contractor shall furnish
the department, upon request, written verification of liability
protection in accordance with section 768.28, Florida Statutes.
Nothing herein shall be construed to extend any party's
liability beyond that provided in section 768.28, Florida
Statutes. (See also indemnification paragraph above.)
ABUSE, NEGLECT AND EXPLOITATION REPORTING
In compliance with Chapter 415. Florida Statutes, an employee of the
Contractor who knows, or has reasonable cause to suspect, that a child,
aged person or disabled adult is or has been abused, neglected, or
exploited, shall immediately report such knowledge or suspicion to the
State of Florida central abuse registry and tracking system on the
statewide toll-free telephone number (1-800-96ABUSE)
J. TRANSPORTATION DISADVANTAGED
If clients are to be transported under this contract, the Contractor
will comply with the provisions of Chapter 427, Florida Statutes, and
Rule Chapter 41-2, Florida Administrative Code.
K. SAFEGUARDING INFORMATION
Not to use or disclose any information concerning a recipient of
services under this contract for any purpose not in conformity with
applicable state and federal regulations (42 CFR 431.304-307
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Confidentiality Statement), except upon written consent of the
recipient, or the custodial parent or legal guardian of the recipient,
as authorized by law.
L. CLIENT INFORMATION
To submit management, program, and client identifiable data, as
specified in this contract.
M. ASSIGNMENTS AND SUBCONTRACTS
To neither assign the responsibility of this contract to another
party nor subcontract for any of the work contemplated under
this contract without prior written approval of the department
and agency. No such approval by the department and agency of any
assignment or subcontract shall be deemed in any event or in any
manner to provide for the incurrence of any obligation of the
department or agency in addition to the total dollar amount
agreed upon in this contract. All such assignments or
subcontracts shall be subject to the conditions of this contract
(except Section I, Paragraph P.I., Section II, Paragraph B., and
Section I, Paragraph W, unless the subcontractor is a political
subdivision of the state) and to any conditions of approval that
the department or agency shall deem necessary.
Unless otherwise stated in the contract between the Contractor
and subcontractor, payments made by the Contractor to the
subcontractor must be within seven (7) working days after
receipt by the Contractor of full or partial payments from the
agency in accordance with section 287.0585, Florida Statutes.
Failure to pay within seven (7) working days will result in a
penalty charged against the Contractor and paid to the
subcontractor in the amount of one-half of 1 percent of the
amount due, per day from the expiration of the period allowed
herein for payment. Such penalty shall be in addition to actual
payments owed and shall not exceed fifteen (15) percent of the
outstanding balance due.
3. That this contract and its Attachments I, II, III, IV, V, and VI
as referenced are binding upon the Contractor, its successors,
subcontractors, assignees and transferees.
N. FINANCIAL REPORTS
To provide financial reports to the department as specified in
Attachment I.
O. RETURN OF FUNDS
To return to the agency any overpayments due to unearned funds
or funds disallowed pursuant to the terms of this contract that
were disbursed to the Contractor by the agency. The Contractor
shall return any overpayment to the agency within forty (40)
calendar days after either discovery by the Contractor, or
notification by the agency, of the overpayment. In the event
that the Contractor or its independent auditor discovers an
overpayment has been made, the Contractor shall repay said
overpayment within forty (40) calendar days without prior
notification from the agency. In the event that the agency first
discovers an overpayment has been made, the agency will notify
the Contractor by letter of such a finding. Should repayment not
be made in a timely manner, the agency will charge interest of
one (1) percent per month compounded on the outstanding balance
after forty (40) calendar days after the date of notification or
discovery.
2. For universities located in the state of Florida, should
repayment not be made within forty (40) calendar days after the
date of notification, the agency will notify the State
Comptroller's Office who will then enact a transfer of the
amounts owed from the state university's account to the account
of the Agency for Health Care Administration.
P. PURCHASING
PRIDE
It is expressly understood and agreed that any articles which
are the subject of, or are required to carry out this contract
shall be purchased from Prison Rehabilitative Industries and
Diversified Enterprises. Inc. (PRIDE) identified under Chapter
946. Florida Statutes, in the same manner and under the
procedures set forth in subsections 946.515(2) and (4), Florida
Statutes. For purposes of this contract, the person, firm, or
other business entity carrying out the provisions of this
contract shall be deemed to be substituted for the department
insofar as dealings with PRIDE. This clause is not applicable to
any subcontractors, unless otherwise required by law. An
abbreviated list of products/services available from PRIDE may
be obtained by contacting PRIDE'S Tallahassee branch office at
(850) 487-3774 or SunCom 277-3774.
2. Procurement of Products or Materials with Recycled Content
Additionally, it is expressly understood and agreed that any
products or materials which are the subject of, or are required
to carry out this contract shall be procured in accordance with
the provisions of section 403.7065 and 287.045, Florida
Statutes.
3. Equity in Contracting
Pursuant to Section 287.09451, F.S., and in compliance with the
governor's One Florida Initiative, Executive Order 99-281, the
department is committed to embracing diversity and providing
fair and equal opportunities to all qualified businesses to
compete for state contracts, so that vendors for procurement of
goods and services reflect the diversity of the state's
population. The department requests a report monthly
demonstrating university in the provider's selection of vendors
for procurement of goods and services.
Q. CIVIL RIGHTS REQUIREMENTS
1. To give this assurance in consideration of and for the purpose
of obtaining federal grants, loans, contracts (except contracts
of insurance or guaranty), property, discounts, or other federal
financial assistance to programs or activities receiving or
benefiting from federal financial assistance. The Contractor
agrees to complete the Civil Rights Compliance Questionnaire,
DOEA Form 101 A and B, if services are provided to clients and
if fifteen (15) or more persons are employed.
ensure that it will comply with:
Title VI of the Civil Rights Act of 1964, as
amended, 42 U.S.C. 2000d et seq., which
prohibits discrimination on the basis of race,
color, or national origin.
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b. Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits discrimination
on the basis of handicap.
c. Title IX of the Education Amendments of 1972, as
amended, 20 U.S.C. 1681 et seq., which prohibits
discrimination on the basis of sex.
d. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination on
the basis of age.
e. Section 654 of the Omnibus Budget Reconciliation Act of
1981, as amended 42 U.S.C. 9849, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation or
beliefs.
f. The Americans with Disabilities Act of 1990, 42 USC,
12101, et.seq., which prohibits discrimination on the
basis of disability and requires reasonable
accommodations.
g. All regulations, guidelines, and standards as are now or
may be lawfully adopted under the above statutes.
3. To establish procedures to handle complaints of discrimination
involving services or benefits through this contract related to
employment and labor issues. The contractor shall advise
clients, employees, and participants of the right to file a
complaint, the right to appeal a denial or exclusion from the
services or benefits from this contract, and their right to a
fair hearing. Complaints of discrimination involving services or
benefits through this contract may also be filed with the
Secretary of the department or the appropriate federal or state
agency.
4. That compliance with this assurance is a condition of continued
receipt of or benefit from federal financial assistance, and
that it is binding upon the Contractor, its successors,
transferees, and assignees for the period during which such
assistance is provided. The Contractor further assures that all
contractors, subcontractors, sub-grantees, or others with whom
it arranges to provide services or benefits to participants or
employees in connection with any of its programs and activities
are not discriminating against those participants or employees
in violation of the above statutes, regulations, guidelines, and
standards. In the event of failure to comply, the Contractor
understands that the department, at its discretion, seeks a
court order requiring compliance with the terms of this
assurance or seeks other appropriate judicial or administrative
relief, including but not limited to, termination of and denial
of further assistance.
R. REQUIREMENTS OF SECTION 287.058, FLORIDA STATUTES
To submit bills for fees or other compensation for service or
expenses in sufficient detail for a proper pre-audit and
post-audit thereof.
2. Where applicable, to submit bills for any travel expenses in
accordance with section 112.061, Florida Statutes.
To provide units of deliverables, including reports, findings,
and drafts as specified in this contract to be received and
accepted by the contract manager prior to payment.
4. To comply with the criteria and final date by which such
criteria must be met for completion of this contract as
specified in section III, paragraph A-2 of this contract.
5. To allow public access to all documents, papers, letters, or
other materials subject to the provisions of Chapter 119,
Florida Statutes, and made or received by the Contractor in
conjunction with this contract. It is expressly understood that
substantial evidence of the Contractor's refusal to comply with
this provision shall constitute a breach of contract.
S. WITHHOLDINGS AND OTHER BENEFITS
To be responsible for Social Security and Income Tax
withholdings.
2. To not be entitled to state retirement or leave benefits except
where the Contractor is a state agency.
3. Unless justified by the Contractor and agreed to by the
department in Attachment N/A, section N/A the department will
not furnish services of support (e.g., office space, office
supplies, telephone service, secretarial, or clerical support)
normally available to career service employees.
T. SPONSORSHIP
1. As required by section 286.25, Florida Statutes, if the
Contractor is a non-governmental organization which sponsors a
program financed wholly or in part by state funds, including any
funds obtained through this contract, it shall, in publicizing,
advertising or describing the sponsorship of the program state:
"Sponsored by: Physicians Healthcare Plans, Inc. and the State
of Florida Department of Elder Affairs and the Agency For Health
Care Administration." If the sponsorship reference is in written
material, the words "State of Florida, Department of Elder
Affairs and the Agency For Health Care Administration" shall
appear in the same size letters and type as the name of the
organization. This shall include, but is not limited to, any
correspondence or other writing, publication or broadcast that
refers to such program.
2. If the contractor is a governmental entity or political
subdivision of the state, the department requests compliance
with the conditions specified in the above paragraph.
3. To not use the words "The State of Florida Department of Elder
Affairs" or "The Agency for Health Care Administration" to
indicate sponsorship of a program otherwise financed unless
specific authorization has been obtained by the department prior
to use.
U. FINAL INVOICE
To submit the final invoice for payment to the agency no more than 90
days after the contract ends or is terminated; if the Contractor fails
to do so, all right to payment is forfeited and the agency will not
honor any requests submitted after the aforesaid time period. Any
payment due under the terms of this contract may be withheld until all
reports due from the Contractor and necessary adjustments thereto have
been approved by the agency.
V. USE OF FUNDS FOR LOBBYING PROHIBITED
To comply with the provisions of section 216.347, Florida Statutes,
which prohibits the expenditure of contract funds for the purpose of
lobbying the Legislature, a judicial branch or a state agency.
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W. PUBLIC ENTITY CRIME
Denial or revocation of the right to transact business with public
entities. It is the intent of the legislature to place the following
restrictions on the ability of persons convicted of public entity crimes
to transact business with the department or agency per section 287.133,
Florida Statutes:
A person or affiliate who has been placed on the convicted vendor list
following a conviction for a public entity crime may not submit a bid on
a contract to provide any goods or services to a public entity, may not
submit a bid on a contract with a public entity for the construction or
repair of a public building or public work, may not submit bids on
leases of real property to a public entity, may not be awarded or
perform work as a contractor, supplier, subcontractor, or consultant
under a contract with any public entity, and may not transact business
with any public entity in excess of the threshold amount provided in s.
287.017 for CATEGORY TWO for a period of 36 months form the date of
being placed on the convicted vendor list.
X. CONFLICT OF INTEREST
The Contractor hereby agrees that it will ensure that its employees,
board members, management and subcontractors, will avoid any conflict of
interest or the appearance of a conflict of interest when disbursing or
using the funds described in this agreement or when contracting with
another entity which will be paid by the funds described in this
agreement. A conflict of interest includes but is not limited to
receiving, or agreeing to receive, a direct or indirect benefit, or
anything of value from a provider, client, subcontractor, or any person
wishing to benefit from the use or disbursement of these funds. To avoid
conflict of interest a Contractor must ensure that all individuals make
a disclosure to the department of any relationship which may be, or may
be perceived to be as a conflict of interest within thirty (30) days of
an individual's original appointment or placement on a board, or if the
individual is serving as an incumbent, within days of the commencement
of the contract.
Y. SUCCESSORS AND TRANSFEREES
This contract and its attachments are binding on the recipient and its
successors and transferees.
II. THE DEPARTMENT AND AGENCY AGREE:
A. CONTRACT AMOUNT
To pay for contracted services according to the conditions of this
contract in an amount not to exceed $ 10,350,926.00 subject to the
availability of funds. The State of Florida's performance and obligation
to pay under this contract is contingent upon an annual appropriation by
the Legislature. The costs of services paid under any other contract or
from any other source are not eligible for reimbursement under this
contract.
B. CONTRACT PAYMENT
Pursuant to Section 215.422. Florida Statutes, agencies shall take no
longer than 5 working days to inspect and approve goods and services,
unless bid specifications or the contract specifies otherwise. With the
exception of payments to health care contractors for hospital, medical,
or other health care services, if payment is not available within 40
days, measured from the latter of the date the invoice is received or
the goods or services are received, inspected and approved, a separate
interest penalty set by the Comptroller pursuant to Section 55.03,
Florida Statutes, will be due and payable in addition to the invoice
amount. Payments to health care contractors for hospitals, medical or
other health care services, shall be made not more than 35 days from the
date eligibility for payment is determined, and the interest penalty is
set by Subsection 215.422(13). Florida Statutes. Invoices returned to a
vendor due to preparation errors will result in a payment delay. Invoice
payment requirements do not start until a properly completed invoice is
provided to the agency.
A Vendor Ombudsman has been established within the Department of Banking
and Finance. The duties of this individual include acting as an advocate
for vendors who may be experiencing problems in obtaining timely
payment(s) from a state agency. The Vendor Ombudsman may be contacted at
(850) 488-2924 or by calling the State Comptroller's Hotline,
1-800-848-3792.
III. THE CONTRACTOR, DEPARTMENT AND AGENCY MUTUALLY AGREE:
A. EFFECTIVE DATE
This contract shall begin on July 1, 2002 or the date on which
all parties have signed the contract, whichever is later.
2. This contract shall end on June 30, 2003.
B. TERMINATION
TERMINATION AT WILL
This contract may be terminated by a party upon no less than
sixty days (60) calendar days notice, without cause, unless a
lesser time is mutually agreed upon by all parties. Said notice
shall be delivered by certified mail, return receipt requested,
or in person with proof of delivery. In the event the provider
terminates a contract at will the provider agrees to submit, at
the time it serves notice of intent to terminate, a plan which
identifies procedures to ensure services to clients will not be
interrupted or suspended by the termination.
2. TERMINATION BECAUSE OF LACK OF FUNDS
In the event funds to finance this contract become unavailable
due to lack of allocation of funds by the Administration
Commission or the Legislature, the agency will notify the
Contractor in writing within twenty-four (24) hours after the
agency learns of such unavailability of funds. Said notice shall
be delivered by certified mail, return receipt requested, or in
person with proof of delivery. In the event of a fiscal
emergency of the State of Florida as determined by the
Administration Commission or the Legislature, the department, in
consultation with the agency may terminate the contract no less
than twenty-four (24) hours after the contractor has received
written notice. The agency shall be the final authority as to
the availability of funds.
3. TERMINATION FOR BREACH
Unless the Contractor's breach is waived by the department in
writing, or the provider fails to cure the breach within the
time specified by the department, the department may, by written
notice to the Contractor, terminate this contract or breach if
the provider fails to cure such breach within thirty
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(30) days after the Contractor receives from the department
written notification explaining the nature of the material
breach; provided however, the department may terminate this
contract for material breach upon no less than twenty four (24)
hours written notice to the Contractor if the Contractor has
committed a material breach of the contract which causes an
immediate danger to the public health and if the Contractor has
not cured such breach within the notice period upon no less than
twenty-four (24) hours notice. Said notice shall be delivered by
certified mail, return receipt requested, or in person with
proof of delivery. If applicable, the department may employ the
default provisions in Chapter 60A-1.006(3). Florida
Administrative Code.
If the Contractor does not receive all or a substantial portion
of its capitation payment within (10) days after it is due. the
Contractor shall furnish written notification to the department
and the Contractor may terminate this contract if the agency
fails to make payment within twenty (20) days after the
department's receipt of such notice.
Waiver of breach of any provisions of this contract shall not be
deemed to be a waiver of any other breach and shall not be
construed to be a modification of the terms of this contract.
The provisions herein do not limit the department's or agency's
right to remedies at law or to damages of legal or equitable
nature.
C. SUSPENSION
The department may, for reasonable cause, temporarily suspend
the use of funds by a Contractor pending corrective action, or
pending a decision on terminating the contract. Reasonable cause
is such cause as would compel a reasonable person to suspend the
use of funds pursuant to this contract: it includes, but is not
limited to. the Contractor's failure to permit inspection of
records, or to provide reports, or to rectify deficiencies noted
by the department within the time specified by the department,
or to utilize funds as agreed in this contract, or such other
cause as might constitute breach of any of the terms of this
contract.
2. The department may prohibit the Contractor from receiving
further payments and may prohibit the Contractor from incurring
additional obligations of funds. The suspension may apply to any
part, or to all of the Contractor's operations
3. To suspend operations of the Contractor, the department will
notify the Contractor in writing by Certified Mail of the action
taken, the reason(s) for such action: and the conditions of the
suspension. The notification will also indicate what corrective
actions are necessary to remove the suspension: the Contractor's
right to a review of the department's decision and give the
Contractor the appropriate time period to request a review
before the effective date of the suspension (unless Contractor
actions warrant an immediate suspension).
D. NOTICE AND CONTACT
The name, address and telephone number of the contract manager
for the department:
Anne Frost
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, Florida 32399
(850) 414-2308
2. The name, address and telephone number of the representative for
the agency:
Susan Kaempfer
Agency for Health Care Administration
2727 Mahan Drive
Mail Stop 20
Tallahassee, Florida 32308
(850)487-2618
3. The name, address and telephone number of the representative of
the Contractor responsible for administration of the program
under this contract is:
JoAnne Dutcher. Director
Physicians Healthcare Plans, Inc.
398 West Camino Gardens Boulevard, Suite 109
Boca Raton, Florida 33432
(561) 750-8866 ext. 2222
4. If different representatives are designated after execution of
this contract, notice of the new representative will be rendered
in writing to the other parties and attached to the originals of
this contract.
E. RENEGOTIATION OR MODIFICATION
Modifications of provisions of this contract shall only be valid
when they have been reduced to writing and duly signed. The
parties agree to renegotiate this contract if federal and/or
state revisions of any applicable laws, or regulations make
changes in this contract necessary.
2. The rate of payment and the total dollar amount may be adjusted
retroactively to reflect price level increases and changes in
the rate of payment when these have been established through the
appropriations process and subsequently identified in the
agency's operating budget.
F. NAME, MAILING AND STREET ADDRESS OF PAYEE
The name (Contractor name as shown on page 1 of this contract)
and mailing address of the official payee to whom the payment
shall be made:
Physicians Healthcare Plans, Inc.
1410 North Westshore Boulevard, Suite 200
Tampa, Florida 33607
The name of the contact person and street address where
financial and administrative records are maintained:
Peter Jimenez
Physicians Healthcare Plans, Inc.
55, Alahambra Plaza, 7th Floor
Coral Gables, Florida 33134
G. ALL TERMS AND CONDITIONS INCLUDED
This contract and Attachments I, II, III, IV, V, and VI as referenced,
contain all terms and conditions agreed upon by the parties.
Page 6 of 7
IN WITNESS THEREOF, the parties hereto have caused this seven (7) page contract
to be executed by their undersigned officials as duly authorized.
CONTRACTOR: Physicians Healthcare STATE OF FLORIDA, DEPARTMENT OF ELDER
Plans, Inc. AFFAIRS
SIGNED BY: /s/ Miguel B. Fernandez SIGNED BY: /s/ Terry F. White
----------------------- ---------------------------
NAME: Miguel B. Fernandez NAME: Terry F. White
-----------------------
TITLE: Chief Executive Officer TITLE: Secretary
-----------------------
DATE: 6-25-02 DATE: 6/27/02
----------------------- ---------------------------
CONTRACTOR FEDERAL ID NUMBER
65-0318864
- ----------------------------
STATE OF FLORIDA, AGENCY FOR
CONTRACTOR FISCAL YEAR ENDING DATE: HEALTH CARE ADMINISTRATION
December 31
- -----------------------------------
SIGNED BY: /s/ Rhonda M. Medows, M.D.
---------------------------
NAME: Rhonda M. Medows, M.D.
TITLE: Secretary
DATE: 6/27/02
---------------------------
CONTRACT IS NOT VALID UNTIL SIGNED
AND DATED BY ALL PARTIES
Page 7 of 7
ATTACHMENT I
STATE OF FLORIDA
DEPARTMENT OF ELDER AFFAIRS
AGENCY FOR HEALTH CARE ADMINISTRATION
CONTRACT NO. 2002-2003-02
Attachment I- 1 of 55
Contract No. 2002-2003-02
DEFINITIONS ................................................................. 4
SECTION 1 GENERAL CONTRACT REQUIREMENTS ................................... 8
1.1 Contractor Qualifications ....................................... 8
1.2 Contract Management ............................................. 8
1.3 Insolvency Protection ........................................... 9
1.4 Surplus Requirements ............................................ 10
1.5 Bonds ........................................................... 10
1.6 Insurance ....................................................... 11
1.7 Interest and Savings ............................................ 11
1.8 Third Party Resources ........................................... 11
1.9 Ownership and Management Disclosure ............................. 12
1.10 Subcontracts .................................................... 13
1.11 Independent Provider ............................................ 16
1.12 Termination ..................................................... 16
1.13 State Ownership ................................................. 17
1.14 Damages from Federal Disallowances .............................. 17
1.15 Offer of Gratuities ............................................. 17
1.16 Attorneys Fees .................................................. 17
1.17 Venue or Court of Jurisdiction .................................. 17
1.18 Assignment ...................................................... 18
1.19 Force Majeure ................................................... 18
1.20 Disputes of Appropriate Enrol1ments.............................. 18
1.21 Misuse of Symbols, Emblems, or Names in Reference to Medicaid ... 19
1.22 Non-Renewal ..................................................... 19
1.23 Reporting ....................................................... 19
1.24 Legal Action Notification ....................................... 19
1.25 Fiscal Intermediary ............................................. 19
1.26 Sanctions ....................................................... 19
1.27 Federal Provisions .............................................. 20
SECTION 2 RECIPIENT ELIGIBILITY TO PARTICIPATE IN THE PROJECT.............. 20
2.1 Eligibility ..................................................... 20
2.2 Eligibility Determination ....................................... 20
2.3 Persons Not Eligible for Enrollment in the Project .............. 20
SECTION 3 MARKETING, CHOICE COUNSELING, ENROLLMENT AND DISENROLLMENT....... 21
3.1 Marketing/ Choice Counseling .................................... 21
3.2 Enrollment Procedures ........................................... 21
3.3 Effective Date of Enrollment .................................... 21
3.4 Transition Care Planning ........................................ 22
3.5 Orientation ..................................................... 22
3.6 Disenrollment ................................................... 23
SECTION 4 SERVICE PROVISIONS............................................... 24
4.1 General ......................................................... 24
4.2 Long-Term Care Services ......................................... 25
4.3 Acute-Care Services ............................................. 28
4.4 Optional Services ............................................... 29
4.5 Expanded Services ............................................... 30
4.6 Minimum Long-Term Care Service Provider Qualifications .......... 30
4.7 Acute Care Provider Qualifications .............................. 31
4.8 Availability/Accessibility of Services .......................... 31
4.9 Staffing Requirements ........................................... 32
4.10 Integration of Care ............................................. 32
4.11 Plan of Care .................................................... 33
4.12 Out of Network Use of Non-Emergency Services .................... 34
Attachment I- 2 of 55
Contract No. 2002-2003-02
SECTION 5 QUALITY ASSURANCE AND IMPROVEMENT REQUIREMENTS .................. 35
5.1 General ......................................................... 35
5.2 Quality Assurance Program ....................................... 35
5.3 Quality Assurance Committee ..................................... 35
5.4 Quality of Care Studies ......................................... 36
5.5 Independent Quality Review ...................................... 36
SECTION 6. GRIEVANCE PROCEDURES ............................................ 36
SECTION 7 ENROLLEE RECORDS ................................................ 40
SECTION 8 REPORTING REQUIREMENTS .......................................... 40
8.1 General Requirements ............................................ 40
8.2 Enrollment, Disenrollment, and Cancellation Report for Payment .. 41
8.3 Contractor Disenrollment Summary ................................ 42
8.4 Encounter Data .................................................. 43
8.5 Grievance Report ................................................ 45
SECTION 9 FINANCIAL REPORTING ............................................. 45
9.1 General ......................................................... 45
9.2 Audited Financial Statements .................................... 45
9.3 Unaudited Quarterly Financial Statements ........................ 46
9.4 Financial Reporting Template .................................... 46
9.5 Balance Sheet ................................................... 47
9.6 Statement of Revenues, Expenses, and Net Worth .................. 50
9.7 Statement of Changes in Financial Position and Net Worth ........ 53
SECTION 10 PAYMENT ......................................................... 54
10.1 Payment to Contractor ........................................... 54
10.2 Capitation Rates ................................................ 55
10.3 Payment in Full ................................................. 55
10.4 Capitation Rate Adjustments ..................................... 55
10.5 Payment Errors .................................................. 55
Attachment I- 3 of 55
Contract No. 2002-2003-02
DEFINITIONS
The following terms as used in this contract, shall be construed and/or
interpreted as follows, unless the context otherwise expressly requires a
different construction and/or interpretation. In the event of a conflict in
language between the definitions, attachments and other sections of the
contract, the language in the core contract shall govern.
ADL - Activities of Daily Living; include, dressing, grooming, bathing, eating,
transferring in and out of bed or a chair, walking, climbing stairs, toileting,
bladder/bowel control, and the wearing and changing of incontinent briefs.
Adverse Determination - Adverse determination means any instance in which
coverage for the requested service is denied, reduced, or terminated. The
contractor's decision to deny, reduce or terminate coverage must be based on the
review of whether an admission, availability of care, continued stay, or other
service required in accordance with this contract meets the contractor's
requirements for medical necessity, appropriateness, health care setting, level
of care, or effectiveness
Agency - State of Florida, Agency for Health Care Administration.
Ancillary Services - Services provided at a hospital include, but are not
limited to, radiology, pathology, neurology, and anesthesiology as specified in
the Hospital Coverage and Limitations Handbook.
Area Agency on Aging - an agency designated by the department to develop and
administer a plan for a comprehensive and coordinated system of services for
older persons.
Benefits - a schedule of medical or social services to be delivered to enrollees
covered under this contract.
CMS - Centers for Medicare and Medicaid Services.
Capitation Rate - the monthly fee paid by the agency to the contractor for each
enrollees enrolled under the contract for the provision of services during the
payment period.
