EXHIBIT 10.1
CONTRACT NO. FA522
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STANDARD CONTRACT
THIS CONTRACT is entered into between the State of Florida, AGENCY FOR HEALTH
CARE ADMINISTRATION, hereinafter referred to as the "AGENCY", whose address is
2727 Mahan Drive, Tallahassee, Florida 32308, and WELL CARE HMO, INC. d/b/a/
STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the "VENDOR", whose
address is 6800 N. Dale Mabry Highway, Suite 168, Tampa, Florida 33614-3988, a
Florida Profit Corporation, to provide health care services to Medicaid
beneficiaries.
I. THE VENDOR HEREBY AGREES:
A. GENERAL PROVISIONS
1. To provide services according to the terms and
conditions set forth in this Contract, ATTACHMENT I,
Scope of Services, and all other attachments named
herein which are attached hereto and incorporated by
reference.
2. To perform as an independent vendor and not as an
agent, representative, or employee of the Agency.
3. To recognize that the State of Florida, by virtue of
its sovereignty, is not required to pay any taxes on
the services or goods purchased under the terms of
this Contract.
B. FEDERAL LAWS AND REGULATIONS
1. If this Contract contains federal funds, the Vendor
shall comply with the provisions of 45 CFR, Part 74,
and/or 45 CFR, Part 92, and other applicable
regulations as specified in ATTACHMENT I.
2. If this Contract contains federal funding in excess
of $100,000, the Vendor must, upon Contract
execution, complete the Certification Regarding
Lobbying form, ATTACHMENT IV. If a Disclosure of
Lobbying Activities form, Standard Form LLL, is
required, it may be obtained from the Agency's
Contract Manager. All disclosure forms as required by
the Certification Regarding Lobbying form must be
completed and returned to the Agency's Contract
Manager.
3. Pursuant to 45 CFR, Part 76, if this Contract
contains federal funding in excess of $25,000, the
Vendor must, upon Contract execution, complete the
Certification Regarding Debarment, Suspension,
Ineligibility, and Voluntary Exclusion
Contracts/Subcontracts, ATTACHMENT V.
C. AUDITS AND RECORDS
1. To maintain books, records, and documents (including
electronic storage media) pertinent to performance
under this Contract in accordance with generally
accepted accounting procedures and practices which
sufficiently and properly reflect all revenues and
expenditures of funds provided by the Agency under
this Contract.
AHCA CONTRACT NO. FA522, PAGE 1 OF 10
2. To assure that these records shall be subject at all
reasonable times to inspection, review, or audit by
state personnel and other personnel duly authorized
by the Agency, as well as by federal personnel.
3. To maintain and file with the Agency such progress,
fiscal and inventory reports as specified in
ATTACHMENT I, and other reports as the Agency may
require within the period of this Contract. In
addition, access to relevant computer data and
applications which generated such reports should be
made available upon request.
4. To provide a financial and compliance audit to the
Agency as specified in ATTACHMENT II and to ensure
that all related party transactions are disclosed to
the auditor. Additional audit requirements are
specified in ATTACHMENT I.
5. To include these aforementioned audit and record
keeping requirements in all approved subcontracts and
assignments.
D. RETENTION OF RECORDS
1. To retain all financial records, supporting
documents, statistical records, and any other
documents (including electronic storage media)
pertinent to performance under this Contract for a
period of five (5) years after termination of this
Contract, or if an audit has been initiated and audit
findings have not been resolved at the end of five
(5) years, the records shall be retained until
resolution of the audit findings.
2. Persons duly authorized by the Agency and federal
auditors, pursuant to 45 CFR, Part 74 and/or 45 CFR,
Part 92, shall have full access to and the right to
examine any of said records and documents.
3. The rights of access in this section must not be
limited to the required retention period but shall
last as long as the records are retained.
E. MONITORING
1. To provide reports as specified in ATTACHMENT I.
These reports will be used for monitoring progress or
performance of the contractual services as specified
in ATTACHMENT I.
2. To permit persons duly authorized by the Agency to
inspect any records, papers, documents, facilities,
goods and services of the Vendor which are relevant
to this Contract.
F. INDEMNIFICATION
The Contractor shall save and hold harmless and indemnify the
State of Florida and the Agency against any and all liability,
claims, suits, judgments, damages or costs of whatsoever kind
and nature resulting from the use, service, operation or
performance of work under the terms of this Contract,
resulting from any act, or failure to act, by the Vendor, his
subcontractor, or any of the employees, agents or
representatives of the Vendor or subcontractor.
AHCA CONTRACT NO. FA522, PAGE 2 OF 10
G. INSURANCE
1. To the extent required by law, the Vendor will be
self-insured against, or will secure and maintain
during the life of the Contract, Worker's
Compensation Insurance for all his employees
connected with the work of this project and, in case
any work is subcontracted, the Vendor shall require
the subcontractor similarly to provide Worker's
Compensation Insurance for all of the latter's
employees unless such employees engaged in work under
this Contract are covered by the Vendor's self
insurance program. Such self insurance or insurance
coverage shall comply with the Florida Worker's
Compensation law. In the event hazardous work is
being performed by the Vendor under this Contract and
any class of employees performing the hazardous work
is not protected under Worker's Compensation
statutes, the Vendor shall provide, and cause each
subcontractor to provide, adequate insurance
satisfactory to the Agency, for the protection of his
employees not otherwise protected.
2. The Vendor shall secure and maintain Commercial
General Liability insurance including bodily injury,
property damage, personal & advertising injury and
products and completed operations. This insurance
will provide coverage for all claims that may arise
from the services and/or operations completed under
this Contract, whether such services and/or
operations are by the Vendor or anyone directly, or
indirectly employed by him. Such insurance shall
include a Hold Harmless Agreement in favor of the
State of Florida and also include the State of
Florida as an Additional Named Insured for the entire
length of the Contract. The Vendor is responsible for
determining the minimum limits of liability necessary
to provide reasonable financial protections to the
Vendor and the State of Florida under this Contract.
3. All insurance policies shall be with insurers
licensed or eligible to transact business in the
State of Florida. The Vendor's current certificate of
insurance shall contain a provision that the
insurance will not be canceled for any reason except
after thirty (30) days written notice to the Agency's
Contract Manager.
H. ASSIGNMENTS AND SUBCONTRACTS
To neither assign the responsibility of this Contract to
another party nor subcontract for any of the work contemplated
under this Contract without prior written approval of the
Agency. No such approval by the Agency of any assignment or
subcontract shall be deemed in any event or in any manner to
provide for the incurrence of any obligation of the Agency in
addition to the total dollar amount agreed upon in this
Contract. All such assignments or subcontracts shall be
subject to the conditions of this Contract and to any
conditions of approval that the Agency shall deem necessary.
I. FINANCIAL REPORTS
To provide financial reports to the Agency as specified in
ATTACHMENT I.
J. RETURN OF FUNDS
To return to the Agency any overpayments due to unearned funds
or funds disallowed pursuant to the terms of this Contract
that were disbursed to the
AHCA CONTRACT NO. FA522, PAGE 3 OF 10
Vendor by the Agency. The Vendor shall return any overpayment
to the Agency within forty (40) calendar days after either
discovery by the Vendor, its independent auditor, or
notification by the Agency, of the overpayment.
K. PURCHASING
1. P.R.I.D.E.
It is expressly understood and agreed that any
articles which are the subject of, or required to
carry out this Contract shall be purchased from the
corporation identified under Chapter 946, Florida
Statutes, if available, in the same manner and under
the same procedures set forth in Section 946.515(2),
(4), Florida Statutes; and for purposes of this
Contract the person, firm or other business entity
carrying out the provisions of this Contract shall be
deemed to be substituted for this agency insofar as
dealings with such corporation are concerned.
The "Corporation identified" is PRISON REHABILITATIVE
INDUSTRIES AND DIVERSIFIED ENTERPRISES, INC.
(P.R.I.D.E.) which may be contacted at:
P.R.I.D.E.
2720-G Blair Stone Road
Tallahassee, Florida 32301
(850) 487-3774
Toll Free: 1-800-643-8459
Website: www.pridefl.com
2. RESPECT OF FLORIDA
It is expressly understood and agreed that any
articles that are the subject of, or required to
carry out, this Contract shall be purchased from a
nonprofit agency for the blind or for the severely
handicapped that is qualified pursuant to Chapter
413, Florida Statutes, in the same manner and under
the same procedures set forth in Section 413.036(1)
and (2), Florida Statutes; and for purposes of this
Contract the person, firm, or other business entity
carrying out the provisions of this Contract shall be
deemed to be substituted for the state agency insofar
as dealings with such qualified nonprofit agency are
concerned.
The "nonprofit agency" identified is RESPECT of
Florida which may be contacted at:
RESPECT of Florida.
2475 Apalachee Parkway, Suite 205
Tallahassee, Florida 32301-4946
(850) 487-1471
Website: www.respectofflorida.org
3. PROCUREMENT OF PRODUCTS OR MATERIALS WITH RECYCLED
CONTENT
It is expressly understood and agreed that any
products which are required to carry out this
Contract shall be procured in accordance with the
provisions of Section 403.7065, Florida Statutes.
AHCA CONTRACT NO. FA522, PAGE 4 OF 10
L. CIVIL RIGHTS REQUIREMENTS/VENDOR ASSURANCE
The Vendor assures that it will comply with:
1. 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.
2. Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits
discrimination on the basis of handicap.
3. Title IX of the Education Amendments of 1972, as
amended, 20 U.S.C. 1681 et seq., which prohibits
discrimination on the basis of sex.
4. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination
on the basis of age.
5. Section 654 of the Omnibus Budget Reconciliation Act
of 1981, as amended, 42 U.S.C. 9849, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation
or beliefs.
6. The Americans 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.
7. All regulations, guidelines, and standards as are now
or may be lawfully adopted under the above statutes.
The Vendor agrees that compliance with this assurance
constitutes a condition of continued receipt of or benefit
from funds provided through this Contract, and that it is
binding upon the Vendor, its successors, transferees, and
assignees for the period during which services are provided.
The Vendor further assures that all contractors,
subcontractors, subgrantees, or others with whom it arranges
to provide services or benefits to participants or employees
in connection with any of its programs and activities are not
discriminating against those participants or employees in
violation of the above statutes, regulations, guidelines, and
standards.
M. DISCRIMINATION
An entity or affiliate who has been placed on the
discriminatory vendor list may not submit a bid, proposal, or
reply on a contract to provide any goods or services to a
public entity; may not submit a bid, proposal, or reply on a
contract with a public entity for the construction or repair
of a public building or public work; may not submit bids,
proposals, or replies on leases of real property to a public
entity; may not be awarded or perform work as a contractor,
supplier, subcontractor, or consultant under a contract with
any public entity; and may not transact business with any
public entity. The Florida Department of Management Services
is responsible for maintaining the discriminatory vendor list
and intends to post the list on its website. Questions
regarding the discriminatory vendor list may be directed to
the Florida Department of Management Services, Office of
Supplier Diversity at (850) 487-0915.
N. REQUIREMENTS OF SECTION 287.058, FLORIDA STATUTES
1. To submit bills for fees or other compensation for
services or expenses in sufficient detail for a
proper pre-audit and post-audit thereof.
2. Where applicable, to submit bills for any travel
expenses in accordance with Section 112.061, Florida
Statutes. The Agency may, when specified
AHCA CONTRACT NO. FA522, PAGE 5 OF 10
in N/A, establish rates lower than the maximum
provided in Section 112.061, Florida Statutes.
3. To provide units of deliverables, including reports,
findings, and drafts, in writing and/or in an
electronic format agreeable to both parties, as
specified in ATTACHMENT I, to be received and
accepted by the Contract Manager prior to payment.
4. To comply with the criteria and final date by which
such criteria must be met for completion of this
Contract as specified in Section III, Paragraph A. of
this Contract.
5. To allow public access to all documents, papers,
letters, or other material made or received by the
Vendor in conjunction with this Contract, unless the
records are exempt from Section 24(a) of Article I of
the State Constitution and Section 119.07(1), Florida
Statutes. It is expressly understood that substantial
evidence of the Vendor's refusal to comply with this
provision shall constitute a breach of Contract.
6. In accordance with Section 287.057 (14), this
Contract may be renewed for a period that may not
exceed three (3) years or the term of the original
Contract, whichever period is longer, unless
otherwise specified in ATTACHMENT I. Renewal of this
Contract shall be in writing and subject to the same
terms and conditions set forth in the initial
Contract prior to Contract termination. A renewal
contract may not include any compensation for costs
associated with the renewal. Renewals are contingent
upon satisfactory performance evaluations by the
Agency and subject to the availability of funds. A
renewal clause, including terms under which the cost
may change, must be specified in the invitation to
bid, request for proposal, or other bid instrument,
if applicable. This Contract may not be renewed if it
is the result of an emergency or single source method
of procurement.
O. SPONSORSHIP
As required by Section 286.25, Florida Statutes, if the Vendor
is a nongovernmental organization which sponsors a program
financed wholly or in part by state funds, including any funds
obtained through this Contract, it shall, in publicizing,
advertising or describing the sponsorship of the program,
state:
"Sponsored by WELL CARE HMO, INC. D/B/A STAYWELL HEALTH PLAN
OF FLORIDA and the State of Florida, AGENCY FOR HEALTH CARE
ADMINISTRATION".
If the sponsorship reference is in written material, the words
"State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION"
shall appear in the same size letters or type as the name of
the organization.
P. FINAL INVOICE
The Vendor must submit the final invoice for payment to the
Agency no more than 90 days after the Contract ends or is
terminated. If the Vendor fails to do so, all right to payment
is forfeited and the Agency will not honor any requests
submitted after the aforesaid time period. Any payment due
under
AHCA CONTRACT NO. FA522, PAGE 6 OF 10
the terms of this Contract may be withheld until all reports
due from the Vendor and necessary adjustments thereto have
been approved by the Agency.
Q. USE OF FUNDS FOR LOBBYING PROHIBITED
To comply with the provisions of Section 216.347, Florida
Statutes, which prohibits the expenditure of Contract funds
for the purpose of lobbying the Legislature, the judicial
branch or a state agency.
R. PUBLIC ENTITY CRIME
A person or affiliate who has been placed on the convicted
vendor list following a conviction for a public entity crime
may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public
entity, and may not transact business with any public entity
in excess of the threshold amount provided in Section 287.017,
Florida Statutes, for category two, for a period of 36 months
from the date of being placed on the convicted vendor list.
S. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
To comply with the Department of Health and Human Services
Privacy Regulations in the Code of Federal Regulations, Title
45, Sections 160 and 164, regarding disclosure of protected
health information as specified in ATTACHMENT III.
T. CONFIDENTIALITY OF INFORMATION
Not to use or disclose any confidential information, including
social security numbers that may be supplied under this
Contract pursuant to law, and also including the identity or
identifying information concerning a Medicaid recipient or
services under this Contract for any purpose not in conformity
with state and federal laws, except upon written consent of
the recipient, or his/her guardian.
U. EMPLOYMENT
To comply with Section 274A (e) of the Immigration and
Nationality Act. The Agency shall consider the employment by
any contractor of unauthorized aliens a violation of this Act.
If the Vendor knowingly employs unauthorized aliens, such
violation shall be cause for unilateral cancellation of this
Contract. The Vendor shall be responsible for including this
provision in all subcontracts with private organizations
issued as a result of this Contract.
V. VENDOR PERFORMANCE
Penalties or sanctions for unsatisfactory performance under
this Contract are specified in ATTACHMENT I, if applicable.
II. THE AGENCY HEREBY AGREES:
A. CONTRACT AMOUNT
To pay for contracted services according to the conditions of
ATTACHMENT I in an amount not to exceed $634,852,345.00,
subject to the availability of funds.
AHCA CONTRACT NO. FA522, PAGE 7 OF 10
The State of Florida's performance and obligation to pay under
this Contract is contingent upon an annual appropriation by
the Legislature.
