Exhibit 10.32
MEDICAL SERVICES CONTRACT
FLORIDA HEALTHY KIDS CORPORATION
and
PHYSICIANS HEALTHCARE PLANS, INC.
FOR
ORANGE, OSCEOLA AND SEMINOLE
Amendment #1 - Effective December 1, 2001
Amendment #3 - Effective December 1, 2002
FLORIDA HEALTHY KIDS CORPORATION
CONTRACT FOR MEDICAL SERVICES
TABLE OF CONTENTS
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
2-2 Payments
2-3 Reduced Fee Arrangements
2-3-1 Specialty Fee Arrangements
2-3-2 Children's Medical Services
2-4 Quarterly Program Updates
2-5 Change in Benefit Schedule
2-6 Marketing
2-7 Forms and Reports
2-8 Coordination of Benefits
2-9 Entitlement to Reimbursement
SECTION 3 PHYSICIANS HEALTHCARE PLANS, INC.
3-1 Benefits
3-2 Access to Care
3-3 Marketing Materials
3-4 Use of Name
3-5 Eligibility
3-6 Effective Date of Coverage
3-7 Termination of Participation
3-8 Continuation of Coverage Upon Termination of this Agreement
3-9 Individual Contracts
3-10 Refusal of Coverage
3-11 Extended Coverage
3-12 Grievances and Complaints
3-13 Claims Payment
3-14 Notification
3-15 Rates
3-16 Rate Modification
3-17 Conditions of Services
3-18 Medical Records Requirements
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3-18-1 Medical Quality Review and Audit
3-19 Quality Enhancement
3-19-1 Authority
3-19-2 Staff
3-19-3 Peer Review
3-19-4 Referrals
3-20 Availability of Records
3-21 Audits
3-21-1 Accessibility of Records
3-21-2 Financial Audit
3-21-3 Post-Contract Audit
3-21-4 Accessibility for Monitoring
3-22 Indemnification
3-23 Confidentiality of Information
3-24 Insurance
3-25 Lobbying Disclosure
3-26 Reporting Requirements
3-27 Participant Liability
3-28 Protection of Proprietary Information
3-29 Regulatory Filings
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
4-2 Multi-year Agreement
4-3 Entire Understanding
4-4 Independent Contractor
4-5 Assignment
4-6 Notice
4-7 Amendments
4-8 Governing Law
4-9 Contract Variation
4-10 Attorney's Fees
4-11 Representatives
4-12 Termination
4-13 Contingency
SECTION 5 EXHIBITS
Exhibit A: Premium Payment and Rates
Exhibit B: Enrollment Dates
Exhibit C: Benefits
Exhibit D: Coordination of Benefits
Exhibit E: Access Standards
Exhibit F: Grievance Procedure
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Exhibit G: Eligibility
Exhibit H: Reporting Requirements
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AGREEMENT TO PROVIDE
COMPREHENSIVE HEALTH CARE SERVICES
This agreement is made by and between the Florida Healthy Kids
Corporation, hereinafter referred to as "FHKC" and PHYSICIANS HEALTHCARE PLANS,
INC., hereinafter referred to as "PHP".
WHEREAS, FHKC has been specifically empowered in subsections 624.91 (4)
(b) 4, 7, 8 and 10, Florida Statutes, to enter into contracts with HMO's,
insurers, or any provider of health care services, meeting standards established
by FHKC, for the provision of comprehensive health insurance coverage to
participants; and
WHEREAS, Sections 641.2017 (1) and (2), Florida Statutes, allows PHP to
enter such a contractual arrangement on a prepaid per capita basis whereby PHP
assumes the risk that costs exceed the amount paid on a prepaid per capita
basis; and
WHEREAS, FHKC desires to increase access to health care services and
improve children's health; and
WHEREAS, FHKC did issue an Invitation to Participate in the FHKC School
Enrollment-Based Health Insurance Program inviting PHP as well as other
entities, to submit a proposal for the provision of those comprehensive health
care services set forth in the Invitation to Participate; and
WHEREAS, PHP's proposal in response to the Invitation to Participate was
selected through a competitive bid process as the most responsive bids; and
WHEREAS, PHP has assured FHKC of full compliance with the standards
established in this Agreement and agrees to promptly respond to any required
revisions or changes in the FHKC operating procedures which may be required by
law or implementing regulations; and
WHEREAS, FHKC is desirous of using PHP's provider network to deliver
comprehensive health care services to all eligible FHKC participants in Orange,
Osceola and Seminole Counties;
NOW, THEREFORE, in consideration of the premises and the mutual
covenants and promises contained herein, the parties agree as follows:
SECTION 1 GENERAL PROVISIONS
1-1 Definitions
As used in this agreement, the term:
A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be provided
by PHP in accordance with standards set by FHKC and
further described in Exhibit C.
B. "THE PROGRAM" shall mean the project established by FHKC
pursuant to Section 624.91, Florida Statutes and
specified herein.
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C. "PARTICIPANT" means those individuals meeting FHKC
standards of eligibility and who have been enrolled in
the program.
D. "PHP PROVIDERS" shall mean those providers set forth in
the participant's handbook as from time to time amended.
E. "CO-PAYMENT" is the payment required of the participant
at the time of obtaining service. In the event the
participant fails to pay the required co-payment, PHP
may decline to provide non-emergency or non-urgently
needed care.
SECTION 2 FLORIDA HEALTHY KIDS CORPORATION RESPONSIBILITIES
2-1 Participant Identification
FHKC shall promptly furnish to PHP information to sufficiently identify
participants in the Comprehensive Health Care Services plan authorized by this
agreement. Additionally, FHKC shall provide PHP a compatible computer tape, or
other computer-ready media, with the names of participants along with monthly
additions or deletions throughout the term of this contract in accordance with
the following:
A. With respect to participants who enroll during open enrollment,
such listing shall be furnished not less than seven (7) working
days prior to the effective date of coverage.
B. With respect to additions and deletions occurring after open
enrollment, such listing shall be furnished not less than seven
(7) working days prior to effective date of coverage.
C. With respect to both A and B above, furnish a supplemental list
of eligible participants by the third day after the effective
date of coverage. PHP shall adjust enrollment retroactively to
the 1st day of that month in accordance with the supplemental
list and as listed in Exhibit B.
D. FHKC may request PHP to accept additional participants after the
supplemental listing for enrollment retroactive to the 1st of
that coverage month. Such additions will be limited to those
participants who made timely payments but were not included on
the previous enrollment reports. If such additions exceed more
than one percent on that month's enrollment, PHP reserves the
right to deny FHKC's request.
2-2 Payments
FHKC will promptly forward the authorized premiums in accordance with Exhibit A
attached hereto and incorporated herein as part of this Agreement on or before
the 1st day of each month this Agreement is in force commencing with the 1st day
of October, 1998. Premiums are past due on the 15th day of each month.
In the case of non-payment of premiums by the 15th day of the month for that
month of coverage, PHP shall have the right to terminate coverage under this
contract, provided FHKC is given written notice prior to such termination.
Termination of coverage shall be retroactive to the last day for which premium
payment has been made.
2-3 Reduced Fee Arrangements
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2-3-1 Specialty Service Fee Arrangements
Upon prior approval of PHP, FHKC shall have the right to
negotiate specialty service fee arrangements with non-PHP
affiliated providers and make such rates available to PHP. In
such cases if there is a material impact on the premium, the
premium in Exhibit A will be adjusted by PHP in a manner
consistent with sound actuarial practices.
2-3-2 Children's Medical Services Network
If there is a material impact on the premium in Exhibit A due to
the implementation of the Children's Medical Services Network as
created in Chapter 391, Florida Statutes, PHP agrees to reduce
the premium in Exhibit A in an amount consistent with sound
actuarial practices.
2-4 Program Updates
FHKC shall provide PHP with updates on program highlights such as participant
demographics, profiles, newsletters, legislative or regulatory inquiries and
program directives.
2-5 Change in Benefit Schedule
FHKC agrees that any changes to the participant benefit schedule as set forth in
Exhibit C attached hereto and incorporated herein as part of this Agreement,
shall only be made as the parties hereto may mutually agree in writing.
2-6 Marketing
FHKC will market the program primarily through the Orange, Osceola and Seminole
school districts. FHKC agrees that PHP shall be allowed to participate in any
scheduled marketing efforts to include, but not be limited to, any scheduled
open house type activities. However, PHP is prohibited from any direct marketing
to applicants or the use of FHKC's logo, name or corporate identity unless such
activity has received prior written authorization from FHKC. Written
authorization must be received for every individual activity.
FHKC will have the right of approval or disapproval of all descriptive plan
literature and forms.
2-7 Forms and Reports
FHKC agrees that PHP shall participate in the development of any FHKC
eligibility report formats which may be required from time to time.
2-8 Coordination of Benefits
FHKC agrees that PHP shall be able to coordinate health benefits with other
insurers as provided for in Florida Statutes and the procedures contained in
Exhibit D attached hereto and incorporated herein as part of this Agreement.
If PHP identifies a participant covered through another health benefits program,
PHP shall notify FHKC. FHKC shall make the decision as to whether the
participant may continue coverage through FHKC in accordance with the
eligibility standards contained herein.
2-9 Entitlement to Reimbursement
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In the event PHP provides medical services or benefits to participants who
suffer injury, disease or illness by virtue of the negligent act or omission of
a third party, PHP shall be entitled to reimbursement from the participant, at
the prevailing rate, for the reasonable value of the services or benefits
provided. PHP shall not be entitled to reimbursement in excess of the
participant's monetary recovery for medical expenses provided, from the third
party.
SECTION 3 PHP RESPONSIBILITIES
3-1 Benefits
PHP agrees to make its provider network available to FHKC participants in
Orange, Osceola and Seminole Counties and to provide the comprehensive health
care services as set forth in Exhibit C attached hereto and by reference made a
part hereof.
3-2 Access to Care
PHP agrees to meet or exceed the appointment and geographic access standards for
pediatric care existing in the community and as specifically provided for in
Exhibit E attached hereto and incorporated herein as a part of this Agreement.
In the event PHP's provider network is unable to provide those medically
necessary benefits specified in Exhibit C, for any reason, except force majeure,
PHP shall be responsible for those contract benefits obtained from providers
other than PHP for eligible FHKC participants. In the event PHP fails to meet
those access standards set forth in Exhibit E, FHKC may, after following
procedures set forth in Exhibit E, direct its participants to obtain such
contract benefit from other providers and may contract for such services. All
financial responsibility related to services received under these specific
circumstances shall be assumed by PHP.
3-3 Marketing Materials
PHP agrees that it shall not utilize the marketing materials, logos, trade
names, service marks or other materials belonging to FHKC without FHKC's consent
which shall not be unreasonably withheld.
PHP will be responsible for all preparation, cost and distribution of members
PHP handbooks, plan documents, materials, and orientation, for FHKC
participants. Materials will be appropriate to the population served and unique
to the program.
3-4 Use of Name
PHP consents to the use of its name in any marketing and advertising or media
presentations describing FHKC, which are developed and disseminated by FHKC to
participants, employees, employers, the general public or the Orange, Osceola
and Seminole counties school systems, provided however, PHP reserves the right
to review and concur in any such marketing materials prior to their
dissemination.
3-5 Eligibility
PHP agrees to accept participants who meet the eligibility standards contained
in Exhibit G attached hereto and incorporated herein as a part of this
Agreement. Provided, PHP reserves the right upon reasonable notification to
periodically review certain eligibility determinations and FHKC shall ensure all
records and findings concerning a particular eligibility determination will be
made available with reasonable promptness.
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3-6 Effective Date of Coverage
Coverage for every participant shall become effective at 12:01 a.m. EST/EDT, as
appropriate, and as indicated in Exhibit B.
3-7 Termination of Participation
A participant's coverage under this program shall terminate on the last day of
the month in which the participant:
A. ceases to be eligible to participate in the program;
B. establishes residence outside the service area; or
C. is determined to have acted fraudulently in obtaining coverage
hereunder.
3-8 Continuation of Coverage Upon Termination of this Agreement
PHP agrees that, upon termination of this Agreement for any reason, unless
instructed otherwise by FHKC, it will continue to provide inpatient services to
FHKC participants who are then inpatients until such time as such participants
have been appropriately discharged. However, PHP shall not be required to
provide such extended benefits beyond 12 calendar months from the date the
Agreement is terminated.
If PHP terminates this Contract at its sole option and through no fault of the
FHKC and if on the date of termination a participant is totally disabled and
such disability commenced while coverage was in effect, that participant shall
continue to receive all benefits otherwise available under this contract for the
condition under treatment which caused such total disability until the earlier
of (1) the expiration of the contract benefit period for such benefits; (2)
determination by the Medical Director of PHP that treatment is no longer
medically necessary; (3) twelve (12) months from the date of termination of
coverage; (4) a succeeding carrier elects to provide replacement coverage
without limitation as to the disability condition; provided however, that
benefits will be provided only so long as the participant is continuously
totally disabled and only for the illness or injury which caused the total
disability.