Care Plan - A plan which describes the service needs of each recipient, showing
the projected duration, desired frequency, type of provider furnishing each
service, and scope of the services to be provided.
CARES - Comprehensive Assessment and Review for Long Term Care Services. A
nursing home pre-admission assessment program, which provides a comprehensive,
on-site assessment of individuals seeking admission to a nursing home under a
state assisted program. The program explores all available options to nursing
home placement and recommends, and may facilitate alternative placements for
individuals who are determined able to remain in the community.
CFR - Code of Federal Regulations.
Complaint - Complaint means any expression of dissatisfaction by an enrollee,
including dissatisfaction with the administration, claims practices, or
provision of services, which relates to the quality of care provided by a
provider pursuant to the contractor's contract and which is submitted to the
contractor or to a state agency. A complaint is part of the informal steps of a
grievance procedure and is not part of the formal steps of a grievance procedure
unless it is a grievance.
Complainant - a person who has filed a complaint regarding the contractor
pursuant to Section 641.47(5), Florida Statutes, as amended by Chapter 97-159
Laws of Florida.
Contractor - the organizational entity serving as the primary contractor and
with whom this agreement is executed. The term contractor shall include all
employees, subcontractors, agents, volunteers, and anyone acting on behalf of,
in the interest of, or for a contractor.
Covered Services - see Benefits.
Department - Department of Elder Affairs.
DHHS - United States Department of Health and Human Services.
Disenrollment - the discontinuance of an enrollee's membership in the
contractor's plan.
Attachment I- 4 of 55
Contract No. 2002-2003-02
Durable Medical Equipment - medical equipment that can withstand repeated use;
is primarily and customarily used to serve a medical purpose; is generally not
useful in the absence of illness or injury; and is appropriate for use in the
recipient's home.
Enrollee - a Medicaid recipient who is enrolled in the contractor's Long Term
Care Community Diversion Program.
Enrollment - the process by which an eligible Medicaid recipient becomes an
enrollee in the Long Term Care Community Diversion Program.
Facility - any premises (a) owned, leased, used or operated directly or
indirectly by or for the contractor or its affiliates for purposes related to
this contract; or (b) maintained by a subcontractor to provide services on
behalf of the contractor.
Fair Hearing - the opportunity to present one's case to a reviewing authority in
accordance with the terms and conditions in 42 CFR Part 431, State Organization
and General Administration, Subpart E, and 59G-1.030, Florida Administrative
Code.
Fiscal Agent - any corporation or other legal entity that has contracted with
the agency to receive, process and adjudicate claims under the Medicaid program.
Furnished - means supplied, given, prescribed, ordered, provided, or directed to
be provided in any manner.
Grievance - means a written complaint submitted by or on behalf of an enrollee
to the contractor or a state agency regarding the availability, coverage for the
delivery, or quality of services required in accordance with this contract. This
also includes a complaint regarding an adverse determination made pursuant to
utilization review; claims payment, handling, or reimbursement for services
required in accordance with this contract; or matters pertaining to the
contractual relationship between an enrollee and the contractor. A grievance
does not include a written complaint submitted by or on behalf of an enrollee
eligible for a grievance and appeals procedure provided by the contractor
pursuant to contract with the federal government under Title XVIII of the Social
Security Act.
Grievance Procedure - a written protocol and procedure, in compliance with
Section 641.511, Florida Statutes, as amended by Chapter 97-159, Laws of
Florida, detailing an organized process by which enrollees or providers may file
a grievance.
Grievant - an enrollee, subcontractor, or other service provider that files a
grievance with the contractor.
HMO - Health Maintenance Organization as certified pursuant to Chapter 641,
Florida Statutes.
Hospital - a facility licensed in accordance with the provisions of Chapter 395,
Florida Statutes, or the applicable laws of the state in which the service is
furnished.
IADL - Instrumental Activities of Daily Living; include making and answering
telephone calls, shopping, transportation ability, preparing meals, laundry,
light housekeeping, heavy chores, taking medication, and managing money.
ICP - The Medicaid Institutional Care Program.
Ineligible Recipient - a Medicaid recipient that does not qualify for enrollment
in the Long Term Care Community Diversion Program.
Insolvency - A financial condition that exists when an entity is unable to pay
its debts as they become due in the usual course of business, or when the
liabilities of the entity exceed its assets.
Lead Agency - means an entity designated by an area agency on aging and given
the authority and responsibility to coordinate services for functionally
impaired elderly persons.
Long-Term Care Record - a record that includes information regarding the medical
and long-term care services an enrollee is receiving including the plan of care
and documentation of case management activities including efforts to coordinate
and integrate the delivery of all services to the enrollee.
Attachment I- 5 of 55
Contract No. 2002-2003-02
Marketing - any activity conducted by or on behalf of the contractor where
information regarding the services offered by the contractor is disseminated in
order to encourage eligible enrollees to enroll or accept any application for
enrollment in the Long Term Care Community Diversion Program developed under
this contract.
Medicaid - the medical assistance program authorized by Title XIX of the federal
Social Security Act, 42 U.S.C.s.1396 et seq., and regulations there under, as
administered in this state by the agency under Section 409.901 et seq., Florida
Statutes.
Medicaid HMO - an HMO as defined in the Medicaid State Plan.
Medicare - the medical assistance program authorized by Title XVIII of the
federal Social Security Act, 42 U.S.C.s. 1395 et seq., and regulations there
under.
Nursing Facility - an institutional care facility licensed under Chapter 395,
Florida Statutes, or Chapter 400, Florida Statutes, that furnishes medical or
allied inpatient care and services to individuals needing such services.
Other Qualified Provider - a contracted provider who meets the qualifications of
Section 430.703(7), Florida Statutes.
Outpatient - a patient of an organized medical facility or distinct part of that
facility who is expected by the facility to receive and who does receive
professional services for less than a 24-hour period regardless of the hour of
admission, whether or not a bed is used, or whether or not the patient remains
in the facility past midnight.
Peer Review - an evaluation of the professional practices of a provider by peers
of the provider in order to assess the necessity, appropriateness, and quality
of care furnished as such care is compared to that customarily furnished by the
provider's peers and to recognized health care standards.
Plan of Care - See Care Plan.
Prepaid Health Plan or Plan - the prepaid health care plan developed by the
contractor in performance of its duties and responsibilities under this
contract; or a contractual arrangement between the agency and a comprehensive
health care contractor for the provision of Medicaid care, goods, or services on
a prepaid basis to Medicaid recipients.
Primary Care Physician - a Medicaid-participating or prepaid health
plan-affiliated physician practicing as a general or family practitioner,
internist, pediatrician, obstetrician, gynecologist, or other specialty approved
by the agency, who furnishes primary care and patient management services to an
enrollee.
Prior Authorization - the act of authorizing specific services before they are
rendered.
Project - Long Term Care Community Diversion Program.
Protocols - written guidelines or documentation outlining steps to be followed
for handling a particular situation, resolving a problem, or implementing a plan
of medical, social, nursing, psycho social, developmental and educational
services.
Provider - a person or entity who is responsible for or directly provides any
medical or social services authorized by this contract.
Provider Handbook - a document that provides information to a Medicaid provider
regarding enrollee eligibility, claims submission and processing, provider
participation, covered care, goods, or services and limitations, procedure codes
and fees, and other matters related to Medicaid program participation.
Quality Assurance - the process of assuring that the delivery of health care is
appropriate, timely, accessible, available, and medically necessary.
Attachment I- 6 of 55
Contract No. 2002-2003-02
Recipient - any individual whom the Department of Children and Families
determines is eligible, pursuant to federal and state law, to receive medical or
allied care, goods, or services for which the agency may make payments under the
Medicaid program and is enrolled in the Medicaid program.
Risk - the potential for loss that is assumed by an entity and that may arise
because the cost of providing care, goods, or services may exceed the capitation
or other payment made by the agency to the plan under terms of the contract.
Service Area - the designated geographical area within which the contractor is
authorized by contract to furnish covered services to enrollees and within which
the enrollees reside.
State - State of Florida.
Subcontract - an agreement entered into by a contractor for the provision of
benefits to enrollees or to perform any administrative function or service for
the contractor specifically related to securing or fulfilling the contractor's
obligations under this contract. Subcontracts include, but are not limited to
the following: agreements with all providers of medical or ancillary services,
unless directly employed by the contractor; management or administrative
agreements; third party billing or other indirect administrative/fiscal
services, including provision of mailing lists or direct mail services; and any
contract which benefits any person with a control interest in the contractor's
organization.
Subcontractor - any person to which the contractor has contracted or delegated
some of its functions, services or its obligations under this contract.
Surplus - Net worth, i.e., total assets minus total liabilities.
Third Party Resources - an individual, entity, or program, excluding Medicaid,
that is, may be, could be, should be, or has been liable for all or part of the
cost of medical services related to any medical assistance covered by Medicaid.
An example is an individual's auto insurance company, which typically provides
payment of some medical expenses related to automobile accidents and injuries.
Transportation - an appropriate means of conveyance furnished to an enrollee to
obtain services authorized under this contract.
Transition Care Services - services necessary in order to safely maintain a
person in the community both prior to and after the effective date of their
enrollment in the project until the initial Plan of Care is implemented.
Transition Period - the period of time from the effective date of enrollment
until the initial Plan of Care is effective.
Urgent Grievance - an adverse determination when the standard timeframe of the
grievance procedure would seriously jeopardize the life or health of an
enrollee, or the enrollee's ability to regain maximum function.
Violation - each determination by the department and/or agency that a contractor
failed to act as specified in the contract or in applicable statutes or rules
governing Medicaid prepaid health plans. Each day that an ongoing violation
continues may be considered for the purposes of this contract to be a separate
violation. In addition, each instance of failing to furnish necessary and/or
required services or items to enrollees is considered for purposes of this
contract to be a separate violation.
Attachment I- 7 of 55
Contract No. 2002-2003-02
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT REQUIREMENTS
SECTION GENERAL CONTRACT REQUIREMENTS
CONTRACTOR QUALIFICATIONS
To qualify as a long-term care community diversion program contractor,
the contractor must:
A. Have a certificate of authority from the Florida Department of
Insurance to operate as a health maintenance organization (HMO)
pursuant to Chapter 641 Part I, Florida Statutes, and have a
health care provider certificate from the Agency for Health Care
Administration (agency) pursuant to Chapter 641.49, Florida
Statutes, for those counties in the service area in which the
applicant will apply to provide services or;
B. Have a license issued pursuant to Chapter 400, Florida Statutes,
and meet the provisions of an "other qualified provider" set
forth in Section 430.703(7), Florida Statutes, including
satisfying all financial and quality assurance requirements for
a provider service network as specified in Section 409.912,
Florida Statutes, and;
C. Have, or have a subcontractor that has, prior experience in
providing home and community-based long-term care services in
the project service area and;
D. Have the capacity to integrate the delivery of acute and
long-term care services to enrollees; and
E. Meet all the requirements to enroll as a Medicaid prepaid health
services provider; and
F. Meet all other requirements in the remaining provisions of this
contract and its attachments.
1.2 CONTRACT MANAGEMENT
A. STATE RESPONSIBILITIES
1. The Department of Elder Affairs (department) and the
Agency for Health Care Administration (agency) will
share contract management responsibilities for the
project. General responsibilities of the department and
agency are outlined in this subsection. The Area Agency
on Aging in the project service area may also be
designated to serve as an agent of the department in
executing contract management responsibilities. The
department will have the right to approve, disapprove,
or require modification of procedures developed by the
contractor under the contract where necessary to assure
compliance with department or agency rules or the
contract.
B. DEPARTMENT RESPONSIBILITIES
1. Develop, analyze and revise policies and procedures for
the project in consultation with the agency.
2. Approve, in consultation with the agency, the
contractor's readiness to deliver services under the
contract.
3. Determine the clinical eligibility of persons applying
for Medicaid long-term care assistance through the
Comprehensive Assessment and Review for Long-Term Care
Services (CARES) program.
4. Provide, through the CARES program, information
regarding long-term care options to persons applying for
Medicaid long-term care assistance.
5. Provide policy clarification and contract clarification,
in consultation with the agency, as requested by the
contractor.
6. Monitor, with the agency, the contractor's compliance
with the terms of the contract and impose appropriate
corrective and remedial measures as warranted.
7. Analyze and monitor data provided by the contractor
pursuant to the terms of the contract.
8. Receive all materials that must be submitted by the
contractor and forward them to the appropriate entity.
Attachment I- 8 of 55
Contract No. 2002-2003-02
9. Oversee the daily operations of the project in terms of
enrollment and payments to the contractor.
10. Serve as the liaison between the contractor and the
agency.
C. AGENCY RESPONSIBILITIES
1. Calculate capitation payment rates for the services
included in the contract.
2. Make Medicaid provider handbooks available to the
contractor.
3. Provide policy and contract clarification, in
consultation with the department, as requested by the
contractor.
4. Monitor, with the department, the contractor's
compliance with the terms of the contract and impose
appropriate corrective and remedial measures as
warranted.
5. Make Medicaid capitation payments to the contractor
through the Medicaid fiscal agent.
6. Oversee all the activities of the Medicaid fiscal agent
related to the project.
7. Serve as a liaison between the contractor and the
Medicaid fiscal agent.
8. Approve, in consultation with the department, the
contractor's readiness to deliver services under the
contract.
9. Approve, in consultation with the department, all
consumer information materials developed by the
contractor for use in the project.
10. Serve as the liaison between the department and the
Medicaid Fiscal Agent.
D. CONTRACTOR RESPONSIBILITIES
1. The contractor is responsible for the administration and
management of all contractor functions, including all
subcontracts, employees, agents and anyone acting for or
on behalf of the contractor.
2. The contractor will not interpret general Medicaid
policy. When interpretations are required, the
contractor must submit written requests to the contract
manager. The contract manager will contact the
appropriate agencies in responding to the request.
3. If the contractor delegates administrative and
management functions to a third party administrator
(TPA), the TPA must be licensed to do business as a TPA
in Florida. Such delegation to a TPA does not relieve
the contractor of responsibility for the administration
and management required under this contract.
4. The relationship between management personnel and the
governing body must be set forth in writing, including
each person's authority, responsibilities and function.
5. The contractor must develop and maintain written
policies and procedures to implement the provisions of
the contract.
6. The contractor must agree to the responsibilities and to
the performance of all services as set forth in all
provisions of this contract and its attachments.
1.3 INSOLVENCY PROTECTION
A. The contractor must establish a restricted insolvency protection
account with a federally guaranteed financial institution
licensed to do business in Florida in accordance with Section
1903(m)(1) of the Social Security Act (amended by Section 4706
of the Balanced Budget Act of 1997), and Section 409.912(15)(a),
Florida Statutes. The contractor must deposit into that account
five percent of the capitation payments made by the agency each
month until a maximum total of two percent of the annualized
total current contract amount is reached. No interest may be
withdrawn from this account until the minimum balance of 2% of
the contract annual amount is reached. Withdrawals from the
account may not cause the balance therein to fall below the 2%
of annual contract amount minimum. This provision will remain in
effect as long as the contractor continues to contract with the
department and agency. The restricted insolvency protection
account may be drawn upon with the authorized signatures of two
persons designated by the contractor, one person designated by
the agency, and one person designated by the department. The
signature card must be resubmitted when a change in authorized
personnel occurs. If the authorized persons remain the same, the
contractor must submit an attestation to this effect annually.
All such agreements or other signature cards must be approved in
advance by the agency. Upon request, a
Attachment I- 9 of 55
Contract No. 2002-2003-02
sample form (Multiple Signature Verification Agreement) will be
supplied by the department.
B. In the event that a determination is made by the agency, in
consultation with the department, that the contractor is
insolvent, as defined in the glossary, the agency may draw upon
the amount solely with the two authorized signatures of
representatives of the department and agency and funds may be
disbursed to meet financial obligations incurred by the
contractor under this contract. The contractor shall provide a
statement of account balance within 15 calendar days of request
by the agency.
C. If the contract is terminated, expired, or not continued, the
account balance shall be released by the agency to the
contractor upon receipt of proof of satisfaction of all
outstanding obligations incurred under this contract.
D. In the event the contract is terminated or not renewed and the
contractor is insolvent, the agency may draw upon the insolvency
protection account to pay any outstanding debts the contractor
owes the agency including, but not limited to, overpayments made
to the contractor, and fines imposed under the contract or
Section 641.52, Florida Statutes, for which a final order has
been issued. In addition, if the contract is terminated or not
renewed and the contractor is unable to pay all of its
outstanding debts to health care providers, the department,
agency and the contractor agree to the court appointment of an
impartial receiver for the purpose of administering and
distributing the funds contained in the insolvency protection
account. Should a receiver be appointed, he must give
outstanding debts owed to the agency priority over other claims.
E. Pursuant to Section 409.912(15)(b), Florida Statutes, the
department, in consultation with the agency may waive the
insolvency protection account requirement, in writing, when
evidence of adequate insolvency insurance and reinsurance are on
file with the agency which will protect enrollees in the event
the contractor is unable to meet its obligations.
1.4 SURPLUS REQUIREMENTS
A. All new contractors, after initial contract execution but prior
to initial member enrollment, must submit to the department, if
a private entity, proof of working capital in the form of cash
or liquid assets excluding revenues from Medicaid premium
payments equal to at least the first three months of operating
expenses or $200,000, whichever is greater. This provision shall
not apply to contractors who have been providing services to
members for a period exceeding three continuous months.
B. In accordance with Section 409.912(14), Florida Statutes, the
contractor must maintain at all times in the form of cash,
investments that mature in less than 180 calendar days allowable
as admitted assets by the Department of Insurance, and
restricted funds of deposits controlled by the agency (including
the plan's insolvency protection account) or the Department of
Insurance, a surplus amount equal to one and one half times the
contractor's monthly Medicaid prepaid revenues. In the event
that the contractor's surplus (as defined in the glossary) falls
below an amount equal to one and one half times the contractor's
monthly Medicaid prepaid revenues, the department will cease the
contractor's enrollment authorizations until the required
balance is achieved, or may terminate the contract.
1.5 BONDS
A. The contractor must secure and maintain during the life of the
contract a blanket fidelity bond from a company doing business
in the State of Florida on all personnel in its employment and
its board of directors. The bond must be issued in the amount of
at least $250,000 per occurrence. Said bond must protect the
department and agency from any losses sustained through any
fraudulent or dishonest act or acts committed by any employees
of the provider and subcontractors, if any. The contractor must
submit proof of coverage within 60 calendar days after execution
of the contract and prior to the
Attachment I- 10 of 55
Contract No. 2002-2003-02
delivery of services. For fidelity bonds to be acceptable, a
surety company must comply with the provisions of Chapter 624,
Florida Statutes. The contractor must submit proof of the
fidelity bond annually during the contract renewal period.
B. A contractor applying as an "other qualified provider" set forth
in Section 430.703(7), Florida Statutes, must secure and
maintain, during the life of the contract, a performance bond
from a company doing business in the State of Florida. The bond
must guarantee the contractor's performance and obligations in
accordance with the terms, conditions and agreements in this
contract and be issued in the amount of $500,000.
1.6 INSURANCE
A. The contractor must obtain and maintain, at all times, adequate
insurance coverage including general liability insurance,
professional liability and malpractice insurance, fire and
property insurance, and director's omission and error insurance.
All insurance coverage must comply with the provisions set forth
in Section 4-191.069, Florida Administrative Code, except that
the reporting, administrative, and approval requirements will be
submitted to the department in addition to the Department of
Insurance. All insurance policies must be written by insurers
licensed to do business in the State of Florida and be in good
standing with the Department of Insurance. The contractor must
submit all policy declaration pages annually or whenever there
is a change in insurer or policy provisions to the contract
manager. Each certificate of insurance must provide for
notification to the department in the event of termination of
the policy.
B. The contractor must secure and maintain during the life of the
contract, worker's compensation insurance for all of its
employees connected with the work under the contract. Such
insurance must comply with the Florida Worker's Compensation
Law, Chapter 440, and Florida Statutes. Policy declaration pages
must be submitted to the department annually.
1.7 INTEREST AND SAVINGS
A. Interest generated through investments made by the contractor of
funds provided to the contractor pursuant to this contract will
be the property of the contractor and will be used at the
contractor's discretion.
B. The contractor will retain any savings realized under the
contract after all bills, charges, and fines are paid.
1.8 THIRD PARTY RESOURCES
A. The contractor will be responsible for making every reasonable
effort to determine the legal liability of third parties to pay
for services rendered to enrollees under this contract. The
contractor has the same rights to recovery of the full value of
services as the agency. (See Section 409.910, Florida Statutes)
The following standards govern recovery.
B. If the contractor has determined that third party liability
exists for part or all of the services provided directly by the
contractor to an enrollee, the contractor must make reasonable
efforts to recover from third party liable sources the value of
services rendered.
C. If the contractor has determined that third party liability
exists for part or all of the services provided to an enrollee
by a subcontractor or referral provider, and the third party is
reasonably expected to make payment within 120 calendar days,
the contractor may pay the subcontractor or referral provider
only the amount, if any, by which the subcontractor's allowable
claim exceeds the amount of the anticipated third party payment;
or, the contractor may assume full responsibility for third
party collections for service provided through the subcontractor
or referral provider.
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Contract No. 2002-2003-02
D. The contractor may not withhold payment for services provided to
an enrollee if third party liability or the amount of liabilitys
cannot be determined, or if payment shall not be available
within a reasonable time, beyond 120 calendar days from the date
of receipt.
E. When both the agency and the contractor have liens against the
proceeds of a third party resource, the agency shall prorate the
amount due to Medicaid to satisfy such liens under Section
409.910, Florida Statutes, between the agency and the
contractor. This prorated amount shall satisfy both liens in
full.
F. The agency may, at its sole discretion, offer to provide third
party recovery services to the contractor. If the contractor
elects to authorize the agency to recover on its behalf, the
contractor shall be required to provide the necessary data for
recovery in the format prescribed by the agency. All recoveries,
less the agency's cost to recover shall be income to the
contractor. The cost to recover must be expressed as a
percentage of recoveries and must be fixed at the time the
contractor elects to authorize the agency to recover on its
behalf.
G. All funds recovered from third parties shall be treated as
income for the contractor.
1.9 OWNERSHIP AND MANAGEMENT DISCLOSURE
A. Federal and state laws require full disclosure of ownership,
management and control of Medicaid HMOs, including other
qualified providers. Disclosure must be made on forms prescribed
by the agency for the areas of ownership and control interest
(Form HCFACMS 1513), business transactions (42 CFR 455.105),
public entity crimes (Section 287.133(3)(a), Florida Statutes),
and debarment and suspension (52 Fed. Reg., pages 20360-20369,
and Section 4707 of the Balanced Budget Act of 1997). The forms
are available through the department and are to be submitted to
the department with the initial application and then resubmitted
on an annual basis. The contractor must disclose any changes in
management as soon as those occur. In addition, the contractor
must submit to the department full disclosure of ownership and
control of Medicaid HMOs at least 60 calendar days before any
change in the contractor's ownership or control occurs.
B. The following definitions apply to ownership disclosure:
1. A person with an ownership interest or control interest
means a person or corporation that:
a. Owns, indirectly or directly, 5 percent or more
of the contractor's capital or stock, or
receives 5 percent or more of its profits;
b. Has an interest in any mortgage, deed of trust,
note, or other obligation secured in whole or in
part by the contractor or by its property or
assets and that interest is equal to or exceeds
5 percent of the total property or assets; or
c. Is an officer or director of the contractor if
organized as a corporation, or is a partner in
the contractor if organized as a partnership.
2. The percentage of direct ownership or control is
calculated by multiplying the percent of interest that a
person owns by the percent of the contractor's assets
used to secure the obligation. Thus, if a person owns 10
percent of a note secured by 60 percent of the
contractor's assets, the person owns 6 percent of the
contractor.
3. The percent of indirect ownership or control is
calculated by multiplying the percentage of ownership in
each organization. Thus, if a person owns 10 percent of
the stock in a corporation that owns 80 percent of the
contractor's stock, the person owns 8 percent of the
contractor.
C. Changes in management are defined as any change in the
management control of the contractor. Examples of such changes
are those listed below or equivalent positions by another title.
1. Changes in the Board of Directors or Officers of the
contractor, Medical Director, Chief Executive Officer,
Administrator, and Chief Financial Officer;
2. Changes in the management of the contractor where the
contractor has decided to contract out the operation of
the contractor to a management corporation. The
contractor must disclose such changes in management
control and provide a copy of
Attachment I- 12 of 55
Contract No. 2002-2003-02
the contract agreement to the contract manager for
approval at least 60 calendar days prior to the
management contract start date.
D. In accordance with Section 409.912(29), Florida Statutes, the
contractor must annually conduct a background check with the
Florida Department of Law Enforcement on all persons with five
percent or more ownership interest in the contractor, or who
have executive management responsibility for the managed care
plan, or have the ability to exercise effective control of the
contractor. The contractor must submit information to the
department for such persons who have a record of illegal conduct
according to the background check. The department will keep a
record of all background checks to be available for department
and agency review upon request.
1. In accordance with Section 409.907(8), Florida Statutes,
contractors with an initial contract beginning on or
after July 1, 1997, must submit, prior to execution of a
contract, complete sets of fingerprints of principals of
the contractor to the agency for the purpose of
conducting a criminal history record check.
2. Principals of the contractor are defined in Section
409.907(8)(a), Florida Statutes.
E. The contractor must submit to the department, within five
working days, any information on any officer, director, agent,
managing employee, or owner of stock or beneficial interest in
excess of five percent of the contractor who has been found
guilty of, regardless of adjudication, or who entered a plea of
nolo contendere or guilty to, any of the offenses listed in
Section 435.03, Florida Statutes.
F. In accordance with Section 409.912(8), Florida Statutes, the
department and agency will not contract with an entity that has
an officer, director, agent, managing employee, or owner of
stock or beneficial interest in excess of five percent of the
contractor, who has committed any of the above listed offenses.
In order to avoid termination, the contractor must submit a
corrective action plan, acceptable to the department, that
ensures such person is divested of all interest and/or control
and has no role in the operation and management of the
contractor
G. The contract is subject to the provisions of Chapter 112,
Florida Statutes. The contractor must disclose the name of any
officer, director, or agent who is an employee of the State of
Florida, or any of its agencies. Further, the contractor must
disclose the name of any state employee who owns, directly or
indirectly, an interest of five percent or more in the officer's
firm or any of its branches. The contractor covenants that it
presently has no interest and shall not acquire any interest,
direct or indirect, which would conflict in any manner or degree
with the performance of the services hereunder. The contractor
further covenants that in the performance of the contract no
person having any such known interest shall be employed. No
official or employee of the department or agency and no other
public official of the State of Florida or the federal
government who exercises any functions or responsibilities in
the review or approval of the undertaking of carrying out the
contract must, prior to completion of this contract, voluntarily
acquire any personal interest, direct or indirect, in this
contract or proposed contract.