B. CONTRACT PAYMENT
Section 215.422, Florida Statutes, provides that agencies have
5 working days to inspect and approve goods and services,
unless bid specifications, Contract or purchase order
specifies otherwise. With the exception of payments to health
care providers for hospital, medical, or other health care
services, if payment is not available within forty (40) days,
measured from the latter of the date the invoice is received
or the goods or services are received, inspected and approved,
a separate interest penalty set by the Comptroller pursuant to
Section 55.03, F. S., will be due and payable in addition to
the invoice amount. To obtain the applicable interest rate,
please contact the Agency's Fiscal Section at (850) 488-5869,
or utilize the Department of Financial Services website at
www.dfs.state.fl.us/interest.html. Payments to health care
providers for hospitals, medical or other health care
services, shall be made not more than 35 days from the date of
eligibility for payment is determined, and the daily interest
rate is .0003333%. Invoices returned to a vendor due to
preparation errors will result in a payment delay. Invoice
payment requirements do not start until a properly completed
invoice is provided to the Agency. A Vendor Ombudsman, whose
duties include acting as an advocate for vendors who may be
experiencing problems in obtaining timely payment(s) from a
State agency, may be contacted at (850) 410-9724 or by calling
the State Comptroller's Hotline, 1-800-848-3792.
III. THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:
A. EFFECTIVE/END DATE
This Contract shall begin upon execution by both parties or
JULY 1, 2004, (whichever is later) and end JUNE 30, 2006,
inclusive.
B. TERMINATION
1. TERMINATION AT WILL
This Contract may be terminated by either party upon
no less than thirty (30) calendar days written
notice, without cause, unless a lesser time is
mutually agreed upon by both parties. Said notice
shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery.
2. TERMINATION DUE TO LACK OF FUNDS
In the event funds to finance this Contract become
unavailable, the Agency may terminate the Contract
upon no less than twenty-four (24) hours written
notice to the Vendor. Said notice shall be delivered
by certified mail, return receipt requested, or in
person with proof of delivery. The Agency shall be
the final authority as to the availability of funds.
3. TERMINATION FOR BREACH
Unless the Vendor's breach is waived by the Agency in
writing, the Agency may, by written notice to the
Vendor, terminate this Contract upon no less than
twenty-four (24) hours written notice. Said notice
shall be delivered by certified mail, return receipt
requested, or in person with
AHCA CONTRACT NO. FA522, PAGE 8 OF 10
proof of delivery. If applicable, the Agency may
employ the default provisions in Chapter
60A-1.006(4), Florida Administrative Code.
Waiver of breach of any provisions of this Contract shall not
be deemed to be a waiver of any other breach and shall not be
construed to be a modification of the terms of this Contract.
The provisions herein do not limit the Agency's right to
remedies at law or to damages.
C. CONTRACT MANAGERS
1. The Agency's Contract Manager's name, address and
telephone number for this Contract is as follows:
CHRISTINA LOPEZ
AGENCY FOR HEALTH CARE ADMINISTRATION
2727 MAHAN DRIVE, MS 50
TALLAHASSEE, FL 32308
(850) 487-2355
2. The Vendor's Contract Manager's name, address and
telephone number for this Contract is as follows:
TODD S. FARHA
WELL CARE HMO INC.,
D/B/A STAYWELL HEALTH PLAN OF FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
(813) 290-6377
3. All matters shall be directed to the Contract
Managers for appropriate action or disposition. A
change in Contract Manager by either party shall be
reduced to writing through an amendment to this
Contract by the Agency.
D. RENEGOTIATION OR MODIFICATION
1. Modifications of provisions of this Contract shall
only be valid when they have been reduced to writing
and duly signed during the term of the Contract. The
parties agree to renegotiate this Contract if federal
and/or state revisions of any applicable laws, or
regulations make changes in this Contract necessary.
2. The rate of payment and the total dollar amount may
be adjusted retroactively to reflect price level
increases and changes in the rate of payment when
these have been established through the
appropriations process and subsequently identified in
the Agency's operating budget.
E. NAME, MAILING AND STREET ADDRESS OF PAYEE
1. The name (Vendor name as shown on Page 1 of this
Contract) and mailing address of the official payee
to whom the payment shall be made:
WELL CARE HMO INC., D/B/A STAYWELL HEALTH PLAN OF
FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
AHCA CONTRACT NO. FA522, PAGE 9 OF 10
2. The name of the contact person and street address
where financial and administrative records are
maintained:
TODD S. FARHA
WELL CARE HMO INC., D/B/A STAYWELL HEALTH PLAN OF
FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
F. ALL TERMS AND CONDITIONS
This Contract and its attachments as referenced herein contain
all the terms and conditions agreed upon by the parties.
IN WITNESS THEREOF, the parties hereto have caused this 186 page Contract, which
includes any referenced attachments, to be executed by their undersigned
officials as duly authorized. This Contract is not valid until signed and dated
by both parties.
VENDOR: WELL CARE HMO INC., STATE OF FLORIDA, AGENCY FOR
D/B/A STAYWELL HEALTH HEALTH CARE ADMINISTRATION
PLAN OF FLORIDA
SIGNED SIGNED
BY: _____________________________ BY:____________________________
NAME: TODD S. FARHA NAME: ALAN LEVINE
TITLE: PRESIDENT AND CHIEF EXECUTIVE TITLE:SECRETARY
OFFICER
DATE: _____________________________ DATE:_____________________________
FEDERAL ID NUMBER (OR SS NUMBER FOR AN INDIVIDUAL): 59-2583622
VENDOR FISCAL YEAR ENDING DATE: DECEMBER 31, 2004
List of attachments included as part of this Contract:
Specify
Type Number Description (include number of pages)
- ----------------------------------------------------------------------
Attachment I Scope of Services (166 Pages)
Attachment II Financial and Compliance Audit (3 Pages)
Attachment III Health Insurance Portability and
Accountability Act of 1996 Compliance
(2 Pages)
Attachment IV Certification Regarding Lobbying (1 Page)
Attachment V Certification Regarding Debarment (1 Page)
Attachment VI 2004-2005 HMO Rates (3 Pages)
AHCA CONTRACT NO. FA522, PAGE 10 OF 10
July 2004 Medicaid HMO Contract
ATTACHMENT I
SCOPE OF SERVICES
10.0 COVERED SERVICES AND ELIGIBLE BENEFICIARIES
10.1 GENERAL
The health maintenance organization vendor, hereinafter referred to as
the plan, shall comply with all the provisions of this contract and its
amendments, if any, and shall act in good faith in the performance of
the contract provisions. The plan shall develop and maintain written
policies and procedures to implement the provisions of this contract.
The plan agrees that failure to comply with these provisions may result
in the assessment of penalties and/or termination of the contract in
whole or in part, as set forth in this contract.
The plan shall comply with all pertinent Agency rules in effect
throughout the duration of the contract.
The plan shall comply with all current Agency handbooks noticed in or
incorporated by reference in rules relating to the provision of
services set forth in sections 10.4, Covered Services, and 10.5,
Optional Services, except where the provisions of the contract alter
the requirements set forth in the handbooks. In addition, the plan
shall comply with the limitations and exclusions in the Agency
handbooks unless otherwise specified by this contract. In no instance
may the limitations or exclusions imposed by the plan be more stringent
than those specified in the handbooks. Pursuant to 42 CFR 438.210(a)
the plan must furnish services up to the limits specified by the
Medicaid program. The plan may exceed these limits. However, service
limitations shall not be more restrictive than the Florida
fee-for-service program, pursuant to 42 CFR 438.210(a).
Upon implementation of the Medicaid Prepaid Mental Health program in
each Area the plan shall provide community mental health services and
mental health targeted case management services in accordance with
section 10.11, Behavioral Health Care, of this contract. Sections 2.2,
2.3 and 2.5 of the Area specific Prepaid Mental Health Plan (PMHP)
requests for proposals (RFP) will apply to the respective Area members.
All other general behavioral health service requirements shall also
apply.
The plan may offer services to enrolled Medicaid beneficiaries in
addition to those covered services specified in sections 10.4, Covered
Services, 10.8, Manner of Service Provision, and 10.9, Quality and
Benefit Enhancements. These services must be specifically defined in
regards to amount, duration and scope, and must be approved in writing
by the Agency prior to implementation.
The plan shall have a quality improvement program that ensures
enhancement of quality of care and emphasize quality patient outcomes.
The Agency may restrict the plan's enrollment activities if acceptable
quality improvement and performance indicators based on HEDIS and other
outcome measures to be determined by the Agency are not met. Such
restrictions may include the termination of mandatory assignments.
10.2 ELIGIBLE BENEFICIARIES
The categories of eligible beneficiaries authorized to be enrolled in
the plan are: Low Income Families and Children; Foster Care; Sixth
Omnibus Budget Reconciliation Act (SOBRA) Children; Supplemental
Security Income (SSI) Medicaid Only; SSI Medicare Part B Only; and SSI
Medicare Parts A & B. Beneficiaries who are residents of Assisted
Living Facilities (ALFs) and not enrolled in an ALF waiver program are
eligible for enrollment in the plan. Title XXI MediKids are eligible
for enrollment in the plan in accordance with section 409.8132, F.S.
Except as otherwise specified in this contract, Title XXI MediKids
eligible participants are entitled to the same conditions and services
as currently eligible Title XIX Medicaid beneficiaries. In addition,
women enrolled in the plan who change eligibility categories to the
SOBRA eligibility category due to their pregnancy will remain eligible
for enrollment in the plan.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 1 OF 166
\
July 2004 Medicaid HMO Contract
10.3 INELIGIBLE BENEFICIARIES
The following categories describe beneficiaries who are not eligible to
enroll in the plan:
a. Medicaid eligible beneficiaries who, at the time of
application for enrollment and/or at the time of enrollment,
are domiciled or residing in an institution, including nursing
facilities (because the beneficiary was assessed by
Comprehensive Assessment and Review for Long Term Care (CARES)
and found to be at a custodial level of care), intermediate
care facilities for persons with developmental disabilities,
state hospitals or correctional institutions.
b. Medicaid eligible beneficiaries who are receiving services
through a hospice program, the Medicaid AIDS waiver (Project
AIDS Care) program, a prescribed pediatric extended care
center, or enrolled in Children's Medical Services.
c. Medicaid eligible beneficiaries who are also members of a
Medicare-funded health maintenance organization (HMO).
d. Medicaid eligible beneficiaries whose Medicaid eligibility has
been determined through the medically needy program.
e. Qualified Medicare beneficiaries (QMBs).
f. Medicaid eligible beneficiaries who have other credible health
care coverage like TriCare or a private HMO.
g. Medicaid eligible beneficiaries who reside in the following:
1. Residential commitment programs/facilities operated
through the Department of Juvenile Justice (DJJ).
2. Residential group care operated by the Family Safety
and Preservation Program in the Department of
Children and Families (DCF).
3. Children's residential treatment facilities purchased
through the Alcohol, Drug Abuse, and Mental Health
Program Office (ADM) in DCF (Purchased Residential
Treatment Services - PRTS).
4. ADM residential treatment facilities licensed as
Level I and II facilities.
5. Residential Level I and Level II substance abuse
treatment programs pursuant to section
65D-30.007(2)(a) and (b), F.A.C.
h. Family Planning waiver beneficiaries.
i. Medicaid eligible beneficiaries in the following programs may
not enroll in a frail/elderly component of a Medicaid HMO:
1. An aged/disabled waiver program
2. The Channeling program
3. Developmental Services Waiver
4. TANF beneficiaries
5. The Assisted Living for the Elderly waiver, or
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 2 OF 166
July 2004 Medicaid HMO Contract
j. Medicaid eligible beneficiaries who are members of the Florida
Assertive Community Treatment Team (FACT team) in those areas
in which the HMO is responsible for community mental health
and targeted case management services.
k. Participants in the Sub-acute Inpatient Psychiatric Program
(SIPP).
l. Pregnant women not enrolled in the plan prior to the effective
date of their SOBRA eligibility.
10.4 COVERED SERVICES
The plan shall ensure the provision of the following covered services
as defined and specified in sections 10.1, General and 10.8, Manner of
Service Provision:
Child Health Check-Up Inpatient Hospital
Services
Community Mental Health Services. Mental Health
Targeted Case
Management
Family Planning Services Outpatient Hospital
and Emergency
Services
Freestanding Dialysis Centers Physician Services
Hearing Services Prescribed Drug
Services
Home Health Services and Durable Medical Equipment Therapy Services
Independent Laboratory and X-Ray Services Visual Services
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 3 OF 166
WellCare HMO d/b/a StayWell Health Plan of Florida Medicaid HMO Contract
July 1, 2004
10.5 OPTIONAL SERVICES
These services are rendered within Medicaid guidelines at the option of
the plan and the Agency.
Covered Not Covered
Dental Services _____________________ X
Transportation Services X (Dade Only) _____________________
Frail/Elderly Program X
_____________________
(in accordance with Exhibit 110.4 of this contract)
10.6 EXPANDED SERVICES
These services are defined as those offered by the plan and approved by
the Agency, which are as follows:
a. Services in excess of the amount, duration and scope of those
listed in sections 10.4, Covered Services, and 10.5, Optional
Services.
b. Services and benefits not listed in sections 10.4 and 10.5.
c. The plan may offer an Agency approved over-the-counter
expanded drug benefit, not to exceed $10.00 per household, per
month. Such benefits shall be limited to non-prescription
drugs containing a National Drug Code (NDC) number, and first
aid and birth control supplies. Such benefits must be offered
through a plan's pharmacy or plan's subcontract with a
pharmacy. The plan shall make payments for the
over-the-counter drug benefit directly to the pharmacy.
The following is a list of expanded services:
1. OVER THE COUNTER DRUGS AND FIRST AID ITEMS not to exceed $10 per
month, per household through mail order program.
2. ADULT DENTAL SERVICES FOR BENEFICIARIES AGE 21 AND ABOVE office
visits, x-rays, exams as needed, two cleanings per year, no limit
on one and two surface filings (amalgam and silver), one three
surface silver filling per year, four simple extractions at no
cost (non emergency), two surgical extractions per year (non
emergency) when medically necessary.
3. ADULT EYE EXAMS AND GLASSES FOR BENEFICIARIES AGE 21 AND ABOVE
Unlimited routine eye exams and unlimited glasses as medically
necessary.
4. ADULT HEARING SERVICES FOR BENEFICIARIES AGE 21 AND ABOVE One
hearing aid (limited selection) every three years, if medically
necessary.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 4 OF 166
July 2004 Medicaid HMO Contract
10.7 EXCLUDED SERVICES
The plan is not obligated to provide for the services that are not
specified in sections 10.4, Covered Services, 10.5, Optional Services,
10.6, Expanded Services and 10.9, Quality and Benefit Enhancements.
Plan members who require services available through Medicaid but not
covered by this contract shall receive these services through the
existing Medicaid fee-for-service reimbursement system. The plan shall
determine the need for these services and refer the member to the
appropriate service provider. The plan may request the assistance of
the local Medicaid Field Office for referral to the appropriate service
setting.
For members requiring long term care institutional services,
institutional services for persons with developmental disabilities or
state hospital services, the plan shall consult the DCF office to
identify appropriate methods of assessment and referral. The plan is
responsible for transition and referral to appropriate service
providers, including helping the member to obtain an attending
physician. Members requiring these services shall be disenrolled from
the plan in accordance with section 30.11, Disenrollment, of this
contract, except as required by Frail Elderly Program component
requirements, see Exhibit 110.4.
10.8 MANNER OF SERVICE PROVISION
The Florida Medicaid Program provides multiple services/programs for
Medicaid eligible beneficiaries. The service definitions that follow
are those required by federal or state rule. The plan must furnish
services up to the limits specified by the Medicaid program. The plan
is responsible for contracting with providers who meet all provider and
service and product standards specified in the Agency's Medicaid
Services Coverage and Limitations handbooks and the plan's provider
handbooks, which must be incorporated in all plan subcontracts by
reference, for each service category covered by the plan. Exceptions
exist where different standards are specified elsewhere in this
contract or if the standard is waived in writing by the Division of
Medicaid on a case-by-case basis when the member's medical needs would
be equally or better served in an alternative care setting or using
alternative therapies or devices within the prevailing medical
community.