For the purpose of this section, a participant who is "totally disabled" shall
mean a participant who is physically unable to work, as determined by the
Medical Director of PHP, due to an illness or injury at any gainful job for
which the participant is suited by education, training, experience or ability.
Pregnancy, childbirth or hospitalization in and of themselves do not constitute
"total disability". In the case of maternity coverage, when participant is
eligible for such coverage, when not covered by a succeeding carrier, a
reasonable period of extension of benefits shall be granted. The extension of
benefits shall be only for the period of pregnancy, and shall not be based on
total disability.
3-9 Participant Certificates and Handbooks
PHP will issue participant certificates and handbooks to all FHKC designated
participants. Except as specifically provided in Sections 3-8 and 3-11 hereof,
all participant rights and benefits shall terminate upon termination of this
Agreement or upon termination of participation in the program.
3-10 Refusal of Coverage
PHP shall not refuse to provide coverage to any participant on the basis of past
or present health status.
3-11 Extended Coverage
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With regards to those participants who have been terminated pursuant to Section
3-7 A, PHP will offer individual coverage to all participants without regard to
health condition or status.
3-12 Grievances and Complaints
PHP agrees to provide all FHKC participants a Grievance Process and make reports
quarterly to the FHKC, as required, in accordance with Exhibit F attached hereto
and incorporated herein as a part of this Agreement.
In addition, the grievance and complaint procedures shall be governed by the
following rules and guidelines:
A. There must be sufficient support staff (clerical and
professional) available to process grievances.
B. Staff must be educated concerning the importance of the
procedure and the rights of the enrollee.
C. Someone with problem solving authority must be part of the
grievance procedure.
D. In order to initiate the grievance process, such grievance must
be filed in writing.
E. The parties will provide assistance to grievant during the
grievance process to the extent FHKC deems necessary.
F. Grievances shall be resolved within sixty days from initial
filing by the participant, unless information must be collected
from providers located outside the authorized service area or
from non-contract providers. In such exceptions, an additional
extension shall be authorized upon establishing good cause.
G. A record of informal complaints received which are not
grievances shall be maintained and shall include the date, name,
nature of the complaint and the disposition.
3-13 Claims Payment
PHP will pay any claims from its offices located at 777 South Harbor Island
Blvd., Tampa, Florida 33602 (or any other designated claims office located in
its service area). PHP will pay clean claims filed within thirty (30) working
days or request additional information of the claimant necessary to process the
claim.
3-14 Notification
PHP shall immediately notify FHKC of:
A. Any judgment, decree, or order rendered by any court of any
jurisdiction or Florida Administrative Agency enjoining PHP from
the sale or provision of service under Chapter 641, Part II,
Florida Statutes.
B. Any petition by PHP in bankruptcy or for approval of a plan of
reorganization or arrangement under the Bankruptcy Act or
Chapter 631, Part I, Florida Statutes, or an admission seeking
the relief provided therein.
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C. Any petition or order of rehabilitation or liquidation as
provided in Chapters 631 or 641, Florida Statutes.
D. Any order revoking the Certificate Of Authority granted to PHP.
E. Any administrative action taken by the Department of Insurance
or Agency for Health Care Administration in regard to PHP.
F. Any medical malpractice action filed in a court of law in which
a FHKC participant is a party (or in whose behalf a
participant's allegations are to be litigated).
G. The filing of an application for change of ownership with the
Florida Department of Insurance.
H. On a monthly basis, inform FHKC of any changes to the provider
network that differ from the network presented in the original
bid proposal, including discontinuation of any primary care
providers or physician practice associations or groups with
Healthy Kids enrollees on their panels.
3-15 Rates
The rate charged for provision of Comprehensive Health Care Services shall be as
stated in Exhibit A.
3-16 Rate Modification
I. Annual Adjustment
Upon request by PHP, the Board of Directors of the FHKC may
approve an adjustment to the premium effective only on October
1, however each adjustment must meet the following minimum
conditions:
A. Any request to adjust the premium must be received by
the preceding April 1;
B. The request for an adjustment must be accompanied by a
supporting independent actuarial memorandum; and
C. The proposed premium shall not be excessive or
inadequate in accordance with the standards established
by the Department of Insurance for such determination.
II. Coverage\Copayment Adjustment
In the event, FHKC requires a change in coverage or benefits to
be effective immediately, PHP shall have the right within ninety
(90) calendar days from the effective date of the such change to
propose in writing any adjustment to premium necessitated by
such change. Such proposed premium adjustments shall comply with
paragraph (d) of Section I above and upon approval of FHKC shall
be retroactive to
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the effective date of such change. The retroactive payment of
the adjusted premium shall apply only to non-subsidized
participants. The proposed premium increase shall not be
excessive or inadequate as determined by an independent actuary
mutually acceptable to both FHKC and PHP.
3-17 Conditions of Services
Services shall be provided by PHP under the following conditions:
A. Appointment. Participants shall first contact their assigned
primary care physician for an appointment in order to receive
non-emergency health services.
B. Provision of Services. Services shall be provided and paid for
by PHP only when PHP performs, prescribes, arranges or
authorizes the services. Services are available only from and
under the direction of PHP and neither PHP nor PHP Physicians
shall have any liability or obligation whatsoever on account of
any service or benefit sought or received by any member from any
other physician or other person, institution or organization,
unless prior special arrangements are made by PHP and confirmed
in writing except as provided for in Section 3-2.
C. Hospitalization. PHP does not guarantee the admission of a
participant to any specific hospital or other facility or the
availability of any accommodations or services therein.
Inpatient Hospital Service is subject to all rules and
regulations of the hospital or other medical facility to which
the member is admitted.
D. Emergency Services. Exceptions to Section 3-17 A, B and C are
services which are needed immediately for treatment of an injury
or sudden illness where delay means risk of permanent damage to
the participant's health. PHP shall provide and pay for
emergency services both inside and outside the service area.
3-18 Medical Records Requirements
PHP shall require providers to maintain medical records for each participant
under this contract in accordance with applicable state and federal law.
3-18-1 Medical Quality Review and Audit
FHKC shall conduct an independent medical quality review of PHP
at the conclusion of the first twelve months of coverage. The
independent auditor's report will include a written review and
evaluation of care provided to FHKC participants in Orange,
Osceola and Seminole Counties.
3-19 Quality Enhancement (Assurance)
The PHP shall have a quality enhancement program. If the PHP has an existing
program, it must satisfy the FHKC's quality enhancement standards. Approval will
be based on the PHP adherence to the minimum standards listed below.
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3-19-1 Quality Enhancement Authority. The Plan shall have a quality
enhancement review authority which shall:
(a) Direct and review all quality enhancement activities.
(b) Assure that quality enhancement activities take place in
all areas of the plan.
(c) Review and suggest new or improved quality enhancement
activities.
(d) Direct task forces/committees in the review of focused
concern.
(e) Designate evaluation and study design procedures.
(f) Publicize findings to appropriate staff and departments
within the plan.
(g) Report findings and recommendations to the appropriate
executive authority.
(h) Direct and analyze periodic reviews of enrollees'
service utilization patterns.
3-19-2 Quality Enhancement Staff. The plan shall provide for quality
enhancement staff which has the responsibility for:
(a) Working with personnel in each clinical and
administrative department to identify problems related
to quality of care for all covered professional
services.
(b) Prioritizing problem areas for resolution and designing
strategies for change.
(c) Implementing improvement activities and measuring
success.
(d) Performing a quarterly review of a random selection of
10 percent or 50 enrollee records, whichever is fewer.
Reviewing elements shall include management of specific
diagnosis, appropriateness and timeliness of care,
comprehensiveness of and compliance with the plan of
care, and evidence of special screening for high risk
individuals or conditions.
(e) Providing outcome of any Quality Enhancement activities
involving children 5-19 years of age to the FHKC.
3-19-3 Peer Review Authority. The plan's quality enhancement program
shall have a peer review component and a peer review authority.
Scope of Activities
(a) The review of the practice methods and patterns of
individual physicians and other health care
professionals.
(b) The ability and responsibility to evaluate the
appropriateness of care rendered by professionals.
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(c) The authority to implement corrective action when deemed
necessary.
(d) The responsibility to develop policy recommendations to
maintain or enhance the quality of care provided to plan
participants.
(e) A review process which includes the appropriateness of
diagnosis and subsequent treatment, maintenance of
medical record requirements, adherence to standards
generally accepted by professional group peers, and the
process and outcome of care.
(f) The maintenance of written minutes of the meetings and
provision of reports to FHKC of any activities related
to FHKC participants.
(g) Peer review must include examination of morbidity and
mortality.
3-19-4 Referrals To Peer Review Authority
(a) All written and/or oral allegations of inappropriate or
aberrant service must be referred to the Peer Review
Authority.
(b) Recipients and staff must be advised of the role of the
Peer Review Authority and the process to advise the
authority of situations or problems.
(c) All grievances related to medical treatment must be
presented to the Authority for examination and, when a
FHKC participant is involved, the outcome of the
grievance resolution reported to FHKC.
3-20 Availability of Records
PHP shall make all records available at its own expense for review, audit, or
evaluation by authorized federal, state and FHKC personnel. The location will be
determined by PHP subject to approval of FHKC. Access will be during normal
business hours and will be either through on-site review of records or through
the mail.
Copies of all records, will be sent to FHKC by certified mail within seven
working days of request. It is FHKC's responsibility to obtain sufficient
authority, as provided for by applicable statute or requirement, to provide for
the release of any patient specific information or records requested by the
FHKC, State or Federal agencies.
3-21 Audits
3-21-1 Accessibility of Records
PHP shall maintain books, records, documents, and other evidence
pertaining to the administrative costs and expenses of the
contract relating to the individual participants for the
purposes of audit requirements. These records, books, documents,
etc., shall be available for review by authorized federal, state
and FHKC personnel during the contract period and five (5) years
thereafter, except if an audit is in progress or audit findings
are yet unresolved in which case records shall be kept until all
tasks are completed. During the contract period these records
shall be available at PHP's offices at all reasonable times.
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After the contract period and for five years following, the
records shall be available at PHP's chosen location subject to
the approval of FHKC. If the records need to be sent to FHKC,
PHP shall bear the expense of delivery. Prior approval of the
disposition of PHP and subcontractor records must be requested
and approved if the contract or subcontract is continuous.
This agreement is subject to unilateral cancellation by FHKC if
PHP refuses to allow such public access.
3-21-2 Financial Audit
Upon reasonable notice by FHKC, PHP shall permit an independent
audit by FHKC of its financial condition or performance standard
in accordance with the provisions of this agreement and the
Florida Insurance Code and regulations adopted thereunder.
3-21-3 Post-Contract Audit
PHP agrees to cooperate with the post-contract audit
requirements of appropriate regulatory authorities and in the
interim will forward promptly PHP's annual audited financial
statements to the FHKC. In addition, PHP agrees to the
following:
PHP agrees to retain and make available upon request, all books,
documents and records necessary to verify the nature and extent
of the costs of the services provided under this Agreement, and
that such records will be retained and held available by PHP for
such inspection until the expiration of four (4) years after the
services are furnished under this Agreement. If, pursuant to
this Agreement and if PHP's duties and obligations are to be
carried out by an individual or entity subcontracting with PHP
and that subcontractor is, to a significant extent, owns or is
owned by or has control of or is controlled by PHP, each
subcontractor shall itself be subject to the access requirement
and PHP hereby agrees to require such subcontractors to meet the
access requirement.
PHP understands that any request for access must be in writing
and contain reasonable identification of the documents, along
with a statement as to the reason that the appropriateness of
the costs or value of the services in question cannot be
adequately or efficiently determined without access to its books
or records. PHP agrees that it will notify FHKC in writing
within ten (10) days upon receipt of a request for access.
3-21-4 Accessibility for Monitoring
PHP shall make available to all authorized federal, state and
FHKC personnel, records, books, documents, and other evidence
pertaining to the contract as well as appropriate personnel for
the purpose of monitoring under this contract. The monitoring
shall occur periodically during the contract period.
3-22 Indemnification
PHP agrees to indemnify and hold harmless FHKC from any losses resulting from
negligent, dishonest, fraudulent or criminal acts of PHP, its officers, its
directors, or its employees, whether acting alone or in collusion with others.
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PHP shall indemnify, defend, and hold FHKC and its officers, employees and
agents harmless from all claims, suits, judgments or damages, including court
costs and attorney fees, arising out of any negligent or intentional torts by
PHP.