1.10 SUBCONTRACTS
The contractor is responsible for all work performed under this
contract, but may, with the written approval of the department, enter
into subcontracts for the performance of work required under this
contract. All subcontracts and amendments executed by the contractor
must meet the following requirements and all model provider subcontracts
must be approved, in writing, by the department in advance of
implementation. All subcontractors must be eligible for participation in
the Medicaid program; however, the subcontractor is not required to
participate in the Medicaid program as a provider. Subcontracts are
required with all major providers of services.
The contractor must not 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 state law, solely on the basis of such license, or
certification, in
Attachment I- 13 of 55
Contract No. 2002-2003-02
accordance with Section 4704 of the Balanced Budget Act of 1997. This
paragraph shall not be construed to prohibit a contractor from including
providers only to the extent necessary to meet the needs of the
contractor's enrollees or from establishing any measure designed to
maintain quality and control costs consistent with the responsibilities
of the organization. No subcontract, which the contractor enters into
with respect to performance under the contract, shall in any way relieve
the contractor of any responsibility for the performance of duties under
this contract. The contractor must assure that all tasks related to the
subcontract are performed in accordance with the terms of this contract.
The contractor must identify, in its subcontracts, any aspect of service
that may be further subcontracted by the subcontractor. All model and
executed subcontracts and amendments used by the contractor under this
contract must be in writing, signed, and dated by the contractor and the
subcontractor and meet the following requirements:
A. IDENTIFICATION OF CONDITIONS AND METHOD OF PAYMENT:
1. The contractor agrees to make payment to all
subcontractors pursuant to Section 641.3155, Florida
Statutes. If third party liability exists, payment of
claims must be determined in accordance with Section
70.201, Third Party Resources.
2. Provide for prompt submission of information needed to
make payment.
3. Make full disclosure of the method and amount of
compensation or other consideration to be received from
the contractor. The provider must not charge for any
service provided to the recipient at a rate in excess of
the rates established by the contractor's subcontract
with the provider in accordance with Section
1128B(d)(l), Social Security Act (enacted by Section
4704 of the Balanced Budget Act of 1997).
4. Require an adequate record system be maintained for
recording services, charges, dates and all other
commonly accepted information elements for services
rendered to recipients under the contract.
5. Physician incentive plans must comply with 42 CFR
417.479. The contractor shall make no specific payment
directly or indirectly under a physician incentive plan
to a physician or physician group an inducement to
reduce or limit medically necessary services furnished
to an individual enrollee. Incentive plans must not
contain provisions that provide incentives, monetary or
otherwise, for the withholding of medically necessary
care. The contractor must disclose information on
provider incentive plans listed in 42 CFR 417.479(h)(1)
and 417.479(1) at the times indicated in 42 CFR
417.479(d)-(g). All such arrangements must be submitted
to the department for approval, in writing, prior to
use. If any other type of withhold arrangement currently
exists, it must be omitted from all subcontracts.
6. Specify whether the contractor will assume full
responsibility for third party collections in accordance
with Section 70.201, Third Party Resources.
B. PROVISIONS FOR MONITORING AND INSPECTIONS:
1. Provide that the department, agency and DHHS may
evaluate through inspection or other means the quality,
appropriateness and timeliness of services performed.
2. Provide for inspections of any records pertinent to the
contract by the department, agency and DHHS.
3. Require that records be maintained for a period not less
than five years from the close of the contract and
retained further if the records are under review or
audit until the review or audit is complete. (Prior
approval for the disposition of records must be
requested and approved by the provider if the
subcontract is continuous.)
4. Provide for monitoring and oversight by the contractor
and the subcontractor to provide assurance that all
licensed medical professionals are credentialed in
accordance with the contractor's and the agency's
credentialing requirements as found in Section 20.5.1,
Credentialing and Re-credentialing Policies and
Procedures, if the contractor has delegated the
credentialing to a subcontractor.
5. Provide for monitoring of services rendered to enrollees
sponsored by the provider.
C. SPECIFICATION OF FUNCTIONS OF THE SUBCONTRACTOR:
1. Identify the population covered by the subcontract.
Attachment I- 14 of 55
Contract No. 2002-2003-02
2. Specify the amount, duration and scope of services to be
provided by the subcontractor, including a requirement
that the subcontractor continue to provide services
through the term of the capitation period for which the
agency has paid the contractor.
3. Provide for timely access to appointments.
4. Provide for submission of all reports and clinical
information required by the contractor.
5. Provide for the participation in any internal and
external quality improvement, utilization review, peer
review, and grievance procedures established by the
contractor.
D. PROTECTIVE CLAUSES:
1. Require safeguarding of information about enrollees in
accordance with 42 CFR, Part 431, Subpart F.
2. Require compliance with HIPAA privacy and security
provisions.
3. Require an exculpatory clause, which survives
subcontract termination including breach of subcontract
due to insolvency, that assures that enrollees, the
department, or agency may not be held liable for any
debts of the subcontractor and, in accordance with 42
CFR 447.15, that the recipient is not liable to the
provider for any services for which the contractor is
liable as specified in Section 641.3154, Florida
Statutes.
4. Contain a clause indemnifying, defending and holding the
department, agency, and the contractor's enrollees
harmless from and against all claims, damages, causes of
action, costs or expense, including court costs and
reasonable attorney fees arising from the subcontract
agreement. This clause must survive the termination of
the subcontract, including breach due to insolvency. The
department may waive this requirement for itself, but
not the contractor's enrollees, for damages in excess of
the statutory cap on damages for public entities if the
subcontractor is a public health entity with statutory
immunity. All such waivers must be approved in writing
by the department.
5. Require that the subcontractor secure and maintain
during the life of the subcontract worker's compensation
insurance for all of its employees connected with the
work under this contract unless such employees are
covered by the protection afforded by the contractor.
Such insurance must comply with the Florida's Worker's
Compensation Law.
6. Pursuant to Section 641.315(9), Florida Statutes,
contain no provision that prohibits a physician from
providing inpatient services in a contracted hospital to
an enrollee if such services are determined by the
organization to be medically necessary and covered
services under the organization's contract with the
contract holder.
7. Contain no provision restricting the provider's ability
to communicate information to the provider's patient
regarding medical care or treatment options for the
patient when the provider deems knowledge of such
information by the patient to be in the best interest of
the health of the patient.
8. Pursuant to Section 641.315(10), contain no provision
requiring providers to contract for more than one HMO
product or otherwise be excluded.
9. Pursuant to Section 641.315(6), Florida Statutes,
contain no provision that in any way prohibits or
restricts the health care provider from entering into a
commercial contract with any other contractor.
10. Specify that if the subcontractor delegates or
subcontracts any functions of the contractor, that the
subcontract or delegation include all the requirements
of this section.
11. Make provisions for a waiver of those terms of the
subcontract that, as they pertain to Medicaid
recipients, are in conflict with the specifications of
this contract.
12. Specify procedures and criteria for extension,
renegotiation, and termination, and that the provider
must give 60 days' advance written notice to the
contractor, and the Department of Insurance before
canceling the contract with the contractor for any
reason. Nonpayment for goods or services rendered by the
provider to the
Attachment I- 15 of 55
Contract No. 2002-2003-02
contractor is not a valid reason for avoiding the 60 day
advance notice of cancellation pursuant to Section
641.315(2)(a)2., Florida Statutes. A copy of the notice
must be filed simultaneously with the department.
Pursuant to Section 641.315(2)(b), Florida Statutes, specify that the
contractor will provide 60 days' advance written notice to the provider
and the Department of Insurance before canceling, without cause, the
contract with the provider, except in the case in which a patient's
health is subject to imminent danger or a physician's ability to
practice medicine is effectively impaired by an action by the Board of
Medicine or other governmental agency, in which case notification must
be provided to the agency immediately. A copy of the notice submitted to
the Department of Insurance must be filed simultaneously with the
agency.
The department may waive this requirement and permit the contractor to
enter into a letter of agreement with certain facilities, licensed under
Chapter 400, Part II, Florida Statutes and enrolled in the Medicare and
Medicaid programs, when it is determined by the department to be in the
best interest of the enrollee(s) to do so.
1.11 INDEPENDENT PROVIDER
It is expressly agreed that the contractor and any subcontractors and
agents, officers, and employees of the contractor or any subcontractors,
in the performance of this contract shall act in an independent capacity
and not as officers and employees of the department, agency or the State
of Florida. It is further expressly agreed that this contract shall not
be construed as a partnership or joint venture between the contractor or
any subcontractor and the department, agency or the State of Florida.
1.12 TERMINATION
A. In conjunction with Part III section B, titled Termination in
the core contract, termination procedures are required. The
party initiating the termination must render written notice of
termination to the other parties to this agreement by certified
mail, return receipt requested, or in person with proof of
delivery, or by facsimile letter followed by certified mail,
return receipt requested. The notice of termination must specify
the nature of termination, the extent to which performance of
work under the contract is terminated, and the date on which
such termination shall become effective. In accordance with
1932(e)(4), Social Security Act, the department and agency shall
provide the contractor with an opportunity for a hearing prior
to termination for cause.
B. Upon receipt of final notice of termination, on the date and to
the extent specified in the notice of termination, the
contractor must:
1. Stop work under the contract, but not before the
termination date.
2. Cease enrollment of new enrollees under the contract.
3. Assign to the State those subcontracts as directed by
the department's and agency's contracting officer
including all the rights, title and interest of the
contractor for performance of those subcontracts.
4. At least 30 calendar days prior to the termination
effective date, provide written notification to all
enrollees of the following information: the date on
which the contractor will no longer participate in the
State's Medicaid program; and instructions on contacting
the department's CARES office to obtain information on
their long-term care options.
5. Take such action as may be necessary, or as the
department and agency may direct, for the protection of
property related to the contract, which is in the
possession of the provider, and in which the department
and agency have or may acquire an interest.
6. Not accept its prepaid payment for any requests for
payment submitted after the contract ends. Any payments
due under the terms of the contract may be withheld
Attachment I- 16 of 55
Contract No. 2002-2003-02
until the department receives from the contractor all
written and properly executed documents as required by
the written instructions of the department.
7. Continue to serve or arrange for provision of services
to the enrollees enrolled pursuant to the contract on a
fee-for-service basis up to 45 days from the
notification of termination date.
8. In the event the department has terminated this contract
in one or more counties of the state, complete the
performance of this contract in all other areas in which
the contractor has not been terminated.
1.13 STATE OWNERSHIP
The department and agency will have the right to use, disclose, or
duplicate, all information and data developed, derived, documented, or
furnished by the contractor resulting from the contract. Nothing herein
will entitle the department and agency to disclose to third parties data
or information which would otherwise be protected from disclosure by
state or federal law.
DAMAGES FROM FEDERAL DISALLOWANCES
In addition to any remedies available through the contract, in law or
equity, the contractor must reimburse the agency for any federal
disallowances or sanctions imposed on the department or agency as a
result of the contractor's failure to abide by the terms of the
contract.
1.15 OFFER OF GRATUITIES
By signing this agreement, the contractor signifies that no recipient of
or a delegate of Congress, nor any elected or appointed official or
employee of the State of Florida, the General Accounting Office,
Department of Health and Human Services, Centers for Medicare and
Medicaid Services, or any other federal department has or will benefit
financially or materially from this procurement. The department may
terminate the contract if it is determined that gratuities of any kind
were offered to or received by any officials or employees from the
offeror, his agent, or employees.
ATTORNEYS' FEES
In the event of a dispute, each party to the contract will be
responsible for its own attorney's fees except as otherwise provided by
law.
VENUE OR COURT OF JURISDICTION
For purposes of any legal action occurring as a result of or under the
contract, between the contractor and the department or agency, the place
of proper venue will be Leon County. The parties expressly agree that:
A. The appropriate circuit or county court in Leon County, Florida
will have jurisdiction of all equitable matters.
B. The department will have the discretion to resolve all other
matters by informal hearing.
C. The department will have the sole discretion to remove any case
to the Division of Administrative Hearings for a formal hearing.
D. In the event of concurrent or overlapping jurisdiction, the
department will determine the proper forum.
Attachment I- 17 of 55
Contract No. 2002-2003-02
1.18 ASSIGNMENT
A. Except as provided below or with the prior written approval of
the department, which approval will not be unreasonably
withheld, the contract and the monies which may become due are
not to be assigned, transferred, pledged or hypothecated in any
way by the contractor, including by way of an asset or stock
purchase of the contractor and will not be subject to execution,
attachment or similar process by the contractor.
B. Exceptions for HMOs licensed under Section 641, Florida
Statutes, are as follows:
1. As provided by Section 409.912(17). Florida Statutes,
when a merger or acquisition of a contractor has been
approved by the Department of Insurance pursuant to
Section 628.4615, Florida Statutes, the department shall
approve the assignment or transfer of the appropriate
Medicaid HMO contract upon the request of the surviving
entity of the merger or acquisition if the contractor
and the surviving entity have been in good standing with
the department and agency for the most recent 12 month
period, unless the department determines that the
assignment or transfer would be detrimental to the
Medicaid recipients or the Medicaid program.
2. To be in good standing, a contractor must not have
failed accreditation or committed any material violation
of the requirements of Section 641.52, Florida Statutes,
and must meet the requirements in this contract.
3. For the purposes of this section, a merger or
acquisition means a change in controlling interest of a
contractor, including an asset or stock purchase.
1.19 FORCE MAJEURE
The department and agency will not be liable for any excess cost to the
contractor if the department's or agency's failure to perform the
contract arises out of causes beyond the control and without the result
of fault or negligence on the part of the department or agency. In all
cases, the failure to perform must be beyond the control without the
fault or negligence of the department or agency. The contractor will not
be liable for performance of the duties and responsibilities of the
contract when its ability to perform is prevented by causes beyond its
control. These acts must occur without the fault or negligence of the
contractor. These include destruction to the facilities due to
hurricanes, fires, war, riots, and other similar acts. Annually by May
31, the contractor must submit to the department for approval an
emergency management plan specifying what actions the contractor must
conduct to ensure the ongoing provisions of health services in a natural
disaster or man-made emergency.
1.20 DISPUTES OF APPROPRIATE ENROLLMENTS
Any disputes arising in and under this contract, including disputes
relating to the appropriateness of enrollments authorized by CARES staff
pursuant to section 2.1 of this contract, will be decided by the
department in consultation with the agency. This provision excludes
matters brought forth by enrollees. The department must reduce its
decision to writing and serve a copy on the contractor. The decision of
the department will be final and conclusive. This contract with numbered
attachments represents the entire agreement between the contractor, the
department, and the agency with respect to the subject matter in it and
supersedes all other contracts between the parties when it is duly
signed and authorized by the contractor, the department and the agency.
Correspondence and memoranda of understanding do not constitute part of
this contract. In the event of a conflict of language between the
contract and any attachments to the contract, the provisions of the
contract will govern. However, the department and agency reserve the
right to clarify any contractual relationship in writing with the
concurrence of the contractor and such clarification will govern.
Pending final determination of any dispute, the contractor must proceed
diligently with the performance of the contract and in accordance with
the department's direction.
Attachment I- 18 of 55
Contract No. 2002-2003-02
1.21 Misuse of Symbols, Emblems, or Names in Reference to Medicaid
No person or contractor may use, in connection with any item
constituting an advertisement, solicitation, circular, book, pamphlet or
other communication, or a broadcast, telecast, or other production,
alone or with other words, letters, symbols or emblems the words
"Medicaid," or "Department of Elder Affairs," or "Agency for Health Care
Administration," except as required in the core contract unless prior
written approval is obtained from the department. Specific written
authorization from the department is required to reproduce, reprint, or
distribute any department or agency form, application, or publication,
for a fee. State and local governments are exempt from this prohibition.
A disclaimer that accompanies the inappropriate use of the program or
the department or agency's terms does not provide a defense. Each piece
of mail or information constitutes a violation.
1.22 NON-RENEWAL
The contract will be renewed only upon mutual consent of the parties.
Either party may decline to renew the contract for any reason. The
parties agree there is no property interest under the contract.
1.23 REPORTING
The contractor is responsible for complying with all the reporting
requirements in accordance with the contract. The department will
provide the contractor with the appropriate reporting formats,
instructions, submission timetables, and technical assistance when
required. The department reserves the right to modify the reporting
requirements to which the contractor must adhere. Failure of the
contractor to submit the required reports accurately and within the time
frames specified, may result in the withholding of three (3) percent of
the next monthly capitation payment by the agency pending receipt of the
reports.
1.24 LEGAL ACTION NOTIFICATION
The contractor must give the department by certified mail immediate
written notification (no later than 30 calendar days after service of
process) of any action or suit filed or of any claim made against the
contractor by any subcontractor, vendor, or other party which results in
litigation related to this contract for disputes or damages exceeding
the amount of $50,000. In addition, the contractor must immediately
advise the department of the insolvency of a subcontractor or of the
filing of a petition in bankruptcy by or against a subcontractor.
1.25 FISCAL INTERMEDIARY
If the contractor utilizes a fiscal intermediary service organization as
defined in Section 641.316, Florida Statutes, such organization must be
licensed to do business as a fiscal intermediary service organization in
the state of Florida. Such delegation does not relieve the contractor of
responsibility for the administration and management required under this
contract.
1.26 SANCTIONS
A. In accordance with Section 4707 of the Balanced Budget Act of
1997, and Section 409.912(19), F.S, the following sanctions may
be imposed against the contractor if it is determined that the
contractor has violated any provision of this contract, or the
applicable statutes or rules governing Medicaid HMOs:
1. Suspension of the contractor's enrollment.
Attachment I- 19 of 55
Contract No. 2002-2003-02
2. Suspension or revocation of payments to the plan for
Medicaid recipients enrolled during the sanction period.
If the contractor has violated the contract, the
contractor may be ordered to reimburse the complainant
for out-of-pocket medically necessary expenses incurred
or order the contractor to pay non-network plan
providers who provide medically necessary services.
3. Imposition of a fine for violation of the contract with
the department and agency, pursuant to Section
409.912(19), Florida Statutes.
4. Termination pursuant to the contract.
B. Unless the duration of a sanction is specified, a sanction will
remain in effect until the department is satisfied that the
basis for imposing the sanction has been corrected and is not
likely to recur.
1.27 FEDERAL PROVISIONS
The contractor is subject to any changes in Federal law, regulations, or
other policy guidance from the Centers for Medicare and Medicaid
Services during the term of this contract.
SECTION 2 RECIPIENT ELIGIBILITY TO PARTICIPATE IN THE PROJECT
2.1 ELIGIBILITY
Recipients eligible for project enrollment must be:
A. 65 years of age or older.
B. Medicare Parts A & B eligible.
C. Medicaid eligible with incomes up to the Institutional Care
Program level (ICP).
D. Reside in the project service area.
E. Determined by CARES to be at risk of nursing home placement and
meet one or more of the following clinical criteria:
1. Require some help with five or more activities of daily
living (ADLs); or
2. Require some help with four ADLs plus requiring
supervision or administration of medication; or
3. Require total help with two or more ADLs; or
4. Have a diagnosis of Alzheimer's disease or another type
of dementia and require some help with three or more
ADLs; or
5. Have a diagnosis of a degenerative or chronic condition
requiring daily nursing services.
F. Determined by CARES to be a person who, on the effective date of
enrollment, can be safely served with home and community-based
services.
2.2 ELIGIBILITY DETERMINATION
A. The Florida Department of Children and Families (formerly the
Department of Health and Rehabilitative Services) and the
federal Social Security Administration determine a person's
financial and categorical Medicaid eligibility. Financial
eligibility for the project will be up to the Medicaid ICP
income and asset level.
B. The department's CARES program determines a person's clinical
eligibility for the project.
2.3 PERSONS NOT ELIGIBLE FOR ENROLLMENT IN THE PROJECT
A. Persons residing outside the project service area.
B. Persons residing in a state hospital, intermediate care facility
for persons with developmental disabilities, or a correctional
institution.
Attachment I- 20 of 55
Contract No. 2002-2003-02
C. Persons receiving services through a Medicaid or Medicare
hospice program.
D. Persons participating in or enrolled in another Medicaid waiver
project.
E. Medicaid eligible recipients who are served by the Florida
Assertive Community Treatment Team(FACT team).
F. Persons enrolled in any other Medicaid capitated long-term care
program.
SECTION 3 MARKETING, CHOICE COUNSELING, ENROLLMENT AND DISENROLLMENT
3.1 MARKETING/ CHOICE COUNSELING
A. The contractor may not market to prospective enrollees face to
face.
B. The contractor may use mass marketing strategies, approved by
the department, to communicate information regarding the project
to prospective enrollees.
C. CARES staff will provide prospective enrollees with information
regarding their Medicaid long-term care options. These options
may include: enrolling in the project, participating in another
Medicaid home and community-based services waiver program,
placement in a nursing home, or declining long-term care
assistance.
D. CARES staff will also perform a choice counseling function for
the project. The choice counseling function includes providing
the prospective enrollee with contractor prepared, and
department approved, marketing materials, and explaining the
following:
1. The concept of managed care and the integrated delivery
of acute and long-term care.
2. The advantages to the enrollees of the integration and
coordination of acute and long-term care.
3. The qualifications for enrollment in the project.
4. That the enrollee has the right to choose any of the
contractors (pending the qualification of more than one
contractor) in the service area and may change
contractors if the enrollee is not satisfied with
his/her initial choice.
5. The benefits provided under the project.
3.2 ENROLLMENT PROCEDURES
A. When a person is determined to be both financially and
clinically eligible and chooses to enroll in this project, CARES
staff will enroll the person in the project and complete a
project enrollment form.
B. CARES staff will forward the approved enrollment form to the
prospective contractor, and forward a copy of the form to the
appropriate Area Agency on Aging.
C. The contractor will forward the enrollment information to the
Medicaid fiscal agent through the enrollment, disenrollment, and
cancellation report for payment. This information must be
transmitted to the fiscal agent by the monthly reporting
deadline (usually the Wednesday preceeding the next to last
Saturday of the month) in order to be effective for the
subsequent month.
D. The contractor will not be allowed to deny enrollment to anyone
that is enrolled by CARES except as provided for in section 1.20
3.3 EFFECTIVE DATE OF ENROLLMENT
In general, enrollment is effective at 12:01 a.m. on the first day of
the calendar month that the enrollee's name appears on the report for
payment issued by the Medicaid fiscal agent. Enrollment may begin
retroactively when the contractor and the CARES staff agree that
services must begin immediately pursuant to section 3.4 of this
document. Enrollment is in whole months except when retroactive
enrollment is agreed to, and in the case of those enrolling in hospice
care pursuant to Chapter 409.912(30), Florida Statutes.
Attachment I- 21 of 55
Contract No. 2002-2003-02
3.4 TRANSITION CARE PLANNING
Transition care services are those services necessary in order to safely
maintain a person in the community both prior to and after the effective
date of their enrollment in the project up until the time the Plan of
Care is implemented.
CARES staff will notify the contractor, the lead agency, and when
appropriate, hospital discharge planning staff regarding the need for a
transition care plan. CARES staff will forward, to each of these
entities, any information collected during the clinical eligibility
determination process related to the person's health status, functional
status, caregiver, social support system, living environment and how
current service needs are being met.
By the first date of enrollment, the contractor must provide transition
care services in collaboration with CARES staff, and be able to assume
responsibility for meeting the enrollee's care needs. The contractor
must ensure that enrollment in the project does not interrupt or delay
the delivery of services needed by the enrollee.
3.5 ORIENTATION
A. Prior to or on enrollment the contractor must provide each new
enrollee with a written notice of the effective date of
enrollment and a plan ID card which includes the contractor's
name, address and the member services telephone number.
B. The contractor must notify, within five (5) working days from
the effective date of enrollment, all new enrollees, or their
representatives to schedule program orientation. Within two (2)
weeks from the date on which the contractor notifies the new
enrollee, face-to-face project orientation must be completed.
C. The contractor shall assure that appropriate foreign language
versions of all materials are developed and available to members
and potential members. The contractor shall provide interpreter
services in person where practical, but otherwise by telephone,
for applicants or members whose primary language is a foreign
language. Foreign language versions of materials are required
if, as provided annually by the agency, the population speaking
a particular foreign (non-English) language in a county is
greater than five (5) percent.
D. The contractor must provide each new enrollee with an enrollee
handbook prior to or at the time of orientation. The enrollee
handbook must be written so it can be read and understood by the
enrollees or their representatives and must include the
following items:
1. The project benefit's package including any benefit
limitations.
2. An explanation of the role of the case manager.
3. A list of the service providers in the contractor's
network including their address and telephone number.
4. Information regarding the enrollee's right to choose a
provider from the list of providers within the
contractor's network.
5. Instructions on how enrollees obtain access to the
services included in their care plans.
6. The consequences of obtaining care from out-of-network
providers.
7. Grievance procedures which include each step the
enrollee must take from reporting an informal complaint
to a formal grievance, including contact information,
timelines, and procedures.
8. Information regarding the enrollee's right to disenroll
at any time and instructions to initiate the
disenrollment process. Information must explain that if
voluntary disenrollment is requested prior to the fiscal
agent's monthly processing deadline, disenrollment will
be effective the first of the following month. If
voluntary disenrollment is requested after the fisca1
agent's monthly processing deadline, disenrollment will
not take place until the first of the month subsequent
to the next month.
Attachment I- 22 of 55
Contract No. 2002-2003-02
9. Information regarding the enrollee's rights and
responsibilities.
10. Information regarding the confidentiality of enrollee
records.
11. Information regarding the health care advanced
directives pursuant to Chapter 765, Florida Statutes.
12. Notification to the enrollee that the following items
are available to them upon request:
a. A detailed description of the contractor's
authorization and referral process for services.
b. A detailed description of the contractor's
process used to determine whether services are
medically necessary.
c. A detailed description of the contractor's
quality assurance program.
d. A detailed description of the contractor's
credentialing process.
e. The policies and procedures relating to the
contractor's prescription drug benefits program.
f. The policies and procedures relating to the
confidentiality and disclosure of the enrollee's
medical records.
3.6 DISENROLLMENT
A. Enrollees must be allowed to voluntarily disenroll at any time.
If voluntary disenrollment is requested prior to the fiscal
agent's monthly processing deadline, disenrollment will be
effective the first of the following month. If voluntary
disenrollment is requested after the fiscal agent's monthly
processing deadline, disenrollment will not take place until the
first of the month subsequent to the next month.
B. The contractor must ensure that it does not restrict the
enrollee's right to voluntarily disenroll in any way, and that
it does not deter the enrollee's contact with the state.