10.8.1 CHILD HEALTH CHECK-UP
Child Health Check-Up (CHCUP) services are comprehensive and preventive
health examinations provided on a periodic basis that are aimed at
identifying and correcting medical conditions in children and young
people (birth through 20 years of age). Policies and procedures are
described in the Child Health Check-Up Services Coverage and
Limitations Handbook. Policy requirements include:
a. The health screening examination shall consist of:
comprehensive health and developmental history including
assessment of past medical history, developmental history and
behavioral health status; comprehensive unclothed physical
examination; developmental assessment; nutritional assessment;
appropriate immunizations according to the appropriate
Recommended Childhood Immunization Schedule for the United
States; laboratory testing (including blood lead test where
required; for children who the plan identifies through blood
lead screenings as having abnormal levels of lead, the plan
shall provide case management follow-up services as required
in chapter 2 of the Child Health Check-Up Services Coverage
and Limitations Handbook.); health education (including
anticipatory guidance); dental screening (including a direct
referral to a dentist, or to a Prepaid Dental Health Plan
(PDHP) where applicable for members beginning at 3 years of
age or earlier as indicated); vision screening including
objective testing when required; and hearing screening
including objective testing, when required; diagnosis and
treatment; and referral and follow-up, as appropriate.
b. Members shall be informed by the Agency through its fiscal
agent, of screenings due in accordance with the periodicity
schedule as specified in the Medicaid Child Health Check-Up
Services Coverage and Limitations Handbook. The plan is
required to contact members and follow-up on the state-issued
CHCUP letter to encourage the member to come in for a health
assessment and preventive care.
c. Members must be referred to appropriate service providers for
further assessment and treatment of conditions found in the
examination within six months after the request for a CHCUP.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 5 OF 166
July 2004 Medicaid HMO Contract
d. Members must be offered scheduling assistance to make medical
appointments and to obtain transportation.
e. This service includes the maintenance of a coordinated system
to follow the member through the entire range of screening and
treatment, as well as supplying CHCUP training to providers.
f. In accordance with section 409.912, F.S., the plan shall
achieve a CHCUP screening rate of at least 60 percent for
those members who are continuously enrolled for at least eight
(8) months. This screening compliance rate shall be based on
the CHCUP screening data reported by the plan pursuant to
section 60.0, Reporting Requirements of this contract, and the
data reported shall be monitored by the Agency for accuracy.
The plan must complete both the CHCUP Report template and the
- 60 percent Screening Ratio Template. If the plan does not
achieve the 60 percent screening ratio, a corrective action
plan is required to be filed with the Agency no later than
February 15th. Any data reported that is found to be
inaccurate shall be disallowed by the Agency and the Agency
may consider such findings as being in violation of the
contract (refer to section 70.17, Sanctions).
In addition to the above requirement, the plan shall adopt
annual screening and participation goals to achieve at least
an 80 percent CHCUP screening and participation rate in
accordance with section 5360, Annual Participation Goals, of
the State Medicaid Manual. If the plan does not meet the 80
percent screening and participation ratios, a corrective
action plan must be filed with the Agency no later than
February 15th.
10.8.2 DENTAL SERVICES (OPTIONAL)
Dental services are defined in the Medicaid Dental Services Coverage
and Limitations Handbook. Children's Medicaid dental services include
diagnostic services, preventive treatment, restorative treatment,
endodontic treatment, periodontal treatment, restorative treatment,
surgical procedures and/or extractions, orthodontic treatment and
complete and partial dentures for beneficiaries under age 21. Complete
and partial denture relines and repairs are also included, as well as
adjunctive and emergency services. Adult services include medically
necessary, emergency dental procedures to alleviate pain or infection.
Emergency dental care shall be limited to emergency oral examinations,
necessary radiographs, extractions, and incision and drainage of
abscess.
10.8.3 DIABETES SUPPLIES AND EDUCATION
In the same manner as specified in section 641.31, F.S., the plan shall
provide coverage for medically appropriate and necessary equipment,
supplies, and services used to treat diabetes, including outpatient
self-management training and educational services, if the member's
primary care physician, or the physician to whom the patient has been
referred who specializes in treating diabetes, certifies that the
equipment, supplies and services are necessary.
10.8.4 FAMILY PLANNING SERVICES
These services are rendered for the purposes of enabling eligible
beneficiaries to make comprehensive, informed decisions about family
size and/or spacing of births as specified in the Medicaid Services
Coverage and Limitations handbooks. The provider provides the following
minimum services: plan and referral; education and counseling; initial
examination; diagnostic procedures and routine laboratory studies;
contraceptive drugs and supplies; and follow-up care in accordance with
the Medicaid Physicians Services Coverage and Limitations Handbook.
Policy requirements include:
a. The plan shall furnish the services on a voluntary and
confidential basis.
b. The plan shall allow members full freedom of choice of family
planning methods covered under the Medicaid program, including
Medicaid covered implants, when there are no medical
contraindications.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 6 OF 166
July 2004 Medicaid HMO Contract
c. In accordance with section 381.0051, F.S., the plan shall
render these services to eligible members under the age of 18
provided the member is married, a parent, pregnant, has
written consent by a parent or legal guardian, or in the
opinion of a physician, the member may suffer health hazards
if the service is not provided.
d. The provisions of this subsection shall not be interpreted so
as to prevent a provider or other person from refusing to
furnish any contraceptive or family planning service,
supplies, or information for medical or religious reasons; and
the provider or other person shall not be held liable for such
refusal.
e. Pursuant to 42 CFR 431.51 (b), the plan shall allow each
member to obtain family planning services from any
participating Medicaid provider and require no prior
authorization for such services. If the member receives
services from a non-plan Medicaid provider, then the plan must
reimburse at the Medicaid reimbursement rate, unless another
payment rate is negotiated.
f. In accordance with section, 409.912, F.S. the plan shall make
available and encourage all pregnant women and mothers with
infants to receive, scheduled postpartum visits for the
purpose of voluntary family planning, including discussion of
all methods of contraception, as appropriate, and counseling
and services for family planning to all women and their
partners. The plan shall direct providers to maintain
documentation in the medical records to reflect this.
10.8.5 FREESTANDING DIALYSIS FACILITY SERVICES
Program requirements are specified in section 409.906, F.S., and the
Freestanding Dialysis Center Services Coverage and Limitations
Handbook. Such services must be provided in accordance with the policy
and service provisions specified by fee-for-service Medicaid.
10.8.6 HEARING SERVICES
These services include a hearing evaluation, diagnostic testing and
selective amplification procedures necessary to certify an individual
for a hearing aid device, and fitting and dispensing of hearing aids
and repair services as specified in the Medicaid Hearing Services
Coverage and Limitations Handbook. Medical and surgical treatment for
hearing disorders is part of physician services.
10.8.7 HOME HEALTH CARE SERVICES AND DURABLE MEDICAL EQUIPMENT
These services are intermittent nursing services by a registered nurse
or licensed practical nurse and/or personal care services by a home
health aide with accompanying necessary medical supplies, appliances
and durable equipment appropriate for use in the beneficiary's place of
residence. These services are provided for eligible beneficiaries
primarily to maintain physical and emotional comfort and to assist the
beneficiary toward independent living in a safe environment as
specified in the Medicaid Home Health Services Coverage and Limitations
and the Durable Medical Equipment (DME)/Medical Supplies Services
Coverage and Limitations Handbook. Policy requirements include, but are
not limited to:
a. All services and medical equipment furnished by the plan shall
be contained in an individualized written plan of care
developed by health care professionals, including the
attending physician. The plan of care is designed to meet the
medical, health, and rehabilitative needs of the recipient and
is approved by the attending physician as evidenced by his or
her original signature and re-approved at least:
- Every 60 days or whenever the beneficiary's condition
for home health services changes.
- For disposable medical supplies, the medical
necessity must be re-determined every 6 months and
the prescription cannot be dated more than 14 days
after initiation.
- For oxygen services, the medical necessity renewal
time frame is 12 months.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 7 OF 166
July 2004 Medicaid HMO Contract
b. Services rendered by a home health aide shall be under the
continuous supervision of a registered nurse.
c. All services provided to Medicaid beneficiaries in their place
of residence shall be prescribed by a physician. Provision of
medically necessary supplies/DME does not require a
beneficiary to be homebound.
d. Medical equipment as specified in the DME/Medical Supplies
Services Coverage and Limitations Handbook.
10.8.8 HOSPITAL SERVICES
10.8.8.1 INPATIENT
These services are medically necessary services ordinarily furnished by
a state licensed acute care hospital for the medical care and treatment
of inpatients provided under the direction of a physician or dentist in
a hospital maintained primarily for the care and treatment of patients
with disorders other than mental diseases. Inpatient hospital services
include but are not limited to medical supplies, diagnostic and
therapeutic services, use of facilities, drugs and biologicals, room
and board, nursing care and all supplies and equipment necessary to
provide adequate care as specified in the Medicaid Hospital Services
Coverage and Limitations Handbook. This service includes inpatient care
for any diagnosis including psychiatric and mental health (Baker Act
and non-Baker Act), tuberculosis and renal failure when provided by
general acute care hospitals in both emergent and non-emergent
conditions. Inpatient hospital services include rehab hospital care.
Rehab inpatient care days are also counted as inpatient hospital days.
The plan may provide services in a nursing home as downward
substitution for inpatient care. Such services shall not be counted as
inpatient hospital days.
The service also includes the following:
a. Medically necessary and appropriate transplants: bone marrow,
all ages; cornea, all ages; and kidney, all ages. For other
transplants not covered by Medicaid, the evaluations,
pre-transplant care and post-transplant follow-up care are
covered by Medicaid and, therefore, must be covered by the
plan even though the transplant procedure is not covered.
Transplant service components are also covered under
outpatient services, physician services and prescribed drug
services per the applicable Medicaid Services Coverage and
Limitations handbooks.
The plan is not responsible for the cost of transplant
evaluations, pre-transplant care and post transplant
follow-up, when an adult member (age 21 and over) is listed
with the United Network for Organ Sharing (UNOS) as a level
1A, 1B, or 2 candidate for heart transplant. The plan must
disenroll these members at the conclusion of the transplant
evaluation and cannot re-enroll the member until at least
one-year post transplant.
The plan is not responsible for the cost of a completed adult
heart transplant evaluation regardless of whether or not the
beneficiary was determined a candidate for a transplant. The
plan is responsible for the cost of adult heart transplant
evaluations that are not completed for any reason.
The plan is not responsible for the cost of pre-transplant
care and post transplant follow-up when a member has been
listed as a candidate for a pediatric heart, lung or
heart/lung transplant (ages 20 and under) or a liver
transplant (all ages). If, at the conclusion of the transplant
evaluation, the beneficiary is listed with UNOS as a level 1A,
1B or 2 for heart, lung or heart/lung or 1, Model End Stage
Renal Disease (meld) score of 11-25, for a liver transplant,
the plan will disenroll the beneficiary. The beneficiary will
have the option to re-enroll at one-year post transplant. The
plan is responsible for the cost of the above transplant
evaluations.
b. Physical therapy services when necessary and provided during a
member's inpatient stay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 8 OF 166
July 2004 Medicaid HMO Contract
c. The plan shall be at risk for the provision of up to 45 days
of inpatient hospital care for each enrolled member, as
determined necessary by the physician responsible for
discharging an enrolled member from the hospital.
d. The plan shall provide up to 45 days of inpatient coverage per
member from July 1 or the initial date of enrollment whichever
comes later, continuing through June 30.
d. The plan shall provide up to 28 inpatient hospital days in an
inpatient hospital substance abuse treatment program for
pregnant substance abusers who meet ISD Criteria with Florida
Medicaid modifications as specified in InterQual Level of Care
2003-Acute Criteria-Pediatric and /or InterQual Level of Care
2003-Acute Criteria-Adult (McKesson Health Solutions, LLC,
"McKesson"), 2003 Edition or the most current edition, for use
in screening cases admitted to Rehabilitative Hospitals and
CON approved rehabilitative units in acute care hospitals with
admission dates of January 1, 2003 and after. In addition, the
plan shall provide inpatient hospital treatment for severe
withdrawal cases exhibiting medical complications which meet
the severity of illness criteria under the alcohol/substance
abuse system-specific set which generally requires treatment
on a medical unit where complex medical equipment is
available. Withdrawal cases (not meeting the severity of
illness criteria under the alcohol/substance abuse criteria)
and substance abuse rehabilitation (other than for pregnant
women), including court ordered services, are not covered in
the inpatient hospital setting. Such inpatient hospital care
shall be included in the 45 days of inpatient hospital care
for which the plan is at risk, as specified in c. and d.
above.
f. The plan is responsible for the cost of transporting a member
from a non-participating facility or hospital to a
participating facility or hospital if the reason for transport
is solely for the plan's convenience, regardless of whether
the plan covers Medicaid transportation services.
g. The plan shall adhere to the provisions of the Newborns' and
Mothers' Health Protection Act (NMHPA) of 1996 regarding
postpartum coverage for mothers and their newborns and comply
with the provisions of section 641.31, F.S.
1. The plan shall provide for at least a 48-hour
hospital length of stay following a normal vaginal
delivery, and at least a 96-hour hospital length of
stay following a Cesarean section. In connection with
coverage for maternity care, the hospital length of
stay is required to be decided by the attending
provider in consultation with the mother.
2. The plan shall prohibit the following practices:
Denying the mother or newborn child eligibility, or
continued eligibility, to enroll or renew coverage
under the terms of the plan, solely for the purpose
of avoiding the NMHPA requirements;
Providing monetary payments or rebates to mothers to
encourage them to accept less than the minimum
protections available under NMHPA;
Penalizing or otherwise reducing or limiting the
reimbursement of an attending provider because the
provider provided care in a manner consistent with
NMHPA;
Providing incentives (monetary or otherwise) to an
attending provider to induce the provider to provide
care in a manner inconsistent with NMHPA;
Restricting benefits for any portion of the 48-hour
(or 96-hour) period prescribed by NMHPA in a manner
that is less favorable than the benefits provided for
any preceding portion of the hospital stay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 9 OF 166
July 2004 Medicaid HMO Contract
10.8.8.2 OUTPATIENT
Outpatient hospital services are preventive, diagnostic, therapeutic,
or palliative care under the direction of a physician at a licensed
acute care hospital. Such outpatient hospital services include
emergency room, dressings, splints, oxygen and physician ordered
services and supplies necessary for the clinical treatment of a
specific diagnosis or treatment as specified in the Medicaid Hospital
Services Coverage and Limitations Handbook. Emergency medical services
as defined in section 100.0, Glossary, of this contract, are specified
in the Medicaid Hospital Services Coverage and Limitations Handbook and
section 20.10, Emergency Care Requirements. Policy requirements
include:
a. The plan shall provide outpatient hospital services and
emergency medical care services as medically necessary and
appropriate and without any specified dollar limitation.
b. The plan shall cover the cost to all members of any medically
necessary duration of stay in a non-designated facility, which
resulted from a medical emergency until such time as they can
be safely transported to a plan facility.
c. The plan shall have a procedure for the authorization of
dental care and associated ancillary services provided in an
outpatient hospital setting if that care meets the following
requirements;
- Is provided under the direction of a dentist at a
licensed hospital;
- Is medically necessary or, if not usually considered
medically necessary, is considered medically
necessary in a hospital setting due to the
beneficiary's disability, the beneficiary's mental
health condition, or the beneficiary's abnormal
behavior due to emotional instability or a
developmental disability, which necessitates the
services being provided in a hospital.
10.8.8.3 HOSPITAL ANCILLARY SERVICES
Ancillary services that are provided by the hospital include, but are
not limited to, radiology, pathology, neurology, neonatology and
anesthesiology. When the plan or plan's authorized physician authorizes
these services (either inpatient or outpatient), the plan must
reimburse the professional component of the service at the Medicaid
line item rate, unless another reimbursement rate has been negotiated.
This is also required for emergency services rendered by non-plan
physicians for ancillary services provided in a hospital setting.
10.8.9 IMMUNIZATIONS
In accordance with section 1905(r)(1) of the Social Security Act, the
plan shall participate or direct its providers to participate in the
Vaccines For Children Program (VFC), the program administered by the
Department of Health (DOH), Bureau of Immunizations, which provides
vaccines at no charge to physicians, and eliminates any need to refer
children to county health departments (CHD) for immunizations. For
immunizations covered by Medicaid but not provided through VFC the plan
shall be responsible for coverage and reimbursement to the provider.