PHP shall hold all enrolled participants harmless from all claims for payment of
covered services, except co-payments, including court costs and attorney fees
arising out of or in the course of this contract pertaining to covered services.
In no case will FHKC or program participants be liable for any debts of the PHP.
PHP agrees to indemnify, defend, and save harmless FHKC, its officers, agents,
and employees from:
A. Any claims or losses attributable to a service rendered by any
subcontractor, person, or firm performing or supplying services,
materials, or supplies in connection with the performance of the
contract regardless of whether FHKC knew or should have known of
such improper service, performance, materials or supplies.
B. Any failure of PHP, its officers, employees, or subcontractors
to observe Florida law, including but not limited to labor laws
and minimum wage laws, regardless of whether the FHKC knew or
should have known of such failure.
With respect to the rights of indemnification given herein, FHKC agrees to
provide to PHP, if known to FHKC, timely written notice of any loss or claim and
the opportunity to mitigate, defend and settle such loss or claim as a condition
to indemnification
3-23 Confidentiality of Information
PHP shall treat all information, and in particular information relating to
participants which is obtained by or through its performance under the contract,
as confidential information to the extent confidential treatment is provided
under state and federal laws. PHP shall not use any information so obtained in
any manner except as necessary for the proper discharge of its obligations and
securement of its rights under the contract.
All information as to personal facts and circumstances concerning participants
obtained by PHP shall be treated as privileged communications, shall be held
confidential, and shall not be divulged without the written consent of FHKC or
the participant, provided that nothing stated herein shall prohibit the
disclosure of information in summary, statistical, or other form which does not
identify particular individuals. The use or disclosure of information concerning
participants will be limited to purposes directly connected with the
administration of the contract. It is expressly understood that substantial
evidence of PHP's refusal to comply with this provision shall constitute a
breach of contract.
3-24 Insurance
PHP shall not commit any work in connection with the contract until it has
obtained all types and levels of insurance required and approved by appropriate
state regulatory agencies. The insurance includes but is not limited to worker's
compensation, liability, fire insurance, and property insurance. Upon request,
FHKC shall be provided proof of coverage of insurance by a certificate of
insurance accompanying the contract documents.
FHKC shall be exempt from and in no way liable for any sums of money which may
represent a deductible in any insurance policy. The payment of such a deductible
shall be the sole responsibility of PHP and/or subcontractor holding such
insurance. The same holds true of any premiums paid on any insurance policy
pursuant to this contract. Failure to provide proof of coverage may result in
the contract being terminated.
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 16 of 41
3-25 Lobbying Disclosure
PHP shall comply with applicable state and federal requirements for the
disclosure of information regarding lobbying activities of the firm,
subcontractors or any authorized agent. Certification forms shall be filed by
PHP certifying that no state or federal funds have been or will be used in
lobbying activities, and the disclosure forms shall be used by PHP to disclose
lobbying activities in connection with the Program that have been or will be
paid for with non-federal funds.
3-26 Reporting Requirements
PHP agrees to provide on a timely basis the quarterly statistical reports
detailed in Exhibit H to FHKC which FHKC must have to satisfy reporting
requirements.
3-27 Participant Liability
PHP hereby agrees that no FHKC participant shall be liable to PHP or any PHP
network providers for any services covered by FHKC under this Agreement. Neither
PHP or any representative of PHP shall collect or attempt to collect from an
FHKC participant any money for services covered by the program and neither PHP
nor representatives of PHP may maintain any action at law against a FHKC
participant to collect money owed to PHP by FHKC. FHKC participants shall not be
liable to PHP for any services covered by the participant's contract with FHKC.
This provision shall not prohibit collection of co-payments made in accordance
with the terms of this Agreement. Nor shall this provision prohibit collection
for services not covered by the contract between FHKC and the participants.
3-28 Protection of Proprietary Information
PHP and FHKC mutually agree to maintain the integrity of all proprietary
information, including but not limited to membership lists, including names,
addresses and telephone numbers. Neither parties will disclose or allow to be
disclosed proprietary information, by any means, to any person without the prior
written approval of the other party. All proprietary information will be so
designated.
This requirement does not extend to routine reports and membership disclosure
necessary for efficient management of the program.
3-29 Regulatory Filings
PHP will forward all regulatory filings, (i.e., documents, forms and rates)
relating to this contract to FHKC for their review and approval. Once such
regulatory filings are approved, FHKC will submit them to the Department of
Insurance on PHP's behalf.
SECTION 4 TERMS AND CONDITIONS
4-1 Effective Date
This Agreement shall be effective on the first (1st) day of January, 1999 and
shall remain in effect through September 30,2001.
4-2 Multiple Year Agreement
Parties hereto agree this is a "Multiple Year Agreement" meaning this Agreement
which is effective as of January
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 17 of 41
1, 1999 shall extend through September 30, 2001, and shall thereafter be
automatically renewed for no more than (2) successive one year periods. Either
party may elect not to renew this Agreement and in that event shall give written
notice to said effect to the other party at least six (6) months prior to the
expiration of the then current term.
4-3 Entire Understanding
This Agreement embodies the entire understanding of the parties in relationship
to the subject matter hereof. No other agreement, understanding or
representation, verbal or otherwise, relative to the subject matter hereof
exists between the parties at the time of execution of this Agreement.
4-4 Independent Contractor
The relations of PHP to the FHKC shall be solely that of an independent
contractor. As an independent contractor, PHP agrees to comply with the
following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended, 42
U.S.C. 2000d et seq., which prohibits discrimination on
the basis of race, color, or national origin.
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
29 U.S.C. 601 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. 9848, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation or
beliefs.
f. The American with Disabilities Act of 1990, P.L.
101-336, which prohibits discrimination on the basis of
disability and requires reasonable accommodation for
persons with disabilities.
g. Section 274A (e) of the Immigration and Nationalization
Act, FHKC shall consider the employment by any
contractor of unauthorized aliens a violation of this
Act. Such violation shall be cause for unilateral
cancellation of this contract.
4-5 Assignment
This Agreement may not be assigned by PHP without the express prior written
consent of FHKC. Any purported assignment shall be deemed null and void.
This contract and the monies which may become due hereunder are not assignable
by PHP except with the prior written approval of FHKC.
4-6 Notice
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 18 of 41
Notice required or permitted under this Agreement shall be directed as follows:
For PHYSICIANS HEALTH CARE PLAN:
PHYSICIANS HEALTHCARE PLANS, INC.
2333 PONCE DE LEON BLVD., SUITE 303
CORAL GABLES, FL 33134
For FHKC:
EXECUTIVE DIRECTOR
FLORIDA HEALTHY KIDS CORPORATION
POST OFFICE BOX 980
TALLAHASSEE, FL 32302
or to such other place or person as written notice thereof may
be given to the other party.
4-7 Amendment
Not withstanding anything to the contrary contained herein, this Agreement may
be amended by mutual written consent of the parties at any time.
4-8 Governing Law
This Agreement shall be construed and governed in accordance with the laws of
the State of Florida.
4-9 Contract Variation
If any provision of the contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both FHKC and PHP
shall be relieved of all obligation arising under such provisions. If the
remainder of the contract is capable of performance, it shall not be affected by
such declaration or finding and shall be fully performed. In addition, if the
laws or regulations governing this contract should be amended or judicially
interpreted as to render the fulfillment of the contract impossible or
economically infeasible, both FHKC and PHP will be discharged from further
obligations created under the terms of the contract.
4-10 Attorneys Fees
In the event that either party deems it necessary to take legal action to
enforce any provision of this Agreement the court or hearing officer, in his
discretion, may award costs and attorneys' fees to the prevailing party. Legal
actions are defined to include administrative proceedings.
4-11 Representatives
Each party shall designate a representative to serve as the day to day
management of FHKC School Based Health Insurance Plan, helping to resolve
services questions, assuring proper arbitration in the event of a dispute, as
well as responding to general administrative and procedural problems. These
individuals will be the principal points of contact for all inquiries unless the
designated representatives specifically refer the inquiry to another party
within their respective organizations.
4-12 Termination
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 19 of 41
A. Termination for Cause
FHKC shall have the absolute right to terminate for cause, this
Agreement, and all obligations contained hereunder. Cause shall be
defined as any material breach of PHP's responsibilities as set forth
herein, which can not be cured by PHP within 30 days from the date of
written notice from FHKC but, if the default condition cannot be cured
within the 30 days, PHP may, if it has commenced reasonable efforts to
correct the condition within that 30 day period, have up to 90 days to
complete the required cure. Nothing in this Agreement shall extend this
90 day period except the mutual consent of the parties hereto.
PHP shall have the absolute right to terminate for cause this Agreement,
and all obligations contained hereunder. Cause shall be defined as any
material breach of FHKC's responsibilities as set forth herein, which
can not be cured by FHKC within 30 days from the date of written notice
from PHP but, if the default condition cannot be cured within the 30
days, FHKC may, if it has commenced reasonable efforts to correct the
condition within that 30 day period, have up to 90 days to complete the
required cure. Nothing in this Agreement shall extend this 90 day period
except the mutual consent of the parties hereto.
B. Change of Controlling Interest
FHKC shall have the absolute right to elect to continue or terminate
this Agreement, at its sole discretion, in the event of a change in the
controlling interest of PHP. PHP shall provide notice of regulatory
agency approval prior to any transfer or change in control, and FHKC
shall have ten (10) days thereafter to elect continuation or termination
of this Agreement.
4-13 Contingency
This Agreement and all obligations created hereunder, are subject to
continuation and approval of funding of the FHKC by the appropriate
state and federal or local agencies.
IN WITNESS WHEREOF the parties hereto have executed this Agreement on
the 16th day of NOVEMBER, 1998.
PHYSICIANS HEALTHCARE PLANS, INC.
BY:
/s/ Daisy Gomez /s/ Peter L. Jimenez
- ------------------------ ------------------------------
Witness Name: PETER L. JIMENEZ
Title Vice President
FLORIDA HEALTHY KIDS CORPORATION
BY:
/s/ Jennifer K. Lloyd /s/ Rose M. Naff
- ------------------------ ------------------------------
Witness Rose M. Naff
Executive Director
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 20 of 41
EXHIBIT A
HEALTH SERVICES AGREEMENT
The Comprehensive Health Care Services premium for participants in the Florida
Healthy Kids School Enrollment-Based Health Insurance Program for the coverage
period January 1,1999 through September 30, 2000 shall be $65.31 per member per
month.
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 21 of 41
EXHIBIT B
ENROLLMENT PROCEDURES
1. All FHKC eligible participants will be provided with necessary
enrollment materials and forms from FHKC or its assignee.
2. FHKC will provide PHP with eligible participants who have selected PHP
or who have been assigned by FHKC to PHP according to the provisions of
Section 2 - 1 via an enrollment tape, using a tape layout to be
specified by FHKC.
3. Upon receipt of such enrollment tape, PHP acting as an agent for FHKC
shall provide each participant with an enrollment package including:
A. A members PHP card displaying participants name, participation
number, and effective date of coverage.
B. Participants handbook.
C. Current listing of primary care and hospital providers.
4. All additions or deletions will be submitted in accordance with
referenced sections of this Agreement and Exhibit B.
5. Upon receipt of monthly tape from FHKC, PHP will process all new
enrollments and provide new participants with enrollment package
described above.
6. Deletions will be processed by PHP and participants will be notified in
writing by regular mail advising them of the effective date of deletion.
7. A waiting period of sixty days will be imposed on those participants who
voluntarily cancel their coverage by non-payment of the required monthly
premium. Canceled participants must request reinstatement from FHKC and
wait at least sixty days from the date of that request before coverage
can be reinstated.
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 22 of 41
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
The following health care benefits are included under this contract and PHP
shall pay an enrollee's covered expenses up to a lifetime maximum of $1 million
per covered enrollee.
BENEFIT LIMITATIONS CO-PAYMENT
A. Inpatient Hospital Services All admissions must be authorized by NONE
PHP.
All covered services provided for the
medical care and treatment of an The length of the patient stay shall
enrollee who is admitted as an inpatient be determined based on the medical
to a hospital licensed under part I of condition of the enrollee in relation
Chapter 395. to the necessary and appropriate level
of care.
Covered services include: physician's Room and board may be limited to
services; room and board; general semi-private accommodations, unless a
nursing care; patient meals; use of private room is considered medically
operating room and related facilities; necessary or semi-private
use of intensive care unit and services; accommodations are not available.
radiologic, laboratory and other
diagnostic tests; drugs; medications; Private duty nursing limited to
biologicals; anesthesia and oxygen circumstances where such care is
services; special duty nursing; medically necessary.
radiation and chemotherapy; respiratory
therapy; administration of whole blood Admissions for rehabilitation and
plasma; physical, speech and physical therapy are limited to 15
occupational therapy; medically days per contract year.
necessary services of other health
professionals.