C. Immediately upon receiving a voluntary request for
disenrollment, the contractor must inform the enrollee of
disenrollment procedures and notify the Department of Elder
Affairs.
D. The contractor must make disenrollment assistance available
during business hours. This assistance must be available through
a toll-free telephone number or face-to-face contact. The
contractor's written disenrollment procedure must list the staff
responsible for this type of assistance.
E. The contractor must keep a daily log of all verbal and written
disenrollment requests and the disposition of such requests. The
contractor must ensure that disenrollment request logs are
maintained in an identifiable manner, involuntary disenrollment
documents are maintained in an identifiable enrollee record, and
enrollees who wish to file a grievance are afforded appropriate
notice and opportunity to do so.
F. The contractor shall assure that appropriate foreign language
versions of all disenrollment materials are developed and
available to members. The contractor shall provide interpreter
services in person where practical, but otherwise by telephone,
for members whose primary language is foreign. Foreign language
versions of disenrollment materials are required if, as provided
annually by the agency, the population speaking a particular
foreign (non-English) language in a county is greater than five
(5) percent.
G. Involuntary disenrollments are limited to the following reasons:
1. Enrollee death.
2. Ineligibility for Medicaid.
3. Ineligibility for the project.
4. Moving outside the project's service area.
5. Fraudulent use of the enrollee's Medicaid ID card.
6. Non-cooperation, subject to department approval.
H. After providing at least one verbal and at least one written
warning of the full implications of failure to follow a
recommended plan of care, the contractor may submit an
involuntary disenrollment request to the department for an
enrollee who continues
Attachment I- 23 of 55
Contract No. 2002-2003-02
not to comply. The department may approve such a request
provided that a written explanation of reason for disenrollment
is given to the enrollee prior to the effective date and
provided that the enrollee's actions are not related to the
enrollee's medical or mental condition. Enrollees must be given
a reasonable opportunity to comply with the plan of care
subsequent to each verbal and written warning before
disenrollment is made effective except in instances where the
enrollee's actions threaten the health, safety, or well being of
service providers or contractor's staff or representatives.
Enrollees who are disenrolled through this section are not
eligible for re-enrollment without the permission of the
contractor.
I. The contractor may also submit an involuntary disenrollment
request for an enrollee whose behavior is disruptive, unruly,
abusive, or uncooperative to the extent that his or her
enrollment with the contractor seriously impairs the
contractor's ability to furnish services to either the enrollee
or other enrollees. The contractor must provide at least one
verbal and one written warning to the enrollee regarding the
implications of his or her actions. A written explanation of the
reason for disenrollment must be given to the enrollee prior to
submitting the disenrollment request. The department may approve
such requests provided the contractor has documented the actions
described above and the enrollee's actions are not related to
the enrollee's medical or mental condition. Enrollees who are
disenrolled through this action are not eligible for
re-enrollment without the permission of the contractor.
J. For enrollees who wish to disenroll to participate in the
Medicaid or Medicare hospice program, the contractor must submit
a disenrollment request to the department for the enrollee
immediately upon obtaining notice that the enrollee has been or
will be admitted. The disenrollment will be effective upon the
date of admission to the hospice.
K. Disenrollment request forms, whether completed by the
contractor, the enrollee, or the department, must contain the
following information: name, address, telephone number, reason
for disenrollment with brief explanation, a signature by the
enrollee or designee (for voluntary requests submitted by the
enrollee), date, signatures by the contractor's staff (for
involuntary disenrollments submitted by the contractor), and an
indication as to whether or not the enrollee wishes to file a
grievance.
L. All disenrollments, including those subject to prior approval,
must be completed through the submission of a disenrollment
report to the Medicaid fiscal agent in the enrollment,
disenrollment, and cancellation report for payment.
M. The contractor must provide disenrollment data via the
disenrollment report on the first available transmission after
the date of receipt of the disenrollment request. In no event
will the contractor submit a disenrollment report with an
effective date later than 49 calendar days after the
contractor's receipt of a voluntary disenrollment request.
SECTION 4 SERVICE PROVISIONS
4.1 GENERAL
A. The contractor must bear the underwriting risk of all services
covered under this contract.
B. Services are to be provided in accordance with an individualized
plan of care. The plan of care is developed by the contractor in
consultation with the enrollee and must include those services
that are determined through assessment to be necessary to
address the health and social service needs of the enrollee.
C. The contractor must directly provide at least one of the
services listed in section 4.2.
D. The contractor must not require any co-payment or cost sharing
from the enrollees except where the Florida Department of
Children and Families has assessed a patient responsibility
amount for financial contributions by the enrollee toward
nursing facility and assisted living services.
Attachment I- 24 of 55
Contract No. 2002-2003-02
E. The contractor must not allow enrollees to be charged for missed
appointments.
F. The contractor is responsible for Medicare co-insurance and
deductibles for contractor covered services. The contractor
shall reimburse providers for Medicare deductibles and
co-insurance Medicaid guidelines or the rate negotiated with the
provider.
G. All services delivered by the contractor to enrollees, either
directly or through a subcontract, must be guided by the
following service delivery principles:
1. Services must be individualized as a result of a
competent, comprehensive understanding of an enrollee's
multiple needs.
2. Services must be delivered in a timely fashion in the
least restrictive, cost-effective and appropriate
setting.
3. Long-term care services must be based upon an enrollee's
plan of care and include goals, objectives, and specific
treatment strategies.
4. Services must be coordinated to address comprehensive
needs and provide continuity of care.
5. Services must be delivered regardless of geographic
location within the service area, level of functioning,
cultural heritage, degree of illness of the enrollee.
6. The project's administration and service delivery system
must ensure the participation of the enrollee in care
planning and delivery, and, as appropriate, allow for
the participation of the family, significant others, and
caregivers.
7. The contractor shall provide interpreter services in
person where practical, but otherwise by telephone, for
applicants or enrollees whose primary language is
foreign. Foreign language versions of materials are
required if, as provided annually by the agency, the
population speaking a particular foreign (non-English)
language in a county is greater than five (5) percent.
8. Services must be delivered by qualified providers as
defined in sections 4.4 and 4.5. The contractor must
have a credentialing system approved by an accreditation
organization that has been approved by the agency
pursuant to Section 641.512, Florida Statutes. The
system must include procedures for credentialing
long-term care providers.
9. All facilities providing services to enrollees must be
accessible to persons with disabilities, be smoke free,
and have adequate space, supplies, good sanitation, and
fire and safety procedures.
4.2 LONG-TERM CARE SERVICES
With the exception of nursing facility services, the long-term care
services in this section are authorized under the Medicaid home and
community-based waiver.
A. Adult Companion Services: Non-medical care, supervision and
socialization provided to a functionally impaired adult.
Companions assist or supervise the enrollee with tasks such as
meal preparation or laundry and shopping, but do not perform
these activities as discrete services. The provision of
companion services does not entail hands-on nursing care. This
service includes light housekeeping tasks incidental to the care
and supervision of the enrollee.
B. Adult Day Health Services: Services provided pursuant to Chapter
400, Part V, Florida Statutes. For example, services furnished
in an outpatient setting, encompassing both the health and
social services needed to ensure optimal functioning of an
enrollee, including social services to help with personal and
family problems, and planned group therapeutic activities. Adult
day health services include nutritional meals. Meals are
included as a part of this service when the patient is at the
center during meal times. Adult day health care provides medical
screening emphasizing prevention and continuity of care
including routine blood pressure checks and diabetic maintenance
checks. Physical, occupational and speech therapies indicated in
the enrollee's plan of care are furnished as components of this
service. Nursing services which include periodic evaluation,
medical supervision and supervision of self-care services
directed toward activities of daily living and personal hygiene
are also a component of this service. The inclusion of physical,
occupational and speech therapy services and nursing
Attachment I- 25 of 55
Contract No. 2002-2003-02
services as components of adult day health services does not
require the contractor to contract with the adult day health
provider to deliver these services when they are included in an
enrollee's plan of care. The contractor may contract with the
adult day health provider for the delivery of these services or
the contractor may contract with other providers qualified to
deliver these services pursuant to the terms of this contract.
C. Assisted Living Services: Personal care services, homemaker
services, chore services, attendant care, companion services,
medication oversight, and therapeutic social and recreational
programming provided in a home-like environment in an assisted
living facility licensed pursuant to Chapter 400 Part II,
Florida Statutes, in conjunction with living in the facility.
This service does not include the cost of room and board
furnished in conjunction with residing in the facility. This
service includes 24 hour on-site response staff to meet
scheduled or unpredictable needs in a way that promotes maximum
dignity and independence, and to provide supervision, safety and
security. Individualized care is furnished to persons who reside
in their own living units (which may include dual occupied units
when both occupants consent to the arrangement) which may or may
not include kitchenette and/or living rooms and which contain
bedrooms and toilet facilities. The resident has a right to
privacy. Living units may be locked at the discretion of the
resident, except when a physician or mental health professional
has certified in writing that the resident is sufficiently
cognitively impaired as to be a danger to self or others if
given the opportunity to lock the door. The facility must have a
central dining room, living room or parlor, and common activity
areas, which may also serve as living rooms or dining rooms. The
resident retains the right to assume risk, tempered only by a
person's ability to assume responsibility for that risk. Care
must be furnished in a way that fosters the independence of each
consumer to facilitate aging in place. Routines of care
provision and service delivery must be consumer-driven to the
maximum extent possible, and treat each person with dignity and
respect. Assisted living services may also include: physical
therapy, occupational therapy, speech therapy, medication
administration, and periodic nursing evaluations. The contractor
may arrange for other authorized service providers to deliver
care to residents of assisted living facilities in the same
manner as those services would be delivered to a person in their
own home.
D. Case Management Services: Services which facilitate enrollees
gaining access to other needed services regardless of the
funding source for the services, and which contribute to the
coordination and integration of care delivery. The contractor
will provide this service directly.
E. Chore Services: Services needed to maintain the home as a clean,
sanitary and safe living environment. This service includes
heavy household chores such as washing floors, windows and
walls, tacking down loose rugs and tiles, and moving heavy items
of furniture in order to provide safe entry and exit.
F. Consumable Medical Supply Services: The provision of disposable
supplies used by the enrollee and care giver, which are
essential to adequately care for the needs of the enrollee.
These supplies enable the enrollee to perform activities of
daily living or stabilize or monitor a health condition.
Consumable medical supplies include adult disposable diapers,
tubes of ointment, cotton balls and alcohol for use with
injections, medicated bandages, gauze and tape, colostomy and
catheter supplies, and other consumable supplies. Not included
are items covered under the Medicaid home health service,
personal toiletries, and household items such as detergents,
bleach, and paper towels, or prescription drugs.
G. Environmental Accessibility Adaptation Services: Physical
adaptations to the home required by the enrollee's plan of care
which are necessary to ensure the health, welfare and safety of
the enrollee or which enable the enrollee to function with
greater independence in the home and without which the enrollee
would require institutionalization. Such adaptations may include
the installation of ramps and grab-bars, widening of doorways,
modification of bathroom facilities, or installation of
specialized electric and plumbing systems to accommodate the
medical equipment and supplies which are necessary for the
welfare of the enrollee. Excluded are those
Attachment I- 26 of 55
Contract No. 2002-2003-02
adaptations or improvements to the home that are of general
utility and are not of direct medical or remedial benefit to the
enrollee, such as carpeting, roof repair, or central air
conditioning. Adaptations which add to the total square footage
of the home are not included in this benefit. All services must
be provided in accordance with applicable state and local
building codes.
H. Escort Services: Personal escort for enrollees to and from
service providers. An escort may provide language interpretation
for people who have hearing or speech impairments or who speak a
language different from that of the provider. Escort providers
assist enrollees in gaining access to services.
I. Family Training Services: Training and counseling services for
the families of enrollees served under this contract. For
purposes of this service, "family" is defined as the individuals
who live with or provide care to a person served by the
contractor and may include a parent, spouse, children,
relatives, foster family, or in-laws. "Family" does not include
persons who are employed to care for the enrollee. Training
includes instruction and updates about treatment regimens and
use of equipment specified in the plan of care to safely
maintain the enrollee at home.
J. Financial Assessment/Risk Reduction Services: Assessment and
guidance to the caregiver and enrollee with respect to financial
activities. This service provides instruction for and/or actual
performance of routine, necessary, monetary tasks for financial
management such as budgeting and bill paying. In addition, this
service also provides financial assessment to prevent
exploitation by sorting through financial papers and insurance
policies and organizing them in a usable manner. This service
provides coaching and counseling to enrollees to avoid financial
abuse, to maintain and balance accounts that directly relate to
the enrollees living arrangement at home, or to lessen the risk
of nursing home placement due to inappropriate money management.
K. Home Delivered Meals: Nutritionally sound meals to be delivered
to the residence of an enrollee who has difficulty shopping for
or preparing food without assistance. Each meal is designed to
provide 1/3 of the Recommended Dietary Allowance (RDA). Home
delivered meals may be hot, cold, frozen, dried, canned or a
combination of hot, cold, frozen, dried, canned with a
satisfactory storage life.
L. Homemaker Services: General household activities (meal
preparation and routine household care) provided by a trained
homemaker.
M. Nutritional Assessment/Risk Reduction Services: An assessment,
hands-on care, and guidance to caregivers and enrollees with
respect to nutrition. This service teaches caregivers and
enrollees to follow dietary specifications that are essential to
the enrollee's health and physical functioning, to prepare and
eat nutritionally appropriate meals and promote better health
through improved nutrition. This service may include
instructions on shopping for quality food and on food
preparation.
N. Personal Care Services: Assistance with eating, bathing,
dressing, personal hygiene, and other activities of daily
living. This service includes assistance with preparation of
meals, but does not include the cost of the meals themselves.
This service may also include housekeeping chores such as bed
making, dusting and vacuuming, which are incidental to the care
furnished or which are essential to the health and welfare of
the enrollee, rather than the enrollee's family.
O. Personal Emergency Response Systems (PERS): The installation and
service of an electronic device which enables enrollees at high
risk of institutionalization to secure help in an emergency. The
PERS is connected to the person's phone and programmed to signal
a response center once a "help" button is activated. The
enrollee may also wear a portable "help" button to allow for
mobility. PERS services are generally limited to those enrollees
who live alone or who are alone for significant parts of the day
and who would otherwise require extensive supervision.
P. Respite Care Services: Services provided to enrollees unable to
care for themselves furnished on a short-term basis due to the
absence or need for relief of persons normally providing the
care. Respite care does not substitute for the care usually
provided by a registered nurse, a licensed practical nurse or a
therapist. Respite care is provided in
Attachment I- 27 of 55
Contract No. 2002-2003-02
the home/place of residence. Medicaid licensed hospital, nursing
facility, or assisted living facility.
Q. Occupational Therapy: Treatment to restore, improve or maintain
impaired functions aimed at increasing or maintaining the
enrollee's ability to perform tasks required for independent
functioning when determined through a multi-disciplinary
assessment to improve an enrollee's capability to live safely in
the home setting.
R. Physical Therapy: Treatment to restore, improve or maintain
impaired functions by using activities and chemicals with heat,
light, electricity or sound, and by massage and active,
resistive, or passive exercise when determined through a
multi-disciplinary assessment to improve an enrollee's
capability to live safely in the home setting.
S. Speech Therapy: The identification and treatment of neurological
deficiencies related to feeding problems, congenital or
trauma-related maxillofacial anomalies, autism, or neurological
conditions that effect oral motor functions. Therapy services
include the evaluation and treatment of problems related to an
oral motor dysfunction when determined through a
multi-disciplinary assessment to improve an enrollee's
capability to live safely in the home setting.
T. Nursing Facility Services: Services furnished in a health care
facility licensed under Chapter 395 or Chapter 400 Part II,
Florida Statutes. When an enrollee is placed in a nursing
facility the enrollee continues to receive acute care services,
however, the home and community-based long-term care waiver
services cease.
4.3 ACUTE-CARE SERVICES
The following services are covered for Medicaid recipients based on the
Medicaid state plan approved by the federal Centers for Medicare and
Medicaid Services. These services are covered in the project to the
extent that they are not covered by Medicare or are reimbursed by
Medicaid pursuant to Medicaid's Medicare cost-sharing policies.
A. Community Mental Health Services: Community-based rehabilitative
services, which are psychiatric in nature, recommended or
provided by a psychiatrist or other physician. Such services
must be provided in accordance with the policy and service
provisions specified in the Medicaid Community Mental Health
Coverage and Limitations Handbook except that the provider need
not be a community mental health center.
B. Hearing Services: Services including a hearing evaluation,
diagnostic testing and selective amplification procedures
necessary to certify an enrollee for a hearing aid device;
fitting and dispensing of hearing aids; and repair services as
specified in the Medicaid Hearing Services Coverage and
Limitations Handbook. Medical and surgical treatment for hearing
disorders is part of physician services.
C. Home Health Care Services: Intermittent or part-time nursing
services provided by a registered nurse or licensed practical
nurse, or personal care services provided by a licensed home
health aide, with accompanying necessary medical supplies,
appliances, and durable medical equipment. Such services must be
provided in accordance with the policy and service provisions
specified in the Medicaid Home Health Coverage and Limitations
Handbook.
D. Independent Laboratory and Portable X-ray Services: Medically
necessary and appropriate diagnostic laboratory procedures and
portable x-rays ordered by a physician or other licensed
practitioner of the healing arts as specified in the Independent
Laboratory and Portable X-ray Services Coverage and Limitations
Handbook.
E. Inpatient Hospital Services: Medically necessary services,
including ancillary services, furnished to inpatient enrollees,
provided under the direction of a physician or dentist, in a
hospital maintained primarily for the care and treatment of
patients with disorders other than mental diseases. Such
services must be provided in accordance with the policy and
service provisions specified in the Medicaid Hospital Coverage
and Limitations Handbook.
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Contract No. 2002-2003-02
F. Outpatient Hospital/Emergency Medical Services: Outpatient
preventive, diagnostic, therapeutic, or palliative care provided
under the direction of a physician at a licensed hospital. Such
services include emergency room, dressings, splints, oxygen,
physician ordered services and supplies necessary for the
clinical treatment of a specific diagnosis or treatment as
specified in the Medicaid Hospital Coverage and Limitations
Handbook.
G. Physician Services: Those services and procedures rendered by a
licensed physician at a physician's office, patient's home,
hospital, nursing facility or elsewhere when dictated by the
need for preventive, diagnostic, therapeutic or palliative care,
or for the treatment of a particular injury, illness, or disease
as specified in the Medicaid Physicians Coverage and Limitations
Handbook.
H. Prescribed Drug Services: Products and services associated with
dispensing medicinal drugs pursuant to a valid prescription as
defined in Chapter 465, Florida Statutes (the "Florida Pharmacy
Act"). This benefit generally includes all legend drugs
dispensed to enrollees in outpatient settings and includes
patent or proprietary preparations. Covered drugs, injectables
and other prescribed drug services are described in the
Prescribed Drugs Services and Limitations Handbook. These
services also include payment for Medicaid reimbursable
psychotropic drugs. The contractor must furnish those drugs in
dosage forms currently covered by the Medicaid Program and must
not place a dollar limit on this service. The contractor must
not have a pharmacy benefits management program that is more
restrictive than Medicaid fee-for-service. The contractor's
pharmacy benefits management program must comply with all
applicable federal and state laws.
I. Visual Services: These services include a visual examination;
fitting, dispensing, and adjustment of eyeglasses; follow-up
examinations, and contact lenses as specified in the Medicaid
Visual Services Coverage and Limitations Handbook. Examinations
and treatment for eye diseases are part of the physician
services program. Specific information to order glasses is
available in Chapter 4 of the Medicaid Visual Services Coverage
and Limitations Handbook. Lenses must meet American National
Standards Institute (ANSI) standards. Eyeglasses are available
through Prison Rehabilitative Industries and Diversified
Enterprise (PRIDE) or may be purchased elsewhere if available at
lower prices for comparable quality than those charged by the
Division of Corrections optical laboratory. An abbreviated list
of products/services available from PRIDE may be obtained by
contacting PRIDE's Tallahassee branch office at (850) 487-3774.
4.4 OPTIONAL SERVICES
The following services may be rendered within Medicaid guidelines at the
option of the contractor:
A. DENTAL SERVICES: The contractor may choose to provide adult
dental services as defined in the Medicaid Dental Coverage and
Limitations Handbook including services necessary to seat
complete dentures, and repair and reline dentures for enrollees.
Extractions and other surgical procedures, essential to the
preparation of the mouth for dentures, are included only if the
enrollee is to receive dentures. The adult dental service does
not include routine preventive, restorative, or palliative
treatment.
B. TRANSPORTATION SERVICES: The contractor may choose to provide
transportation. These services are the arrangement and provision
of an appropriate mode of transportation for enrollees to
receive necessary medical services. Types of transportation
services include: ambulance, non-emergency medical vehicles,
public and private transportation vehicles, and air ambulances
as specified in the Medicaid Transportation Coverage and
Limitations Handbook.
Attachment I- 29 of 55
Contract No. 2002-2003-02
4.5 EXPANDED SERVICES
The contractor may provide services offered by the plan and approved by
the agency in excess of the amount, duration, and scope of those listed
in Sections 4.2, Long-Term Care Services, 4.3 Acute Care Services, and
4.4. Optional Services.
4.6 MINIMUM LONG-TERM CARE SERVICE PROVIDER QUALIFICATIONS
The long-term care services authorized in this project must be provided
in accordance with the following requirements.
A. Adult Companion Services: Providers must be employed by a
licensed home health agency pursuant to Chapter 400, Part IV,
Florida Statutes, or have a certificate of registration issued
by the Agency for Health Care Administration pursuant to Section
400.509, Florida Statutes.
B. Adult Day Health Services: Providers must be licensed by the
Agency for Health Care Administration as an adult day care
center pursuant to Chapter 400, Part V, Florida Statutes, or
meet the adult day care center exemption requirements in Section
400.553, Florida Statutes.
C. Assisted Living Facility Services: Providers must be licensed
pursuant to Chapter 400, Part III, Florida Statutes.
D. Case Management Services: Providers must have a Bachelor's
Degree in Social Work, Sociology, Psychology, Nursing,
Gerontology or a related field and be trained or have experience
in geriatric case management and must complete four hours of
in-service training annually.
E. Chore Services: Providers must be a lead agency as defined in
Section 430.203(9), Florida Statutes; a home health agency
licensed in accordance with Chapter 400, Part IV, Florida
Statutes; a pest control agency licensed pursuant to Section
482.071, Florida Statutes; a construction contractor licensed to
do home repair pursuant to Section 489.131, Florida Statutes; or
a person, employed by or under the direct supervision of the
contractor, who the contractor has confirmed is qualified by
training or experience to provide chore services and who has
received the following training:
1. Safety and home accident prevention.
2. Enrollee record confidentiality.
3. Project policies and procedures.
4. Background and purpose of the program.
5. Emergency procedures in the event of a crisis during the
course of work.
6. House and yard cleaning and sanitation.
7. Simple repairs and the use of related tools and
equipment.
8. Training about the aging process and first aid.
F. Consumable Medical Supply Services: Providers must be pharmacies
or drug stores permitted under Section 465.022, Florida
Statutes; medical supply companies licensed pursuant to Chapter
205, Florida Statutes; or home health agencies licensed pursuant
to Chapter 400, Part IV, Florida Statutes.
G. Environmental Accessibility Adaptation Services: Providers must
be properly licensed pursuant to state and local building
requirements, and be confirmed by the provider to have knowledge
and experience needed to satisfactorily perform the service.
H. Escort Services: Providers must be lead agencies as defined in
Section 430.203(9), Florida Statutes; home health agencies
licensed pursuant to Chapter 400, Part IV, Florida Statutes; or
persons employed by or working under the direct supervision of
the contractor and trained in the following areas: the dynamics
of aging; communication and assistance with hearing and visually
impaired patients; emergency procedures; and enrollee
confidentiality.
I. Family Training Services: Providers must be home health agencies
licensed pursuant to Chapter 400, Part IV, Florida Statutes;
lead agencies as defined in Section 430.203(9), Florida
Statutes; or licensed medical practitioners providing training
or counseling within the scope of their practice.
Attachment I- 30 of 55
Contract No. 2002-2003-02
J. Financial Assessment/Risk Reduction Services: Services must be
provided by persons who have been confirmed to be qualified to
perform the service by experience and training such as certified
financial planners, bank employees or individual bookkeepers,
lead agencies as defined in Section 430.203(9), Florida
Statutes; or qualified persons employed by or working under the
direct supervision of the contractor.
K. Home Delivered Meal Providers: Providers must be lead agencies
as defined in Section 430.203(9), Florida Statutes with a
contract or referral agreement for the preparation of meals; or
be employed by or under subcontract with the contractor and meet
the food service standards as defined in Chapters 500 and 509,
Florida Statutes.
L. Homemaker Service Providers: Services must be provided by home
health agencies licensed pursuant to Chapter 400, Part IV,
Florida Statutes; lead agencies as defined in Section
430.203(9), Florida Statutes; or have a certificate of
registration issued by the agency pursuant to Section 400.509,
Florida Statutes.
M. Nutritional Assessment Risk Reduction Services: Services must be
provided by Registered Licensed Dietitians or other health
professionals functioning in their legal scope of practice. A
dietetic technician (DTR) may, according to the American
Dietetic Association, assist a dietitian and assume full
responsibility under supervision of a Registered Licensed
Dietitian for a wide range of duties including counseling
enrollees on specific diets. Nutritional education materials
must be approved by a Registered Licensed Dietitian. Providers
may include lead agencies as defined in Section 430.203(9),
Florida Statutes.
N. Nursing Facility Services: Providers must be licensed under
Chapter 395 or Chapter 400 Part II, Florida Statutes.
O. Personal Care Providers: Providers must be lead agencies as
defined in Section 430.203(9), Florida Statutes; Certified
Nursing Assistants under Nurse Registries licensed pursuant to
Section 400.506, Florida Statutes; or home health agencies
licensed pursuant to Chapter 400, Part IV, Florida Statutes.
P. Respite Care Providers: Providers must be employed by a licensed
home health agency pursuant to Chapter 400, Part IV, Florida
Statutes; have a certificate of registration issued by the
Agency for Health Care Administration pursuant to Section
400.509, Florida Statutes; or be lead agencies as defined in
Section 430.203(9), Florida Statutes.
Q. Occupational, Physical, and Speech Therapy Providers: Providers
must be home health agencies licensed pursuant to Chapter 400,
Part IV, Florida Statutes, or, providers holding current
registration, certification, or licenses pursuant to Chapters
455, 468, and 486, Florida Statutes.