The plan is required to:
a. Provide immunizations in accordance with the childhood
immunization schedule as approved by the appropriate
Recommended Childhood Immunization Schedule for the United
States or when it is shown to be medically necessary for the
child's health in accordance with section 409.912, F.S.
b. Document that the plan is enrolled in the VFC program or that
its physicians have directly enrolled.
c. Ensure its physicians have a sufficient supply of vaccines
from the plan if the plan is the VFC enrollee. If the plan's
physicians are directly enrolled in the VFC program, they
shall be directed to maintain adequate vaccine supplies.
d. Pay no more than the Medicaid program vaccine administration
fee of $10.00 per administration unless another rate is
negotiated with the provider.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 10 OF 166
July 2004 Medicaid HMO Contract
Title XXI MediKids participants do not qualify for the Vaccines for
Children Program as specified in this section. For immunizations
provided to Title XXI MediKids participants, the plan shall advise
providers to bill Medicaid fee-for-service directly at a rate
determined by the Agency. The administration fee is included in the
capitation rates for both Title XXI MediKids and Title XIX Medicaid
programs.
10.8.10 INDEPENDENT LABORATORY AND PORTABLE X-RAY SERVICES
These services are medically necessary and appropriate diagnostic
laboratory procedures and portable x-rays ordered by a physician or
other licensed practitioner of the healing arts. Policies, procedures
and services covered by each program are described in the Medicaid
Independent Laboratory Services Coverage and Limitations Handbook; and
the Portable X-Ray Services Coverage and Limitations Handbook.
The programs encompass only those services approved by Medicaid for a
licensed independent laboratory or portable x-ray company under the
related service requirements and limitations described in the services
coverage and limitations handbooks. Laboratory and x-ray services
provided by a hospital, clinic or Medicaid provider enrolled as
physician services providers are not included in these programs. Such
services provided by a hospital, physician or clinic is included in the
definition of hospital, physician or clinic, as appropriate. In
addition, such services provided via a hospital setting are also
discussed under section 10.8.8.3, Hospital Ancillary Services. Policy
requirements include:
a. The plan must furnish, at a minimum, those laboratory and
portable x-ray procedures currently covered by the independent
laboratory and portable x-ray programs as described in their
respective handbooks.
b. The plan shall pay for laboratory tests provided by public
providers as specified in section 20.8.9, Public Provider
Claims, without prior authorization as specified in section
110.1, Laboratory Tests And Associated Office Visits To Be
Paid By Plan Without Prior Authorization When Initiated By
County Health Department.
10.8.11 PHYSICIAN SERVICES
Physician services are those services and procedures rendered by a
licensed physician at a physician's office, patient's home, hospital,
nursing facility or elsewhere when dictated by the need for preventive,
diagnostic, therapeutic or palliative care, or for the treatment of a
particular injury, illness or disease as specified in the Medicaid
Physician Services Coverage and Limitations Handbook. For purposes of
this contract advanced registered nurse practitioner (ARNP) services,
physician assistant services (PA), podiatry services, ambulatory
surgical centers service, CHD services, rural health clinic services,
federally qualified health center (FQHC) services, birthing center
services (including the services of certified nurse midwives licensed
under chapter 464, F.S., and midwives licensed under chapter 467,
F.S.), and chiropractic services are included as physician services
because they can be provided by a physician and, as such, are included
in the capitation rate paid to the plan. These services must be
provided as specified in the appropriate Medicaid Services Coverage and
Limitations handbook. Their listing does not mean that the services
must be performed by the indicated professional category or at the
indicated location. Policy requirements include:
a. The plan shall furnish the full range of the preventive
medicine services program components as described in the
Medicaid Coverage and Limitations handbooks.
b. The plan shall furnish psychiatrist services as medically
necessary for Medicaid beneficiaries, which may be rendered in
the psychiatrist's office or in an outpatient or inpatient
setting.
c. The plan shall exclude the provision of experimental and
clinically unproven procedures. (See section 409.905, F.S.)
d. The plan shall provide for adult health screenings as
specified in the Agency's Medicaid Services Coverage and
Limitations Handbooks.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 11 OF 166
July 2004 Medicaid HMO Contract
e. The provisions of sections 641.19, 641.31 and 641.51, F.S. are
incorporated by reference and as such the plan shall allow
members to use network chiropractic, dermatological services,
podiatric services, and OB/GYN services without authorization.
f. Pursuant to section 4712 of the Balanced Budget Act of 1997,
plans contracting with FQHCs and rural health clinics (RHCs)
must reimburse those entities at rates comparable to those
rates paid for similar services in the FQHC's or RHC's
community. The plan shall report quarterly to the Agency the
payment rates and the payment amounts made to FQHCs and RHCs
for contractual services provided by these entities.
g. Notwithstanding subsection 20.8.9, Public Provider Claims,
without prior authorization, the plan shall pay, at the
contracted rate or the Medicaid fee-for-service rate, all
valid claims initiated in any CHD for office visits,
prescribed drugs, and laboratory services directly related to
DCF emergency shelter medical screening, and tuberculosis as
specified in section 110.1, Laboratory Tests And Associated
Office Visits To Be Paid By Plan Without Prior Authorization
When Initiated By County Health Department, once the CHD has
notified the plan and has provided the plan's primary care
provider with results of such testing and the associated
office visit. Reimbursement by the plan for such services is
required only if the CHD provides the plan with copies of the
appropriate medical record.
h. The plan shall have a procedure for the authorization of
medically necessary dental care and associated ancillary
services provided in licensed ambulatory surgical center
settings if that care is provided under the direction of a
dentist as described in State Plan. Medical necessity shall be
determined in accordance with section 641.31, F.S.
10.8.11.1 PREGNANCY RELATED REQUIREMENTS
a. Florida's Healthy Start Prenatal Risk Screening.
The plan shall ensure that the provider offers, as required by
section 383.14, F.S., and Rule 64C-7.009, F.A.C., Florida's
Healthy Start prenatal risk screening to each member who is
pregnant as part of her first prenatal visit. The plan shall
ensure the provider uses the DOH prenatal risk DH Form 3134,
which can be obtained from the local county health department.
The plan shall ensure the provider retains a copy of the
completed screening instrument in the member's medical record
and shall provide a copy to the member. The plan shall ensure
the provider submits the completed DH Form 3134 to the county
health department in the county where the prenatal screen was
completed within ten business days of completion. The plan is
strongly encouraged to collaborate with the Healthy Start care
coordinator within the patient's county of residence to assure
risk-appropriate care is delivered.
b. Florida's Healthy Start Infant (Postnatal) Screening
Instrument.
Risk factor information for the Florida's Healthy Start Infant
(Postnatal) Risk Screening Instrument (DH Form 3135) is taken
from the Certificate of Live Birth and is generally completed
by the staff who complete the Certificate of Live Birth. Plans
providing birthing services shall ensure the provider
completes Florida's Healthy Start Infant (Postnatal) Risk
Screening Instrument on each live birth and offer the family
referral to further Healthy Start services as appropriate. The
plan must ensure the provider submits the Infant (Postnatal)
Risk Screening Instrument with the Certificate of Live Birth
to the CHD in the county where the infant was born. DH Form
3135 can be obtained from the local county health department.
The plan shall ensure the provider retains a copy of the
completed screening instrument in the member's medical record
and provide a copy to the member.
c. Pregnant women or infants who do not score high enough to be
eligible for Healthy Start care coordination may be referred
for services regardless of their score on the Healthy Start
risk screen in the following ways:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 12 OF 166
July 2004 Medicaid HMO Contract
1. If the referral is to be made at the same time the
risk screen is administered, the provider may
indicate on the risk screening form that the woman or
infant is invited to participate based on factors
other than score.
2. If the determination is made subsequent to risk
screening, the provider may directly refer the woman
or infant to the Healthy Start care coordination
provider based on assessment of actual or potential
factors associated with high risk, such as HIV,
Hepatitis B, substance abuse, or domestic violence.
d. The plan shall refer all pregnant, breastfeeding and
postpartum women, infants and children up to age five to the
local Women, Infants and Children (WIC) office. For the
initial referral for WIC certification, the plan must complete
the Florida WIC program Medical Referral Form with the current
height or length and weight (taken within 60 days of the WIC
appointment); hemoglobin or hematocrit (see chart below); and
any identified medical/nutritional problems. For subsequent
WIC certifications the plan shall encourage its providers to
coordinate with the local WIC office to provide the above
referral data from the most recent CHCUP. Each time a WIC
Referral Form is completed, the plan shall ensure the provider
gives a copy of the WIC Referral Form to the member and
retains a copy in the member's medical record.
WIC CATEGORY WIC BLOOD WORK SCREENING SCHEDULE
Pregnant Woman Once during the current pregnancy
Breastfeeding Woman up to 1 year postpartum Once after delivery
Postpartum Woman (not breastfeeding) up to
6 months postpartum Once after delivery/termination of pregnancy
Infant Once between 6-12 months of age (preferably
between 9-12 months)
Child 1 - 2 years Once, preferably between 15 - 18 months
Child 2 - 5 years Once every year unless an abnormal value is
found, (<11.1gm/dl hemoglobin, <33%
hematocrit) then a follow-up blood
test is required at six month intervals
e. The plan shall ensure the provider provides, as required by
Chapter 381, F.S., all women of childbearing age HIV
counseling and offer them HIV testing. For prevention, early
identification of women with HIV infection, and reduction of
perinatal transmission, the plan shall ensure that its
providers counsel and offer HIV testing to all women of
childbearing age. Florida law requires all pregnant women to
be counseled and offered HIV testing at the initial prenatal
care visit and again at 28-32 weeks. If a pregnant woman
declines HIV testing, a signed objection must be attempted, in
accordance with section 384.31, F.S. and Ch. 64D-3.019,
Florida Administrative Code. The plan shall ensure that all
pregnant women who are HIV infected are counseled about and
offered the latest anti-retroviral regimen recommended by the
U.S. Department of Health and Human Services, Public Health
Service Task Force entitled Recommendations for the Use of
Antiretroviral Drugs in Pregnant HIV-1 Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV-1
Transmission in the United States. To receive a copy of the
guidelines, contact the Florida Department of Health, Bureau
of HIV/AIDS at (850) 245-4334, or you may reach the DHHS
website at http://aidsinfo.nih.gov/guidelines/.
f. The plan shall ensure that providers routinely screen all
Medicaid eligible women receiving prenatal care for the
Hepatitis B surface antigen (HBsAg) early in each pregnancy,
preferably during the first prenatal visit. All pregnant women
shall be routinely tested for the hepatitis B surface antigen
(HBsAg) at the time of the first examination relating to the
current pregnancy. Pregnant women who tested negative at the
first visit and are considered high-risk for hepatitis B
infection shall have a second HBsAG test performed at 28 to 32
weeks of pregnancy. This test shall be performed at the same
time that other routine prenatal screening is ordered. All
HBsAg-positive women shall be reported to the local county
health department. Women who are HBsAg-positive shall be
referred to Healthy Start regardless of their Healthy Start
screening score.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 13 OF 166
July 2004 Medicaid HMO Contract
g. Infants born to HBsAg-positive members shall receive Hepatitis
B Immune Globulin (HBIG) and the Hepatitis B vaccine once they
are physiologically stable, preferably within 12 hours of
birth and shall complete the hepatitis B vaccine series
according to the recommended vaccine schedule per the
guidelines established by the appropriate Recommended
Childhood Immunization Schedule for the United States. These
infants shall be tested for HBsAg and Hepatitis B surface
antibodies (anti-HBs) six months after the completion of the
vaccine series to monitor the success or failure of the
therapy. A positive HBsAg result in any child aged 24 months
or less shall be report to the local county health department
within 24 hours. Infants born to women who are HBsAg-positive
shall be referred to Healthy Start regardless of their Healthy
Start screening score.
h. All HBsAg-positive prenatal or postpartum women, their
infants, and contacts shall be reported to the Perinatal
Hepatitis B Prevention Coordinator at the local County Health
Department. Information collected for each individual shall
include: name, date of birth, race, ethnicity, address, ex
(infants and contacts), laboratory test performed and date
sample collected, due date or EDC, whether or not prenatal
care was received (prenatal woman), and immunization dates
(infants and contacts). Use of the current Perinatal Hepatitis
B Case and Contact Report (DH Form 1876) is strongly
encouraged but not required. This form may be obtained from
the Department of Health. For further information please see
Rule 64D-3.013 of the Florida Administrative Code at website:
http://fac.dos.state.fl.us/faconline/chapter64.pdf and/ or
contact your county or state Perinatal Hepatitis B Prevention
Coordinator.
i. The plan shall allow pregnant women to choose the plan's
contracted or staff OB/GYNs as their primary care physicians
to the extent that the OB/GYN is willing to participate as a
primary care provider. The plan shall not require more
restrictive authorization criteria for OB/GYN primary care
physicians than it has for non-OB/GYN primary care physicians.
If the plan requires prior authorization for ancillary
services, it may require that an OB/GYN obtain prior
authorization for certain pregnancy-related ancillary services
(such as non-stress-tests, ultrasounds), and amniocentesis.
j. The plan is required to provide the most appropriate and
highest level of quality care for pregnant members. Required
care also includes the following:
1. PRENATAL CARE: Requirements include a pregnancy test
and a nursing assessment with referrals to a
physician, physician's assistant or nurse
practitioner for comprehensive evaluation; case
management through the gestational period according
to the needs of the client; referrals and follow-up.
The high medical risk diagnoses are listed in
Appendix B of the Medicaid Physician Services
Coverage and Limitations Handbook and REQUIRE DIRECT
CARE BY THE PHYSICIAN.
The plan must schedule return or more frequent visits
as the member's condition warrants, at least every
four weeks until the 32nd week, every two weeks until
the 36th week, and every week thereafter until
delivery, unless the member's condition requires more
frequent visits.
For members who fail to keep appointments, the plan
must contact the members as soon as possible and
arrange for their necessary and continued prenatal
care. Members must be assisted if necessary in making
delivery arrangements.
All pregnant women must be screened for tobacco use
with provision of smoking cessation counseling and
appropriate treatment as needed.
2. NUTRITION ASSESSMENT/COUNSELING: The plan shall
ensure the provider provides nutrition assessment and
counseling to all pregnant members. Nutrition
assessment/counseling should include the provision of
safe and adequate nutrition for infants by the
protection and promotion of breastfeeding and by the
proper use of breast milk substitutes. The plan
should make a mid-level nutrition assessment.
Individualized diet counseling and a nutrition care
plan are to be provided by public health
nutritionists, nurses or physicians following
nutrition assessments. The nutrition care plan must
be documented in the member's medical record by the
person providing counseling.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 14 OF 166
July 2004 Medicaid HMO Contract
3. OBSTETRICAL DELIVERY: The plan must develop and use
generally accepted and approved protocols for both
low risk and high risk deliveries which shall reflect
the highest standards of the medical profession,
including Healthy Start, prenatal screen specified in
section B.4.h Florida's Healthy Start Prenatal Risk
Screening, of this attachment, and ensure that its
providers use such protocols. A preterm delivery risk
assessment must be determined and documented in the
member's medical record by the 28th week.
If the delivery is determined to be high risk,
obstetrical care during labor and delivery must
include preparation by all attendants of
extraordinary symptomatic evaluation, progress
through the final stages of labor and immediate
postpartum care. The high medical risk diagnoses are
listed in Appendix B of the Medicaid Physician
Services Coverage and Limitations Handbook and
require direct care by the physician.
4. NEWBORN CARE: The plan must ensure the provider
provides for the highest level of care for the
newborn beginning immediately after birth, which must
include but is not limited to:
a) Instilling of a prophylaxis into each eye of
the newborn in accordance with section
383.04 F.S.
b) Securing of a cord blood sample for
laboratory testing for type Rh determination
and direct Coombs test when the mother is Rh
negative.
c) Weighing and measuring of the newborn.
d) Inspecting for abnormalities and/or
complications.
e) Administering of one half milligram of
vitamin K.
f) APGAR scoring.
g) Any other necessary and immediate need for
referral and consultation from a specialty
physician, such as the Healthy Start
(postnatal) infant screen, as specified in
section B.4.i., Florida's Healthy Start
Infant (Postnatal), of this attachment.
h) NEWBORN HEARING SCREENINGS: All newborn and
infant hearing screenings must be conducted
by an audiologist licensed under Chapter
468, F.S.; a physician licensed under
Chapter 458 or 459, F.S.; or an individual
who has completed documented training
specifically for newborn hearing screenings
and who is directly or indirectly supervised
by a licensed physician or licensed
audiologist.