Shall Not Include Experimental or
Investigational Procedures as defined
as a drug, biological product, device,
medical treatment or procedure that
meets any one of the following
criteria, as determined by the Plan:
1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied
to the circumstances of a particular
patient is the subject of ongoing
phase I, II or III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular
patient is under study with a written
protocol to determine maximum
tolerated
Enrollee Benefit Schedule Page 23 of 41
Inpatient Services, (cont'd) dose, toxicity, safety, efficacy, or
efficacy in comparison to conventional
alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services.
B. Emergency Services Must use a PHP designated facility or $10 per visit
provider for emergency care unless the (waived if primary care physician
Covered Services include visits to an time to reach such facilities or authorizes or if admitted)
emergency room or other licensed providers would mean the risk of
facility if needed immediately due to an permanent damage to patient's health.
injury or illness and delay means risk
of permanent damage to the enrollee's
health.
C. Maternity Services and Newborn Infant is covered for up to three (3) NONE
Care days following birth or until the
infant is transferred to another
Covered services include maternity and medical facility, whichever occurs
newborn care; prenatal and postnatal first.
care; initial inpatient care of
adolescent participants, including Coverage may be limited to the fee for
nursery charges and initial pediatric or vaginal deliveries.
neonatal examination.
D. Organ Transplantation Services Coverage is available for transplants NONE
and medically related services if
Covered services include pretransplant, deemed necessary and appropriate
transplant and postdischarge services within the guidelines set by the Organ
and treatment of complications after Transplant Advisory Council or the
transplantation. Bone Marrow Transplant Advisory
Council.
Enrollee Benefit Schedule Page 24 of 41
C. Outpatient Services Services must be provided directly by No co-payment for well child care,
PHP or through pre-approved referrals. preventive care or for routine vision
and hearing screenings.
Preventive, diagnostic, therapeutic,
palliative care, and other services
provided to an enrollee in the
outpatient portion of a health facility Routine hearing and screening must be $3 per office visit
licensed under chapter 395. provided by primary care physician.
Covered services include Well-child Family planning limited to one annual
care, including services recommended in visit and one supply visit each ninety
the Guidelines for Health Supervision of days.
Children and Youth as developed by
Academy of Pediatrics; immunizations and Chiropractic services shall be
injections; health education counseling provided in the same manner as in the
and clinical services; family planning Florida Medicaid program.
services, vision screening; hearing
screening; clinical radiologic, Podiatric services are limited to one
laboratory and other outpatient visit per day totaling two visits per
diagnostic tests; ambulatory surgical month for specific foot disorders.
procedures; splints and casts; Routine foot care must be for
consultation with and treatment by conditions that result in circulatory
referral physicians; radiation and embarrassment or desensitization.
chemotherapy; chiropractic services;
podiatric services.
Dental services must be provided to an
oral surgeon for medically necessary
reconstructive dental surgery due to
injury.
Treatment for temporomandibular joint
(TMJ) disease is specifically
excluded.
Shall Not Include Experimental or
Investigational Procedures as defined
as a drug, biological product, device,
medical treatment or procedure that
meets any one of the following
criteria, as determined by the Plan:
1. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure when applied
to the circumstances of a particular
patient is the subject of ongoing
phase I, II or III clinical trials or
2. Reliable Evidence shows the drug,
biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular
patient is under study with a written
protocol to determine maximum
tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to
conventional alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
Enrollee Benefit Schedule Page 25 of 41
Outpatient Services, (cont'd) delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services.
D. Behavioral Health Services All services must be provided directly
by PHP or upon approved referral.
Covered services include inpatient and
outpatient care for psychological or Inpatient services are limited to not INPATIENT: NONE
psychiatric evaluation, diagnosis and more than thirty inpatient days per
treatment by a licensed mental health contract year for psychiatric
professional. admissions, or residential services in
lieu of inpatient psychiatric
admissions; however, a minimum of ten
of the thirty days shall be available
only for inpatient psychiatric
services when authorized by PHP
physician.
Outpatient services are limited to a OUTPATIENT: $3 per visit
maximum of forty outpatient visits per
contract year.
E. Substance Abuse Services All services must be provided directly INPATIENT: NONE
by PHP or upon approved referral.
Includes coverage for inpatient and
outpatient care for drug and alcohol
abuse including counseling and placement
assistance. Inpatient services are limited to not
more than seven inpatient days per
contract year for medical
detoxification only and thirty days
residential services.
Outpatient services include evaluation, Outpatient visits are limited to a OUTPATIENT: $3 per visit
diagnosis and treatment by a licensed maximum of forty visits per contract
practitioner. year.
Enrollee Benefit Schedule Page 26 of 41
F. Therapy Services All treatments must be performed $3 per visit
directly or as authorized by PHP.
Covered services include physical,
occupational, respiratory and speech Limited to up to twenty-four treatment
therapies for short-term rehabilitation sessions within a sixty day period per
where significant improvement in the episode or injury, with the sixty day
enrollee's condition will result. period beginning with the first
treatment.
G. Home Health Services Coverage is limited to skilled nursing $3 per visit
services only.
Includes prescribed home visits by both Meals, housekeeping and personal
registered and licensed practical nurses comfort items are excluded.
to provide skilled nursing services on a
part-time intermittent basis.
Services must be provided directly by
PHP.
H. Hospice Services Once a family elects to receive $3 per visit
hospice care for an enrollee, other
services that treat the terminal
Covered services include reasonable and condition will not be covered.
necessary services for palliation or
management of an enrollee's terminal
illness. Services required for conditions
totally unrelated to the terminal
condition are covered to the extent
that the services are covered under
this contract.
Enrollee Benefit Schedule Page 27 of 41
I. Nursing Facility Services All admissions must be authorized by NONE
PHP and provided by a PHP affiliated
facility.
Covered services include regular nursing
services, rehabilitation services, drugs Participant must require and receive
and biologicals, medical supplies, and skilled services on a daily basis as
the use of appliances and equipment ordered by PHP physician.
furnished by the facility.
The length of the enrollee's stay
shall be determined by the medical
condition of the enrollee in relation
to the necessary and appropriate level
of care, but is no more than 100 days
per contract year.
Room and board is limited to
semi-private accommodations unless a
private room is considered medically
necessary or semi-private
accommodations are not available.
Specialized treatment centers and
independent kidney disease treatment
centers are excluded.
Private duty nurses, television, and
custodial care are excluded.
Admissions for rehabilitation and
physical therapy are limited to
fifteen days per contract year.
J. Durable Medical Equipment and Equipment and devices must be provided NONE
Prosthetic Devices by authorized PHP supplier.
Equipment and devices that are medically Covered prosthetic devices include
indicated to assist in the treatment of artificial eyes and limbs, braces, and
a medical condition and specifically other artificial aids.
prescribed as medically necessary by
enrollee's PHP physician. Low vision and telescopic lenses are
not included.
Hearing aids are covered only when
medically indicated to assist in the
treatment of a medical condition.
Enrollee Benefit Schedule Page 28 of 41
K. Refractions Enrollee must have failed vision $3 per visit
screening by primary care physician.
Examination by a PHP optometrist to
determine the need for and to prescribe Corrective lenses and frames are $10 for corrective lenses
corrective lenses as medically limited to one pair every two years
indicated. unless head size or prescription
changes. Coverage is limited to
Medicaid frames with plastic or SYL
non-tinted lenses.
L. Pharmacy Covered drugs are limited to the $3 per prescription for up to a 31-day
Florida Medicaid formulary with supply
generic substitution.
Prescribed drugs for the treatment of
illness or injury or injury. Brand name products are covered if a
generic substitution is not available
or where the prescribing physician
indicates that a brand name is
medically necessary.
All medications must be dispensed
through PHP or a PHP designated
pharmacy.
All prescriptions must be written by
the participant's primary care
physician, PHP approved specialist or
consultant physician.
M. Transportation Services Must be in response to an emergency $10 per service
situation.
Emergency transportation as determined
to be medically necessary in response to
an emergency situation.
PHP - ORANGE, OSCEOLA AND SEMINOLE Page 29 of 41
EXHIBIT D
WORKER'S COMPENSATION, THIRD PARTY CLAIM
PERSONAL INJURY PROTECTION BENEFITS, AND
COORDINATION OF BENEFITS
A. WORKER'S COMPENSATION
Worker's compensation benefits are primary to all benefits which may be
provided pursuant to this contract. In the event PHP provides services
or benefits to a participant who is entitled to worker's compensation
benefits, PHP shall complete and submit to the appropriate carrier, such
forms, assignments, consents and releases as are necessary to enable PHP
to obtain payment, or reimbursement, under the worker's compensation
law.
B. THIRD PARTY CLAIMS
In the event PHP provides medical services or benefits to participants
who suffer injury, disease or illness by virtue of the negligent act or
omission of a third party, PHP shall be entitled to reimbursement from
the participant, at the prevailing rate, for the reasonable value of the
services or benefits provided. PHP shall not be entitled to
reimbursement in excess of the participant's monetary recovery for
medical expenses provided, from the third party.
C. NO-FAULT. PERSONAL INJURY PROTECTION AND MEDICAL PAYMENTS COVERAGE
As noted in the Florida Statutes (F.S. 641.31(8)), automobile no-fault,
personal injury protection, and medical payments insurance, maintained
by or for the benefit of the participant, shall be primary to all
services or benefits which may be provided pursuant to this contract. In
the event PHP provides services or benefits to a participant who is
entitled to the aforesaid automobile insurance benefits, the
parent/guardian or participant shall complete and submit to PHP, or to
the automobile insurance carrier, such forms, assignments, consents and
releases as are necessary to enable PHP to obtain payment or
reimbursement from such automobile insurance carrier.
D. COORDINATION OF BENEFITS AMONG HEALTH INSURERS
PHP shall coordinate benefits in accordance with NAIC principles as may
be amended from time to time. If any benefits to which a participant is
entitled under this contract are also covered under any other group
health benefit plan or insurance policy, the benefits hereunder shall be
reduced to the extent that benefits are available to participant under
such other plan or policy whether or not a claim is made for the same,
subject to the following:
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT D
(Continued)
1. The rules establishing the order of benefit determination between this
contract and other plan covering the participant on whose behalf a claim
is made are as follows:
(a) The benefits of a policy or plan which covers the person as an
employee, member, or subscriber, other than as a dependent are
determined before those of the policy or plan which covers the
person as a dependent.
(b) Except as stated in paragraph C, when two or more policies or
plans cover the same child as a dependent of different parents:
(l)The benefits of the policy or plan of the parent whose
birthday, excluding year of birth, falls earlier in a year are
determined before those of the policy of the parent whose
birthday, excluding year of birth, falls later in that year; but
(2)If both parents have the same birthday, the benefits of the
policy or plan which covered the parent for a longer period of
time are determined before those of the policy or plan which
covered the parent for shorter period of time. However, if a
policy or plan subject to the rule based on the birthday of the
parents as stated above coordinates with an out-of-state policy
or plan which contains provisions under the benefits of a policy
or a person as a dependent of a male are determined before those
of a policy or plan which covers the person as a dependent of a
female and if, as a result, the policies or plans do not agree
in the order of benefits, the provisions or the other policy or
plan shall determine the order of benefits.
(c) If two or more policies or plans cover a dependent child of
divorced or separated parents, benefits for the child are
determined in this order:
(l)First, the policy or plan of the parent with custody of the
child;
(2)Second, the policy or plan of the spouse of the parent with
custody of the child, and
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT D
(Continued)
(3)Third, the policy or plan of the parent not having custody of
the child. However, if the specific terms of a court decree
state that one of the parents is responsible for the health care
expenses of the child and of the entity obliged to pay or
provide the benefits of the policy or plan or that parent has
actual knowledge of those terms, the benefits of that policy are
determined first. This does not apply with respect to any claim
determination period or plan or policy year during which any
benefits are actually paid or provided before the entity has
that knowledge.
(d) The benefits of a policy or plan which covers a person as an
employee which is neither laid off nor retired, or as that
employee's dependent, are determined before those of a policy or
plan which covers that person as a laid off or retired employee
or as that employee's dependent. If the other policy or plan is
not subject to this rule, and if, as result, the policies or
plans do not agree on the order of benefits, this paragraph
shall not apply.
(e) If none of the rules in paragraph a, paragraph b, paragraph c,
or paragraph d, determine the order of benefits of the policy or
plan which covered an employee, member or subscriber for a
longer period of time are determined before those of the policy
or plan which covered that person for the shorter period of
time.