R. Personal Emergency Response System Service Providers: Providers
must meet the requirements as defined in Chapter 489, Part II,
Florida Statutes.
4.7 ACUTE CARE PROVIDER QUALIFICATIONS
For the acute care services that are covered under the contract and are
also covered by Medicare, the provider qualifications will be those of
the Medicare program.
For the acute care services covered under the contract that are not
covered by Medicare, the contractor must meet the provider requirements
of the Medicaid programs except that provider type limitations
associated with certain services will not apply when other provider
types can legally perform the service.
4.8 AVAILABILITY/ACCESSIBILITY OF SERVICES
The contractor must make available and accessible sufficient facilities,
service locations, service sites, and personnel to provide the services.
The contractor's network of providers must be accessible to the
enrollees in its service area. Services covered under this contract must
be available to enrollees to the same extent that such services are
available in the project service area to persons, with comparable
functional impairment and health conditions that are not served under
this contract.
Attachment I- 31 of 55
Contract No. 2002-2003-02
The contractor must establish appropriate scheduling guidelines for
service delivery. These guidelines must be communicated in writing to
providers in the contractor's network. The contractor must develop a
process for monitoring the scheduling of service delivery and the actual
time enrollees must wait to receive the service. When the service
delivery scheduling, or waiting times are excessive the contractor must
take appropriate action to ensure adequate service delivery.
The contractor must arrange for a 24 hour on-call system for each
enrollee. The system may vary by enrollee and should be reflected in the
enrollee's plan of care. The system should provide for the availability
of a qualified person with information regarding the enrollee's plan of
care.
4.9 STAFFING REQUIREMENTS
A. A person designated to be responsible for the contract.
B. A licensed physician, board certified in geriatrics, to serve as
a consultant for the contract.
C. A person, qualified by training, to be responsible for the
contract's quality assurance and improvement systems.
D. A person designated to be responsible for the contractor's
orientation, outreach and educational activities who is
qualified by training and experienced in working with frail
elders.
E. A person designated to be responsible for the health information
and/or the enrollee records system.
F. A person designated to be responsible for the processing and
resolution of grievances.
G. Sufficient support staff to conduct daily business in an orderly
manner, including having enrollee services staff directly
available during business hours for enrollee services
consultation, as determined through management and medical
reviews. The contractor must maintain sufficient staff available
24 hours per day to handle care inquiries.
H. A person designated to be responsible for the contractor's
utilization control. A person designated to be responsible for
case management and qualified case managers in sufficient
numbers to ensure that the case management requirements are met.
J. A plan for recruiting and retaining health care practitioners
who are minorities as defined in Section 288.703(3), Florida
Statutes, as required by Section 641.27 in Chapter 96-199, Laws
of Florida.
4.10 INTEGRATION OF CARE
A. Project case managers are responsible for long-term care
planning and for developing and carrying out strategies to
coordinate and integrate the delivery of all acute and long-term
care services to enrollees.
B. For those persons enrolled in the contractor's Medicare+Choice
plan (where applicable), the contractor must have protocols to
ensure that all acute care services and services are
coordinated. The enrollee's case manager must coordinate with
the primary care physician, as well as the enrollee or other
appropriate person, in the development of acute and long-term
care plans. The contractor must ensure that all subcontractors,
delivering services covered by the contract, agree to cooperate
with the goal of an integrated and coordinated service delivery
system for the enrollee.
C. When contract enrollees elect to remain in the Medicare
fee-for-service system, the contractor must establish protocols
to ensure that services are coordinated to the maximum extent
feasible. The case manager must actively pursue coordination
with the enrollee's primary care physician and other care
providers.
Attachment I- 32 of 55
Contract No. 2002-2003-02
D. In addition, the contractor will be responsible for the
following activities to facilitate care coordination:
1. The contractor must implement a systematic process for
generating or receiving referrals and, with the
enrollee's written consent, sharing clinical and
treatment plan information, including management of
medications.
2. The contractor must implement a systematic process for
obtaining consent from enrollees or their
representatives to share confidential medical and
treatment planning information with providers.
3. The contractor must implement a systematic process for
coordinating care with organizations which are not part
of the contractor's network of providers but are
otherwise important to the health and well-being of
enrollees.
4. For enrollees in an assisted living or nursing facility,
the contractor will ensure coordination with the
medical, nursing, or administrative staff designated by
the facility to ensure that the enrollees have timely
and appropriate access to the contractor's providers and
to coordinate care between those providers and the
facility's providers.
4.11 PLAN OF CARE
A. The contractor is required to develop an individualized written
plan of care, in a format approved by the department, for every
new enrollee within 10 calendar days of the effective date of
enrollment.
B. Services included in the plan of care will be determined by the
contractor in consultation with the enrollee and be necessary to
address health and social service needs of the enrollee
identified through an assessment.
C. The plan of care must be based on a comprehensive assessment of
the enrollee's health status, physical and cognitive
functioning, environment, social supports, and end-of-life
decisions. The plan of care must clearly identify barriers to
the enrollee and caregivers, if applicable. The case manager
must discuss barriers and explore potential solutions with the
enrollee, and caregivers when applicable. The plan of care must
detail all interventions designed to address specific barriers
to independent functioning. The plan may include services
provided through the enrollee's own informal network or by
volunteers from community social service agencies or other
organizations such as churches and synagogues.
D. In developing the plan of care, the contractor must:
1. Assess the immediacy of the new enrollee's services
needs and include a description of the project
participant's condition (e.g., ADL and IADL limitations,
incontinence, cognitive impairment, arthritis, high
blood pressure), as identified through an appropriate
comprehensive assessment and a medical history review.
2. Identify any existing care plans and service providers
and assess the adequacy of current services.
3. Provide for continuous care to the new enrollee if the
enrollee is receiving active treatment prior to the
effective date of enrollment.
4. Ensure that the care plan contains, at a minimum,
information about the enrollee's medical condition, the
type of services to be furnished, the amount, frequency
and duration of each service, and the type of provider
to furnish each service.
5. Ensure that treatment interventions address identified
problems, needs, and conditions. In consultation with
the enrollee and, as appropriate, the enrollee's legal
guardian or caregiver, the plan of care must specify the
long-term care service interventions, and when such
services are the responsibility of the contractor, the
medical interventions for the enrollee.
6. Ensure that review of the care plan is performed through
face-to-face contact with the enrollee at least every
six (6) months to determine the appropriateness and
adequacy of services and to ensure that the services
furnished are consistent with the nature and severity of
the enrollee's needs.
Attachment I- 33 of 55
Contract No. 2002-2003-02
7. Ensure that the care plan is reviewed sooner than the
minimum required time frame if in the opinion of the
medical professionals involved in the care of the
enrollee there is reason to believe significant changes
have occurred in the enrollee's condition or in the
services the enrollee receives, or an enrollee or an
enrollee's legal representative requests another review
due to the changes in the enrollee's physical or mental
condition.
8. The contractor will work to ensure the maintenance or
creation of an enrollee's informal network of caregivers
and services providers. Primary caregivers, family,
neighbors and other volunteers will be integrated into
an enrollee's plan of care when it is determined through
multi-disciplinary assessment and care planning that
these services would improve the enrollee's capability
to live safely in the home setting and are agreed to by
the enrollee.
9. The contractor will implement a systematic process for
determining whether enrollees have advance directives,
health care powers of attorney, or do not resuscitate
orders. This information will become part of the
enrollee's medical record and these orders and
preferences will be integrated into the care
coordination process.
E. A copy of the plan of care must be forwarded to the enrollee's
primary care physician.
F. A copy of the plan of care must be forwarded to the department's
CARES office within 30 days of development.
G. Revisions to the plan of care must be done in consultation with
the enrollee, the caregiver, and when feasible the primary care
physician. If the primary care physician is not under contract
with the contractor to deliver services to the enrollee, an
effort must be made by the case manager to obtain physicians
input regarding care plan revisions. Changes in service
provision resulting from a care plan review must be implemented
within ten (10) calendar days of the review date.
4.12 OUT OF NETWORK USE OF NON-EMERGENCY SERVICES
Unless otherwise specified in this document, when an enrollee uses
non-emergency services available under the project from a
non-subcontracted provider, the contractor is not liable for the cost of
such utilization unless the contractor referred the enrollee to the
non-subcontracted provider or authorized such out-of-network
utilization. The contractor must provide timely approval or denial of
authorization of out-of-network use through the assignment of a prior
authorization number which refers to and documents the approval. A
contractor may not require paper authorization as a condition of an
enrollee receiving treatment if the contractor has an automated
authorization system. Written follow-up documentation of the approval
must be provided to the out-of-network provider within one business day
from the request for approval. The enrollee is liable for the cost of
such unauthorized use of contract-covered services from
non-subcontracted providers.
However, in accordance with the Balanced Budget Act of 1997, and
pursuant to 42 CFR 422.100(b)(1)(iv), the plan must also cover
post-stabilization services without authorization, regardless of whether
the enrollee obtains the service within or outside the plan's network,
for the following situations:
A. Post stabilization care services that were pre-approved
by the plan; or were not pre-approved by the plan
because the plan did not respond to the treating
provider's request for pre-approval within one hour
after being requested to approve such care, or could not
be contacted for pre-approval.
B. Post stabilization services are services subsequent to
an emergency that a treating physician views as
medically necessary after an emergency medical condition
has been stabilized. These are not emergency services,
but are non-emergency services that the plan chooses not
to cover out-of-plan except in the circumstances
described above.
Attachment I- 34 of 55
Contract No. 2002-2003-02
SECTION 5 QUALITY ASSURANCE AND IMPROVEMENT REQUIREMENTS
5.1 GENERAL
The contractor's quality assurance program must address the needs of
enrollees, promote improved clinical outcomes and quality of life, and
identify and address service delivery issues. The quality assurance
program required by this section must comply with applicable provisions
of Section 409.912(24), Florida Statutes, and Section 641.51, Florida
Statutes, and may be incorporated into an existing quality improvement
system.
5.2 QUALITY ASSURANCE PROGRAM
The contractor must formally adopt a quality assurance program for
enrollees. The quality assurance program must include written goals,
policies, and procedures that ensure enhancement of quality of life for
enrollees, emphasize quality patient outcomes, and, to the extent
feasible, promote the coordination of acute and long-term care services.
The quality assurance program must have a system to identify and
prioritize problem areas for resolution and a process to design and
implement strategies to resolve identified problems. The system must
include: a process for changing the current quality assurance program as
needed; a protocol that dictates the active involvement of the medical
director, the quality assurance director, medical/clinical providers,
and the director of the program; and a description of the mechanism for
measuring the success of quality assurance strategies and for providing
feedback to all providers involved in the program. Specifically, the
contractor must have a quality assurance program which includes the
following:
A. A written description of the quality assurance program.
B. Written responsibilities of the governing body for monitoring,
evaluating, and improving care.
C. A procedure for quality assurance program supervision.
D. Assurance of adequate resources to carry out the program's
specified activities effectively.
E. A protocol for provider participation in the quality assurance
program.
F. A procedure for delegation of quality assurance responsibilities
to designated personnel.
G. A procedure for credentialing and re-credentialing providers.
H. A procedure for informing enrollees about their rights and
responsibilities.
I. Assurance of availability of and accessibility to services and
care.
J. A procedure to ensure the accessibility and availability of
medical and long-term care records, as well as proper record
keeping, and a process for record review.
K. A procedure for utilization review.
L. A procedure for quality assurance program documentation.
M. A procedure for coordination of quality assurance activities
with other management activities.
N. A continuity of care system.
O. An active quality assurance committee.
5.3 QUALITY ASSURANCE COMMITTEE
The contractor must have a quality assurance committee that is either a
separate mechanism for addressing the quality assurance concerns of
eligible frail enrollees, or incorporated into an existing quality
assurance committee.
The quality assurance committee must:
A. Oversee quality of life indicators such as, but not limited to
the degree of personal autonomy, provision of services and
supports to assist people in exercising medical and social
choices, self-direction of care and maximum use of natural
support networks.
Attachment I- 35 of 55
Contract No. 2002-2003-02
B. Review grievances identified through the contractor's formal and
informal complaint procedures and through external oversight.
C. Review case records of all fair hearings and document internal
complaint/grievance steps involved in the fair hearing.
D. Review quality assurance policies, standards and written
procedures to ensure that they adequately address the needs of
its enrollees.
E. Review utilization of services with adverse or unexpected
outcomes for its enrollees.
F. Develop and periodically review written guidelines, procedures
and protocols on areas of concern in the care of the frail
elderly; for example: falls, incontinence, dementia, depression,
congestive heart failure, inadequate family care, family
caregiver stress, family conflict, out-of-home placements,
alcohol problems, and problems of compliance in procedures of
medical treatment.
G. Develop an ethics committee to review ethical questions such as
end-of-life decisions and advance directives.
H. Develop a system of peer review by physicians and other service
providers.
5.4 QUALITY OF CARE STUDIES
The contractor must conduct quality of care studies to monitor the
quality, appropriateness, and effectiveness of enrollee care. The
studies must include quarterly reviews of long-term care records of
enrollees who have received services during the previous quarter. Review
elements include management of diagnosis, appropriateness and timeliness
of care, comprehensiveness of and compliance with the plan of care, and
evidence of special screening for, and monitoring of, high risk persons
and conditions.
In accordance with Section 409.912(24) Florida Statutes, the studies
must:
A. Target specific conditions and health service delivery issues
appropriate to enrollees for focused monitoring and evaluation.
B. Use clinical care standards or practice guidelines to
objectively evaluate health services delivery issues and the
care the contractor delivers or fails to deliver for acute and
long-term care conditions.
C. Use quality indicators derived from the clinical care standards
or practice guidelines to screen and monitor care and services
delivered.
The contractors selection of conditions and issues to study should be
based on member profile data.
5.5 INDEPENDENT QUALITY REVIEW
The agency shall provide for an independent review of all Medicaid
services provided or arranged by the contractor. The review shall be
performed at least once annually by an entity outside state government.
If the independent review indicates that quality of care is not
acceptable pursuant to contractual requirements, the department may
restrict the contractor's enrollment until quality of care issues are
resolved.
SECTION 6. GRIEVANCE PROCEDURES
A. The contractor must develop and implement grievance procedures,
subject to department and agency written approval, prior to
implementation. The contractor must refer all enrollees and
providers on behalf of enrollees who are dissatisfied with the
contractor, to the grievance coordinator for the appropriate
follow-up and documentation in accordance with the contractor's
approved grievance procedures.
Attachment I- 36 of 55
Contract No. 2002-2003-02
B. The contractor must make copies of the approved grievance
procedures available to the enrollee and to a provider acting on
behalf of an enrollee.
C. The contractor's grievance procedures must incorporate the time
limitations in section (D) and include the following
requirements:
1. How to pursue redress of a grievance.
2. Names of the appropriate employees or a list of
grievance departments that are responsible for
implementing the contractor's grievance procedures. The
list must include the address and the toll-free
telephone number of each grievance department and the
address of the Statewide Provider and Subscriber
Assistance Panel and its toll-free hotline telephone
number - Agency for Health Care Administration, Bureau
of Consumer Protection and Health Quality, Building 1,
Room 339, 2727 Mahan Drive, Tallahassee, Florida 32308,
(850) 419-3456-Extension 6.
3. Allow for the participation of a representative of the
Department of Elder Affairs.
4. Provide assurance that all enrollees who are
dissatisfied with the contractor are referred to the
grievance coordinator for the appropriate follow-up and
documentation and that someone with problem solving
authority on behalf of the contractor is included in the
grievance process.
5. Upon request, the contractor or the contractor's
grievance assistant, as appropriate, must provide the
enrollee or provider with a grievance form(s) within
three (3) business days of request.
6. Respond to a complaint from an enrollee within a
reasonable time after its submission. At the time of
receipt of the initial complaint, the contractor must
inform the enrollee that the enrollee has a right to
file a written grievance at any time and that assistance
in preparing the written grievance will be provided by
the contractor. This requirement also includes a
provision where the contractor must offer to meet with
the enrollee during the formal grievance process at the
administrative offices of the contractor within the
service area or at a location within the service area
convenient to the enrollee.
7. If the contractor is unable to resolve the grievance to
the enrollee's satisfaction, the contractor must provide
a final decision letter to the enrollee that includes
the following:
a. A notice of the right to appeal upon completion
of the full grievance procedure and supply the
agency with a copy of the final decision letter.
In addition, for expedited grievances, the
contractor must provide the enrollee notice of
the right to appeal immediately upon request.
b. A notice that the enrollee may request a review
of the contractor's decision concerning the
grievance by the Statewide Provider and
Subscriber Assistance Panel, and that such
request must be made by the enrollee within 365
days after receipt of the final decision letter
from the contractor. The contractor must also
inform the enrollee how to initiate such a
review, and must include the panel's address and
telephone number as follows: Agency for Health
Care Administration, Bureau of Consumer
Protection and Health Quality, Building I, Room
339, 2727 Mahan Drive, Tallahassee, Florida
32308, (888) 419-3456 Extension 6. In accordance
with Section 408.7056, Florida Statutes, the
Statewide Provider and Subscriber Assistance
Panel will not consider a grievance taken to
Medicaid fair hearing.
c. A notice that the enrollee retains the right to
pursue a Medicaid fair hearing, as provided by
Rule 65-2.042. F.A.C., in addition to pursuing
the contractor's grievance procedure, and may
contact the Department of Children and Families
at the following address to pursue a Medicaid
fair hearing: Office of Public Assistance
Appeals Hearings, 1317 Winewood Boulevard,
Building 5, Room 203, Tallahassee, Florida
32399, (859)488-1429.
Attachment I- 37 of 55
Contract No. 2002-2003-02
8. Require the participation of physician(s) in reviewing
medically related grievances.
9. Method for classification of the urgency of grievances
and for establishing time limits for an expedited review
within which such grievances must be resolved. In an
expedited review, all necessary information, including
the contractor's decision, must be transmitted between
the contractor and the enrollee, or the provider acting
on behalf of the enrollee, by telephone, facsimile, or
the most expeditious method available. In any case when
the expedited review process does not resolve a
difference of opinion between the contractor and the
enrollee or the provider acting on behalf of the
enrollee, the enrollee or the provider acting on behalf
of the enrollee may submit a written grievance to the
Statewide Provider and Subscriber Assistance Panel. The
contractor must not provide an expedited retrospective
review of an adverse determination. A request for an
expedited review may be submitted orally or in writing.
Unless it is submitted in writing, for purposes of the
grievance reporting requirements, the request must be
considered an appeal of a utilization review decision
and not a grievance.
10. Notify enrollees that they may voluntarily pursue
binding arbitration in accordance with the terms of the
contract if offered by the contractor, after completing
the grievance procedure and as an alternative to the
Statewide Provider and Subscriber Assistance Panel. Such
notice must include an explanation that the enrollee may
incur some costs.
11. Describe of the process through which a enrollee may, at
any time, contact the toll-free telephone hotline of
the agency, (888) 419-3456, to inform it of the
unresolved grievance.
12. State that the enrollee has the right to pursue a
Medicaid fair hearing as provided by Rule 65-2.042,
F.A.C., in addition to pursuing the contractor's
grievance procedure. It must also state that the
enrollee always has the right to appeal to the agency
and the Statewide Provider and Subscriber Assistance
Panel after receiving a final disposition of the
grievance through the organization's grievance process
with the following exception; a grievance taken to
Medicaid fair hearing will not be considered by the
Panel. In addition, the contractor must notify enrollees
of the right to a Medicaid fair hearing at orientation,
during care plan development, and at any time an action
is taken to reduce, suspend or terminate services, or to
deny or terminate participation of the service providers
within the contractor's network.
D. TIME LIMITATIONS
1. The contractor must notify enrollees that a grievance
must be submitted within one year after the date of
occurrence of the action initiating the grievance.
2. With the exception of urgent grievances, the
contractor's grievance procedures must have guidelines
in place to resolve a grievance within 60 days after
receipt of the grievance, or within a maximum of 90 days
if the grievance involves the collection of information
outside the service area. These time limitations can be
tolled if the contractor has notified the enrollee, in
writing, that additional information is required for
proper review of the grievance and that such time
limitations are tolled until such information is
provided. After the contractor receives the requested
information, the time allowed for completion of the
grievance process resumes.
3. For an expedited review, the contractor must make a
decision and notify the enrollee, or the provider acting
on behalf of the enrollee, as expeditiously as the
enrollee's medical condition requires, but in no event
more than 72 hours after receipt of the request for
review. If the expedited review is a concurrent review
determination (utilization review conducted during the
enrollee's course of treatment) the service must be
continued without liability to the enrollee until the
enrollee has been notified of the determination. The
contractor must provide written confirmation of its
decision concerning an expedited review within 2 working
days after providing notification of that decision, if
the initial notification was not in writing. The
contractor must provide reasonable access, not to exceed
24 hours after receiving a request for an expedited
review, to an
Attachment I- 38 of 55
Contract No. 2002-2003-02
appropriate clinical peer who can perform the expedited
review. The clinical peer or peers must not have been
involved in the initial adverse determination.
4. In the case of an adverse determination the contractor
must make available, to the enrollee, a review of the
grievance by an internal review panel; such review must
be requested within 30 days after the contractor's
transmittal of the final determination notice of an
adverse determination. A majority of the panel must be
persons who previously were not involved in the initial
adverse determination. A person who previously was
involved in the adverse determination may appear before
the panel to present information or answer questions.
The panel must have the authority to bind the contractor
to the panel's decision. The contractor must ensure that
a majority of the persons reviewing a grievance
involving an adverse determination are providers who
have appropriate expertise. The contractor must issue a
copy of the written decision of the review panel to the
enrollee and to the provider, if any, who submits a
grievance on behalf of an enrollee. In cases where there
has been a denial of coverage of service, the reviewing
provider must not be a provider previously involved with
the adverse determination.
E. Both informal and formal steps must be available to resolve
grievances. A grievance is not considered formal until it is
written and signed by an enrollee or completed on such forms as
prescribed and received by the contractor. A complaint is not
considered a grievance until the complaint is written and
received by the contractor.
F. Procedural steps must be clearly specified in the enrollee
handbook for enrollees and the provider manual for providers,
including the address, telephone number and office hours of the
grievance coordinator.
G. The contractor must insure that appropriate foreign language
versions of grievance materials are developed and available to
enrollees and potential enrollees. These foreign language
versions of materials are required if the population speaking a
particular foreign (non-English) language in a county is greater
than five (5) percent.
H. The contractor must have sufficient support staff available to
process grievances within the required time frames, and to
assist the enrollee in properly filing grievances. The staff
must also be educated concerning the importance of the grievance
procedure and the rights of the enrollee.
I. The contractor must specify phone numbers for the enrollee,
subcontractor or other service provider to call to present a
complaint or to contact the grievance coordinator. Each phone
number must be toll-free within the enrollee's geographic area
and provide reasonable access to the contractor without undue
delays. There must be an adequate number of phone lines to
handle incoming grievances.
J. Grievance procedures must be clearly specified in the enrollee
handbook, including the address, telephone number and office
hours of the grievance coordinator.
K. The contractor must maintain an accurate record of each formal
grievance. Each record must include the following:
1. A complete description of the grievance, the enrollee's
name and address, the provider's name and address, and
the contractor's name and address.
2. A complete description of the contractor's factual
findings and conclusions after the completion of the
full formal grievance procedure.
3. A complete description of the contractor's conclusions
pertaining to the grievance as well as the contractor's
final disposition of the grievance.
4. A statement as to which levels of grievance procedure
the grievance has been processed and how many more
levels of the grievance procedure are remaining before
the grievance has been processed through the
contractor's entire grievance procedure.
L. A record of informal complaints received which are not
grievances must be maintained and include date, time, nature of
complaint and disposition. The contractor must submit this
report upon request by the department.
Attachment I- 39 of 55
Contract No. 2002-2003-02
M. A report on grievances must be submitted on a monthly basis as
required in the Reporting Requirements section of this document.
The report must list the number and nature of all formal
grievances that have not been resolved to the satisfaction of
the enrollee, after the enrollee has utilized the full grievance
procedure of the contractor.
SECTION 7 ENROLLEE RECORDS
A. The contractor is responsible for assuring that there is
a complete long-term care record for each enrollee.
B. The contractor must use procedures that promote the
development of a centralized, comprehensive medical and
long-term care record for enrollees. The contractor must
ensure, with written consent of the enrollee, all
providers involved in the enrollees care have access to
the enrollee's record for the purpose of providing care.
C. The contractor must maintain an enrollee records system
which is consistent with professional standards and
which permits the prompt retrieval of information. Each
record must include timely information accurately
documented and must be readily available to all
appropriate and authorized practitioners involved in the
integration and coordination of care.
D. The contractor will ensure that all subcontract
providers, including medical specialists and long-term
care providers, properly document the care provided to
enrollees including, diagnoses determined, medications
prescribed, and treatment plans developed.
E. The contractor will ensure that enrollee record
information is accessible only to authorized persons in
accordance with written consent or an executed
authorization granted by the enrollee or the enrollee's
representative and with all applicable federal and state
laws, rules and regulations.
F. The contractor must disclose enrollee records, including
enrollee and caregiver identifying information to the
department and agency in order to fulfill the
department's and agency's obligation to oversee the
performance or to conduct assessment, investigation, or
evaluation of this contract. Not withstanding provisions
to the contrary, release of material to the department
and agency will not be construed as public disclosure of
confidential information.
SECTION 8 REPORTING REQUIREMENTS
8.1 GENERAL REQUIREMENTS
The contractor is responsible for complying with all reporting
requirements established by the department and agency. The contractor
will be responsible for assuring the accuracy and completeness of all
required reports as well as the timely submission of each report. The
contractor will be furnished with the appropriate reporting formats,
instructions, submission timetables and technical assistance as
required.
A. Level of Analysis: The following levels of analysis will be
used, as indicated, for the required reports:
1. Individual Level - One report is required for each
enrollee, e.g., one grievance record for each grievance,
one record per hospital discharge.
2. Location Level - One report required for each nine-digit
Medicaid provider number the contractor has under
contract.
3. Contractor Level - One report is required for each
seven-digit Medicaid provider number the contractor has
under contract.
Attachment I- 40 of 55
Contract No. 2002-2003-02
Example: ABC Health Plan, Medicaid Provider Number
1234567, operates three locations: ABC of Palm Beach
(123456701), ABC of Indian River (123456702), and ABC of
Martin (123456703). A plan level report would be
summarized over all plans with the seven-digit Medicaid
provider code (1234567). A location level report would
have one report for each nine-digit provider number
(123456701, 123456702, and 123456703).