5. POSTPARTUM CARE: Plans must provide a postpartum examination
for the mother within six weeks after delivery. This visit
shall include voluntary family planning, including a
discussion of all methods of contraception, as appropriate.
The plan shall ensure that eligible newborns be appropriately
enrolled and that continuing care of the newborn be provided
through the Child Health Check-Up program component.
10.8.11.2 HYSTERECTOMIES, STERILIZATIONS, AND ABORTIONS
The plan must maintain a log of all hysterectomy, sterilization, and
abortion procedures performed for plan members. The log must include,
at a minimum, member name and identifying information and date and
type of procedure.
10.8.12 PRESCRIBED DRUG SERVICES
These services are defined as those products and services associated
with the dispensing of medicinal drugs pursuant to a valid
prescription as defined in chapter 465, F.S. (the "Florida Pharmacy
Act"). This benefit
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 15 OF 166
July 2004 Medicaid HMO Contract
generally includes all legend drugs dispensed to members in outpatient
settings and includes patent or proprietary preparations as well.
Covered drugs, injectables, food supplements and other prescribed drug
services are described in the Prescribed Drugs Services Coverage,
Limitations and Reimbursement Handbook. These services also include
payment for Medicaid reimbursable psychotropic drugs. Policy
requirements include:
a. The plan shall make available those drugs and dosage forms
currently covered by the Medicaid Program.
b. The plan shall not arbitrarily deny or reduce the amount,
duration, or scope of prescriptions solely because of the
diagnosis, type of illness, or condition. The plan may place
appropriate limits on prescriptions based on criteria such as
medical necessity or for the purpose of utilization control,
provided the services can reasonably be expected to achieve
the purpose set forth in the State Plan. The plan may not
place limits on prescription drugs listed in section 409.912,
F.S., such as anti-psychotics, anti-depressants and
HIV-specific anti-retrovirals.
c. The plan's pharmacy benefit shall comply with all applicable
federal and state laws. The plan shall submit for Agency
review a description of its pharmacy benefit, including but
not limited to its formulary and prior authorization process.
This information must be submitted to the Agency within 30
days following the effective date of this contract and prior
to any changes.
d. The plan shall provide one course of twelve weeks duration or
the manufacturer's recommendation per year of nicotine
replacement therapy, either nicotine transdermal patches or
nicotine gum, to members who are currently smoking and desire
to quit smoking in accordance with the Medicaid Prescribed
Drug Services Coverage, Limitations and Reimbursement
Handbook.
e. The plan shall comply with the settlement agreement for
Hernandez, et. al. v. Medows, case number 02-20964
Civ-Gold/Simonton. The plan shall ensure that its enrollees
are receiving the functional equivalent of those goods and
services received by Medicaid fee-for-service recipients in
accordance with the Hernandez settlement. Additionally, the
plan shall maintain a log of all correspondence and
communications from enrollees relating to the Ombudsman
process. Plan enrollees are third party beneficiaries for this
section of this contract.
f. The plan shall conduct surveys of participating plan
pharmacies for compliance with the Hernandez settlement and
this contract. The plan shall document these surveys and
maintain the survey documents and site visit results for at
least five years.
g. The plan shall provide name brand drugs in compliance with
Florida law. The plan shall reimburse a pharmacy for the cost
of a multi-source brand drug if the prescriber writes in his
or her own handwriting on the valid prescription that the drug
is medically necessary (and otherwise complies with F.S.
465.025) and the prescriber submits a form to the plan. The
form shall be the functional equivalent of the F.D.A. MedWatch
form. The form will require the prescriber to confirm in
writing that an individual patient has had an adverse reaction
to a generic drug or has had, in his or her medical opinion,
better medical results when taking the brand name drug.
10.8.13 THERAPY SERVICES
Medicaid therapy services provide physical, speech-language (including
augmentative and alternative communication systems), occupational and
respiratory therapies. Medicaid pays only for therapy services that are
medically necessary for the provision of therapy evaluations and
individual therapy treatment. Medicaid therapy services are limited to
children and young people who are under the age of 21 as specified in
the Therapy Services Coverage and Limitations Handbook. In addition,
adults are covered for physical and respiratory therapy services under
the outpatient hospital services program as specified in the Medicaid
Hospital Services Coverage and Limitations Handbook. Policy
requirements include:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 16 OF 166
July 2004 Medicaid HMO Contract
a. Members must be referred to appropriate service providers for
further assessment and treatment of conditions.
b. Members must be offered scheduling assistance in making
treatment appointments and obtaining transportation.
c. This service includes the maintenance of a coordinated system
to follow the member through the entire range of screening and
treatment.
d. The Agency shall reimburse schools participating in the
certified school match program pursuant to sections 236.0812
and 409.908, F.S., for school-based therapy services rendered
to members in accordance with section 20.8.10, Certified
School Match Program.
e. The provision of school-based therapy services to a plan
member is not a replacement, substitution, or fulfillment of a
service prescription or doctors' orders for therapy services
external to this plan.
10.8.14 TRANSPORTATION SERVICES (OPTIONAL)
These services are the arrangement and provision of an appropriate mode
of transportation for members to receive necessary medical care
services. Types of transportation services include: ambulance,
non-emergency medical vehicles, public and private transportation
vehicles and air ambulances as specified in the Medicaid Transportation
Services Coverage and Limitations Handbook. Policy requirements
include:
a. The plan must assure that providers of transportation are
appropriately licensed and insured in accordance with the
provisions of the Medicaid Transportation Services Coverage
and Limitations Handbook.
b. The plan must provide transportation for its members seeking
necessary Medicaid services whether or not those services are
covered under terms of this contract.
c. The plan is not required to follow the requirements of the
Commission for the Transportation Disadvantaged or the
Transportation Coordinating Boards as set forth in chapter
427, Florida Statutes.
d. The plan will be responsible for the cost of transporting a
member from a non-participating facility or hospital to a
participating facility or hospital if the reason for transport
is solely for the plan's convenience, regardless of whether
the plan covers Medicaid transportation services.
10.8.15 VISUAL SERVICES
These services include a visual examination; the fitting, dispensing,
and adjustment of eyeglasses; follow-up examinations, and contact
lenses as specified in the Medicaid Visual and Optometric Services
Coverage and Limitations Handbooks. Examinations for eye diseases and
treatment are part of the physician and optometric services programs.
Lenses must meet American National Standards Institute (ANSI)
standards. Eyeglasses are available through Prison Rehabilitative
Industries and Diversified Enterprise (PRIDE) if available at lower
prices for comparable quality than those charged by the Division of
Corrections optical laboratory. An abbreviated list of
products/services available from PRIDE may be obtained by contacting
PRIDE's Tallahassee branch office at (850) 487-3774 or Suncom 277-3774.
10.9 QUALITY AND BENEFIT ENHANCEMENTS
In addition to those covered services specified in this section, the
plan shall offer those quality and benefit enhancements to enrolled
Medicaid beneficiaries as specified below. Quality and benefit
enhancements shall be offered in community settings that are accessible
to members. The plan shall inform members and providers of the quality
and benefit enhancement programs, and how to access those services,
through the member and provider handbooks. The plan shall develop and
maintain written policies and procedures to implement these
enhancements. Annual training of providers that is sponsored by
multiple plans shall meet
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 17 OF 166
July 2004 Medicaid HMO Contract
the provider training requirements for the programs listed below
provided that the plan is a co-sponsor of the training. The plan is
encouraged to actively collaborate with community agencies and
organizations, including county health departments, local Early
Intervention Programs, Healthy Start Coalitions, and local school
districts in offering these services. If the plan involves the member
in existing community programs for purposes of meeting the quality and
benefit enhancements requirements, the plan is encouraged to document
referrals and follow-up on the member's receipt of services from the
community provider.
CHILDREN'S PROGRAMS: The plan shall provide regular general wellness
programs targeted specifically towards plan members from birth to the
age of five or the plan shall make a good faith effort to involve
members in existing community children's programs. Programs shall
promote increased utilization of prevention and early intervention
services for at risk families with children in the target population.
The plan shall pay for services recommended by the Early Intervention
Program when they are covered services and medically necessary. The
plan shall offer annual training for providers that promotes proper
nutrition, breastfeeding, immunizations, CHCUP, wellness, prevention
and early intervention services.
DOMESTIC VIOLENCE: The plan shall have primary care physicians screen
members for signs of domestic violence, and shall offer referral
services to applicable domestic violence prevention community
agencies.
PREGNANCY PREVENTION: Regularly scheduled pregnancy prevention
programs shall be conducted by the plan or the plan shall make a good
faith effort to involve members in existing community pregnancy
prevention programs, such as the Abstinence Education Program. The
programs shall be targeted towards teen members, but shall be open to
all members, regardless of age, gender, pregnancy status or parental
consent.
PRENATAL/POSTPARTUM PREGNANCY PROGRAMS: The plan shall provide regular
home visits, conducted by a home health nurse or aide, and counseling
and educational materials to pregnant members and postpartum members
who are not in compliance with the plan's prenatal and postpartum
programs. The plan shall coordinate with the Healthy Start care
coordinator to prevent duplication of services.
SMOKING CESSATION: Regularly scheduled smoking cessation programs
shall be conducted by the plan as an option for all plan members or
the plan shall make a good faith effort to involve members in existing
community smoking cessation programs. Members shall also have access
to smoking cessation counseling. The plan shall provide primary care
physicians with the Quick Reference Guide, a distilled version of the
Public Health Service-sponsored Clinical Practice Guideline, Treating
Tobacco Use and Dependence, to assist in identifying tobacco users and
supporting and delivering effective smoking cessation interventions.
Copies of this guide may be obtained by contacting the DHHS, Agency
for Health Care Research and Quality (AHR) Publications Clearinghouse,
at 1-800-358-9295 or write to P.O. Box 8547, Silver Spring, MD 20907.
SUBSTANCE ABUSE: The plan shall have primary care physicians screen
members for signs of substance abuse as part of prevention evaluation
at the following times and in the following circumstances: initial
contact with a new enrollee; routine physical examination; initial
prenatal contact; when the enrollee evidences serious overutilization
of medical, surgical, trauma, or emergency services; and when
documentation of emergency room visit suggests need. Targeted members
shall be asked to attend community or plan sponsored substance abuse
programs. The plan shall offer substance abuse screening training to
its providers on an annual basis. The plan is encouraged to use the
Florida Supplement to the American Society of Addictions Medicine
Patient Placement Criteria for coordination and treatment of
substance-related disorders with substance abuse providers.
10.10 INCENTIVE PROGRAMS
The plan may offer incentives for members to receive preventive care
services. The plan shall receive written approval from the Agency
prior to the use of any special incentive items for members. Any
incentive program offered must be provided to all eligible individuals
and will not be used to direct individuals to select providers.
Additionally, any limitations and requirements below apply to all
incentive programs.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 18 OF 166 AHCA Form
July 2004 Medicaid HMO Contract
a. Services which are eligible for incentive programs include CHCUP,
immunizations, adult health screenings, family planning, prenatal
care, smoking/tobacco cessation, preventive health classes,
health education for management of chronic conditions, education
in appropriate use of plan services and adolescent/teen good
citizen sessions. All incentive programs must be approved, in
writing, by the Agency prior to use.
b. Incentives must have some health or child development related
function (e.g., clothing, food, books, safety devices, infant
care items, magazine subscriptions to publications which devote
at least 10 percent of their copy and ads to health related
subjects, membership in clubs advocating educational advancement
and healthy lifestyles, etc.). Incentive dollar values must be in
proportion to the importance of the health service to be utilized
(e.g., a tee-shirt for attending one prenatal class but a car
seat for completion of a series of classes).
c. Incentives shall be limited to a dollar value of $10, except in
the case of incentives for the completion of a series of
services, health education, classes, or other educational
activities, in which case the incentive shall be limited to a
dollar value of $50. A special exception to the dollar value
shall be made for infant car seats, strollers, and cloth baby
carriers or slings. Funds spent on transportation of members to
services or childcare provided during the provision of services
shall not be included in the dollar limits on incentives to use
services.
d. The plan may offer an Agency-approved program for pregnant women
in order to encourage the commencement of prenatal care visits in
the first trimester of pregnancy and successful completion of
prenatal and post-partum care to promote early intervention and
prenatal care to decrease infant mortality and low birth weight
and to enhance healthy birth outcomes. The program may include
the provision of maternity and health related items and education
as an incentive. The request for approval must contain a detailed
description of the program and its mission.
10.11 BEHAVIORAL HEALTH CARE
The plan shall provide medically necessary behavioral health care
services pursuant to this section and section 10.1, General, for all
members once it has demonstrated its ability to provide such services.
The plan shall demonstrate its ability by the following: submittal of
a behavioral health services implementation plan that shall be
submitted to the Agency, and through an Agency conducted on-site
survey. See section 60.3 for behavioral health reporting requirements.
All provisions in the Medicaid HMO contract that are not in conflict
with this section are still in effect and are to be performed at the
levels specified in the contract. Where there is a conflict, the
requirements in section 10.11, Behavioral Health Care, prevail.
10.11.1 SERVICE REQUIREMENTS (BEHAVIORAL HEALTH)
The plan shall provide a full range of behavioral health care service
categories authorized under the State Medicaid Plan; sections 2.2, 2.3
and 2.5 of the Area specific Prepaid Mental Health Plan (PMHP)
requests for proposals (RFP) will apply to the respective Area
members.
The plan shall comply with the Mental Health Targeted Case Management
Coverage and Limitations Handbook, the Community Mental Health
Services Coverage and Limitations Handbook, and specific service
requirements as described in the general service requirements of the
PMHP RFP specific to the Medicaid Area except as provided below:
The plan shall continue to provide Prescribed Drug Services in
accordance with section 10.8.12 of this contract.
The plan shall continue to provide outpatient medical services in
accordance with section 10.8.8.2 of this contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 19 OF 166
July 2004 Medicaid HMO Contract
During the contract period the plan will work in conjunction with the
Managed Mental Health Care Advisory Group, Prepaid Providers, and
Behavioral Health Providers to establish clubhouse services in each
AHCA area.
In addition to the above requirements, the plan shall also adhere to
the requirements specified below.
a. Community Treatment of Patients Discharged from State Mental
Hospitals
The plan shall provide medically necessary behavioral health
services to members who have been discharged from any state
mental hospital. The plan of care shall be aimed at encouraging
the members to achieve a high quality of life while living in the
community in the least restrictive environment which is medically
appropriate; and reducing the likelihood that these members shall
be readmitted to a state mental hospital.
b. Evaluation and Treatment Services for Enrolled Children
The plan shall provide the medically necessary evaluation and
treatment services for children referred by DCF, DJJ, and by the
elementary, middle and secondary schools.
The plan shall establish medically necessary children's services
in such a way as to minimize disruption of services available to
high-risk populations currently served by DCF (e.g., children in
delinquent programs, and other in-reach initiatives in schools
and housing projects). The plan shall promptly evaluate, provide
psychological testing to, and serve children (including
delinquent and dependent children) referred by the department in
accordance with medical necessity, and within the time limits
specified in e. below.
The plan shall provide court-ordered evaluation and treatment
required for children who are members pursuant to the
specifications in the Medicaid Community Mental Health Services
Coverage and Limitations Handbook.
For any child receiving services through the plan, the plan must
participate in all DCF or school staffing that may result in the
provision of services for which the plan is responsible. The plan
shall refer children to DCF when residential treatment is
medically necessary. The plan shall not be responsible for
providing any residential treatment for children enrolled in the
plan. Placement shall be coordinated with the appropriate DCF ADM
or DJJ district program office.
The plan's case management of children in the plan is to include
involvement of persons, schools, programs, networks and agencies
that figure importantly in the child's life. The plan shall make
determinations about care based on a comprehensive evaluation,
consultation from the above parties, as indicated, and
appropriate protocols for admission and retention. The Agency
shall monitor services for adequacy and conformity with
agreements.
c. Psychiatric Evaluations for Members Applying for Nursing Home
Admission
The plan shall, upon request from the Alcohol, Drug Abuse and
Mental Health District (ADM) Offices, promptly arrange for and
authorize psychiatric evaluations for members applying for
admission to a nursing facility pursuant to OBRA 1987, and who,
on the basis of a screening conducted by CARES workers, are
thought to need mental health treatment. The examination shall be
adequate to determine the need for "specialized treatment" under
the Act. State regulations have been interpreted by the state to
permit any "mental health professional" defined under section
394.455, F.S., to make the observations preparatory to the
evaluation, although a psychiatrist must sign such evaluations.