2. None of the above rules as to coordination of benefits shall limit the
participant's right to receive direct health services hereunder.
3. Any participant claiming benefits under the contract shall furnish to
PHP all information deemed necessary by it to implement this provision.
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT E
ACCESS STANDARDS
PHP shall maintain a medical staff, under contract, sufficient to permit
reasonably prompt medical service to all participants in accordance with the
following:
1. Geographical Access:
Geographical access to family practice physicians, pediatric physicians,
or ARNP's, experienced in child health care, of approximately twenty
(20) minutes driving time from residence to provider, except that this
driving time limitation shall be reasonably extended in those areas
where such limitation with respect to rural residence is unreasonable.
In such instance, PHP shall provide access for urgent care through
contracts with nearest providers.
2. Timely Treatment:
Timely treatment by providers, such that the participant shall be seen
by a provider in accordance with the following:
A. Emergency care shall be provided immediately;
B. Urgently needed care shall be provided within twenty-four (24)
hours;
C. Routine care of patients who do not require emergency or
urgently needed care shall be provided within seven (7) calendar
days;
D. Physical examinations shall be provided within four (4) weeks of
request for appointment; and
E. Follow-up care shall be provided as medically appropriate.
For the purposes of this section, the following definitions shall apply:
Emergency care is that required for the treatment of an injury or acute
illness which, if not treated immediately, could reasonably result in
serious or permanent damage to the patient's health.
Urgently needed care is that required within a twenty-four (24) hour
period to prevent a condition from requiring emergency care.
Routine care is that level of care which can be delayed without
anticipated deterioration in the patient's medical condition for a
period of seven (7) calendar days.
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT E
(Continued)
By utilization of the foregoing standards, FHKC does not intend to create
standards of care or access different from those which are deemed acceptable
within the PHP service area. Rather FHKC intends that the provider timely and
appropriately respond to patient care needs, as they are presented, in
accordance with standards of care existing within the service area. In applying
the foregoing standards, the provider shall give due regard to the level of
discomfort and anxiety of the patient and/or parent.
In the event FHKC determines that PHP, or its providers, has failed to meet the
access standards herein set forth, FHKC shall provide PHP with written notice of
non-compliance. Such notice can be provided via facsimile or other means,
specifying the failure in such detail as will reasonably allow PHP to
investigate and respond. Failure of PHP to obtain reasonable compliance or
acceptable community care under the following conditions shall constitute a
breach of this agreement:
A. immediately upon receipt of notice for emergency or urgent
problem; or
B. within ten (10) days of receipt of notice for routine visit
access.
Such breach shall entitle FHKC to such legal and equitable relief as may be
appropriate. In particular, FHKC may direct its participants to obtain such
services outside the PHP provider network. PHP shall be financially responsible
for all services under this provision.
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT F
GRIEVANCE, ARBITRATION AND LEGAL PROCESS
A. GRIEVANCE AND ARBITRATION
Complaints or disputes which do not involve allegations of "medical
negligence" against a health care provider as defined in Chapter 768,
Florida Statutes, shall be subject to grievance and arbitration as
hereinafter set forth:
1. Initiation of Complaint:
a. If a participant's complaint cannot be resolved
satisfactorily on an informal basis, the participant
shall complete and submit to Physicians Health Care
Plan, a grievance form recording the participant's name,
address, telephone number, client number and as many
facts as possible related to the problem (date, time,
people, circumstances, etc.). The completed form shall
be filed with the Physicians Health Care Plan Member
Relations Counselor (MRC) within sixty (60) days from
the date the problem occurred.
b. A written response shall be made acknowledging receipt
and filing of said form by the MRC within two (2)
working days from the date written grievance was
received.
c. The Executive Director and Medical Director of
Physicians Health Care Plan, or their designee(s) shall
review the written grievance, conduct a fact-finding
examination, and issue a decision in writing to all
parties concerned, within ten (10) working days from
date the written grievance was received by the MRC.
2. Appeal to the Grievance Committee:
a. If any participant declines to accept the decision of
Executive Director and Medical Director, that
participant has fourteen (14) working days within which
to file a formal written appeal to the Grievance
Committee.
b. The composition of the Grievance Committee shall comply
with appropriate state and federal regulations.
c. The Grievance Committee shall be convened within thirty
(30) days of receipt of the written appeal. The
complaining participant shall present, either in person
or in writing, his/her complaint. Upon completion of the
participant's presentation, the Grievance Committee
shall have seven (7)
PHP - ORANGE, OSCEOLA AND SEMINOLE
days in which to deliberate and issue a formal written
decision. The deliberations of the Grievance Committee
shall be closed to both the complaining participant and
the public.
d. Any decision to resolve the complaint that involves
distribution of Physicians Health Care Plan monies is
subject to confirmation and ratification by Physicians
Health Care Plan's Executive Committee or the Board of
Directors.
3. The participant always has the right to appeal to the FHKC
and/or the Statewide Subscriber Assistance Program prior to
entering arbitration or legal process.
4. Arbitration:
If a participant refuses to accept the decision of the Grievance
Committee, or the decision of the Physicians Health Care Plan
Executive Committee or the Board of Directors, or the Statewide
Subscriber Assistance Program as provided above, such
participant shall file a claim for binding arbitration as
follows:
a. Participant shall initiate the claim by serving on
Physicians Health Care Plan, by registered mail, a
notice of the existence and nature of claims, the remedy
sought, the amount claimed, and a demand for
arbitration. A copy of such letter shall be sent to
Physicians Health Care Plan at the address listed in
Section 4-7. Within thirty (30) calendar days after
initial notice to Physicians Health Care Plan,
participant and Physicians Health Care Plan shall each
designate an arbitrator and notify the other of that
designation. Within thirty (30) days after designation
of the arbitrators and payments of the initial deposits,
the two arbitrators shall select a neutral arbitrator,
and the three arbitrators shall hold a hearing within
210 days from the date of initial designation, at a time
and place designated pursuant to paragraph g below. If
the claimant and respondent agree, in writing, the
arbitration may be conducted by a single arbitrator.
b. All claims based upon the same incident, transaction or
related circumstances shall be arbitrated in one
proceeding, and any claim based upon the incident and
not submitted to arbitration shall be waived and forever
barred to any claimant.
c. The arbitrators shall have jurisdiction only over
parties ("Respondent") actually served or who submit
voluntarily to their jurisdiction.
d. The arbitrators shall not have jurisdiction to determine
PHP - ORANGE, OSCEOLA AND SEMINOLE
whether Physicians Health Care Plan is liable for the
professional negligence of any physician providing
services under the contract.
e. A claim shall be waived and forever barred if, on the
date notice thereof is received by the party served, the
claim, if it were asserted in a civil action filed on
that day, would be barred by the applicable statute of
limitations of the state in which the cause for action
arose. Such determination shall be made by the
arbitrators.
f. Initial service shall be by registered mail, postage
prepaid. Any subsequent notices or other papers required
to be served in the course of arbitration proceedings,
shall be directed to the arbitrators at the address or
addresses which they designate by written notice to the
other party.
g. The neutral arbitrator shall designate the time and
place for the hearing in a county in which an alleged
wrongful act or omission allegedly occurred, except that
if the claim involves both parties, evidence or
witnesses located in more than one country or state, the
arbitrators may select a time and place of hearing to
facilitate presentation of evidence necessary or
desirable for arbitration.
h. Modifications of any matter herein provided for may be
made by mutual agreement of the parties and the neutral
arbitrator. With respect to any matter not expressly
provided for herein, the arbitration shall be governed
by Florida law.
I. The decision of the arbitrators shall be enforceable in
a court of competent jurisdiction.
B. LEGAL PROCESS
Complaints or disputes which do involve allegations of "medical
negligence" against a "health care provider" as defined in Chapter 768,
Florida Statutes, shall be subject to the provision of that chapter as
may be amended from time to time.
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT G
ELIGIBILITY STANDARDS
PARTICIPANT ELIGIBILITY CRITERIA
The following eligibility criteria for participation in the Healthy Kids Program
must be met:
1. The participants must be children who are age 5 through 18.
2. All enrolled participants must have had no comparable health insurance
coverage at the time of program enrollment.
3. Participants must not be enrolled in or eligible for Medicaid, Medicare,
the Children's Medical Services program or other comparable governmental
sponsored health benefits program.
4. In addition to the open enrollment period, new students enrolling in the
Orange, Osceola or Seminole County School Districts may be eligible for
the School Enrollment Based Insurance Program. In order to become a
participant, a student must meet all other eligibility standards and
must apply for coverage within thirty (30) days of entry into the
Orange, Osceola or Seminole County School Systems.
5. In addition to the open enrollment period otherwise eligible
participants may enroll in the program upon submission of proof of
involuntary termination of comparable health insurance coverage,
including termination of eligibility for Medicaid.
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT H
REPORTING REQUIREMENTS
PHP shall provide the following reports and data tapes to FHKC according to the
time schedules detailed below. This information shall include all services
provided by PHP's subcontractors.
I. Data Tape
A quarterly data tape shall be prepared that will contain the following
data fields. The tape shall reflect claims and encounters entered during
the quarter and shall be delivered to FHKC according to the time table
listed below. PHP shall also provide quarterly tapes that reflect claims
run-off once the contract between PHP and FHKC terminates.
REQUIRED DATA FIELDS TO BE CAPTURED
. Provider's name, address and tax I.D. number (and payee's group
number if applicable)
. Patient's name, address, social security number, I.D. number,
birth date, and sex
. Third party payor information, including amount(s) paid by other
payor(s).
. Primary and secondary diagnosis code(s) and treatment(s) related
to diagnosis
. Date(s) of service
. Procedure code(s)
. Unit(s) of service
. Total charge(s)
. Total payment(s)
Additional required hospital fields include the following:
. Date and type of admission (emergency, outpatient, inpatient,
newborn, etc.)
. For inpatient care: covered days and date of discharge
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT H
(Continued)
Specific pharmacy fields include:
. Pharmacy name and tax I.D. number
. Other payor information
. Rx number and date filled
. National drug code, manufacturer number, item number, package
size, quantity, days supply
. Prescriber's Florida Department of Professional Regulations
number
REQUIRED TAPE FORMAT SPECIFICATIONS
The tape format is as follows:
. 1600 BPI
. EBCDIC
. 9 Track
. no labels
. each file not to exceed 100 megs in size
. fixed record length
TIME TABLE FOR DELIVERY OF TAPE
For encounters and claims processed during: Claims tape due to FHKC by:
- --------------------------------------------------------------------------------
January 1 - March 31 April 15
- --------------------------------------------------------------------------------
April 1 - June 30 July 15
- --------------------------------------------------------------------------------
July 1 - September 30 October 15
- --------------------------------------------------------------------------------
October 1 - December 31 January 15
PHP - ORANGE, OSCEOLA AND SEMINOLE
EXHIBIT H
(Continued)
II. Utilization and Cost Information
The following information is to be 1) provided monthly for the current
month as well as year-to-date; and 2) delivered by the last day of each
month for services rendered during the prior month.
. Member months
. Hospital admissions per 1000
. Hospital bed days per 1000
. Surgeries per 1000
. Primary care physician visits per 1000
. Specialist/referral visits per 1000
. Emergency room visits per 1000
. Average length of hospital stay
. Listing of hospital admissions, including admission and
discharge date, diagnosis, type of service, name of hospital,
and amount paid
. Listing of outpatient procedures, including date, diagnosis,
procedure, and name of hospital
. Average cost per hospital day
. Average cost per hospital admission
PHP - ORANGE, OSCEOLA AND SEM1NOLE
AMENDMENT #1
FLORIDA HEALTHY KIDS CORPORATION
PHYSICIANS HEALTH CARE PLANS
ORANGE, OSCEOLA AND SEMINOLE COUNTY
EFFECTIVE DATE - DECEMBER 1, 2001
Orange, Osceola &
Seminole
AMENDMENT #1
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND
PHYSICIANS HEALTH CARE PLANS
THIS AMENDMENT, entered into between the Florida Healthy Kids Corporation,
hereinafter referred to as "FHKC" and PHYSICIANS HEALTH CARE PLANS, hereinafter
referred to as "PHP", amends its contract dated November 16, 1998.
WHEREAS, the contract between FHKC and PHP allows for amendments to said
contract by mutual written consent of the parties;
WHEREAS, the federal regulations governing programs such as FHKC became
effective August 24, 2001 and this Amendment will effectuate the changes
required by said federal regulations;
THEREFORE, be it resolved that the Parties agree to the following amendment of
their contract:
I. Section 1-1 is amended to read:
1-1 Definitions
As used in this agreement, the term:
A. "COMPREHENSIVE HEALTH CARE SERVICES" means those
services, medical equipment, and supplies to be provided
by PHP in accordance with standards set by FHKC and
further described in Exhibit C.