The following table summarizes the required data reporting for the project
LEVEL OF
REPORT NAME ANALYSIS FREQUENCY OF REPORT SUBMISSION MEDIA
- ------------------------------------------------------------------------------------------------------
Enrollment, Disenrollment, and Location Monthly Asynchronous
Cancellation Report for Transfer to Fiscal
Payment Agent
Disenrollment Summary Location Monthly Electronic mail or
diskette
Encounter Data Report Individual Quarterly, within 3 months of Electronic mail or
the end of reporting period diskette
Grievance Report Individual Monthly Electronic mail or
diskette
Financial Statements Contractor Quarterly, within 45 days of AHCA supplied template
end of reporting period on diskette
Audited Financial Contractor Annually, within 90 days of end Electronic mail or
Statement of contractor's fiscal year diskette
Minority Business Individual Monthly by the 15th Electronic mail
Enterprise Contract Level
Reporting
8.2 ENROLLMENT, DISENROLLMENT, AND CANCELLATION REPORT FOR PAYMENT
A. This report is to be submitted monthly to the Florida Medicaid
fiscal agent. This report may only be submitted in a file of the
structure defined below and transmitted asynchronously to the
Medicaid fiscal agent using the communications protocol defined
below. The contractor is required to submit each month the data
shown in the table below for every person who is to be enrolled,
disenrolled, or canceled during the reported monthly period: The
transfer file will be a fixed record length ASCII file (80
bytes) to be transferred to the Medicaid fiscal agent using a
Hayes Compatible Modem of 9600-57600 BPS operating over the
public phone network. The data will be transferred using the
X-MODEM or Z-MODEM transfer protocol. Communications protocol
will be 8 data bits, 1 stop bit, no parity, full duplex, echo
off.
B. The fiscal agent is authorized to process the monthly enrollment
input data as an electronic transaction in which payment is
generated for each enrollee according to the established
capitation rate. On a specified date each month the plan will
receive the remittance invoice accompanied by a payment warrant.
The amount of payment is determined by the number of enrollees
enrolled in each capitation category and any adjustments that
may apply.
C. File Layout for Monthly Enrollment, Disenrollment, and
Cancellation Report for Payment
Attachment I- 41 of 55
Contract No. 2002-2003-02
FIELD START END CHARACTER
DATA ELEMENT NAME LENGTH COLM. COLM. OR NUMERIC
- -------------------------------------------------------------------------------------------------------------------------
6 = enrollment, 2 = disenrollment Action Code 1 1 1 N
Valid 9 digit provider number Provider Number 9 2 10 N
Valid 10 digit Medicaid enrollee I.D. Enrollee Medicaid 10 11 20 N
number Number
Enrollee last name Enrollee Last Name 12 21 32 C
Enrollee first name Enrollee First Name 9 33 41 C
Enrollee date of birth (MMDDYYYY) Enrollee Date of 8 42 49 N
Birth-MM DDYYYY
Contractor assigned enrollee I.D. Contractor Enrollee ID 9 50 58 C
Contractor location, assigned by Contractor Location 10 59 68 C
contractor
Fiscal year identifier, used to represent Contractor Fiscal Year 1 69 69 C
the fiscal or contract year to which Identifier
action code 0 information pertains. Enter
last digit of the last year of the
contract year in which inpatient days were
utilized, (e.g., for the 1996-97 contract
year enter 7)
Number of inpatient days being CAP Contractor Units 3 70 72 N
reported via action code 0 (cap Used - Input
update). Must be right justified in field
Inactive field, zero fill Filler 4 73 76 C
Transaction date (MMYY) Contractor Transaction 4 77 80 C
Date-MMYY
8.3 CONTRACTOR DISENROLLMENT SUMMARY
A. This report provides a uniform means of reporting each
contractor's monthly disenrollments. The report is required to
assess the reasons for each disenrollment and to assure that
enrollees are disenrolled in compliance with contract
guidelines.
B. File Layout for Monthly Disenrollment Summary Reporting
FIELD NAME DESCRIPTION DATA TYPE LENGTH
- -------------------------------------------------------------------------------------------------------------------
CONTRACTOR ID 9 digit provider code (includes 2 digit location) Character 9
FROM-DATE The beginning date of the reporting period Date 8
TO-DATE The ending date of the reporting period Date 8
REPT-TYPE Report Type (always equal to MDS for this report) Character 5
V1 Expects to move Numeric 7
V2 Wishes to see private M.D., practitioner, or Numeric 7
attend another clinic
V3 Dissatisfied with plan policies or procedures Numeric 7
Attachment I- 42 of 55
Contract No. 2002-2003-02
Field Name Description Data Type Length
- -------------------------------------------------------------------------------------------------------------------
V4 Enrolled/Enrolling in other Medicaid HMO Numeric 7
V7 Other Voluntary Numeric 7
I1 Missed 3 consecutive appointments in a continuous Numeric 7
six month period
I2 Moved out of service area Numeric 7
I4 Fraudulent use of Medicaid or plan ID card Numeric 7
I5 Death of enrollee Numeric 7
I6 Loss of Medicaid eligibility Numeric 7
I8 Other involuntary Numeric 7
8.4 ENCOUNTER DATA
The contractor will be required to provide encounter level service
utilization data in an electronic format to the department as specified
below, however additional data may be requested as needed to meet state
and federal requirements:
The Long-Term Care file should be provided as an ASCII, fixed length
text file, one record per enrollee, per month, per line. Each record
will have the following fields (see section 4.2 in your contract for a
full description of each service). Fill with spaces if there were no
units of service provided. Right justify all fields unless noted
otherwise. All "Hours" fields should be accurate to the nearest quarter
hour (.25). Please be sure to enter the hours as a decimal (e.g., 2.5 is
two and a half hours; .25 is a quarter hour).
FIELD UNIT OF START
NAME DESCRIPTION MEASUREMENT LENGTH COL. END COL. TEXT/NUMBER
- ------------------------------------------------------------------------------------------------------------------
SSN Social Security Number 000000000 9 1 9 N
(left justify)
MID Medicaid ID Number 0000000000 10 10 19 N
MO Report month MMYYYY 6 20 25 N
HMKS Adult Companion Services Hours (00000.00) 8 26 33 N
ADHC Adult Day Health Services Hours (00000.00) 8 34 41 N
ALFP Assisted Living Services Days 5 42 46 N
CM Case Management Hours (0000) 5 47 51 N
CHO Chore Services Hours (00000.00) 8 52 59 N
EAA Environmental Episodes 8 60 67 N
Accessibility Adaptations
ESCW Escort Services Hours (00000.00) 8 68 75 N
EST Family Training Services Episodes 5 76 80 N
RRFA Financial Assessment/ Hours (00000.00) 8 81 88 N
Risk Reduction services
HDM Home Delivered Meals Meals 5 89 93 N
HMK Homemaker Services Hours (00000.00) 8 94 101 N
RRNU Nutritional Hours (00000.00) 8 102 109 N
Assessment/Risk
Reduction Services
PECA Personal Care Services Hours (00000.00) 8 110 117 N
EARI Personal Emergency Episodes 5 118 122 N
Response System
Installation
EAR Personal Emergency Day 5 123 127 N
Response System
RESP Respite Care Hours (00000.00) 8 128 135 N
OCTH Occupational Therapy Hours (00000.00) 8 136 143 N
PHTH Physical Therapy Hours (00000.00) 8 144 151 N
SPTH Speech Therapy Hours (00000.00) 8 152 159 N
NF Nursing Facility Services Days 5 160 165 N
The Acute Care file should be provided as an ASCII, fixed length text
file, one record per enrollee, per month, per line. Each record will
have the following fields (see section 4.2 in your contract for a full
description of each service). Fill with spaces if there were no units of
service provided. Right justify all fields unless noted otherwise. For
charges, include actual
Attachment I- 43 of 55
Contract No. 2002-2003-02
amounts for Medicaid (co-pays, payments for non-Medicare covered
services). All "Hours" fields should be accurate to the nearest quarter
hour (.25). Please be sure to enter the hours as a decimal (e.g., 2.5 is
two and a half hours; .25 is a quarter hour).
UNIT OF START END
FIELD NAME DESCRIPTION MEASUREMENT LENGTH COL. COL. TEXT/NUMBER
- --------------------------------------------------------------------------------------------------------------------
SSN Social Security Number (left justify) 000000000 9 1 9 N
Medicaid ID Number
MENTAL Mental Health Services Hours 8 26 33 N
(00000.00)
DENTAL Dental Services including dentures Charges 9 34 42 N
(000000.00)
HEARING Hearing Services including hearing aids Charges 9 43 51 N
(000000.00)
HOME Home Health Care Services Hours 8 52 59 N
(00000.00)
LABXRAY Independent Laboratory or Portable Charges 9 60 68 N
X-ray Services (000000.00)
INPATIENT Inpatient Hospital Services, including Charges 9 69 77 N
E/R that is admitted (000000.00)
OUTPATIENT Outpatient Hospital Services including Charges 9 78 86 N
E/R not admitted to inpatient (000000.00)
PHYSICIAN Physician Services Charges 9 87 95 N
(000000.00)
PRESCRIP Prescribed Drug Services Charges 9 96 104 N
(000000.00)
VISUAL Visual Services including eyeglasses Charges 9 105 113 N
(000000.00)
TRANS Transportation services (not included in Trips 5 114 118 N
Escort services)
A file with DME and Consumable Supplies should be provided as an ASCII fixed
length text file, one record per enrollee, per medical supply code, per line.
Internal codes provided in the Durable Medical Equipment-Medical Supplies
handbook should be used. The handbook may be accessed from the agency's website
as follows:
http://floridamedicaid.consultee-inc.com
Choose Provider Support
Choose Handbooks
Choose Durable Medical Equipment-Medical Supplies (PDF file)
For contractors who use the HCFA 1500, the Medicaid Code for each supply may be
included as well but is optional. The DME/Supply list may be obtained from the
Durable Medical Equipment-Medical Supplies handbook accessible from the agency's
website as specified above.
Field Unit of Start End
Name Description Measurement Length Col Col Text/Number
- ---------------------------------------------------------------------------------------------------------------------
SSN Social Security Number(left 000000000 9 1 9 N
justify)
MID Medicaid ID Number 0000000000 10 10 19 N
MONTH Report Month MMYYYY 6 20 25 N
TYPE 1. DME 1 26 26 N
2. Consumable .Supply
COST Cost of Service Charges 9 37 45 N
(000000.00)
Attachment I- 44 of 55
Contract No. 2002-2003-02
8.5 GRIEVANCE REPORT
A. The Grievance Report provides detailed information about each
enrollee.
B. Structure for Grievance Reporting File
FIELD NAME TYPE WIDTH DESCRIPTION
- ---------------------------------------------------------------------------------------------------------------------
PROV-ID Character 9 Nine digit Medicaid provider number
RECIP-ID Character 9 The enrollee's 9 digit Medicaid ID
number
LAST-NAME Character 15 The enrollee's last name
FIRST-NAME Character 15 The enrollee's first name
MID-INIT Character 1 The enrollee's middle initial
COMP-TYPE Numeric 2 The type of complaint
DISP-DATE Date 8 The date of the disposition
DISP Numeric 2 The disposition of the grievance
1. Referral Made to Specialist 10. In Contractor Grievance Process
2. PCP Appointment Made 11. Referred to Area Agency on Aging
3. Bill Paid 12. Enrollee Sent OLC form
4. Procedure Scheduled 13. Lost Contact with Enrollee
5. Reassigned PCP 14. Hospitalized / Institutionalized
6. Reassigned Center 15. Contractor Complies with Contract
7. Disenrolled Self 16. Reinstated in HMO
8. Disenrolled by Plan 17. Other
9. In HMO QA Review
SECTION 9 FINANCIAL REPORTING
9. GENERAL
The reporting requirements outlined in this section are designed in
accordance with the agency's Medicaid prepaid plan contract financial
reporting requirements.
9.2 AUDITED FINANCIAL STATEMENTS
The contractor must submit annual audited financial statements which
summarize the contractor's financial activities for the contract period.
In addition, the contractor must annually send a statement, signed by
the president of the organization, attesting that no assets of the
contractor have been pledged to secure personal loans. The financial
statements must be submitted no later than three calendar months after
the end of the contractor's fiscal year and must be prepared by an
independent certified public accountant on the accrual basis of
accounting in accordance with generally accepted accounting principles
as established by the American Institute of Certified Public Accountants
(AICPA). Audits performed to meet the requirements of OMB Circular 128
satisfy this requirement. For government owned and operated facilities
operating on a cash method of accounting, data
Attachment I- 45 of 55
Contract No. 2002-2003-02
based on such a method of accounting will be acceptable. The certified
public accountant (CPA) preparing the financial statements must sign
statements as the preparer and in a separate letter state the scope of
his work and opinion in conformity with generally accepted auditing
standards and AICPA statements on auditing standards. The annual audited
report will be for the contractor unless prior approval is obtained from
the department for some other alternative.
If the period covered by this contract is less than six months, the
contractor may request of the department's contract manager, in writing,
an exemption from the requirements of this section for this contract
period. The department's contract manager will grant the exception
provided that all other performance measures are satisfactory and the
contractor provides a complete set of financial statements accompanied
by an attestation of accuracy signed by a corporate officer.
9.3 UNAUDITED QUARTERLY FINANCIAL STATEMENTS
The contractor must submit the following unaudited quarterly financial
statements: Balance Sheet, Statement of Revenues and Expenses, and
Statement of Changes in Financial Position and Net Worth.
A. These statements must be filed, on a diskette using the supplied
spreadsheet template and are due 45 days after the end of each
quarter in a contractor's fiscal year.
B. Quarterly financial reports are to be specific to the operation
of the contractor rather than to a parent or umbrella
organization.
C. The reporting date, and the name of the provider, must be
plainly written or stamped on the certification page, along with
the Chief Executive Officer's (CEO) signature.
D. Do not leave blanks. If no entry is to be made, write ANONE, @
not applicable (N/A) or "-0-" in the space provided. Any item
which cannot be readily classified under one of the printed
items should be entered as an aggregated item and adequately
described.
E. If additional supporting statements or schedules are added in
connection with providing information on the financial
statement, the additions should be properly keyed to the item
being answered (Example - "Current Assets, #4").
F. One copy of the financial template is required to be filed with
the diskette.
G. Minimum requirements needed to run the financial report program
include: IBM compatible computer with an 80286 processor or
higher, 3.5@ disk drive; hard disk drive, graphics display
monitor EGA or VGA, 4 Mb of memory, mouse, MS-DOS 3.1 or later
and Microsoft Windows 3.1 or later, Excel 5.0.
9.4 FINANCIAL REPORTING TEMPLATE
The contractor will be supplied with a template for financial reporting
that can be used with Excel or Lotus 1-2-3 spreadsheet applications. The
spreadsheets are to be completed and the diskette mailed to the
department.
A. Master financial sheet - This is the balance sheet, profit and
loss statement and changes in financial position that reflects
four (4) quarters plus the contractor's fiscal year totals.
Variances have been placed within the quarters to track
fluctuations on a line-item basis. Ratios have been created to
monitor or detect material weaknesses in the contractor.
B. Enrollment sheet - Consists of quarterly summaries of enrollment
detailed by county penetration. Indicators have been placed to
reflect potential over or under enrolling practices.
Attachment I- 46 of 55
Contract No. 2002-20O3-02
C. Profit and Loss sheets - Contains three (3) sheets to track
individual performance by commercial, Medicare, and Medicaid
product lines.
D. Aggregate write-in sheets - These four (4) sheets track any
information recorded on the balance sheet or profit and loss
statements, which needs further explanation.
E. Certification page - Showing the contractor's name, address,
telephone number, and other elements.
9.5 Balance Sheet
A. Balance Sheet Asset Definitions
1. Current Assets - These assets are relatively liquid and
usually held for less than one year. Restricted assets
for grants, contracts and reserves are not included.
Five general types of assets are usually included in the
current asset classification.
a. Cash - Money in any form, cash awaiting deposit,
balances on deposit in checking accounts and
certificates of deposit. Funds with availability
for current use which are restricted by
contract, state reserve requirements or other
formal arrangements are reported as Other
Assets. Loan funds held in escrow are reported
as Other Assets.
b. Secondary Cash Resources - Various investments
that are readily marketable, held for less than
one year or intended for sale within a
twelve-month period. Any funds with availability
for current use but restricted by contract,
state requirement or other formal arrangements
are excluded.
c. Short-Term Receivables - Open accounts
receivable and notes receivable with short-term
maturities of less than one year.
d. Short-Term Prepayments - Expenses, such as
insurance, taxes, rent, paid for in advance of
use in operations. These items are usually
referred to as prepaid expenses.
e. Other - Includes inventories that are consumable
supplies, such as x-ray, laboratory and other
operating supplies. The category includes items
that will be consumed by the contractor during
the current period in ordinary course of
operation and items that are held for resale
such as pharmacy inventories.
2. Other Assets - Assets including insolvency requirements,
contracts, grants and reserves.
3. Property and Equipment - Fixed assets including land,
building improvements, furniture and equipment.
B. Balance Sheet Asset Lines
1. Cash - Cash in the bank or on hand, available for
current use and does not include restricted cash.
2. Short-Term Investments - Readily saleable investments
acquired with temporarily unneeded cash and does not
include restricted securities.
3. Premiums Receivable - Net-Gross amounts collectible from
groups or enrollees who receive services from the
contractor, less the amount accrued for premiums
determined to be uncollectible for the period. This
should not include fee-for-service.
4. Interest Receivable - Interest earned on investments but
not received.
5. Other Receivables - Net-Gross amounts collectible from
sources other than enrollees or groups, less the amount
accrued for receivables determined to be uncollectible
Attachment I- 47 of 55
Contract No. 2002-2003-02
during the period. Example: fee-for-service. This should
not include restricted receivables.
6. Prepaid Expenses - Future expenses paid in advance such
as unexpired insurance.
7. Aggregate Write-ins For Current Assets - Enter the total
of the write-ins listed on the aggregate write-in sheet
for current assets.
8. Total Current Assets - Total of the above categories.
9. Restricted Assets - Assets restricted for statutory
insolvency requirements.
10. Restricted Funds - Assets held for contract (i.e.,
Medicaid) grants, reserves including cash, securities,
receivables, and other.
11. Loan Escrow - Funds for which loan notes have been
signed by the provider but not drawn down. Funds may be
held by the provider or an escrow agent.
12. Long-Term Investments - Investments held for a period
longer than twelve months.
13. Intangible Assets and Goodwill Net - Assets of no
physical substance. These may include patents,
copyrights, licenses, and franchises. Provide gross
amount less amortization.
14. Aggregate Write-ins for Other Assets - Enter the total
of the write-ins listed on lines 1501 through 1597.
15. Total Other Assets - Total of the above categories.
16. Land - Real estate owned by the contractor.
17. Buildings & Improvements - Buildings owned by the
contractor and improvements made to provider-owned
buildings.
18. Construction in Progress - Buildings or improvements in
progress or under construction. These items will be
capitalized upon completion or utilization.
19. Furniture and Equipment - Includes medical equipment,
office equipment and furniture owned by the contractor.
20. Aggregate Write-ins for Other Equipment - Enter the
total of the write-ins listed on the aggregate write-in
for property and equipment.
21. Total Property and Equipment-Net - Total of Property and
Equipment categories, less Accumulated Depreciation. The
cumulative amount of depreciation on property and
equipment. Depreciation is an accounting practice
recognizing the consumption of the value of a fixed
asset during the asset's useful life. Depreciation
expenses are charged to the expense categories
representing the cost center to which the fixed asset is
assigned.
22. Total Assets - Total of Current Assets, Other Assets and
Net Property and Equipment.
23. Details of Write-ins Aggregated for Current Assets -
Show non-restricted current assets, including
inventories, not included in the other Current Assets
categories.
24. Details of Write-ins Aggregated for Other Assets - Show
non-current assets not included in the Other Assets
categories.
25. Details of Write-ins Aggregated for Other Equipment -
Include automobiles, fixtures, and other fixed assets
not reported in other Property and Equipment categories.
Attachment I- 48 of 55
Contract No. 2002-2003-02
C. Balance Sheet Liabilities and Net Worth Definitions
1. Current Liabilities - Obligations whose liquidation is
reasonably expected to occur within one year. Three main
classes or liabilities fall within this definition.
2. Obligations for goods and services which were acquired
for use in the operating cycle - These include claims
for hospital and physician services and accounts
payable.
3. Other debts that may be expected to require payment
within the operating cycle or one year - This includes
short-term notes and the currently maturing portion of
long-term obligations.
4. Revenues received and recorded prior to being earned -
These advances are often described as "deferred
revenues." The obligation to furnish the services or to
refund the payment is recognized as a liability. These
include unearned premiums.
5. Other Liabilities - Liabilities of a long-term nature;
liquidation of liabilities is not expected in the
current year.
6. Net Worth - Includes ownership or donated capital,
restricted funds, reserves, and earnings or losses.
7. Balance Sheet Liabilities and Net Worth Lines.
8. Accounts Payable - Amounts due to creditors for the
acquisition of goods and services (trade and vendors
rather than health care providers) on a credit basis.
9. Claims Payable (Reported) - Claims reported and booked
as payables.
10. Accrued Inpatient Claims (Not reported) - Hospital and
institutional care claims incurred but not reported
and/or booked as payables.
11. Accrued Physician Claims (Not reported) - Claims
incurred but not reported and/or booked as payables for
physicians and ancillary (such as lab and x-ray)
services by providers under an arrangement with the
prepaid health plan. These may include capitation
payments to medical groups or fees to IPAs.
12. Accrued Referral Claims (Not reported) - Claims incurred
but not reported and/or booked as payables for
consultants and referrals to providers outside a
contractor arrangement. These claims are usually paid on
a fee-for-service basis.
13. Accrued Other Medical (Not Reported) - Other incurred
medical expenses but not reported and/or booked as
payables including emergency room, out-of-area services,
and payroll.
14. Accrued Medical Incentive Pool - Accruals for withholds
from IPAs or capitated medical groups and other such
arrangements in which the provider may return incentive
funds to contractors.
15. Unearned Premiums - Income received or booked in advance
of the period to which it applies. A liability exists to
render service in the future.
16. Loans and Notes Payable - The principal amount on loans
due within one year.
17. Aggregate Write-Ins for Current Liabilities - Enter the
total of the write-ins listed on the aggregate write-ins
for current liabilities.
18. Total Current Liabilities - Total of Current Liability
Categories.
19. Loans and Notes - Loans and notes signed by the
contractor not including current portion payable.
Include federal loans.
20. Statutory Liability - Reserve required as a liability by
statute (e.g., government purchaser requirements).
Attachment I- 49 of 55
Contract No. 2002-2003-02
21. Aggregate Write-ins for Other Liabilities - Enter the
total of the write-ins listed on the aggregate write-ins
for other liabilities.
22. Total Other Liabilities - Total of Other Liability
Categories.
23. Total Liabilities - Lines 11 and 15.
24. Donated Capital - Capital donated to nonprofit
organization. Do not include loans. Describe the nature
of donation as well as any restrictions on this capital
in the notes to financial statements.
25. Capital - Par Value of stock. Stated amount of owners's
direct equity in provider.
26. Paid in Surplus - Amount over stated value of Line 17.
Reflects actual amount in excess of par or stated value.
27. Unassigned Surplus - Unassigned Retained Earnings.
Cumulative earnings or deficit from operations, net of
reserves and restricted funds.
28. Aggregate Write-ins for Other Net Worth Items - Enter
the total of the write-ins listed on the aggregate
write-ins for net worth.
29. Total Net Worth - Total of Lines 16 to 20.
30. Total Liabilities and Net Worth - Total of Lines 16 and
22.
31. Details of Write-ins Aggregated for Current Liabilities
- Show current liabilities not included in other Current
Liabilities categories; include accrued payroll and
taxes.
32. Details of Write-ins Aggregated for Other Liabilities -
Show other liabilities of a long-term nature.
33. Details of Write-ins Aggregated for Other Net Worth
Items - May include statutory reserves, subordinated
debt, and accrued interest on subordinated debt.
9.6 STATEMENT OF REVENUES, EXPENSES, AND NET WORTH
A. Revenue: components are broken down to show the sources of
income and revenue dependency on public or private enrollment
bases. Coordination of Benefits (C.O.B.) and Insurance
Recoveries are also shown. Expenses: Medical, Services,
Administration and Marketing components are shown. The report
includes a contra item for year-end adjustments to the full
expenses reported and for withholds or incentives claimed.
Report full accrued revenues and expenses as defined below for
the period. Full expenses, whether or not the contractor
ultimately bears financial responsibility, should be shown. For
example, the full hospital and institutional expenses are shown
in "Inpatient" line. Offsets to these expenses such as C.O.B.
and Insurance Recoveries are shown as revenue. Similarly, full
physician service expenses are shown with a year end adjustment
for withholds or other offsets returned to the provider as a
contra category. Project staff should footnote differences in
reporting if they are unable to report in lines similar to these
revenue/expense accounts.
B. Statement of Revenues, Expenses, and Net Worth Lines
1. Premium - Revenue recognized on a prepaid basis from
enrollees and groups for provision of a specified range
of health services over a defined period of time,
normally one month. Also included are premiums from
Medicare Wrap-Around subscribers for health benefits
which supplement Medicare coverage. If advance payments
are made to the contractor for more than one reporting
period, the portion of the payment that has not yet been
earned must be treated as a liability.
Attachment I- 50 of 55
Contract No. 2002-2003-02
2. Fee-for-Service - Revenue recognized by the contracting
entity for provision of health services to non-enrollees
by contractor providers and to enrollees through
provision of health services excluded from their prepaid
benefit packages.
3. Co-payments - Revenue recognized by the contracting
entity from enrollees on a utilization related basis for
certain health services included in the HMO benefit
package.
4. Title XVIII Medicare - Revenue as a result of an
arrangement between a provider and the Centers for
Medicare and Medicaid Services for services to a
Medicare beneficiary.
5. Title XIX Medicaid - Revenue as a result of an
arrangement between a contractor and a Medicaid state
agency for services to a Medicaid beneficiary.
6. Interest - Interest earned from all sources, including
the federal loan in escrow and reserve accounts.
7. C.O.B. and Insurance Recoveries - Income from
Coordination of Benefits and insurance recoveries.
8. Reinsurance Recoveries - Income from the settlement of
stop-loss (reinsurance) claims.
9. Other Revenue - Revenue from sources not covered in the
previous revenue accounts, such as recovery of bad debts
or gain on sales of capital assets.