The plan shall not be responsible for annual resident reviews or
for providing services as a result of a Pre-admission Screening
Assessment Annual Resident Review (PASSAR) evaluation.
d. The plan shall operate, as part of its crisis support/emergency
services, a 24 hours a day, seven days a week, crisis emergency
hot-line to be available to all members.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 20 OF 166
July 2004 Medicaid HMO Contract
e. The plan shall adhere to the minimum staffing, availability, and
access standards described in the minimum access and staffing
standards, of the Medicaid PMHPs RFPs except for the following
provisions: For a rural county, the Agency may waive the
requirement, in writing, that at least one board certified adult
psychiatrist and at least one board certified child psychiatrist,
or one who meets all education and training criteria for board
certification, are available within thirty minutes typical travel
time of all enrolled beneficiaries if a provider with this
experience is not available.
f. For all members meeting the criteria for mental health targeted
case management as specified in the Medicaid Targeted Case
Management Services Coverage and Limitations Handbook, the plan
shall adhere to the staffing ratio of at least 1 FTE behavioral
health care case manager per 20 children, and at least 1 FTE
behavioral care case manager per 40 adults. Direct service
behavioral health care providers shall not be counted as
behavioral health care case managers.
10.11.2 NON COVERED SERVICES (BEHAVIORAL HEALTH)
If the plan determines the need for behavioral health services not
covered under the contract, the plan shall refer the member to the
appropriate service provider. The plan may request the assistance of
the Medicaid Field Office or the DCF Districts' ADM offices for
referral to the appropriate service setting.
Long term care institutional services of a nursing home, an
institution for persons with developmental disabilities, specialized
therapeutic foster care, children's residential treatment services, or
state hospital services are not covered. For members requiring those
services, the plan shall consult the Medicaid Field Office and/or the
Districts' DCF ADM offices to identify appropriate methods of
assessment and referral. The plan is responsible for transition and
referral to appropriate service providers. Members receiving those
services shall be disenrolled from the plan.
10.11.3 CARE COORDINATION AND MANAGEMENT (BEHAVIORAL HEALTH)
The plan shall be responsible for the coordination and management of
behavioral health care and continuity of care for all enrolled
Medicaid beneficiaries through the following minimum functions:
a. Contacting each new member to authorize the release of their
clinical records within 30 days of enrollment and for current
members within 5 days after their first behavioral health service
provision. The plan shall then request the clinical records from
the previous behavioral health care providers.
b. Minimizing disruption to the member as a result of any change in
service provider or behavioral health care case manager occurring
as a result of this contract. For current members, upon
implementation of this attachment, and for new members,
thereafter, who have been receiving behavioral health care
services, the plan shall continue to authorize and pay valid
claims for services until the plan has reviewed the member's
treatment plan and developed and implemented an appropriate
written transition plan. However, if the previous treating
provider is unable to allow the plan access to the member's
clinical record because the member refuses to release the medical
record, then the plan shall be responsible for up to four
sessions of individual or group therapy, or one psychiatric
medical session, or two one-hour Intensive Therapeutic On Site or
Home and Community Based Rehabilitative Sessions, or six days of
Day Treatment Services.
c. Documenting in behavioral clinical records all member emergency
behavioral encounters and appropriate follow-up and, where
medical in nature, in the primary care physician's medical
record.
d. Documenting all referral services in the members' behavioral
clinical records.
e. Monitoring members admitted to state mental health institutions
as follows: the plan shall participate in discharge planning and
community placement of members who are being discharged within
sixty days of losing their plan enrollment due to state
institutionalization. The Agency may sanction the plan for any
inappropriate over-utilization of state mental hospital services
for its members.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 21 OF 166
July 2004 Medicaid HMO Contract
f. Coordinating hospital and/or institutional discharge planning for
psychiatric admissions and substance abuse detoxification that
includes appropriate post-discharge care.
g. Providing appropriate referral of the member for non-covered
services to the appropriate service setting, and requesting
referral assistance, as needed, from the Medicaid Field Office.
The plan is encouraged to use the Florida Supplement to the
American Society of Addictions Medicine Patient Placement
Criteria for coordination and treatment of substance-related
disorders with substance abuse providers. Coordination of care
with community-based substance abuse agencies shall be included
in protocols developed for continuity of care practices for
enrollees with dual diagnoses of mental illnesses and substance
abuse or dependency.
h. Entering, prior to commencement of services, into agreements with
agencies funded pursuant to chapter 394, Part IV, F.S., that
shall not be a part of the plan's provider network, regarding
coordination of care and treatment of members jointly or
sequentially served. A listing of these agencies is available at
the Medicaid Office. These agreements shall be approved by the
Agency. The plan shall be released from this requirement by the
Agency if good faith efforts are made by the plan and no
agreement is consummated.
i. Providing court ordered mental health evaluations for its
members. The plan shall also provide expert mental health
testimony for its enrolled beneficiaries.
j. Providing appropriate screening, assessment, crisis intervention
and support for members who are in the care and custody of the
state pursuant to the specifications indicated in the Medicaid
Community Mental Health Services Coverage and Limitations
Handbook.
k. Requesting current behavioral health provider information from
all new members upon enrollment. The plan shall solicit these
current providers to enroll in the plan's provider network. The
plan may request in writing that the Agency grant an exemption
for the plan from soliciting a specific provider on a
case-by-case basis.
l. Providing, upon an Assisted Living Facility's (ALF) request, the
plan's procedures for the ALF to follow should an emergent
condition arise with one of its members that reside in an ALF, as
specified in section 409.912, F.S.
m. The plan shall participate, as requested by the DCF district
administrators, in each DCF district's ADM planning process
pursuant to chapter 394.75, F.S.
10.11.4 BEHAVIORAL CLINICAL RECORD REQUIREMENT (BEHAVIORAL HEALTH)
The plan shall maintain a behavioral clinical record for each member
under this contract. The record shall include documentation sufficient
to disclose the quality, quantity, appropriateness and timeliness of
services performed under this contract. Each member's record must be
legible and maintained in detail consistent with good clinical and
professional practice which facilitates effective internal and
external peer review, medical audit, and adequate follow-up treatment.
Identification of the physician or other service provider, date of
service, the units of service and type of service must be clearly
evident for each service provided.
10.11.5 FUNCTIONAL ASSESSMENTS (BEHAVIORAL HEALTH)
The plan shall ensure its providers administer functional assessments
using the Functional Assessment Rating Scales (FARS) (for persons over
age 18) and Child Functional Rating Scale (CFARS) (for persons age 18
and under). The plan shall ensure the provider administers and
maintains the FARS and CFARS for beneficiaries of behavioral health
care services and upon termination of providing such services.
Additionally, the plan must evaluate these data and report outcome
measures to the Agency on an annual basis by August 15.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 22 OF 166
July 2004 Medicaid HMO Contract
10.11.6 OUT-OF-PLAN USE (BEHAVIORAL HEALTH)
The provisions of the Medicaid service requirements of the current
Medicaid Areas PMHP RFPs govern the payment of emergency behavioral
health services within the contract service area. However, the
out-of-area, non-contract provider must notify the plan within 24
hours of the member presenting for emergency behavioral health
services that the member has come to the non-contract provider for
treatment. In cases in which the member has no identification, or is
unable to verbally identify himself when presenting for services, the
provider must notify the plan within 24 hours of learning the member's
identity. The provider must also provide clinical records to the plan
that document that the identity of the member could not be ascertained
due to the member's condition.
If the non-contract provider fails to provide the plan with an
accounting of the member's presence and status within 24 hours after
the member presents for treatment and provides identification, the
plan shall be obligated to pay only for the time period required for
emergency services, as documented by the patient's clinical record.
The plan must review and approve or disapprove out-of-plan emergency
mental health service claims based on the definition of emergency
(behavioral health) services specified in section 100.0, Glossary,
within the time frames specified for emergency claims payment in
section 20.10, Emergency Care Requirements, of this contract.
The plan must submit to the Agency for review and final determination
denied appeals from providers for denied emergency behavioral health
service claims. Such denied appeals must be submitted within ten days
after the plan has made final appeal determination. The plan must pay
within 35 days previously denied emergency mental health service
claims if the decision by the Agency is to honor the claim. The 35-day
period begins when notification of the final decision from the Agency
is received by the plan.
The plan must evaluate and authorize or deny payment for care for
members presenting at non-plan receiving facilities (that are not
crisis stabilization units) within the contract service area for
involuntary examination within three hours of being notified by phone
by the receiving facility. The receiving facility at which the member
presents must notify the plan within four hours of the member
presenting that the member has come to the receiving facility for
treatment. If the receiving facility fails to provide the plan with an
accounting of the member's presence and status within four hours, the
plan shall be obligated to pay only for the first four hours of the
enrollee's treatment, subject to medical necessity.
If the receiving facility is a non-plan receiving facility and
documents in the clinical record that it is unable (after good faith
effort) to identify the patient as a plan member and, therefore, fails
to notify the plan of the member's presence, the plan shall be
obligated to pay for medical stabilization lasting no more than three
days from the date the member presented at the receiving facility, as
documented by the patient's medical record and subject to medical
necessity, unless there is irrefutable evidence in the clinical record
that a longer period was required.
Refer to the provisions of section 20.9, Out-of-plan Use of Non
Emergency Services.
10.11.7 OUTREACH REQUIREMENTS (BEHAVIORAL HEALTH)
At a minimum, the plan shall have an outreach plan that is designed to
encourage members to seek behavioral health care assistance with the
plan when assistance is perceived to be needed. In addition, the
outreach plan shall provide for the following:
a. Outreach communications that are written at the fourth grade
reading level.
b. Outreach communications that are written in a language spoken by
the member.
c. The plan shall develop and implement a program designed to assist
primary care providers in the identification and management of
clinical depression.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 23 OF 166
July 2004 Medicaid HMO Contract
10.11.8 QUALITY IMPROVEMENT REQUIREMENTS (BEHAVIORAL HEALTH)
The plan's quality improvement program shall include a behavioral
health component in order to monitor and assure that behavioral health
services provided are sufficient in quantity, of acceptable quality,
and meet the needs of the enrolled population. Specifically, treatment
plans must identify reasonable and appropriate objectives, planned
services that are appropriate to meet the identified objective, and
retrospective reviews that must confirm that the care provided and its
outcomes were consistent with approved treatment plans and appropriate
for the members' needs.
In determining if behavioral health care is acceptable under current
standards, the plan shall perform the following:
a. A quarterly review of a random selection of 10 percent or 50
member records, whichever is fewer, of members who have received
behavioral health care services during the previous quarter.
b. Review elements for these reviews shall include management of
specific diagnoses, 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.
The plan shall send representation to the local advisory groups that
convene quarterly and report to the Agency on behavioral health
advocacy and programmatic concerns. These groups shall provide
technical and policy advice to the Agency regarding prepaid behavioral
health care.
10.11.9 ADMINISTRATIVE STAFF REQUIREMENTS (BEHAVIORAL HEALTH)
The plan must identify a plan staff person with oversight
responsibility for the behavioral health services required in this
section and to act as liaison to the Agency.
The plan's medical director shall appoint a board certified or board
eligible psychiatrist to oversee the proper provision of covered
behavioral health services to members. This appointment may be to a
subcontractor of the plan.
The Agency shall review and approve the plan's staff and subcontracted
behavioral health care providers in order to determine the plan's
compliance with the requirements of section 20.5, Licensure of Staff,
of this contract, prior to the plan's expansion.
10.11.10 BEHAVIORAL HEALTH SUBCONTRACTS
If the plan subcontracts with a Managed Behavioral Health Organization
(MBHO) for the provision of services stipulated in this section, the
MBHO shall be accredited by one of the recognized national
accreditation organizations.
The plan must submit model subcontracts for each behavioral health
specialist type or facility for Agency approval.
All subcontracts must adhere to the requirements set forth in this
contract, section 70.18, Subcontracts.
10.11.11 MANAGEMENT INFORMATION SYSTEM (BEHAVIORAL HEALTH)
The plan shall perform the following management information system
functions:
a. Maintain member behavioral health service, utilization, and
expenditure profiles, and current and historical data with
beginning and ending dates.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 24 OF 166
July 2004 Medicaid HMO Contract
b. Maintain data documenting behavioral health service utilization
by service, (including procedure code), encounter or claim
information, date of service per encounter/claim, beneficiary
Medicaid ID number, diagnosis, designated groups of
beneficiaries, and providers.
c. Maintain data documenting behavioral health management,
administrative, and service costs.
d. Maintain data sufficient to document behavioral health services
authorized but not yet claimed by direct service provider and by
member.
e. Maintain critical incident data.
f. Maintain clinical and functional member behavioral health
outcomes data.
10.11.12 MONITORING (BEHAVIORAL HEALTH)
Upon implementation, the Agency shall periodically monitor the
behavioral health operation of the plan for compliance with the
provisions of the contract and applicable federal and state laws and
regulations. Such monitoring activities shall include, but are not
limited to, inspection of plan's facilities; review of mental health
staffing patterns and ratios; audit and/or review of all records
developed under this behavioral health benefit, including clinical and
financial records; review of management information systems and
procedures developed under the contract, including appropriate
procedures for Clozaril prescription refills; desk audits of
information and behavioral health outreach provided by the plan; and
review of any other areas or materials relevant to or pertaining to
the behavioral health benefit.
The Agency shall conduct an annual behavioral health clinical audit of
the plan requiring management data be identified and collected for use
by medical audit personnel. Data collected must include information on
the use of behavioral health services and reasons for enrollment and
termination.
10.12 FRAIL/ELDERLY PROGRAM (EXPANDED SERVICE)
The Frail Elderly program is defined in Exhibit 110.4
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 25 OF 166
July 2004 Medicaid HMO Contract
20.0 SCOPE OF WORK
20.1 AVAILABILITY/ACCESSIBILITY OF SERVICES
The plan shall make available and accessible facilities, service
locations, service sites, and personnel sufficient to provide the
covered services. In accordance with section 1932(b)(7) of the Social
Security Act (as enacted by section 4704(a) of the Balanced Budget Act
of 1997), the plan shall provide the Agency with adequate assurances
that the plan, with respect to a service area, has the capacity to
serve the expected enrollment in such service area, including
assurances that the plan: offers an appropriate range of services and
access to preventive and primary care services for the populations
expected to be enrolled in such service area; and maintains a
sufficient number, mix, and geographic distribution of providers of
services. Emergency medical care as required by this agreement shall
be available on a 24 hours a day, seven days a week basis. The plan
must assure that primary care physician services and referrals to
specialty physicians are available on a timely basis, to comply with
the following standards: urgent care - within one day; routine sick
patient care - within one week; and well care - within one month. Each
medical or osteopathic provider shall maintain hospital privileges if
hospital privileges are required for the performance of plan services.
This does not preclude the provider from using admitting panels to
comply with this section. The plan shall have telephone call policies
and procedures that shall include requirements for call response
times, maximum hold times, and maximum abandonment rates.
Primary care physicians and hospital services must be available within
30 minutes typical travel time, and specialty physicians and ancillary
services must be within 60 minutes typical travel time from the
member's residence. For rural areas, if the plan is unable to contract
with specialty or ancillary providers who are within the typical
travel time requirements, the Agency may waive, in writing, these
requirements.
If the plan is unable to provide medically necessary services covered
under the contract to a particular beneficiary, the plan must
adequately and timely cover these services outside of the network for
the beneficiary for as long as the plan is unable to provide them.
The plan must require out-of-network providers to coordinate with
respect to payment and must ensure that cost to the beneficiary is no
greater than it would be if the covered services were furnished within
the network.
The plan must allow each enrollee to choose his or her health care
professional, as defined in section 100.0, Glossary, to the extent
possible and appropriate.
Each plan shall provide the Agency with documentation of compliance
with access requirements no less frequently than the following:
a At the time it enters into a contract with the Agency.
b. At any time there has been a significant change in the plan's
operations that would affect adequate capacity and services,
including but not limited to:
1. Changes in plan services, benefits, geographic service area,
or payments.