B. "THE PROGRAM" shall mean the project established by FHKC
pursuant to Section 624.91, Florida Statutes and
specified herein.
C. "PARTICIPANT" means those individuals meeting FHKC
standards of eligibility and who have been enrolled in
the program.
D. "PHP PROVIDERS" shall mean those providers set forth in
the participant's handbook as from time to time amended.
E. "CO-PAYMENT" or "COST SHARING" is the payment required
of the participant at the time of obtaining service. In
the event the participant fails to pay the required
co-payment, PHP may decline to provide non-emergency or
non-urgently needed care unless the participant meets
the conditions for waiver of co-payments described in
Exhibit C.
F. "FRAUD" shall mean:
1) Any FHKC participant or person who knowingly:
a) Fails, by any false statement,
misrepresentation, impersonation, or
other fraudulent means, to disclose a
material fact used in making a
PHP/Orange, Osceola, Seminole Page 1 of 19
Effective Date: December 1, 2001
[ILLEGIBLE]
determination as to such person's
qualification to receive comprehensive
health care services coverage under the
FHKC program;
b) Fails to disclose a change in
circumstances in order to obtain or
continue to receive comprehensive health
care services coverage under the FHKC
program to which he or she is not
entitled or in an amount larger than
that which he or she is entitled;
c) Aids and abets another person in the
commission of any such act.
2) Any person or FHKC participant who:
a) Uses, transfers, acquires, traffics,
alters, forges, or possess, or
b) Attempts to use, transfer, acquire,
traffic, alter, forge or possess, or
c) Aids and abets another person in the
use, transfer, acquisition, traffic,
alteration, forgery or possession of a
FHKC identification card.
G. "STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)" OR
"TITLE XXI" shall mean the program created by the
federal Balanced Budget Act of 1997 as Title XXI of the
Social Security Act.
II. Section 3-2- Access to Care is amended to read:
3-2-1 Access and Appointment Standards
PHP agrees to meet or exceed the appointment and geographic access
standards for pediatric care existing in the community and as
specifically provided for in Exhibit E attached hereto and incorporated
herein as a part of this Agreement.
In the event PHP's provider network is unable to provide those medically
necessary benefits specified in Exhibit C, for any reason, except force
majeure, PHP shall be responsible for those contract benefits obtained
from providers other than PHP for eligible FHKC participants. In the
event PHP fails to meet those access standards set forth in Exhibit E,
FHKC may, after following procedures set forth in Exhibit E, direct its
participants to obtain such contract benefit from other providers and
may contract for such services. All financial responsibility related to
services received under these specific circumstances shall be assumed by
PHP.
3-2-2 Integrity of Professional Advice to Enrollees
PHP ensures no interference with the advice of health care professionals
to enrollees and that information about treatments will be provided to
enrollees and their families in the appropriate manner.
PHP/Orange, Osceola, Seminole Page 2 of 19
Effective Date: December 1, 2001
PHP agrees to comply with any federal regulations related to physician
incentive plans and any disclosure requirements related to such
incentive plans.
III. Section 3-3 is amended to read:
3-3 Fraud and Abuse (renumber subsequent sections)
PHP ensures that it has appropriate measures in place to ensure against
fraud and abuse. PHP shall report to FHKC any information on violations
by subcontractors or participants that pertain to enrollment or the
payment and provision of health care services under this Agreement.
IV. Section 3-9 is amended to read:
PHP will issue participant certificates, identification cards, provider
network listings and handbooks to all FHKC designated participants
within five business days of receipt of an eligibility tape. Except as
specifically provided in Sections 3-8 and 3-11 hereof, all participant
rights and benefits shall terminate upon termination of this Agreement
or upon termination of participation in the program. All participant
handbooks and member materials must be approved by FHKC prior to
distribution.
V. Section-3-12 is amended to read:
Grievances and Complaints
PHP agrees to provide all FHKC participants a Grievance Process and the
grievance and complaint procedures shall be governed by federal and
state regulations issued for SCHIP, and the following additional rules
and guidelines:
A. There must be sufficient support staff (clerical and
professional) available to process grievances.
B. Staff must be educated concerning the importance of the
procedure and the rights of the enrollee.
C. Someone with problem solving authority must be part of the
grievance procedure.
D. In order to initiate the grievance process, such grievance must
be filed in writing.
E. The parties will provide assistance to grievant during the
grievance process to the extent FHKC deems necessary.
F. Grievances shall be resolved within sixty days from initial
filing by the participant, unless information must be collected
from providers located outside the authorized service area or
from non-contract providers. In such exceptions, an additional
extension shall be authorized upon establishing good cause.
G. A record of informal complaints received that are not grievances
shall be maintained and shall include the date, name, nature of
the complaint and the disposition.
H. The grievance procedures must conform with the federal
regulations governing the State Children's Health Insurance
Program (SCHIP).
I. A quarterly report of all grievances involving FHKC participants
must be submitted to FHKC. The report should list the number of
grievances received during the quarter and the disposition of
those grievances. PHP
PHP/Orange, Osceola, Seminole Page 3 of 19
Effective Date: December 1, 2001
shall also inform FHKC of any grievances that are referred to
the Statewide Subscriber Assistance Panel prior to their
presentation at the panel.
VI. Section 3-14 is amended to read:
3-14 Notification
A. PHP shall immediately notify FHKC of:
1. Any judgment, decree, or order rendered by any court of
any jurisdiction or Florida Administrative Agency
enjoining PHP from the sale or provision of service
under Chapter 641, Part II, Florida Statutes.
2. Any petition by PHP in bankruptcy or for approval of a
plan of reorganization or arrangement under the
Bankruptcy Act or Chapter 631, Part I, Florida Statutes,
or an admission seeking the relief provided therein.
3. Any petition or order of rehabilitation or liquidation
as provided in Chapters 631 or 641, Florida Statutes.
4. Any order revoking the Certificate Of Authority granted
to PHP.
5. Any administrative action taken by the Department of
Insurance or Agency for Health Care Administration in
regard to PHP.
6. Any medical malpractice action filed in a court of law
in which a FHKC participant is a party (or in whose
behalf a participant's allegations are to be litigated).
7. The filing of an application for change of ownership
with the Florida Department of Insurance.
8. Any change in subcontractors who are providing services
to FHKC participants.
B. Monthly Notification Requirements
PHP shall inform FHKC monthly of any changes to the provider
network that differ from the network presented in the original
bid proposal, including discontinuation of any primary care
providers or physician practice associations or groups with
Healthy Kids enrollees on their panels. FHKC may require PHP to
provide FHKC with evidence that its provider network continues
to meet the access standards described in Exhibit E.
VII. Section 3-18 is amended to read:
3-18 Medical Records Requirements
PHP shall require providers to maintain medical records for each
participant under this Agreement in accordance with applicable state and
federal law.
3-18-1 Medical Quality Review and Audit
FHKC shall conduct an independent medical quality review of PHP
at the conclusion of the first twelve months of coverage. The
independent auditor's report will include a written review and
evaluation of care
PHP/Orange, Osceola, Seminole Page 4 of 19
Effective Date: December 1, 2001
provided to FHKC participants in Orange, Osceola, and Seminole
County. Additional reviews may also be conducted after
completion of the baseline review at the discretion of FHKC. PHP
agrees to cooperate in all evaluation efforts conducted or
authorized by FHKC.
3-18-2 Privacy of Medical Records
PHP will ensure that all individual medical records will be
maintained with confidentiality in accordance with state and
federal guidelines. PHP agrees to abide by all applicable state
and federal laws governing the confidentiality of minors and the
privacy of individually identifiable health information.
3-18-3 Requests by Participants for Medical Records
PHP will ensure that each participant may request and receive a
copy of records and information pertaining to that enrollee in a
timely manner. Additionally, the participant may request that
such records be corrected or supplemented.
VIII. Section 3-26 is amended to read:
3-26 Reporting Requirements
PHP agrees to provide on a timely basis the quarterly statistical
reports detailed in Exhibit H to FHKC that FHKC must have to satisfy
reporting requirements. PHP also agrees to attest to the accuracy,
completeness and truthfulness of claims and payment data that are
submitted to FHKC under penalty of perjury. Access to participant claims
data by FHKC, the State of Florida, the federal Centers for Medicaid and
Medicare Services, the Department of Health and Human Services Inspector
General will be allowed to the extent allowed under any state privacy
protections.
IX. A new section 4-4 is created and subsequent sections are renumbered as
follows:
4-4 Relation to Other Laws (renumber subsequent sections)
4-4-1 Health Insurance Portability and Accountability Act
(HIPAA)
Coverage offered under this Agreement is considered creditable
coverage for the purposes of part 7 of subtitle B of title II of
ERISA, title XXVII of the Public Health Services Act and
subtitle K of the Internal Revenue Code of 1986.
Additionally, PHP agrees to comply with all other applicable
provisions of the HIPAA.
4-4-2 Mental Health Parity Act (MHPA)
PHP agrees to comply with the requirements of the Mental Health
Parity Act of 1996 regarding parity in the application of annual
and lifetime dollar limits to mental health benefits in
accordance with 45 CFR 146.136.
4-4-3 Newborns and Mothers Health Protection Act of 1996 (NMHPA)
PHP/Orange, Osceola, Seminole Page 5 of 19
Effective Date: December 1, 2001
PHP agrees to comply with the requirements of the NMHPA of 1996
regarding requirements for minimum hospital stays for mothers
and newborns in accordance with 45 CFR 146.130 and 148.170.
X. Section 4-4 is renumbered and amended to read:
4-4 Independent Contractor
The relationship of PHP to the FHKC shall be solely that of an
independent contractor. As an independent contractor, PHP agrees to
comply with the following provisions:
a. Title VI of the Civil Rights Act of 1964, as amended, 42
U.S.C. 2000d et seq., which prohibits discrimination on
the basis of race, color, or national origin.
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
29 U.S.C. 601 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. 9848, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation or
beliefs.
f. The American with Disabilities Act of 1990, P.L.
101-336, which prohibits discrimination on the basis of
disability and requires reasonable accommodation for
persons with disabilities.
g. Section 274A(e) of the Immigration and Nationalization
Act, FHKC shall consider the employment by any
contractor of unauthorized aliens a violation of this
Act. Such violation shall be cause for unilateral
cancellation of this Agreement.
h. OMB Circular A-l10 (Appendix A-4) which identifies
procurement procedures which conform to applicable
federal law and regulations with regard to debarment,
suspension, ineligibility, and involuntary exclusion of
contracts and subcontracts and as contained in Exhibit I
of this Agreement. Covered transactions include
procurement contracts for services equal to or in excess
of $100,000 and all non-procurement transactions.
i. The federal regulations implementing the State
Children's Health Insurance Program (SCHIP) as found in
42 CFR Parts 431,433,435,436 and 457 and any subsequent
revisions to the regulation.
PHP/Orange, Osceola, Seminole Page 6 of 19
Effective Date: December 1, 2001
XI. Section 4-8 is amended to read as follows:
4-8 Governing Law
This Agreement shall be construed and governed in accordance with the
laws of the State of Florida. In the event any action is brought to
enforce the provisions of this Agreement, venue shall be in Leon County,
Florida.
XII. Exhibits B, C, E and G are hereby amended as attached and incorporated
into the Agreement.
XIII. Exhibit F is removed from the Agreement and the remaining Amendments are
renumbered.
XIV. Exhibits I and J are new Exhibits to the existing Agreement between FHKC
and PHP and are hereby attached and incorporated into the Agreement.
XV. The effective date of this Amendment is December 1, 2001.
All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform with 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
of its attachments are hereby made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this 19 page amendment to be
executed by their officials thereunto duly authorized.
FLORIDA HEALTHY KIDS CORPORATION
/s/ Rose M. Naff
- ----------------------------------------
Rose M. Naff, Executive Director
Date: 12/20/01
PHYSICIANS HEALTH CARE PLANS
/s/ PETER L. JIMENEZ
- ----------------------------------------
Name: PETER L. JIMENEZ
Date: 11/26/01
PHP/Orange, Osceola, Seminole Page 7 of 19
Effective Date: December 1, 2001
EXHIBIT B
ENROLLMENT PROCEDURES
1. All FHKC eligible participants will be provided with necessary
enrollment materials and forms from FHKC or its assignee.
2. FHKC will provide PHP with eligible participants who have selected PHP
or who have been assigned by FHKC to PHP according to the provisions of
Section 2-1 via an enrollment tape, using a tape layout to be specified
by FHKC.
3. Upon receipt of such enrollment tape, PHP acting as an agent for FHKC
shall provide each participant with an enrollment package within five
business days of receipt of an enrollment tape that includes at a
minimum the following items:
A. A membership card displaying participant's name, participation
number and effective date of coverage.