10. Total Revenue - Total of the above revenue accounts.
11. Medical and Hospital - Expenses for health service
delivery including the following components:
a. Physician Services - Expenses for physician
services provided under contractual arrangement
to the contractor including the following:
salaries, including fringe benefits, paid to
physicians for delivery of medical services;
capitated payments paid by the contractor to
physicians for delivery of medical services to
contractor subscribers; and fees paid by the
contractor to physicians on a fee-for-service
basis for delivery of medical services to
contractor subscribers. This includes capitated
referrals. Do not include expenses for medical
personnel time devoted to administrative tasks.
b. Other Professional Services - Compensation,
including fringe benefits, paid by the
contractor to non-physician providers engaged in
the delivery of services and to personnel
engaged in activities in direct support of the
provision of medical services. This includes
dentists, psychologists, optometrists,
podiatrists, extenders, nurses, clinical
personnel such as ambulance drivers,
technicians, para professionals, janitors,
quality assurance analysts, administrative
supervisors, secretaries to medical personnel,
and medical record clerks.
c. Outside Referrals - Expenses for services from
providers not under provider arrangement such as
consultations.
d. Emergency Room, Out-of-Area, Other - Expenses
for other non-contracted health delivery
services incurred by contractor enrollees for
which the contractor is responsible on a
fee-for-service basis. These include emergency
room costs and out-of-area emergency physician
and hospital costs.
e. Occupancy, Depreciation and Amortization -
Expenses associated with medical services
including the amount of depreciation and
amortization
Attachment I- 51 of 55
Contract No. 2002-2003-02
expense which is directly associated with the
delivery of medical services. The costs of
occupancy to the contractor which are directly
associated with the delivery of medical
services. Included in occupancy are costs of
using a facility, fire and theft insurance,
utilities, maintenance, and lease.
f. Inpatient - Inpatient hospital costs of routine
and ancillary services for enrollees while
confined to an acute care hospital. Does not
include out-of-area hospitalization.
g. Routine hospital service includes regular room
and board (including intensive care units,
coronary care units, and other special inpatient
hospital units), dietary and nursing services,
medical surgical supplies, medical social
services, and the use of certain equipment and
facilities for which the contractor does not
customarily make a separate charge.
h. Ancillary services may also include laboratory,
radiology, drugs, delivery room and physical
therapy services. Ancillary services may also
include other special items and services for
which charges are customarily made in addition
to routine service charge. Charges for
non-contractor physician services provided in a
hospital are included in this line item only if
included as an undefined portion of charges by a
hospital to the contractor. Include the cost of
utilizing skilled nursing and intermediate care
facilities. Skilled nursing facilities are
primarily engaged in providing skilled nursing
care and related services for patients who
require medical or nursing care or
rehabilitation service. Intermediate care
facilities are for enrollees who do not require
the degree of care and treatment which a
hospital or nursing care facility provides, but
do require care and services above the level of
room and board.
i. Reinsurance Expenses - Expenses for Reinsurance
or "Stop-loss" insurance.
j. Other Medical - Costs directly associated with
the delivery of medical services under
contractor arrangement which are not
appropriately assigned to the medical expense
categories defined above, e.g., costs of medical
supplies, medical administration expense (except
compensation), malpractice insurance, etc.
k. Incentive Pool Adjustment - A contra category
for adjusting the full medical expenses
reported. For example, physician withholds or
hospital volume discounts returned by or to the
provider should be included here. Adjustments
should be made only on the annual report.
l. Total Medical and Hospital - Total of the above
categories.
C. Administration - Costs associated with the overall management
and operation of the contractor including the following
components:
1. Compensation - All expenses for administrative
services including compensation and fringe
benefits for personnel time devoted to or in
direct support of administration. Include
expenses for management contracts. Do not
include marketing expenses. However, when a
management company pays rent, insurance, and
other non-salary or non-commission payments,
these amounts should not be reported as
compensation.
2. Interest Expenses - Interest on loans paid
during period.
3. Occupancy, Depreciation and Amortization -
Expenses associated with administrative services
including the costs of occupancy to the
contractor entity which are directly associated
with contractor administration. Included in
occupancy are costs of using a facility, fire
and theft insurance,
Attachment I- 52 of 55
Contract No. 2002-2003-02
utilities, maintenance, and lease. Do not
include expenses for marketing in this category.
4. The amount of depreciation and amortization
expense which is directly associated with
administrative services. Depreciation expense is
the incremental consumption of the value of a
fixed asset during the asset's useful life.
5. Amortization Expense - the cost of certain
assets are spread over their estimated service
lives. e.g., leasehold improvements.
6. Marketing - Expenses directly related to
marketing activities including advertising,
printing, marketing representative compensation
and fringe benefits, commissions, broker fees,
travel, occupancy, and other expenses allocated
to the marketing activity.
7. Other - Costs which are not appropriately
assigned to the health plan administration
categories defined above. Included are costs to
update enrollee records, servicing of enrollee
inquiries and complaints, claims adjudication
and payment, legal, audit, data processing,
accounting, insurance, bad debts, and all taxes
except federal income taxes. Do not include
marketing expenses.
8. Total Administration - Total of the above
categories.
9. Total Expenses - Total of Medical and Hospital
and Administration Expenses.
10. Income (Loss) - Excess or deficiency of total
revenues over total expenses.
11. Extraordinary Item - A nonrecurring gain or loss
that meets the following criteria:
a. The event must be unusual. It should be
highly abnormal and unrelated to, or
only incidentally related to, the
ordinary activities of the entity.
b. The event must occur infrequently. It
should be of a type that would not
reasonably be expected to recur in the
foreseeable future.
c. The following gains and losses are
specifically not extraordinary: write-
down or write-off of accounts
receivable, inventory, or intangible
assets; gains or losses from changes in
the value of foreign currency; gains or
losses on disposal of a segment of a
business; gains or losses from the
disposal of fixed assets; effects of a
strike; and adjustments of accruals on
long-term contracts.
12. Provision for taxes - State and federal taxes
for the period (for-profit organizations only).
13. Net Income (Loss) - Excess or deficiency of
total revenues over total expenses less state
and federal taxes for the period.
9.7 STATEMENT OF CHANGES IN FINANCIAL POSITION AND NET WORTH
A. This report reflects the concept of funds as working capital,
rather than the more limited cash concept. Use brackets to show
negative balances. Inclusion of statutory reserves as a
component of working capital is dependent in each situation on
the use of the reserve as defined by the regulatory authority.
The applicable test is whether the reserve is available for use
in current operations. This report shows funds generated and
applied to operations. Sources and applications of funds
indicate funds generated (or lost) from operations, as well as
other sources and applications. Net worth indicates changes in
components of net worth over the past year. Sources of funds
used in operations including the following:
Attachment I- 53 of 55
Contract No. 2002-2003-02
B. Statement of Changes in Financial Position and Net Worth Lines
1. Net Income (Loss) - Report the figure calculated for
this line.
2. Add items not affecting working capital in the current
period - depreciation, amortization and deferred taxes
are expenses not affecting working capital. These
expenses are added back.
3. Depreciation and Amortization
4. Deferred Taxes - These are accrued taxes expensed for
the period which are held for payment to the government
during a later period.
5. Show other expenses not affecting working capital.
6. Other Additions to Working Capital: Additions are
generally from borrowing or from liquidating non-current
assets and include the following:
a. Proceeds from borrowing - Additions from
borrowing which increase current asset accounts.
b. Show other additions to working capital.
c. Total Sources of Funds - Total of the above
categories.
7. Applications - Uses of Working Capital, usually
additions to non-current assets or reductions in long
term liabilities, including the following:
a. Additions to Property and Equipment - Increase
in property and equipment from last period.
b. Reductions in Long-Term Debt - Decrease in
long-term liabilities from last period.
d. Show other uses of Working Capital.
e. Total Applications of Funds - Total of the above
categories.
8. Increase (Decrease) in Working Capital - Excess or
deficiency of Sources over Applications of Funds.
9. Net Worth Beginning of Period
10. Increase (Decreases) in Donated Capital
11. Increase (Decrease) in Capital - (Current year less
previous year)
12. Increase (Decrease) in Reserves and Restricted Funds -
(Current year less previous year)
13. Increase (Decrease) in Unassigned Surplus - (Current
year less previous year)
14. Net Worth End of Period
SECTION 10 PAYMENT
10.1 PAYMENT TO CONTRACTOR
The funds provided in this contract are identified in CFDA #93.778. The
agency, through the Medicaid fiscal agent, will make a fixed rate
payment, not to exceed the amount set forth in Attachment IV, to the
contractor on a monthly basis for the contractor's satisfactory
performance of its duties and responsibilities as set forth in the
contract. The capitation rate will have two components: 1) a payment for
medical care and 2) a payment for long-term care services.
Attachment I- 54 of 55
Contract No. 2002-2003-02
CAPITATION RATES
A. The medical care payment component is developed using the
Medicaid fee-for-service claims experience of Medicaid
enrollees aged 65 or older and who were assessed by CARES staff
to meet nursing home level of care.
B. The long-term care payment component is developed using the
Social Services Estimating Conference figure for the statewide
average cost of nursing home care less patient responsibility.
C. The capitation rate to be paid will be as indicated in
Attachment IV and may be re-calculated at least annually prior
to the beginning of each state fiscal year.
D. The capitation rate to be paid will not exceed that amount which
would have been paid, on an aggregate basis, by Medicaid under
fee-for-service for the same services to a demographically
similar population of enrollees.
10.3 PAYMENT IN FULL
Unless otherwise specified in this contract, the contractor must accept
the capitation payment received each month as payment in full for all
services provided to enrollees covered under this contract and the
administrative costs incurred by the contractor in providing or
arranging for such services.
10.4 CAPITATION RATE ADJUSTMENTS
The contractor and the agency acknowledge that the capitation rate paid
under this contract as specified in Attachment IV of this contract, is
subject to approval by the federal government.
A. Adjustments to funds previously paid and to be paid may be
required. Funds previously paid will be adjusted when capitation
rate revisions are the result of legislatively mandated changes
in Medicaid services, when capitation rate calculations are
determined to have been in error, or an error is made in
enrolling an ineligible person. In such events, the contractor
agrees to refund any overpayment and the agency agrees to pay
any underpayment.
B. The agency agrees to reflect changes in the Medicaid
fee-for-service program. The rate of payment and total dollar
amount may be adjusted with a properly executed amendment when
Medicaid fee-for-service expenditure changes have been
established through the appropriations process and subsequently
identified in the agency's operating budget. Legislatively
mandated changes will take effect on the dates specified in the
legislation.
Payment Errors
If after preparation and electronic submission, a contractor error is
discovered either by the contractor or the agency, the contractor has
ten (10) business days to correct the error and resubmit accurate
reports and/or invoices. Failure to respond within the ten (10) business
day period may result in a loss of any money due the contractor.
Attachment I- 55 of 55
Attachment II
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on
behalf of the undersigned, to any person for influencing or attempting
to influence an officer or an employee of any agency, a member of
Congress, an officer or employee of Congress, or an employee of a member
of Congress in the connection with the awarding of any Federal contract,
the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment or modification of any Federal
contract, grant, loan or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or
will be paid, to any person for influencing or attempting to influence
an officer or an employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress
in the connection with this Federal contract, grant, loan or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL,
Disclosure Form to Report Lobbying, in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be
included in the award documents for all sub-awards at all tiers
(including subcontracts, sub-grants and contracts under grants, loans
and cooperative agreements) and that all sub-recipients shall certify
and disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
/s/ Miguel B. Fernandez 6-25-02
- --------------------------------- ------------------------------
Signature date
/s/ Miguel B. Fernandez 2002-2003-02
- --------------------------------- ------------------------------
name of authorized individual Application or Contract Number
Physicians Healthcare Plans, Inc.
- ---------------------------------
name of organization
55 Alhambra, 7th Floor,
Cotal Gables, Fl. 33134
- --------------------------------
address of organization
Page 1 of 1
Attachment III
Page 1 of 2
INSTRUCTIONS
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS
Each recipient or vendor whose contract equals or exceeds $100,000 in
federal monies must sign this debarment certification prior to contract
execution. Independent auditors who audit federal programs regardless of
the dollar amount are required to sign a debarment certification form.
Neither the Department of Elder Affairs nor its contract recipients or
vendors can contract with subrecipients if they are debarred or
suspended by the federal government.
2. This certification is a material representation of fact upon which
reliance is placed when this contract is entered into. If it is later
determined that the signed knowingly rendered an erroneous
certification, the Federal Government may pursue available remedies,
including suspension and/or debarment.
3. The recipient or vendor shall provide immediate written notice to the
contract manager at any time the recipient or vendor learns that its
certification was erroneous when submitted or has become erroneous by
reason of changed circumstances.
4. The terms "debarred," "suspended," "ineligible," "person," "principal,"
and "voluntarily excluded," as used in this certification, have the
meanings set out in the Definitions and Coverage sections of rules
implementing Executive Order 12549 and 45 CFR (Code of Federal
Regulations), Part 76. You may contact the contract manager for
assistance in obtaining a copy of those regulations.
5. The recipient or vendor further agrees by submitting this certification
that, it shall not knowingly enter into any subcontract with a person
who is debarred, suspended, declared ineligible, or voluntarily excluded
from participation in this contract unless authorized by the Federal
Government.
6. The recipient or vendor further agrees by submitting this certification
that it will require each subrecipient of this contract whose payment
will equal or exceed $100,000 in federal monies, to submit a signed copy
of this certification with each contract.
7. The Department of Elder Affairs and its contract recipients or vendor
may rely upon a certification of a recipient/subrecipients that is not
debarred, suspended, ineligible, or voluntarily exclude from
contracting/subcontracting unless it knows that the certification is
erroneous.
8. If the recipient or vendor is an Area Agency on Aging (AAA), the AAA may
rely upon a certification of a recipient/subrecipient or vendor entity
that is not debarred, suspended, ineligible, or voluntarily excluded
from contracting/subcontracting unless the AAA knows that the
certification is erroneous.
9. The signed certifications of all subrecipients or vendors shall be kept
on file with recipient.
Attachment III
Page 2 of 2
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS
This certification is required by the regulation implementing Executive Order
12549, Debarment and Suspension, signed February; 18, 1986. The guidelines were
published in the May 29, 1987 Federal Register (52 Fed. Reg., pages
20360-20369).
(1) The prospective recipient or vendor certifies, by signing this
certification, that neither he nor his principals is presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in contracting with the Department of Elder
Affairs by any federal department or agency.
(2) Where the prospective recipient or vendor is unable to certify to any of
the statements in this certification, such prospective recipient or
vendor shall attach an explanation to this certification.
Signature /s/ Miguel B. Fernandez
----------------------------------------
Date 6-25-02
---------------------------------------------
/s/ Miguel B. Fernandez, Chief Executive Officer
- -------------------------------------------------
Name and Title of Authorized Individual
(Print or type)
Physicians Healthcare Plans, Inc.
- ---------------------------------
Name of Organization
Attachment IV
PAYMENT
The contractor will be paid a monthly capitation rate in accordance with the
following table:
TABLE 1
Long-Term Care Community Diversion Pilot Project Capitation Rate $ 2342.41
Page 1 of 1
Attachment V
(Page l of 4)
FINANCIAL AND COMPLIANCE AUDIT
The administration of resources awarded by the Agency for Health Care
Administration to the recipient may be subject to audits and/or monitoring by
the Agency as described in this section.
MONITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-133
and Section 215.97, F.S., as revised (see "AUDITS" below), monitoring procedures
may include, but not be limited to, on-site visits by Agency staff, limited
scope audits as defined by OMB Circular A-133, as revised, and/or other
procedures. By entering into this agreement, the recipient agrees to comply and
cooperate with any monitoring procedures/processes deemed appropriate by the
Agency. In the event the Agency determines that a limited scope audit of the
recipient is appropriate, the recipient agrees to comply with any additional
instructions provided by the Agency to the recipient regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews,
investigations, or audits deemed necessary by the Comptroller or Auditor
General.
AUDITS
PART I: FEDERALLY FUNDED
This Attachment is applicable if the recipient is a State or local government or
a non-profit organization as defined in OMB Circular A-133, as revised.
In the event that the recipient expends $300,000 or more in Federal
awards in its fiscal year, the recipient must have a single or
program-specific audit conducted in accordance with the provisions of
OMB Circular A-133, as revised. PART VI of this agreement indicates
Federal resources awarded through the Agency. In determining the Federal
awards expended in its fiscal year, the recipient shall consider all
sources of Federal awards, including Federal resources received from the
Agency. The determination of amounts of Federal awards expended should
be in accordance with the guidelines established by OMB Circular A-133,
as revised. An audit of the recipient conducted by the Auditor General
in accordance with the provisions of OMB Circular A-133, as revised,
will meet the requirements of this part.
2. In connection with the audit requirements addressed in Part I, paragraph
1., the recipient shall fulfill the requirements relative to auditee
responsibilities as provided in Subpart C of OMB Circular A-133, as
revised.
3. If the recipient expends less than $300,000 in Federal awards in its
fiscal year, an audit conducted in accordance with the provisions of OMB
Circular A-133, as revised, is not required. In the event that the
recipient expends less than $300,000 in Federal awards in its fiscal
year and elects to have an audit conducted in accordance with the
provisions of OMB Circular A-133, as revised, the cost of the audit must
be paid from non-Federal resources (i.e., the cost of such an audit must
be paid from recipient resources obtained from other than Federal
entities).
4. Information concerning this section can be found on the Federal Office
of Management and Budget Web page at: http://www.whitehouse.gov/omb/
index
PART II: STATE FUNDED
This part is applicable if the recipient is a nonstate entity as defined by
Section 215.97(2)(1), Florida Statutes.
In the event that the recipient expends a total amount of State
Financial Assistance (i.e., State financial assistance provided to the
recipient to carry out a State project) equal to or in excess of
$300,000 in any fiscal year of such recipient, the recipient must have a
State single or project-specific audit for such fiscal year in
accordance with Section 215.97, Florida Statutes; applicable rules of
the Executive Office of the Governor and the Comptroller, and Chapters
10.550 (local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General. PART VI of this agreement
indicates State Financial Assistance awarded through the Agency by this
agreement. In determining the State Financial Assistance expended in its
fiscal year, the recipient shall consider all sources of State Financial
Assistance, including State Financial Assistance received from the
Agency, other state agencies, and other nonstate entities. State
Financial Assistance does not include Federal direct or pass-through
awards and resources received by the nonstate entity for Federal program
matching requirements.
Attachment V
(Page 2 of 4)
2. In connection with the audit requirements addressed in Part II,
paragraph 1, the recipient shall ensure that the audit complies with the
requirements of Section 215.97(7), Florida Statutes. This includes
submission of a financial reporting package as defined by Section
215.97(2)(d), Florida Statutes, and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for-profit organizations), Rules of
the Auditor General.
3. If the recipient expends less than $300,000 in State Financial
Assistance in its fiscal year, an audit conducted in accordance with the
provisions of Section 215.97, Florida Statutes, is not required. In the
event that the recipient expends less than $300,000 in State Financial
Assistance in its fiscal year and elects to have an audit conducted in
accordance with the provisions of Section 215.97, Florida Statutes, the
cost of the audit must be paid from the nonstate entity's resources
(i.e., the cost of such an audit must be paid from the recipient's
resources obtained from other than State entities).
4. Information concerning this section can be found on the State of Florida
Web page at:
http://www.myflorida.com/myflorida/government/govermorinitiatives/fsaa/
PART III: OTHER AUDIT REQUIREMENTS
45 CFR, Part 74.26(d) extends OMB requirements, as stated in Part I
above, to for-profit organizations.
PART IV: REPORT SUBMISSION
Copies of reporting packages for audits conducted in accordance with OMB
Circular A-133, as revised, and required by PART I of this agreement
shall be submitted, when required by Section .320 (d), OMB Circular
A-133, as revised, by or on behalf of the recipient directly to each of
the following:
A. The Agency for Health Care Administration at the following
address:
See AHCA Standard Contract document, Section III,C,1
B. The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections
.320 (d)(l) and (2), OMB Circular A-133, as revised, should be
submitted to the Federal Audit Clearinghouse), at the following
address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
C. Other Federal agencies and pass-through entities in accordance
with Sections .320 (e) and (f), OMB Circular A-133, as revised.
2. Pursuant to Section .320 (f), OMB Circular A-133, as revised, the
recipient shall submit a copy of the financial reporting package
described in Section .320 (c), OMB Circular A-133, as revised, and any
management letters issued by the auditor, to the Agency at the following
address:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III,C,1.
B. To the Federal Agency or pass-through entity making the request
for a copy of the reporting package.
Copies of financial reporting packages required by PART II of this
agreement shall be submitted by or on behalf of the recipient directly
to each of the following:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III,C,l.
B. The Auditor General's Office at the following address:
Auditor General's Office
Room 401, Pepper Building
111 West Madison Street
Tallahassee, Florida 32399-1450
Attachment V
(Page 3 of 4)
4. Copies of reports or management letters required by PART III of this
agreement shall be submitted by or on behalf of the recipient directly
to:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III,C,l.
B. The Federal Department of Health and Human Services
National External Audit Resources Unit
323 West 8th St., Lucas Place-Room 514
Kansas City, MO 64105.
C. The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections
.320 (d)(1) and (2), OMB Circular A-133, as revised, should be
submitted to the following address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
5 Any reports, management letters, or other information required to be
submitted to the Agency pursuant to this agreement shall be submitted
timely in accordance with OMB Circular A-133, Florida Statutes, and
Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and
for-profit organizations), Rules of the Auditor General, as applicable.
6 Recipients, when submitting financial reporting packages to the Agency
for audits done in accordance with OMB Circular A-133, or Chapters
10.550 (local government entities) or 10.650 (nonprofit and for-profit)
organizations, Rules of the Auditor General, should indicate the date
that the reporting package was delivered from the auditor to the
recipient in correspondence accompanying the reporting package. This can
be accomplished by providing the cover letter from the reporting package
received from the auditor or a cover letter indicating the date the
reporting package was received by the recipient.
PART V: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its
compliance with the terms of this agreement for a period of five (5)
years from the date the audit report is issued, and shall allow the
Agency or its designee, Comptroller, or Auditor General access to such
records upon request. The recipient shall ensure that audit working
papers are made available to the Agency or its designee, Comptroller, or
Auditor General upon request for a period of five (5) years from the
date the audit report is issued unless extended in writing by the
Agency.
NOTE: Section .400(d) of the OMB Circular A-133, as revised, and Section
215.97(5)(a), Florida Statutes, require that the information about
Federal Programs and State Projects included in Part VI of this
attachment be provided to the Provider organization if the Provider is
determined to be a recipient. If Part VI is not included the Provider
has not been determined to be a recipient as defined by the above
referenced federal and state laws.
Attachment V
(Page 4 of 4)
PART VI: SCHEDULE OF FEDERAL AND STATE FUNDING
(Mandatory to be completed by Agency Contract Manager and included as part of
Attachment II, if Provider is determined to be a recipient of either state or
federal financial assistance as defined in the OMB Circular A-133 as revised or
Section 2l5.97(2)(m) F.S. Contract Managers should utilize the Federal funding
checklist to determine the Provider's status per OMB Circular A-133 or the
Florida Single Audit Act Checklists to determine the applicability and
Provider's status per Section 215.97, F.S.)
1. Compliance requirements for Federal Financial Assistance, State Matching
and State Financial Assistance awarded pursuant to this agreement are
included in the Agency Standard Contract document and the Attachment I,
Special Provisions section.
a) Federal Financial Assistance awarded to the recipient pursuant
to this agreement are as follows:
(Check appropriate Federal Program funding source(s) and provide
amount per source.)
Department of Health and Human Services, Center for
Medicaid/Medicare
[X]Medicaid Title 19(CFDA# 93.778) Amount: $
Medical Assistance Payments
[ ]Medicaid Title 21(CFDA# 93.767) Amount: $
Children's Health Insurance program
[ ]Medicaid Title 18,19,CLIA
Survey and Certification(CFDA# 93.777) Amount: $
b) State matching funds awarded to the Recipient pursuant to this
agreement are as follows:
(Check appropriate Federal Program funding source and provide
State matching amount per source.)
Department of Health and Human Services, Center for
Medicaid/Medicare
[ ]Medicaid Title 19(CFDA# 93.778) Amount: $
Medical Assistance Payments
[ ]Medicaid Title 21(CFDA# 93.767 Amount: $
Children's Health Insurance Program
[ ]Medicaid Title 18,19, CLIA (CFDA# 93.777)
Survey and Certification Amount: $
c) State Financial Assistance awarded pursuant to Section 215.97,
F.S., Florida Single Audit Act
(If this section is checked provide CSFA #)
[ ]State Project (CSFA# Amount: $
State Project Title:
Attachment VI
(Page 1 of 2)
CERTIFICATION
REGARDING HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996
COMPLIANCE
This certification is required for compliance with the requirements of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The undersigned Provider certifies and agrees as to abide by the following:
Protected Health Information. For purposes of this
Certification, Protected Health Information shall have the same
meaning as the term "protected health information" in 45 C.F.R.
Section 164.501, limited to the information created or received
by the Provider from or on behalf of the Agency.
2. Limits on Use and Disclosure of Protected Health Information.
The Provider shall not use or disclose Protected Health
Information other than as permitted by this Contract or by
federal and state law. The Provider will use appropriate
safeguards to prevent the use or disclosure of Protected Health
Information for any purpose not in conformity with this Contract
and federal and state law. The Provider will not divulge,
disclose, or communicate in any manner any Protected Health
Information to any third party without prior written consent
from the Agency. The Provider will report to the Agency within
two (2) business days of discovery any use or disclosure of
Protected Health Information not provided for in this Contract
of which the Provider is aware. A violation of this paragraph
shall be a material violation of this Contract.
3. Use and Disclosure of Information for Management,
Administration, and Legal Responsibilities. The Provider is
permitted to use and disclose Protected Health Information
received from the Agency for the proper management and
administration of the Provider or to carry out the legal
responsibilities of the Provider, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where
required by law, or where the Provider obtains reasonable
assurances from the person to whom the Protected Health
Information is disclosed that: (1) the Protected Health
Information will be held confidentially, (2) the Protected
Health Information will be used or further disclosed only as
required by law or for the purposes for which it was disclosed
to the person, and (3) the person notifies the Provider of any
instance of which it is aware in which the confidentiality of
the Protected Health Information has been breached.
4. Disclosure to Subcontractors or Agents. The Provider agrees to
enter into a subcontract with any person, including a
subcontractor or agent, to whom it provides Protected Health
Information received from, or created or received by the
Provider on behalf of, the Agency. Such subcontract shall
contain the same terms, conditions, and restrictions that apply
to the Provider with respect to Protected Health Information.
5. Access to Information. The Provider shall make Protected Health
Information available in accordance with federal and state law,
including providing a right of access to persons who are the
subjects of the Protected Health Information.