2. Enrollment of a new population in the plan.
20.2 MINIMUM STANDARDS
Plans shall provide the following:
a. At least one FTE primary care physician, per county, representing
at least each of these specialties: family practice, pediatrics,
and internal medicine. The plan must ensure primary care
physicians sufficient to ensure adequate accessibility to all
primary care services for all enrolled beneficiaries at all ages.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 26 OF 166
July 2004 Medicaid HMO Contract
b. One FTE primary care physician per l,500 HMO members for
contracted physicians. The ratio may be increased by 750 members
for each FTE advanced registered nurse practitioner or FTE
physician assistant affiliated with the physician or staff
physician as a provider in the practice.
c. One fully accredited general acute care hospital. The Agency may
waive, in writing, the accreditation requirement in rural areas.
d. One birth delivery facility licensed under chapter 383, F.S., or
a hospital with birth delivery facilities licensed under chapter
395. The delivery facility may be part of a hospital or a
freestanding facility.
e. One licensed pharmacy per 2,500 members.
f. A birthing center licensed under chapter 383, F.S., that is
accessible to low risk patients. The Agency may waive, in
writing, this requirement if the plan cannot reach an agreement
with those centers within reasonable travel time for a rate no
greater than the Medicaid rate for those centers.
g. A designated emergency services facility, within 30 minutes
typical travel time, providing care on a 24 hours a day, seven
days a week basis. Such designated emergency service facility
shall have one or more physicians and one or more nurses on duty
in the facility at all times. The Agency may waive, in writing,
the travel time requirement in rural areas.
h. At least one pediatrician or one county health department, a
federally qualified health center or a rural health clinic within
30 minutes of typical travel time, providing care or coverage on
a 24 hours a day, 7 days a week basis. The Agency may waive this
requirement in writing for rural areas and where there are no
pediatricians, county health departments, federally qualified
health centers, or rural health clinics within typical travel
time.
i Facilities with access for persons with disabilities.
j Adequate space, supplies, good sanitation, smoke free, fire and
safety procedures in operation.
k Specialists as required in section 20.7, Specialty Coverage.
Pursuant to section 4707(a) of the Balanced Budget Act of 1997 and
upon development by the federal government, the plan must require each
physician who provides Medicaid services to have a unique identifier
in accordance with the system established under section 1173(b) of the
Social Security Act.
Pursuant to section 409.9122, F.S., the plan shall at least annually
review each primary care physician's active patient load and shall
ensure that additional Medicaid recipients are not assigned to
physicians that have a total active patient load of more than 3,000
patients. As used in this paragraph, the term "active patient" means a
patient who is seen by the same primary care physician, or by a
physician assistant or advanced nurse practitioner under the
supervision of the primary care physician, at least three times within
a calendar year.
Pursuant to section 409.9122, F.S., each primary care physician shall
annually certify to the plan whether or not his or her patient load
exceeds the limits established under this paragraph and the plan shall
accept such certification on face value as compliance with this
paragraph. The Agency shall accept the plan's representations that it
is in compliance with this paragraph based on the certification of its
primary care physician, unless the Agency has an objective indication
that access to primary care is being compromised, such as receiving
complaints or grievances relating to access to care. If the Agency
determines that an objective indication exists that access to primary
care is being compromised, it may verify the patient load
certifications submitted by the plan's primary care physicians and
that the plan is not assigning Medicaid beneficiaries to primary care
physicians who have an active patient load of more than 3,000
patients.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 27 OF 166
July 2004 Medicaid HMO Contract
20.3 ADMINISTRATION AND MANAGEMENT
The plan's governing body shall set policy and has overall
responsibility for the organization. The plan shall be responsible for
the administration and management of all aspects of this contract.
Pursuant to 42 CFR 438.210(b)(2), the plan is responsible for ensuring
consistent application of review criteria for authorization decisions
and consulting with the requesting provider when appropriate. Any
delegation of activities does not relieve the plan of this
responsibility. This includes all subcontracts, employees, agents and
anyone acting for or on behalf of the plan. The plan must have written
policies and procedures for selection and retention of providers.
These policies and procedures must not discriminate against particular
providers that serve high-risk populations or specialize in conditions
that require costly treatments.
a. If the plan delegates claims adjudication functions to a third
party administrator (TPA), the TPA must be licensed to do
business as a TPA in the state of Florida.
b. The relationship between management personnel and the governing
body shall be set forth in writing, including each person's
authority, responsibilities, function, and position descriptions
for key personnel.
c. If any function of the administration or management of the plan
is delegated to another entity, the plan shall:
1. Adhere to all requirements set forth in section 70.18,
Subcontracts, in relation to the delegated entity and any
further subcontractors;
2. Notify the Agency within 10 working days after such
functions are delegated (full or partial delegation),
specify what functions are delegated, identify the plan
staff who is/are responsible for the monitoring of the
delegated functions, and define how the plan will routinely
monitor such functions. Additionally, the plan shall submit
a list of all entities to which the plan has delegated any
functions, including addresses and phone numbers.
d. If any service authorization function is delegated to another
entity, the plan shall ensure that such entity's service
authorization system(s) provide for the following as specified in
the plan's policies and procedures:
Timely authorizations;
Effective dates for the authorization, if appropriate; and
Written confirmation of adverse determination to the provider and
the subscriber as described in section 641.51 F.S.
e. Any delegation of service authorization, claims payment and/or
member services shall include a requirement that the provider and
any further subcontractor adhere to the plan's telephone
requirements for call response times, maximum hold times and
maximum abandonment rates.
f. Pursuant to 42 CFR 438.236(b), the plan shall adopt practice
guidelines that meet the following requirements:
Are based on valid and reliable clinical evidence or a consensus
of health care professionals in the particular field;
Consider the needs of the enrollees.
Are adopted in consultation with contracting health care
professionals.
Are reviewed and updated periodically as appropriate.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 28 OF 166
July 2004 Medicaid HMO Contract
The plan shall disseminate the guidelines to all affected
providers and, upon request, to enrollees and potential
enrollees. The decisions for utilization management, enrollee
education, coverage of services, and other areas to which the
guidelines apply shall be consistent with the guidelines.
20.4 STAFF REQUIREMENTS
The staffing for the HMO developed under this contract must be capable
of fulfilling all contractual requirements. The minimum staff
requirements are as follows:
a. A full-time administrator specifically identified to administer
the day-to-day business activities of the contract. This person
cannot be designated to any other position in this subsection.
b. Sufficient medical and professional support staff to conduct
daily business in an orderly manner, including having member
services staff directly available during business hours for
membership services consultation, as determined through
management and medical reviews. The plan shall maintain
sufficient medical staff available 24 hours per day to handle
emergency care inquiries. The plan shall be required to maintain
sufficient medical staff during non-business hours unless the
plan's computer system auto-approves all emergency service claims
related to screening and treatment.
c. A full-time, licensed physician to serve as medical director to
oversee and be responsible for the proper provision of covered
services to members. The plan's medical director shall be
licensed in accordance with chapter 458 or 459, F.S.
d. A designated person, qualified by training and experience, to
ensure subcontractors' compliance with the medical records
requirements as described in section 20.13 of this contract. This
person shall maintain medical record standards and conduct
medical record reviews according to section 20.14. If the plan is
a staff model HMO, the plan shall designate a person to oversee
its medical record systems.
e. A person trained and experienced in data processing and data
reporting as required to ensure that computer system reports that
are provided to the Agency are accurate, and that computer
systems operate in an accurate and timely manner.
f. A designated person, qualified by training and experience, to be
responsible for the plan's marketing responsibilities if the plan
engages in preenrollment activities.
g. A designated person, qualified by training and experience, in
quality improvement.
h. A designated person, qualified by training and experience, to be
responsible for the plan's utilization management program.
i. A designated person, qualified by training and experience, in the
processing and resolution of appeals and grievances, to be
responsible for the grievance system.
j. A designated person qualified by training and experience, to
investigate fraudulent claims by providers pursuant to sections
641.3915, 626.9891, and 626.989, F.S.
k. Sufficient case management staff, qualified by training and
experience, to conduct case management as defined in section
100.0, Glossary.
20.4.1 FRAUD PREVENTION POLICIES AND PROCEDURES
The plan shall develop and maintain written policies and procedures
for fraud prevention which contain the following:
a. A comprehensive employee training program to investigate
potential fraud.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 29 OF 166
July 2004 Medicaid HMO Contract
b. A review process for claims which shall include:
1. review of providers who consistently demonstrate a pattern
of encounter or service reports that did not occur;
2. review of providers who consistently demonstrate a pattern
of overstated reports or up-coded levels of service;
3. review of providers who altered, falsified, or destroyed
clinical record documentation;
4. review of providers who make false statements about
credentials;
5. review of providers who misrepresent medical information to
justify referrals;
6. review of providers who fail to render medically necessary
covered services that they are obligated to provide
according to their subcontracts;
7. Review of providers who charge Medicaid beneficiaries for
covered services.
The policies and procedures for fraud prevention shall provide for use
of the List of Excluded Individuals and Entities (LEIE) or its
equivalent, to identify excluded parties during the process of
enrolling providers to ensure the plan providers are not in a
non-payment status or excluded from participation in federal health
care programs under section 1128 or section 1128A of the Social
Security Act. The plan must not employ or contract excluded providers
and must terminate providers if they become excluded.
20.5 LICENSURE OF STAFF
The plan is responsible for assuring that all persons, whether they be
employees, agents, subcontractors or anyone acting for or on behalf of
the plan, are properly licensed under applicable state law and/or
regulations and are eligible to participate in the Medicaid program.
The plan shall credential and recredential all plan physicians and
other providers. Hospital ancillary service providers are not required
to be independently credentialed by the plan if those providers only
provide services to the plan through the hospital. School-based
service providers are not required to be credentialed by the plan if
the plan can document that the school has signed one of the
credentialing agreements provided in Appendix A of the Florida
Medicaid Certified School Match Program Services Coverage and
Limitations Handbook assuring that school-based service providers are
Medicaid credentialed.
20.5.1 CREDENTIALING AND RECREDENTIALING POLICIES AND PROCEDURES
The plan's credentialing and recredentialing policies and procedures
shall include the following:
a. Written policies and procedures for credentialing.
b. Formal delegations and approvals of the credentialing process.
c. A designated credentialing committee.
d. Identification of providers who fall under its scope of
authority.
e. A process which provides for verification of the following core
credential information:
1. The practitioner's current valid license. Practitioner's
current license must be on file at all times pursuant to
section 641.495, F.S.
2. The practitioner's current valid Drug Enforcement
Administration (DEA) certificate where applicable.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 30 OF 166
July 2004 Medicaid HMO Contract
3. Proof of the practitioner's medical school graduation,
completion of a residency, and other postgraduate training.
Evidence of Board certification shall suffice in lieu of
proof of medical school graduation, residency and other
postgraduate training.
4. Evidence of specialty board certification, if applicable.
5. Evidence of the practitioner's professional liability claims
history.
6. History of final disciplinary actions, as described in
section 456.039, F.S.
7. Any sanctions imposed on the practitioner by Medicare or
Medicaid.
f. The credentialing process must also include verification of the
following information:
1. The practitioner's work history
2. Evidence of the provider's good standing privileges at the
hospital designated as the primary admitting facility by the
practitioner or good standing of privileges at the hospital
by another plan physician with whom the practitioner has
entered into an arrangement for hospital coverage.
3. The plan must obtain a statement from each practitioner
applicant regarding the following:
(a) Any physical or mental health problems that may affect
the practitioner's ability to provide health care.
(b) Any history of chemical dependency/substance abuse.
(c) Any history of loss of license and/or felony
convictions.
(d) Any history of loss or limitation of privileges or
disciplinary activity.
(e) Attestation to correctness/completeness of the
practitioner's application.
(f) For primary care physicians, attestation of the total
active patient load (all populations: Medicaid
Fee-for-Service, Medicaid HMO, MediPass, Medicare, or
commercial) in accordance with section 409.9122, F.S.
4. Documentation of an initial visit to the office of each
primary care physician and OB/GYN to review the site.
Documentation shall include the following:
(a) The plan has evaluated the provider site against the
plan's organizational standards.
(b) The plan has evaluated the physician's medical record
keeping practices at each site to ensure conformity
with the plan's organizational standards.
(c) The plan has determined that the following documents
are posted: The Agency's statewide consumer call center
telephone number including hours of operation and a
copy of the summary of Florida Patient's Bill of Rights
and Responsibilities, in accordance with section
381.026, F.S. A complete copy of the Florida Patient's
Bill of Rights and Responsibilities shall be available,
upon request by a member, at each primary care
physician's office. The Florida Patient's Bill of
Rights is found in section 110.5, Florida Patient's
Bill of Rights and Responsibilities.
A consumer assistance notice shall also be prominently
displayed in the reception area of the provider in
accordance with section 641.511, F.S.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 31 OF 166
July 2004 Medicaid HMO Contract
g. The process for periodic recredentialing which shall include the
following:
1. The procedure for recredentialing shall be implemented at
least every three years.
2. The plan shall verify the current standing for each
practitioner on items 20.5.1 e. and f.
3. Documentation of periodic visits to the primary care
physician offices documenting site reviews, including review
of the items listed in section 20.5.1 f. 4 of this section
to ensure continued conformance with the plans' standards.
h. The plan shall develop and implement policies and procedures for
approval of new providers, and imposition of sanctions,
termination, suspension, and restrictions of existing providers.
i. The plan shall develop and implement a mechanism for identifying
quality deficiencies which result in the plan's restriction,
suspension, termination, or sanctioning of a practitioner.
j. The plan shall develop and implement an appellate process for
sanctions, restrictions, suspensions and terminations imposed by
the plan against practitioners.
k. The plan shall submit provider networks for initial or expansion
review to the Agency for approval only when the plan has
satisfactorily completed the minimum standards required in
section 20.2, Minimum Standards and the minimum credentialing
steps required in section 20.5.1 e. and f.
20.6 PHYSICIAN CHOICE
The plan agrees to offer each member a choice of primary care
physicians. After making a choice, each member shall have a single
primary care physician.
For Title XXI MediKids and for members assigned by Medicaid, the plan
shall assign primary care physicians taking into consideration last
primary care provider of service (if the provider is known and
available in the plan's network), closest location within the service
area, zip code location, keeping children within the same family
together, age (adults versus children), and sex (OB/GYN). The plan
shall inform members of the following: (1) their primary care
physician assignment, (2) their ability to choose a different primary
care provider, (3) a list of providers from which to make a choice,
and (4) the procedures for making a change. The plan shall provide
this written notice to assigned members by the first day of
enrollment.
20.7 SPECIALTY COVERAGE
The plan shall assure the availability of the following specialists,
as appropriate for both adult and pediatric members, on at least a
referral basis: allergist; cardiologist; endocrinologist; general
surgeon; obstetrical/gynecology (OB/GYN); neurologist; nephrologist;
orthopedist; urologist; dermatologist; otolaryngologist;
pulmonologist; chiropractic physician; podiatrist; ophthalmologist;
optometrist; neurosurgeon; gastroenterologist; oncologist;
radiologist; pathologist; anesthesiologist; psychiatrist; oral
surgeon; physical, respiratory, speech and occupational therapists;
and an infectious disease specialist. If the infectious disease
specialist does not have expertise in HIV and its treatment and care,
then the plan must have another physician with such expertise.
The plan must use specialists with pediatric expertise for children
where the need for pediatric specialty care is significantly different
from the need for adult specialists (e.g., a pediatric cardiologist
for children with congenital heart defects).
The plan must assure access for patients in one or more of Florida's
Regional Perinatal Intensive Care Centers (RPICC) as designated in
sections 383.15 - 383.21, F.S., or a hospital licensed by the Agency
for Neonatal Intensive Care Unit (NICU) Level III beds. The plan must
assure that care for medically high risk
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 32 OF 166
July 2004 Medicaid HMO Contract
perinatal clients is provided in a facility with a neonatal intensive
care unit to meet the appropriate level of need for the client.
The plan must assure access to certified nurse midwife services or
licensed midwife services in accordance with section 641.31, F.S., for
low risk patients. If the plan cannot reach an agreement with those
certified nurse midwives and licensed midwives within reasonable
travel time for a rate no greater than the Medicaid rate for such
services, then the plan must request a waiver and provide
documentation of a "good faith" effort.