B. Participant's handbook that complies with any federal requirements,
including at a minimum, a description of how to access services, a
listing of any copayment requirements, the grievance process and the
covered benefits.
C. Current listing of primary care physicians, specialists and hospital
providers.
4. All additions or deletions will be submitted in accordance with
referenced sections of this Agreement and Exhibit B.
5. Upon receipt of monthly tape from FHKC, PHP will process all new
enrollments and provide new participants with an enrollment package
within five business days of receipt of the enrollment tape.
6. Deletions will be processed by PHP and PHP will notify each cancelled
participant in writing by regular mail of the effective date of
deletion.
7. In accordance with state law, a waiting period of sixty days will be
imposed on those participants who voluntarily cancel their coverage by
non-payment of the required monthly premium. Cancelled participants must
request reinstatement from FHKC and wait at least sixty days from the
date of that request before coverage can be reinstated.
8. FHKC is the sole determiner of eligibility and effective dates of
coverage.
9. PHP must also comply with the guidance issued by the Office of Civil
Rights of the United States Department of Health and Human Services
("Policy Guidance on the Title VI Prohibition against National Origin
Discrimination as it Effects Persons with Limited English Proficiency")
regarding the availability of information and assistance for persons
with limited English proficiency.
PHP/Orange, Osceola, Seminole Page 8 of 19
Effective Date: December 1, 2001
EXHIBIT C
ENROLLEE BENEFIT SCHEDULE
I. Minimum Benefits; Statutory Requirements
PHP agrees to provide, at a minimum, those benefits that are
prescribed by state law under Section 409.815(2)(a-p) and 409.815
(r-t). PHP shall pay an enrollee's covered expenses up to a lifetime
maximum of $1 million per covered enrollee.
The following health care benefits are included under this Agreement:
BENEFIT LIMITATIONS CO-PAYMENTS
- --------------------------------------------------------------------------------
A. Inpatient All admissions must be authorized by NONE
Services PHP.
All covered services The length of the patient stay shall
provided for the be determined based on the medical
medical care and condition of the enrollee in relation
treatment of an to the necessary and appropriate level
enrollee who is of care.
admitted as an Room and board may be limited to
inpatient to a semi-private accommodations, unless a
hospital licensed private room is considered medically
under part I of necessary or semi-private
Chapter 395. accommodations are not available.
Covered services Private duty nursing limited to
include: physician's circumstances where such care is
services; room and medically necessary.
board; general Admissions for rehabilitation and
nursing care; physical therapy are limited to 15
patient meals; use days per contract year.
of operating room Shall Not Include Experimental or
and related Investigational Procedures as defined
facilities; use of as a drug, biological product, device,
intensive care unit medical treatment or procedure that
and services; meets any one of the following
radiological, criteria, as determined by the Plan:
laboratory and other 1. Reliable Evidence shows the drug,
diagnostic tests; biological product, device, medical
drugs; medications; treatment, or procedure when applied
biologicals; to the circumstances of a particular
anesthesia and patient is the subject of ongoing
oxygen services; phase I, II or III clinical trials or
special duty 2. Reliable Evidence shows the drug,
nursing; radiation biological product, device, medical
and chemotherapy; treatment or procedure when applied to
respiratory therapy; the circumstances of a particular
administration of patient is under study with a written
whole blood plasma; protocol to determine maximum
physical, speech and tolerated dose, toxicity, safety,
occupational efficacy, or efficacy in comparison to
therapy; medically conventional alternatives, or
necessary services 3. Reliable Evidence shows the drug,
of other health biological product, device, medical
professionals. treatment, or procedure is being
delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services.
PHP/Orange, Osceola, Seminole Page 9 of 19
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B. Emergency Must use a PHP designated facility or $10 per visit
Services provider for emergency care unless the waived if admitted
Covered Services time to reach such facilities or or authorized by
include visits to an providers would mean the risk of primary care
emergency room or permanent damage to patient's health. physician
other licensed
facility if needed
immediately due to
an injury or illness
and delay means risk
of permanent damage
to the enrollee's
health.
C. Maternity Infant is covered for up to three (3) NONE
Services and Newborn days following birth or until the
Care infant is transferred to another
Covered services medical facility, whichever occurs
include maternity first.
and newborn care;
prenatal and Coverage may be limited to the fee for
postnatal care; vaginal deliveries.
initial inpatient
care of adolescent
participants,
including nursery
charges and initial
pediatric or
neonatal
examination.
D. Organ Coverage is available for transplants NONE
Transplantation and medically related services if
Services deemed necessary and appropriate
Covered services within the guidelines set by the Organ
include Transplant Advisory Council or the
pretransplant, Bone Marrow Transplant Advisory
transplant and Council.
postdischarge
services and
treatment of
complications after
transplantation.
E. Outpatient Services must be provided directly by No co-payment for
Services PHP or through pre-approved referrals. well child care,
Preventive, preventive care or
diagnostic, Routine hearing and screening must be for routine vision
therapeutic, provided by primary care physician. and hearing
palliative care, and screenings.
other services Family planning limited to one annual
provided to an visit and one supply visit each ninety
enrollee in the days. $3 per office
outpatient portion visit
of a health facility Chiropractic services shall be
licensed under provided in the same manner as in the
chapter 395. Florida Medicaid program.
Covered services Podiatric services are limited to one
include Well-child visit per day totaling two visits per
care, including month for specific foot disorders.
those services Routine foot care must be for
recommended in the conditions that result in circulatory
Guidelines for embarrassment or desensitization.
Health Supervision Dental services must be provided to an
of Children and oral surgeon for medically necessary
Youth as developed reconstructive dental surgery due to
by Academy of injury.
Pediatrics;
immunizations and Treatment for temporomandibular joint
injections as (TMJ) disease is specifically
recommended by the excluded.
Advisory Committee
on Immunization Shall Not Include Experimental or
Practices; health Investigational Procedures as defined
education counseling as a drug, biological product, device,
and clinical medical treatment or procedure that
services; family meets any one of the following
planning services, criteria, as determined by PHP:
vision screening; 1. Reliable Evidence shows the drug,
hearing screening; biological product,
clinical
radiological,
laboratory and other
outpatient
diagnostic tests;
ambulatory surgical
procedures; splints
and casts;
consultation with
and treatment
PHP/Orange, Osceola, Seminole Page 10 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
- --------------------------------------------------------------------------------
by referral device, medical treatment, or
physicians; procedure when applied to the
radiation and circumstances of a particular patient
chemotherapy; is the subject of ongoing phase I, II
chiropractic or III clinical trials or
services; podiatric 2. Reliable Evidence shows the drug,
services. biological product, device, medical
treatment or procedure when applied to
the circumstances of a particular
patient is under study with a written
protocol to determine maximum
tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to
conventional alternatives, or
3. Reliable Evidence shows the drug,
biological product, device, medical
treatment, or procedure is being
delivered or should be delivered
subject to the approval and
supervision of an Institutional Review
Board (IRB) as required and defined by
federal regulations, particularly
those of the U.S. Food and Drug
Administration or the Department of
Health and Human Services
E. Behavioral Health All services must be provided directly
Services by PHP or upon approved referral.
Covered services
include inpatient Inpatient services are limited to not INPATIENT:
and outpatient care more than thirty inpatient days per NONE
for psychological or contract year for psychiatric
psychiatric admissions, or residential services in
evaluation, lieu of inpatient psychiatric
diagnosis and admissions; however, a minimum of ten
treatment by a of the thirty days shall be available
licensed mental only for inpatient psychiatric
health professional. services when authorized by PHP
physician.
Outpatient services are limited to a OUTPATIENT: $3 per
maximum of forty outpatient visits per visit
contract year.
F. Substance Abuse All services must be provided directly INPATIENT:
Services by PHP or upon approved referral. NONE
Includes coverage
for inpatient and Inpatient services are limited to not
outpatient care for more than seven inpatient days per
drug and alcohol contract year for medical
abuse including detoxification only and thirty days
counseling and residential services.
placement
assistance. Outpatient visits are limited to a OUTPATIENT: $3 per
Outpatient services maximum of forty visits per contract visit
include evaluation, year.
diagnosis and
treatment by a
licensed
practitioner
G. Therapy Services All treatments must be performed $3 per visit
Covered services directly or as authorized by PHP.
include physical,
occupational, Limited to up to twenty-four treatment
respiratory and sessions within a sixty day period per
speech therapies for episode or injury, with the sixty day
short-term period beginning with the first
rehabilitation where treatment.
significant
improvement in the
enrollee's condition
will result.
H. Home Health Coverage is limited to skilled nursing $3 per visit
Services services only. Meals, housekeeping and
Includes prescribed personal comfort items are excluded.
home visits by both Services must be provided directly by
registered and PHP.
licensed practical
nurses to provide
skilled nursing
services on a
part-time
intermittent basis.
PHP/Orange, Osceola, Seminole Page 11 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
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I. Hospice Services Once a family elects to receive $3 per visit
Covered services hospice care for an enrollee, other
include reasonable services that treat the terminal
and necessary condition will not be covered.
services for
palliation or Services required for conditions
management of an totally unrelated to the terminal
enrollee's terminal condition are covered to the extent
illness. that the services are covered under
this contract.
J.Nursing Facility All admissions must be authorized by NONE
Services PHP and provided by a PHP affiliated
facility.
Covered services Participant must require and receive
include regular skilled services on a daily basis as
nursing services, ordered by PHP physician.
rehabilitation The length of the enrollee's stay
services, drugs and shall be determined by the medical
biologicals, medical condition of the enrollee in relation
supplies, and the to the necessary and appropriate level
use of appliances of care, but is no more than 100 days
and equipment per contract year.
furnished by the
facility. Room and board is limited to
semi-private accommodations unless a
private room is considered medically
necessary or semi-private
accommodations are not available.
Specialized treatment centers and
independent kidney disease treatment
centers are excluded.
Private duty nurses, television, and
custodial care are excluded.
Admissions for rehabilitation and
physical therapy are limited to
fifteen days per contract year.
K. Durable Medical Equipment and devices must be provided NONE
Equipment and by authorized PHP supplier.
Prosthetic Devices
Equipment and Covered prosthetic devices include
devices that are artificial eyes and limbs, braces, and
medically indicated other artificial aids.
to assist in the
treatment of a Low vision and telescopic lenses are
medical condition not included.
and specifically
prescribed as Hearing aids are covered only when
medically necessary medically indicated to assist in the
by enrollee's PHP treatment of a medical condition.
physician.
L. Refractions Enrollee must have failed vision $3 per visit
Examination by a PHP screening by primary care physician.
optometrist to
determine the need Corrective lenses and frames are
for and to prescribe limited to one pair every two years
corrective lenses as unless head size or prescription
medically indicated. changes. $10 for corrective
lenses
Coverage is limited to Medicaid frames
with plastic or SYL non-tinted lenses.
M. Pharmacy Prescribed drugs covered under this $3 per
Prescribed drugs for Agreement shall include all prescribed prescription for
the treatment of drugs covered under the Florida up to a 31-day
illness or injury or Medicaid program. PHP may implement a supply
injury. pharmacy benefit management program if
FHKC so authorizes. Brand name
products are covered if a generic
substitution is not available or where
the prescribing physician indicates
that a brand name is medically
necessary.
All medications must be dispensed
through PHP or a PHP designated
pharmacy.
All prescriptions must be written by
the participant's
PHP/Orange, Osceola, Seminole Page 12 of 19
Effective Date: December 1, 2001
BENEFIT LIMITATIONS CO-PAYMENTS
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primary care physician, PHP approved
specialist or consultant physician.
N. Transportation Must be in response to an emergency $10 per service
Services situation.
Emergency
transportation as
determined to be
medically necessary
in response to an
emergency situation.
II. Cost Sharing Provisions
PHP agrees to comply with all cost sharing restrictions imposed on FHKC
participants by federal or state laws and regulations, including the following
specific provisions:
A. Special Populations
Enrollees identified by FHKC to PHP as Native Americans or
Alaskan Natives are prohibited from paying any cost sharing
amounts.
B. Cost Sharing Limited to No More than Five Percent of Family's
Income FHKC may identify to PHP other enrollees who have met
federal requirements regarding maximum out of pocket
expenditures. Enrollees identified by FHKC as having met this
threshold are not required to pay any further cost sharing for
covered services for a time specified by FHKC.
C. PHP is responsible for informing its providers of these
provisions and ensuring that enrollees under this section incur
no further out of pocket costs for covered services and are not
denied access to services. FHKC will provide these enrollees
with a letter indicating that they may not incur any cost
sharing obligations.