Amendment and Incorporation of Amendments. The Provider shall
make Protected Health Information available for amendment and to
incorporate any amendments to the Protected Health Information
in accordance with 45 C.F.R. Section 164.526.
7. Accounting for Disclosures. The Provider shall make Protected
Health Information available as required to provide an
accounting of disclosures in accordance with 45 C.F.R. Section
164.528.
Attachment VI
(Page 2 of 2)
8. Access to Books and Records. The Provider shall make its
internal practices, books, and records relating to the use and
disclosure of Protected Health Information received from, or
created or received by the Provider on behalf of, the Agency to
the Secretary of the Department of Health and Human Services or
the Secretary's designee for purposes of determining compliance
with the Department of Health and Human Services Privacy
Regulations.
9. Termination. At the termination of this contract, the Provider
shall return all Protected Health Information that the Provider
still maintains in any form, including any copies or hybrid or
merged databases made by the Provider; or with prior written
approval of the Agency, the Protected Health Information may be
destroyed by the Provider after its use. If the Protected Health
Information is destroyed pursuant to the Agency's prior written
approval, the Provider must provide a written confirmation of
such destruction to the Agency. If return or destruction of the
Protected Health Information is determined not feasible by the
Agency, the Provider agrees to protect the Protected Health
Information and treat it as strictly confidential.
In witness whereof, the Provider and the Agency have caused this
Certification to be signed and delivered by their duly
authorized, representatives, as of the date set forth below
Provider State of Florida, Agency for Health Care
By: /s/ Miguel B. Fernandez Administration
-----------------------------
Print Name: Miguel B. Fernandez By: /s/ [ILLEGIBLE]
---------------------- ---------------------------------
Title: Chief Executive Officer Print Name: [ILLEGIBLE]
-------------------------- -------------------------
Date: 6-25-02 Title: [ILLEGIBLE]
--------------------------- -----------------------------
Date: 6/27/02
-------------------------------
AMENDMENT #1
THIS AMENDMENT, entered into between the State of Florida, Department of Elder
Affairs hereinafter referred to as the "department," the Agency for Health Care
Administration hereinafter referred to as the "agency," and Amerigroup Florida,
Inc. (formerly Physicians Healthcare Plans, Inc.), hereinafter referred to as
the "contractor," amends contract number 2002-2003-02.
1. Section III.D.2 is hereby amended to read:
The name, address and telephone number of the representative for the
agency:
Elizabeth Y. Kidder
Agency for Health Care Administration
2727 Mahan Drive
Mail Stop 20
Tallahassee, Florida 32308
(850) 922-7349
2. Section III.G is hereby amended to read
This contract and Attachments I, II, III, IV, V, VI, and Exhibits A, B, and
C as referenced, contain all terms and conditions agreed upon by the
parties.
3. Attachment I, Section 10 is hereby amended to add
If the contractor wishes to terminate a subcontract with an Assisted Living
Facility or a Nursing Facility in which any of its project enrollees are
currently residing, written notice must be provided to the other parties to
this agreement at least ten (10) calendar days prior to notifying the
subcontractor of its intent to terminate. This requirement is waived if the
facility is not licensed or the Department or Agency waives the notice
period.
4. Attachment I, Section 4.1.G.8 is hereby amended to read
Services must be delivered by qualified providers as defined in sections
4.4, 4.5, 4.6, and 4.7. The contractor must have a credentialing system
approved by an accreditation organization that has been approved by the
agency pursuant to Section 641.512, Florida Statutes. The system must
include procedures for credentialing long-term care providers.
5. Attachment I, Section 4.2.T is hereby amended to read:
Nursing Facility Services: Services furnished in a health care facility
licensed under Chapter 395 or Chapter 400 Part II, Florida Statutes.
6. Attachment I, Section 4.4., Optional Services, is hereby amended to revise
the following definition:
A. Dental Services: The contractor may choose to provide adult dental
services as defined in the Medicaid Dental Coverage and Limitations
Handbook.
7. Attachment I, Section 6.M is hereby deleted.
8. Attachment I, Section 8.1.A.3 is hereby amended to read:
Contractor Level - One report is required for each seven-digit Medicaid
provider number the contractor has under contract.
Example: ABC Health Plan, Medicaid Provider Number 1234567, operates three
locations: ABC of Palm Beach (123456701), ABC of Indian River (123456702),
and ABC of Martin (123456703). A contractor level report would be
summarized over all plans with the seven-digit Medicaid Provider number
(1234567). A location level report would have one report for each
nine-digit provider number (123456701, 123456702, and 123456703).
The following table summarizes the required data reporting for the project:
LEVEL OF REPORTING SUBMISSION REPORTING
REPORT NAME ANALYSIS FREQUENCY METHOD LOCATION
----------------------------------------------------------------------------------
Enrollment, Location Monthly, by 5:00 Asynchronous Fiscal
Disenrollment, and PM on the Transfer Agent
Cancellation Wednesday
Report for Payment preceding the
second to last
Saturday
Enrollment and Location Monthly within 5 Electronic Mail, Department
Disenrollment calendar days after Facsimile,
Report the beginning of Compact Disc,
the reporting month Diskette, or Mail
Encounter Data Individual Quarterly, within 3 Electronic Mail, Department
Report months of end of Compact Disc, or
reporting quarter Diskette
Grievance Report Individual Quarterly within 5 Electronic Mail, Department
calendar days of Facsimile,
end of reporting Compact Disc,
quarter Diskette, or Mail
Updated Provider Location Quarterly, within 5 Electronic Mail, Department
Network Listing calendar days of Facsimile,
end of reporting Compact Disc,
quarter Diskette, or Mail
Minority Business Contractor Monthly, by the Electronic Mail, Department
Enterprise Contract 15th of the month Facsimile, and
Report following the Compact Disc, Agency
reporting month Diskette, or Mail
Financial Contractor Quarterly, within Agency Supplied Agency
Statements 45 calendar days of Template on
end of reporting Compact Disc or
quarter Diskette
Audited Financial Contractor Annually, within Electronic Mail, Agency
Statements 90 calendar days of Compact Disc, or
end of contractors' Diskette
fiscal year
2
9. Attachment I, Section 8.1.A.4 is hereby deleted.
10. The format in which monthly enrollment and disenrollment information is
reported to the Department is hereby revised. The contractor agrees to use
the revised format beginning with the submission of enrollment and
disenrollment information for the month of January 2003.
Attachment I, Section 8.3 is hereby amended to read:
ENROLLMENT AND DISENROLLMENT SUMMARY
This report provides a uniform means of reporting each contractor's monthly
enrollments and disenrollments. The report is required to track enrollment
and assess the reasons for each disenrollment, and to ensure that
disenrollments are in compliance with contract guidelines.
This report must be provided as a Microsoft Excel spreadsheet in the format
specified in Exhibit A of this contract. Enrollments and disenrollments
shall be numbered, and information shall be listed in alphabetized
ascending order by enrollee last name, then by enrollee first name.
Information shall pertain only to enrollments or disenrollments that are
effective for the month being reported. For example, the November 2002
report of disenrollments would include information on an enrollee that
expired on October 28, 2002. October 28, 2002 would be provided as the
Disenrollment Reason Occurrence Date for that enrollee in the Enrollment
and Disenrollment Summary report.
11. The format in which encounter data is reported to the Department is
hereby revised. The contractor agrees to use the revised format beginning
with the submission of encounter data for the quarter January through March
2003.
Attachment I, Section 8.4 is hereby amended to read
ENCOUNTER DATA
The contractor shall provide encounter level service utilization data as
specified in Exhibit B of this contract. The services reported represent
the comprehensive array of services that might be necessary to maintain a
member at home while avoiding nursing home placement, including acute and
long-term care services.
These reports must be provided as ASCII, fixed length text files, with two
files, per enrollee, per month. There will be one file for long-term care
services and one file for acute care services. For example, if an enrollee
were enrolled for an entire quarter, you would have three separate records
in each of two separate files that are submitted once for the entire
quarter. These two files, the Long-Term Care Services file and the Acute
Care Services file, must be submitted once every quarter to the Department.
The contractor may resubmit files with more current data during the
subsequent reporting quarter to replace the data previously submitted. If
files are resubmitted, the previously submitted data will be discarded, and
the more recent data will be utilized.
3
Attachment I, Section 8.5 is hereby amended to read:
GRIEVANCE REPORT
This report provides a uniform means of reporting each contractor's
quarterly grievances, and is needed in order to track the number of
grievances, as well as the reason and disposition of grievances. Grievance
reporting provides a method by which to assess the contractor's ability to
manage formal grievances through its internal grievance process.
The Grievance Report must be provided as a Microsoft Excel spreadsheet in
the format specified in Exhibit C of this contract. The Grievance Report
shall be submitted by the contractor to report all formal grievances or
updates to previously reported grievances, or to report whether there have
been no new grievances during the reporting quarter.
13. The contractor agrees to submit a quarterly updated Provider Network
Listing beginning with the reporting quarter January through March 2003.
Attachment I, Section 8.6 is hereby added as follows:
PROVIDER NETWORK LISTING
This updated listing provides current information on the contractor's
provider network to ensure that adequate resources are available to
enrollees at all times.
The Provider Network Listing may be provided electronically as a Microsoft
Word or Excel file, or as a hard copy via facsimile or mail. The Provider
Network Listing shall be updated to include information on providers who
joined the contractor's provider network, or who were terminated from the
contractor's provider network during the reporting quarter.
If the contractor has not added or terminated a subcontract to its provider
network within the reporting quarter, a statement to that effect shall be
provided to the Department in lieu of an updated Provider Network Listing.
14. EXHIBIT A, Enrollment/Disenrollment Summary, is hereby made a part of the
contract.
15. EXHIBIT B, Encounter Data Reporting Format, is hereby made a part of the
contract.
16. EXHIBIT C, Report of Grievances, is hereby made a part of the contract.
This amendment shall begin on January 21, 2003, or the date on which the
amendment has been signed by all parties, whichever is later.
All provisions in the contract and any attachments thereto in conflict
with this amendment shall be and are hereby changed to conform to this
amendment.
4
All provisions in the contract and any attachments thereto in conflict with
this amendment shall be and are hereby changed to conform to this amendment.
All provisions not in conflict with this amendment are still in effect and
are to be performed at the level specified in the contract.
This amendment and all its attachments are hereby made a part of the
contract.
IN WITNESS WHEREOF, the parties hereto have caused this ten (10) page
amendment to be executed by their officials thereunto duly authorized.
CONTRACTOR: AMERIGROUP FLORIDA, INC. STATE OF FLORIDA
(formerly, Physicians DEPARTMENT OF ELDER AFFAIRS
Healthcare Plans, Inc.)
SIGNED BY: /s/ Imtiaz Sattaur SIGNED BY: /s/ Terry F White
---------------------- ----------------------
NAME: Imtiaz Sattaur NAME: Terry F White
----------------------
TITLE: President and CEO TITLE: Secretary
----------------------
DATE: 1/31/03 DATE: 2/11/03
---------------------- ----------------------
CONTRACTOR FEDERAL ID NUMBER:
65-0318864
- -----------------------------
CONTRACTOR FISCAL YEAR ENDING DATE:
December 31
- -----------------------------------
STATE OF FLORIDA
AGENCY FOR HEALTH CARE
ADMINISTRATION
SIGNED BY : /s/ Rhonda M. Medows
----------------------
NAME: Rhonda M. Medows, M.D.
TITLE: Secretary
DATE: 2/17/03
----------------------
5
EXHIBIT A
(Page 1 of 1)
(Plan Name)
ENROLLMENT/DISENROLLMENT SUMMARY
(Reporting Month)
DISENROLLMENT
---------------------------------------------------------------------------------------------
DISENROLLMENT
DISENROLLMENT REASON OCCURRENCE
LAST NAME FIRST NAME MEDICAID ID# SOCIAL SECURITY # REASON CODE* DATE
---------------------------------------------------------------------------------------------
1
2
3
4
5
---------------------------------------------------------------------------------------------
* Disenrollment Reason Codes:
EXP = Expired
ELG = Lost Medicaid Eligibility
HOS = Enrolled in Hospice
NET = Left Provider Network
CTY = Moved Outside of Service Area
INV = Involuntary for Reason Other than Above
VOL = Voluntary for Reason Other than Above
FRD = Fraudulent Use of Medicaid or Plan ID Card
CAN = Enrollment Cancelled Prior to Effective Date
ENROLLMENT
------------------------------------------------------------------------------------------------
DATE OF INITIAL DATE OF SUBSEQUENT
LAST NAME FIRST NAME MEDICAID ID# SOCIAL SECURITY # ENROLLMENT ENROLLMENT **
------------------------------------------------------------------------------------------------
1
2
3
4
5
6
7
8
9
10
------------------------------------------------------------------------------------------------
** If applicable, enter the date of re-enrollment following a period of
appropriate disenrollment
SUMMARY
Final Enrollment for (Previous Reporting Month): ###
Total New Enrollments: ##
Total Disenrollments: (##)
---------
Final Enrollment for (Current Reporting Month): ###
=========
6
SERVICE UTILIZATION REPORTING
The plan shall provide recipient-specific service utilization date in the
electronic format as specified below. The services reported represent the
comprehensive array of services that might be necessary to maintain a member at
home while avoiding nursing home placement, including acute and long-term care
services.
These reports must be provided as ASCII, fixed length text files, with two
files, per recipient, per month. There will be one file for long-term care
services and one file for acute care services. For example, if a recipient were
enrolled for an entire quarter, you would have three separate records in each of
two separate files that are submitted once for the entire quarter. These two
files, the LTC Services file and the Acute Care Services file, must be submitted
once every quarter to your DOEA/AHCA contract manager. You will have up to three
months after the last month in a specific quarter to submit the quarterly
report.
If no units of service are provided in a category or if the category is not
applicable to you, fill that field with the specified number of spaces (using
the spacebar) that match that particular field length. Right justify all fields
unless noted otherwise. For amount paid, include the sum of Medicaid and
Medicare crossover claims (deductibles and co-pays for Medicare claims).* If you
have questions about the definitions of these services please reference the
appropriate Medicaid coverage and limitations handbook for Medicaid state plan
services. Note: Please do not use commas between fields and round currency to
the nearest dollar amount.
FILE LONG-TERM CARE SERVICES
- --------------------------------------------------------------------------------------------------------------
UNIT OF FIELD
FIELD NAME DESCRIPTION MEASUREMENT LENGTH START COL. END COL. TEXT/NUMERIC
- --------------------------------------------------------------------------------------------------------------
SSN Social Security
Number (left
justify) 000000000 9 1 9 Numeric
- --------------------------------------------------------------------------------------------------------------
MEDICAID Medicaid ID
Number 0000000000 10 10 19 Numeric
- --------------------------------------------------------------------------------------------------------------
ENROLL Initial Date of
Program
Enrollment MMYYYY 6 25 Numeric
- --------------------------------------------------------------------------------------------------------------
DISENROL Date of
Disenrollment,
if Applicable MMYYYY 6 31 Numeric
- --------------------------------------------------------------------------------------------------------------
REINST Reinstate date MMYYYY 6 37 Numeric
- --------------------------------------------------------------------------------------------------------------
ALF ALF Resident
Indicator 1=Yes; 2=No 1 38 Numeric
- --------------------------------------------------------------------------------------------------------------
MONTH Report Month MMYYYY 6 Numeric
- --------------------------------------------------------------------------------------------------------------
UNIT OF SERVICE/
LTC SERVICES DESCRIPTION COST
- --------------------------------------------------------------------------------------------------------------
ADCOMP Adult Companion
Services 15 Minute Unit 4 45 48 Numeric
- --------------------------------------------------------------------------------------------------------------
ADAYHLTH Adult Day
Health Services 15 Minute Unit 4 49 52 Numeric
- --------------------------------------------------------------------------------------------------------------
ALFSVS Assisted Living
Services Days 2 53 54 Numeric
- --------------------------------------------------------------------------------------------------------------
ALFSVS$$ Assisted Living
Services Amount Paid 6 55 60 Numeric
- --------------------------------------------------------------------------------------------------------------
ATTCARE Attendant Care
Services 15 Minute Unit 4 61 64 Numeric
- --------------------------------------------------------------------------------------------------------------
CASEAID Case Aide 15 Minute Unit 4 65 68 Numeric
- --------------------------------------------------------------------------------------------------------------
CASEMGMT Case Management
(Internal) 15 Minute Unit 4 69 72 Numeric
- --------------------------------------------------------------------------------------------------------------
CHORE Chore Services 15 Minute Unit 2 73 74 Numeric
- --------------------------------------------------------------------------------------------------------------
COM_MH Community
Mental Health Visit 2 75 76 Numeric
- --------------------------------------------------------------------------------------------------------------
CNMS_$$ Consumable
Medical Supplies Amount Paid 6 77 82 Numeric
- --------------------------------------------------------------------------------------------------------------
COUNSEL Counseling 15 Minute Unit 4 83 86 Numeric
- --------------------------------------------------------------------------------------------------------------
DME_$$ Durable Medical
Equipment Amount Paid 6 87 92 Numeric
- --------------------------------------------------------------------------------------------------------------
ENVIRAA Environmental
Accessibility
Adaptations Job 2 93 94 Numeric
- --------------------------------------------------------------------------------------------------------------
ESCORT Escort Services 15 Minute Unit 4 95 98 Numeric
- --------------------------------------------------------------------------------------------------------------
FAMT_I Family Training
Services
(Individual) 15 Minute Unit 2 99 100 Numeric
- --------------------------------------------------------------------------------------------------------------
FAMT_G Family Training
Services (Group) 15 Minute Unit 2 101 102 Numeric
- --------------------------------------------------------------------------------------------------------------
FINARRS Financial
Assessment
/Risk Reduction
Services 15 Minute Unit 4 [ILLEGIBLE] 106
- --------------------------------------------------------------------------------------------------------------
- ----------
* Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
clients who are also eligible for Medicare.
7
EXHIBIT B
(Page 2 of 3)
- --------------------------------------------------------------------------------------------------------------
UNIT OF FIELD
FIELD NAME DESCRIPTION MEASUREMENT LENGTH START COL. END COL. TEXT/NUMERIC
- --------------------------------------------------------------------------------------------------------------
FINM RRS Financial
Maintenance/Risk
Reduction Services 15 Minute Unit 4 107 110 Numeric
- --------------------------------------------------------------------------------------------------------------
HDMEAL Home Delivered
Meal Meal 2 111 112 Numeric
- --------------------------------------------------------------------------------------------------------------
HOMESRVS Homemaker Services 15 Minute Unit 4 113 116 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 117 120 Numeric
- --------------------------------------------------------------------------------------------------------------
Days 2 121 122 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 123 126 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 127 130 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 131 134 Numeric
- --------------------------------------------------------------------------------------------------------------
PERS_I Personal Emergency
Response System
Installation Job 2 135 136 Numeric
- --------------------------------------------------------------------------------------------------------------
PERS_M Personal Emergency
Response System -
Maintenance Day 2 137 138 Numeric
- --------------------------------------------------------------------------------------------------------------
PEST_I Pest Control -
Initial Visit Job 2 139 140 Numeric
- --------------------------------------------------------------------------------------------------------------
Month 1 141 141 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 142 145 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 146 149 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 150 153 Numeric
- --------------------------------------------------------------------------------------------------------------
Visit 2 154 155 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 156 159 Numeric
- --------------------------------------------------------------------------------------------------------------
15 Minute Unit 4 160 163 Numeric
- --------------------------------------------------------------------------------------------------------------
Days 2 164 165 Numeric
- --------------------------------------------------------------------------------------------------------------
Visit 4 166 169 Numeric
- --------------------------------------------------------------------------------------------------------------
SPTH 15 Minute Unit 4 170 173 Numeric
- --------------------------------------------------------------------------------------------------------------
TRANSPOR Transportation
Services (not
included in Escort
or Adult Day
Health services) Trips 3 174 176 Numeric
- --------------------------------------------------------------------------------------------------------------
OTH_UNIT Other LTC Service
not listed (unit) Unit/Visit 6 177 182 Numeric
- --------------------------------------------------------------------------------------------------------------
35 183 217 Text
- --------------------------------------------------------------------------------------------------------------
Amount Paid 6
- --------------------------------------------------------------------------------------------------------------
35
- --------------------------------------------------------------------------------------------------------------
EXHIBIT B
FILE 2: ACUTE CARE SERVICES
- -------------------------------------------------------------------------------------------------------------
UNIT OF FIELD START END TEXT/NUMERIC
CODE FIELD NAME DESCRIPTION MEASUREMENT LENGTH COL. COL.
- -------------------------------------------------------------------------------------------------------------
ACUTE DESCRIPTION UNITS OF
SERVICES SERVICE/COST
- -------------------------------------------------------------------------------------------------------------
SSN Social Security
Number (left
justify) 000000000 9 1 9 Numeric
- -------------------------------------------------------------------------------------------------------------
MEDICAID Medicaid ID
Number 0000000000 10 10 19 Numeric
- -------------------------------------------------------------------------------------------------------------
MONTH Report Month MMYYYY 6 20 25 Numeric
- -------------------------------------------------------------------------------------------------------------
CLINIC Clinic Services Visit 2 26 27 Numeric
- -------------------------------------------------------------------------------------------------------------
CLINIC$$ Clinic Services Visit 2 28 29 Numeric
Costs
- -------------------------------------------------------------------------------------------------------------
DENTAL Dental Services Visit 6 30 35 Numeric
- -------------------------------------------------------------------------------------------------------------
DENTAL$$ Dental Services
Costs Amount Paid 6 36 41 Numeric
- -------------------------------------------------------------------------------------------------------------
DIALYSIS Dialysis Center Visit 2 42 43 Numeric
- -------------------------------------------------------------------------------------------------------------
DIALYS$$ Dialysis Center
Costs Amount Paid 6 44 49 Numeric
- -------------------------------------------------------------------------------------------------------------
ER Emergency Room
Services Visit 2 50 51 Numeric
- -------------------------------------------------------------------------------------------------------------
ER_$$ Emergency Room
Services Costs Amount Paid 6 52 57 Numeric
- -------------------------------------------------------------------------------------------------------------
FQHC FQHC Services Visit 2 58 59 Numeric
- -------------------------------------------------------------------------------------------------------------
FQHC_$$ FQHC Services
Costs Amount Paid 6 60 65 Numeric
- -------------------------------------------------------------------------------------------------------------
HEAR Hearing Services
Including
hearing aids Amount Paid 6 66 71 Numeric
- -------------------------------------------------------------------------------------------------------------
INPTSVS Inpatient
Hospital Services Day 3 72 74 Numeric
- -------------------------------------------------------------------------------------------------------------
INPTSVSS Inpatient
Hospital
Services Costs Amount Paid 6 75 80 Numeric
- -------------------------------------------------------------------------------------------------------------
Amount Paid 6 81 86 Numeric
- -------------------------------------------------------------------------------------------------------------
??SP Nurse P? Visit 2 87 88 Numeric
- -------------------------------------------------------------------------------------------------------------
??RNP_$$ Nurse P?? Amount Paid 6 89 94 Numeric
- -------------------------------------------------------------------------------------------------------------
?X_$$ Pharmaceuticals Amount Paid 6 95 100 Numeric
- -------------------------------------------------------------------------------------------------------------
PA Physical
Assistant Visit 2 101 102 Numeric
- -------------------------------------------------------------------------------------------------------------
PA_$$ Physical
Assistant Costs Amount Paid 6 103 106 Numeric
- -------------------------------------------------------------------------------------------------------------
MD Physician
Services Visit 2 109 110 Numeric
- -------------------------------------------------------------------------------------------------------------
Physician
Services Costs Amount Paid 6 111 116 Numeric
- -------------------------------------------------------------------------------------------------------------
Encounter 3 117 119 Numeric
- -------------------------------------------------------------------------------------------------------------
OUTPT_$$ Amount Paid 6 120 125 Numeric
- -------------------------------------------------------------------------------------------------------------
Visit 2 126 127 Numeric
- -------------------------------------------------------------------------------------------------------------
PODIAT$$ Amount Paid 6 128 133 Numeric
- -------------------------------------------------------------------------------------------------------------
Rural Health
Services Visit 2 134 135 Numeric
- -------------------------------------------------------------------------------------------------------------
Rural Health
Services Costs Amount Paid 6 136 141 Numeric
- -------------------------------------------------------------------------------------------------------------
SNFREHAS Skilled nursing
facility
services -
rehabilitation ** Amount Paid 6 142 147 Numeric
- -------------------------------------------------------------------------------------------------------------
EYE_$$ Visual Services
including
eyeglasses Amount Paid 6 148 153 Numeric
- -------------------------------------------------------------------------------------------------------------
Other Acute
Service not
listed (unit) Unit/Visit 6 154 159 Numeric
- -------------------------------------------------------------------------------------------------------------
DESCR 1 Description of
other Acute
service 35 160 194 Text
- -------------------------------------------------------------------------------------------------------------
OTH_$ Other Acute
Service not
listed (amount) Amount Paid 6 195 200 Numeric
- -------------------------------------------------------------------------------------------------------------
Description of
other Acute
service 35 201 235 Text
- -------------------------------------------------------------------------------------------------------------
**Medicare Crossovers
EXHIBIT C
(Page 1 of 1)
(Plan Name)
REPORT OF GRIEVANCES
(Reporting Quarter)
Were any new grievances filed during this reporting quarter? YES [ ] NO [ ]
-------------------------------------------------------------------------------------------------------------------------------
ENROLLEE'S ENROLLEE'S ENROLLEE'S ENROLLEE'S GRIEVANCE GRIEVANCE EXPEDITED DISPOSITION DISPOSITION RESOLVED?
LAST NAME FIRST NAME MEDICAID SOCIAL TYPE * DATE REQUEST? TYPE ** DATE (Y OR N)
ID # SECURITY # (Y OR N)
-------------------------------------------------------------------------------------------------------------------------------
1
2
3
4
5
-------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------
Grievance Type
-----------------------------------------------------------------------
1 = Quality of Care 7 = Enrollment/Disenrollment
2 = Access to Care 8 = Termination of Contract
3 = Not Medically Necessary 9 = Unauthorized out of plan svcs
4 = Excluded Benefit 10 = Unauthorized in-plan svcs
5 = Billing Dispute 11 = Benefits available in plan
6 = Contract Interpretation 12 = Other
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Disposition Type
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1 = Reassigned Case Manager 7 = Disenrolled Self
2 = Service Added to Plan of Care 8 = Disenrolled by plan
3 = Service Increased 9 = In QA Review
4 = Changed to Another Provider 10 = In Grievance Process
5 = Reinstated in Plan 11 = Lost Contact with Enrollee
6 = Billing Issue Resolved 12 = Other
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10