III. Other Benefit Provision
All requirements for prior authorizations must conform with
federal and state regulations and must be completed within
fourteen (14) days of request by the enrollee. Extensions to
this process may be granted in accordance with federal and/or
state regulations.
PHP/Orange, Osceola, Seminole Page 13 of 19
Effective Date: December 1, 2001
EXHIBIT E
ACCESS AND CREDENTIALING STANDARDS
PHP shall maintain a medical staff, under contract, sufficient to permit
reasonably prompt medical service to all participants in accordance with the
following:
1. Physician and Medical Provider Standards
PHP shall provide include only board certified pediatricians and
family practice physicians or physician extenders working under
the direct supervision of a board certified practitioner to
serve as primary care physicians in its provider network for
Orange, Osceola, and Seminole County.
Additionally, PHP shall identify a medical home, as defined by
the American Academy of Pediatrics, for each enrollee. The
enrollee shall be given the opportunity to select a primary care
physician and if a physician has not been selected, Insurer will
assign the enrollee to a provider meeting the primary medical
care standards above.
The PHP may request that an individual provider be granted an
exception to this policy by making such a request in writing to
the Corporation and providing the provider's curriculum vitae
and a reason why the provider should be granted an exception to
the accepted standard. Such requests will be reviewed by the
Corporation on a case by case basis and a written response will
be made to PHP on the outcome of the request.
2. Geographical Access:
Geographical access to board certified family practice
physicians, pediatric physicians, primary care dental providers
or ARNP's, experienced in child health care, of approximately
twenty (20) minutes driving time from residence to provider,
except that this driving time limitation shall be reasonably
extended in those areas where such limitation with respect to
rural residence is unreasonable. In such instance, PHP shall
provide access for urgent care through contracts with nearest
providers.
3. Timely Treatment:
Timely treatment by providers, such that the participant shall
be seen by a provider in accordance with the following:
A. Emergency care shall be provided immediately;
B. Urgently needed care shall be provided within
twenty-four (24) hours;
C. Routine care of patients who do not require emergency or
urgently needed care shall be provided within seven (7)
calendar days;
PHP/Orange, Osceola, Seminole Page 14 of 19
Effective Date: December 1, 2001
D. Physical examinations and appointments for dental oral
examinations and routine cleanings shall be provided
within four (4) weeks of request for appointment; and
E. Follow-up care shall be provided as medically
appropriate.
For the purposes of this section, the following definitions shall apply:
Emergency care is that required for the treatment of an injury
or acute illness that, if not treated immediately, could
reasonably result in serious or permanent damage to the
patient's health.
Urgently needed care is that required within a twenty-four (24)
hour period to prevent a condition from requiring emergency
care.
Routine care is that level of care that can be delayed without
anticipated deterioration in the patient's medical condition for
a period of seven (7) calendar days.
By utilization of the foregoing standards, FHKC does not intend to create
standards of care or access different from those which are deemed acceptable
within the PHP service area. Rather FHKC intends that the provider timely and
appropriately respond to patient care needs, as they are presented, in
accordance with standards of care existing within the service area. In applying
the foregoing standards, the provider shall give due regard to the level of
discomfort and anxiety of the patient and/or parent.
In the event FHKC determines that PHP, or its providers, has failed to meet the
access standards herein set forth, FHKC shall provide PHP with written notice of
non-compliance. Such notice can be provided via facsimile or other means,
specifying the failure in such detail as will reasonably allow PHP to
investigate and respond. Failure of PHP to obtain reasonable compliance or
acceptable community care under the following conditions shall constitute a
breach of this agreement:
A. immediately upon receipt of notice for emergency or
urgent problem; or
B. within ten (10) days of receipt of notice for routine
visit access.
Such breach shall entitle FHKC to such legal and equitable relief as may be
appropriate. In particular, FHKC may direct its participants to obtain such
services outside the PHP provider network. PHP shall be financially responsible
for all services under this provision.
PHP/Orange, Osceola, Seminole Page 15 of 19
Effective Date: December 1, 2001
EXHIBIT F
GRIEVANCE, ARBITRATION AND LEGAL PROCESS
DELETE EXHIBIT FROM CONTRACT; RENUMBER
SUBSEQUENT EXHIBITS
PHP/Orange, Osceola, Seminole Page 16 of 19
Effective Date: December 1, 2001
EXHIBIT G
ELIGIBILITY STANDARDS
PARTICIPANT ELIGIBILITY CRITERIA
The following eligibility criteria for participation in the Healthy Kids Program
must be met:
1. The participants must be children who are age 5 through 18, and
the following groups are also eligible:
Children who received coverage prior to October 1, 1998 will be
eligible through their 19th birthday.
2. Participants must meet the eligibility criteria established
under Section 624.91, Florida Statutes and as implemented by
FHKC Board of Directors.
3. Eligible participants may enroll during time periods established
by FHKC Board of Directors and in accordance with Section
624.91, Florida Statutes.
PHP/Orange, Osceola, Seminole Page 17 of 19
Effective Date: December 1, 2001
EXHIBIT I
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY,
AND VOLUNTARY EXCLUSION
CONTRACTS AND SUBCONTRACTS
This certification is required by the regulations 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).
INSTRUCTIONS
A. Each Provider whose contract\subcontract equals or exceeds
$25,000 in federal monies must sign this certification prior to execution of
each contract\subcontract. Additionally, providers who audit federal programs
must also sign, regardless of the contract amount. The Florida Healthy Kids
Corporation cannot contract with these types of providers if they are debarred
or suspended by the federal government.
B. This certification is a material representation of fact upon
which reliance is placed when this contract\subcontract is entered into. If it
is later determined that the signer knowingly rendered an erroneous
certification, the Federal Government may pursue available remedies, including
suspension and/or debarment.
C. The provider shall provide immediate written notice to the
contract manager at any time the provider learns that its certification was
erroneous when submitted or has become erroneous by reason of changed
circumstances.
D. 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. You may contact the contract manager for assistance in
obtaining a copy of those regulations.
E. The provider 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/subcontract unless authorized by the Federal Government.
F. The provider further agrees by submitting this certification
that it will require each subcontractor of this contract/subcontract whose
payment will equal or exceed $25,000 in federal monies, to submit a signed copy
of this certification.
G. The Florida Healthy Kids Corporation may rely upon a
certification of a provider that it is not debarred, suspended, ineligible, or
voluntarily excluded from contracting\subcontracting unless it knows that the
certification is erroneous.
H. This signed certification must be kept in the contract manager's
file. Subcontractor's certifications must be kept at the contractor's business
location.
CERTIFICATION
The prospective provider 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 this
contract/subcontract by any federal agency.
Where the prospective provider is unable to certify to any of the statements in
this certification, such prospective provider shall attach an explanation to
this certification.
Signature Date
Name and Title of Authorized Signee
PHP/Orange, Osceola, Seminole Page 18 of 19
Effective Date: December 1, 2001
EXHIBIT J
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 employee of any agency, a member of congress,
an officer or employee of congress, or an employee of a member of
congress in connection with the awarding of any federal contract, the
making of any federal 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 employee of any agency, a member of congress, an officer or
employee of congress, or an employee of a member of congress in
connection with this federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL,
"Disclosure Form to Report Lobbying," in accordance with its
instructions.
(3) The undersigned shall require that the language of this certification be
included in the award documents for all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans,
and cooperative agreements) and that all subrecipients 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/ PETER L. JIMENEZ 11/26/01
- -------------------------------------------------------
Signature Date
PETER L. JIMENEZ
- -----------------------------
Name of Authorized Individual
PHPI 55 Alnambra Plaza, 7th fl. Coral Gables, PL. 33134
- -------------------------------------------------------
Name and Address of Organization
PHP/Orange, Osceola, Seminole Page 19 of 19
Effective Date: December 1, 2001
STANDARD AMENDMENT TO HEALTH PLAN
AMENDMENT #3
TO THE CONTRACT BETWEEN
THE FLORIDA HEALTHY KIDS CORPORATION
AND
PHYSICIANS HEALTHCARE PLANS
THIS AMENDMENT, entered into between the Florida Healthy Kids Corporation,
hereinafter referred to as "FHKC" and PHYSICIANS HEALTHCARE PLANS, hereinafter
referred to as "PHP", amends its contract dated November 16, 1998.
WHEREAS, the contract between FHKC and PHP allows for amendments to said
contract by mutual written consent of the parties;
WHEREAS, FHKC conducts an annual review of its contracts in order to identify
any contract provisions that require modification in order to conform to changes
in the federal and state laws and regulations as well as to reflect programmatic
changes; and,
THEREFORE, be it resolved that the Parties agree to the following amendment of
their contract:
I. Section 3-19-2 is amended to insert the following after
"information.":
PHP's policies and procedures for handling medical records and
protected health information (PHI) shall be compliant with the
Health Insurance Portability and Accountability Act of 1996
(HIPAA) and shall include provisions for when an enrollee's PHI
may be disclosed without consent or authorization.
II. Section 3-20-2(d) is deleted from the contract.
III. Section 4-4-1 is amended to insert the following after "1986.":
PHP Insurer is responsible for issuing a certificate of
creditable coverage to those FHKC participants who disenroll
from the Program.
IV. Exhibit C, Section E, "Outpatient Services" is amended to
include the following additional provision:
Immunizations are to be provided by the primary care physician.
V. Exhibit E, "Access and Credentialling Standards", Paragraph I,
A. is amended to include the following additional provision:
Primary care physicians must provide covered immunizations to
enrollees.
VI. Exhibit K is a new amendment to the Agreement between FHKC and
Insurer and is hereby attached and incorporated into this
Agreement.
PHP - Orange, Osceola, Seminole Page 1 of 4
Effective Date: December 1, 2002
VII. This contract amendment is effective December 1, 2002.
All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform with 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
of its attachments are hereby made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this four (4) page amendment
to be executed by their officials thereunto duly authorized.
FLORIDA HEALTHY KIDS CORPORATION
- ------------------------------------- -------------------------------
Rose M. Naff, Executive Director Witness
Date:
PHYSICIANS HEALTHCARE PLANS
/s/ Daisy Gomez /s/ [ILLEGIBLE]
- ------------------------------------- -------------------------------
NAME Daisy Gomez Witness
Date: 10/14/02
PHP - Orange, Osceola, Seminole Page 2 of 4
Effective Date: December 1, 2002
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 Insurer certifies and agrees as to abide by the following:
1. 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 FHKC.
2. Limits on Use and Disclosure of Protected Health Information.
The Insurer shall not use or disclose Protected Health
Information other than as permitted by this Contract or by
federal and state law. The Insurer 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 Insurer will not divulge,
disclose, or communicate in any manner any Protected Health
Information to any third party without prior written consent
from the FHKC. The Insurer will report to the FHKC, within two
(2) business days of discovery, any use or disclosure of
Protected Health Information not provided for in this Contract
of which the Insurer 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 Insurer is
permitted to use and disclose Protected Health Information
received from the Insurer for the proper management and
administration of the Insurer or to carry out the legal
responsibilities of the Insurer, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where
required by law, or where the Insurer 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 Insurer 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 Insurer 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 Insurer
on behalf of, the FHKC. Such subcontract shall contain the same
terms, conditions, and restrictions that apply to the Insurer
with respect to Protected Health Information.
5. Access to Information. The Insurer 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.
PHP - Orange, Osceola, Seminole Page 3 of 4
Effective Date: December 1, 2002
6. Amendment and Incorporation of Amendments. The Insurer 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 Insurer shall make Protected
Health Information available as required to provide an
accounting of disclosures in accordance with 45 C.F.R. Section
164.528.
8. Access to Books and Records. The Insurer 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 Insurer on behalf of, the FHKC 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 Insurer
shall return all Protected Health Information that the Insurer
still maintains in any form, including any copies or hybrid or
merged databases made by the Insurer; or with prior written
approval of the FHKC, the Protected Health Information may be
destroyed by the Insurer after its use. If the Protected Health
Information is destroyed pursuant to the FHKC's prior written
approval, the Insurer must provide a written confirmation of
such destruction to the FHKC. If return or destruction of the
Protected Health Information is determined not feasible by the
FHKC, the Provider agrees to protect the Protected Health
Information and treat it as strictly confidential.
CERTIFICATION
- --------------------------------------------------------------------------------
The Insurer and the Florida Healthy Kids Corporation have caused
this Certification to be signed and delivered by their duly
authorized representatives, as of the date set forth below.
Provider Name:
/s/ Daisy Gomez 10/14/02
----------------------------------- ---------------------
Signature Date
Daisy Gomez Gov't Prog. Dir.
-----------------------------------
Name and Title of Authorized Signee
PHP - Orange, Osceola, Seminole Page 4 of 4
Effective Date: December 1, 2002