20.8 CASE MANAGEMENT/CONTINUITY OF CARE
The plan shall be responsible for the management of medical care and
continuity of care for all enrolled Medicaid beneficiaries. The plan
shall maintain written case management continuity of care protocol(s)
that include the following minimum functions:
a. The plan shall have an outreach program and other strategies for
identifying every pregnant member. This shall include case
management, claims analysis, and use of health risk assessment,
etc. The plan shall require its participating providers to notify
the plans of any Medicaid patient who is identified as being
pregnant.
b. Appropriate referral and scheduling assistance of members needing
specialty health care and transportation services, including
those identified through CHCUP screening.
c. Documentation of referral services in members' medical records,
including results.
d. Monitoring of members with ongoing medical conditions and
coordination of services for high utilizers such that the
following functions are addressed as appropriate: acting as a
liaison between the member and providers, ensuring the member is
receiving routine medical care, ensuring that the member has
adequate support at home, assisting members who are unable to
access necessary care due to their medical or emotional
conditions or who do not have adequate community resources to
comply with their care, and assisting the member in developing
community resources to manage the member's medical condition. For
members residing in areas where behavioral health has been
implemented, see section 10.11, Behavioral Health Care of the
contract.
e. Documentation of emergency care encounters in members' records
with appropriate medically indicated follow-up.
f. Coordination of hospital/institutional discharge planning that
includes post-discharge care, including skilled short-term
rehabilitation, and skilled nursing facility care, as
appropriate.
g. Determining the need for non-covered services and referring the
member for assessment and referral to the appropriate service
setting (to include referral to the Women, Infants and Children
program (WIC) and Healthy Start) utilizing assistance as needed
by the Medicaid Field Office. The plan must also refer CHCUP
eligibles to the Medicaid Field Office to obtain assistance in
scheduling dental services and transportation services, if these
services are not covered by the plan.
Pursuant to 42 CFR 438.208(b), the plan must implement procedures to
deliver primary care to and coordinate health care service for all
beneficiaries that:
a. Ensure that each enrollee has an ongoing source of primary care
appropriate to his/her needs and a person or entity formally
designated as primarily responsible for coordinating the health
care services furnished to the beneficiary.
b. Coordinate the services the plan furnishes to the beneficiary
with the services the beneficiary receives from any other managed
care entity during the same period of enrollment.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 33 OF 166
July 2004 Medicaid HMO Contract
c. Share with other managed care organizations serving the
beneficiary with special health care needs the results of its
identification and assessment of the beneficiary's needs to
prevent duplication of those activities.
d. Ensure that in the process of coordinating care, each
beneficiary's privacy is protected in accordance with the privacy
requirements in 45 CFR Part 160 and 164 Subparts A and E, to the
extent that they are applicable.
20.8.1 CHRONIC AND DISABLING CONDITIONS
In accordance with section 641.51, F.S., the plan shall provide
standing referrals to members with chronic and disabling conditions
that require ongoing specialty care. The plan shall develop and
maintain policies and procedures for such referrals.
20.8.2 MEMBERS WITH DEVELOPMENTAL DISABILITIES
When a member has a developmental disability, the plan shall monitor
the member's ongoing medical condition by asking the member or
parent/guardian if the member is receiving services from the DCF,
Office of Developmental Services (DS). If the member is receiving
services from DS, the plan shall:
a. Contact the member, or parent/guardian, as appropriate, for DS
contact information and obtain authorization (if not already
obtained) to seek further information from the member's DS
support coordinator or waiver support coordinator.
b. Contact the member's DS support coordinator or waiver support
coordinator to obtain DS service information and review the need
to coordinate care.
c. Continue to contact the member or the member's parent/guardian
and provider regarding the ongoing coordination of care, as
appropriate.
20.8.3 COORDINATION WITH COMMUNITY MENTAL HEALTH CARE PROVIDERS
When a member residing in an area other than the Agency's areas known
to be receiving behavioral health services, the plan shall ask the
member or parent/guardian if the member is receiving behavioral health
treatment services from a community mental health center, clinic, or
private behavioral health provider. If the member is receiving such
services, the plan shall:
a. Contact the member, or parent/guardian, as appropriate, and
obtain authorization (if not already obtained) to seek further
information from the member's behavioral health treatment
provider.
b. Contact the member's behavioral health treatment provider to
obtain the member's current behavioral health treatment plan, and
review the information in order to coordinate care (this is
particularly relevant for individuals who are taking prescribed
psychotropic medications).
c. Coordinate the member's care with the behavioral health provider,
as appropriate.
For members residing in Agency areas where behavioral health care has
been implemented, see section 10.11, Behavioral Health of the
contract.
20.8.4 NEW MEMBER PROCEDURES
The plan shall contact each new member at least two times, if
necessary, within 90 calendar days of enrollment, to urge scheduling
of an initial appointment with the primary care provider for the
purpose of a health risk assessment (information regarding the health
risk assessment/CHCUP screening for members under the age of 21 may be
found in section 10.8.1, CHCUP).
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 34 OF 166
July 2004 Medicaid HMO Contract
a. For this subsection, contact is defined as mailing a notice to,
or telephoning, a member at the most recent address or telephone
number available.
b. The plan will urge members to see their primary care physicians
within 180 days of enrollment.
c. The plan shall contact each new member within 30 calendar days of
enrollment to request the member to authorize release of his or
her medical records to the plan or its health services
subcontractors from practitioners who treated the member prior to
plan enrollment. The plan shall request or assist the member's
new practitioner in requesting medical records from the previous
practitioners.
d. The plan must use the health risk assessments or the released
medical records to identify members who have not received CHCUP
screenings in the past according to the Agency approved
periodicity schedule.
e. The plan must contact, up to two times if necessary, any members
who are more than two months behind in the periodicity screening
schedule to urge those members or their legal representative to
make an appointment for a screening visit.
f. Within 30 calendar days of enrollment, the plan shall advise
members of and ensure the availability of, a screening for all
members known to be pregnant or who advise the plan that they may
be pregnant. The plan shall refer pregnant members and members
reporting they may be pregnant for appropriate prenatal care
(refer to section 10.8.11.1, Pregnancy Related Requirements).
g. For beneficiaries voluntarily enrolling, Title XXI MediKids and
for beneficiaries who have been automatically reinstated due to
regaining Medicaid eligibility, the plan shall honor any written
documentation of prior authorization of ongoing covered services
for a period of 10 calendar days after the effective date of
enrollment or until the plan's primary care physician assigned to
that member reviews the member's treatment plan, whichever comes
first.
h. For beneficiaries that the state has assigned, the plan shall
honor any written documentation of prior authorization of ongoing
services for a period of one month after the effective date of
enrollment or until the plan's primary care physician assigned to
that member reviews the member's treatment plan, whichever comes
first.
i. For both voluntary and assigned members, written documentation of
prior authorization of ongoing services includes the following,
provided that the services were prearranged prior to enrollment
in the plan:
1. Prior existing orders,
2. Provider appointments, surgeries, and
3. Prescriptions (including prescriptions at non-participating
pharmacies).
The plan cannot delay service authorization if written
documentation is not available in a timely manner; however, the
plan is not required to pay claims for which it has received no
written documentation. The plan shall not deny claims submitted
by a non-contracting provider solely based on the period between
the date of service and the date of clean claim submission unless
that period exceeds 365 days.
The plan shall be responsible for payment of covered services to
the existing treating provider at a prior negotiated rate or
lesser of the provider's usual and customary rate or the
established Medicaid fee-for-service rate for such services until
the plan is able to evaluate the need for ongoing services.
j. For members in the Frail/Elderly program, the plan shall contact
each new member within five days of enrollment and develop a plan
of care. The plan is developed with the member and with others in
the
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 35 OF 166
July 2004 Medicaid HMO Contract
member's care support network, if desired by the member. If the
member has been adjudicated incompetent in accordance with law, is
found by his or her physician to be medically incapable of
understanding his/her rights, or exhibits a significant
communication barrier, the member's guardian, next of kin, or
legally authorized responsible person is permitted to act on the
member's behalf in matters relating to the member's enrollment, plan
of care or services.
If urgent needs are identified, the plan shall take immediate action
to address them. Urgent means any sudden or unforeseen situation
which requires immediate action to prevent hospitalization or
nursing home placement. Examples of urgent situations may be:
hospitalization of spouse or caregiver or increased impairment of a
member living alone who suddenly cannot manage basic needs without
immediate help, hospitalization, or nursing home placement.
20.8.5 PEDIATRICIAN ASSIGNMENT TO PREGNANT WOMEN
The plan must assign a pediatrician or other appropriate primary care
physician to all pregnant members for the care of their newborn babies
no later than the beginning of the last trimester of gestation. If the
plan was not aware that the member was pregnant until she presented for
delivery, the plan must assign a pediatrician or a primary care
physician to the newborn baby within one workday after birth. The plan
shall advise all pregnant members of the members' responsibility to
notify their plan and their DCF public assistance specialists (case
workers) of their pregnancies and the births of their babies.
20.8.6 PROTECTIVE CUSTODY
The plan shall, for enrolled members, comply with Rule 65C-12.002,
Florida Administrative Code (F.A.C.), which requires that all children
taken into protective custody, emergency shelter, or into the foster
care program by the DCF, be physically screened within 72 hours, or
immediately, if required. The plan shall provide such required
examinations or, if unable to do so within the required time frames,
pay claims for such examinations at the lower of a prior negotiated
rate or the established Medicaid fee-for-service rate for such
services. The plan shall pay a prior negotiated rate or the lesser of
the provider's usual and customary rate or the established Medicaid
fee-for-service rate for CHCUP screenings for children whose enrollment
and Medicaid eligibility are undetermined at the time of entry into the
care and custody of the DCF and who are later determined to be enrolled
members at the time the examinations took place.
20.8.7 IMMUNIZATION FROM NON-PLAN PROVIDER
When a member receives immunizations from a non-plan provider, the plan
shall be liable for an immunization administration fee at no less than
the Medicaid rate, as long as the provider contacts the plan at the
time of service delivery and the plan is unable to document to the
provider that the immunization has already been provided to the member,
and the provider has submitted to the plan a claim for such services
and medical records documenting the immunization. The provision of
immunization services by a public provider is described in section
20.8.9, Public Provider Claims.
20.8.8 IMMUNIZATION DATA SHARING
The plan shall encourage its primary care physicians to provide
immunization information to the DCF upon receipt of the member's
written permission and DCF's request, for members requesting temporary
cash assistance from the DCF in order to document that the member has
met the immunization requirements for beneficiaries receiving temporary
cash assistance.
20.8.9 PUBLIC PROVIDER CLAIMS
In accordance with sections 381.0407, F.S. and 409.9122, F.S., without
prior authorization, the plan shall pay claims initiated by any public
provider for:
a. The diagnosis and treatment of sexually transmitted diseases
and other communicable diseases such as tuberculosis and human
immunodeficiency syndrome (refer to section 110.1, Laboratory
Tests and
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 36 OF 166
July 2004 Medicaid HMO Contract
Associated Office Visits to be Paid by Plan without Prior
Authorization when Initiated by County Health Department).
b. The provision of immunizations.
c. Family planning services and related pharmaceuticals.
d. School health services listed in a., b, and c above and for
services rendered on an urgent basis by public providers.
Services rendered on an urgent basis are those health care
services needed to immediately relieve pain or distress for
medical problems such as injuries, nausea and fever, and
services needed to treat infectious diseases and other similar
conditions.
e. In the event that a vaccine-preventable disease emergency is
declared, the plan shall reimburse county health departments
for the cost of the administration of vaccines.
Public providers shall attempt to contact the plan before providing
health care services to their members. Public providers shall provide
the plan with the results of the office visit, including test results,
and shall be reimbursed by the plan at the rate negotiated between the
plan and the public provider or, if a rate has not been negotiated, at
the lesser of either the rate charged by the public provider or the
Medicaid fee-for-service reimbursement rate. The plan shall not deny
public health care services claims for claims submitted by a
non-contracting public provider solely based on the period between the
date of service and the date of clean claim submission unless that
period exceeds 365 days.
For purposes of this subsection, public providers are defined as a
county health department or migrant health center funded under section
329 of the Public Health Services Act or a community health center
funded under section 330 of the Public Health Services Act, as
specified in section 381.0407, F.S.
20.8.10 CERTIFIED SCHOOL MATCH PROGRAM
The Agency shall reimburse schools participating in the certified
school match program pursuant to sections 1011.70 and 409.908, F.S.,
for the following school-based services rendered to members as
referenced in the Medicaid Certified School Match Program Services
Coverage and Limitations Handbook:
a. Speech, occupational and physical therapy services;
b. Behavioral health services;
c. Transportation services; and
d. Other school-based services implemented by the
Agency.
School districts participating in the certified school match program
may be authorized by Medicaid to cover any one, a combination, or all
of the above services indicated. The provision of school-based services
will not be considered a replacement, substitution, or fulfillment of a
service prescription or doctor's orders.
20.8.11 CONTINUED CARE FROM TERMINATED PROVIDERS
In accordance with section 641.51, F.S., the plan shall provide
continued care from terminated providers as follows. The plan shall
develop and maintain policies and procedures for the provision of such
care.
The plan shall allow members for whom treatment is active to continue
care with a terminated treating provider when medically necessary,
through completion of treatment of a condition for which the member was
receiving care at the time of the termination, until the member selects
another treating provider or during the next open enrollment period,
whichever is longer, but not longer than 6 months after the termination
of the contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 37 OF 166
July 2004 Medicaid HMO Contract
The plan shall allow pregnant members who have initiated a course of
prenatal care, regardless of trimester in which care was initiated, to
continue care with a terminated treating provider until completion of
postpartum care.
These requirements do not prevent a provider from refusing to continue
to provide care to a member who is abusive or non-compliant.
For care continued under this section, the plan and the provider shall
continue to abide by the same terms, conditions and payment
arrangements as they existed in the terminated contract.
These requirements shall not apply for treating providers who have been
terminated from the plan for cause.
20.8.12 OUT-OF-PLAN SPECIALLY QUALIFIED PROVIDERS
In accordance with section 641.51, F.S., the plan shall determine when
exceptional referrals to out-of-plan specially qualified providers are
needed to address the unique medical needs of a member (for example,
when a member's medical condition requires testing by a geneticist).
Financial arrangements for the provision of such services shall be
agreed to prior to the provision of services. The plan shall develop
and maintain policies and procedures for such referrals.
20.8.13 INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS
The plan shall implement mechanisms for identifying, assessing and
ensuring the existence of a treatment plan for individuals with special
health care needs, as specified in section 20.12, Quality Improvement.
Mechanisms shall include evaluation of health risk assessments, claims
data, and, if available CPT/ICD-9 codes. Additionally, the plan shall
implement a process for receiving and considering provider and enrollee
input.
In accordance with this contract and 42 CFR 438.208(c)(3), a treatment
plan for an enrollee determined to need a course of treatment or
regular care monitoring must be developed by the enrollee's care
provider with enrollee participation and in consultation with any
specialists caring for the enrollee; approved by the plan in a timely
manner if this approval is required; and developed in accordance with
any applicable Agency quality assurance and utilization review
standards.
Pursuant 42 CFR 438.208(c)(4), for enrollees with special health care
needs determined through an assessment by appropriate health care
professionals (consistent with 42 CFR 438.208(c)(2)) to need a course
of treatment or regular care monitoring, each plan must have a
mechanism in place to allow enrollees to directly access a specialist
(for example, through a standing referral or an approved number of
visits) as appropriate for the enrollee's condition and identified
needs.
20.9 OUT-OF-PLAN USE OF NON-EMERGENCY SERVICES
Unless otherwise specified in this contract, where a member utilizes
services available under the plan other than emergency services from a
non-contract provider, the plan shall not be liable for the cost of
such utilization unless the plan referred the member to the
non-contract provider or authorized such out-of-plan utilization. The
plan shall provide timely approval or denial of authorization of
out-of-plan use through the assignment of a prior authorization number,
which refers to and documents the approval. A plan may not require
paper authorization as a condition of receiving treatment if the plan
has an automated authorization system. Written follow up documentation
of the approval must be provided to the out-of-plan provider within one
business day from the request for approval. The member shall be liable
for the cost of such unauthorized use of contract-covered services from
non-contract providers.
In accordance with section 409.912, F.S., the plan shall reimburse any
hospital or physician that is outside the plan's authorized geographic
service area for plan authorized services provided by the hospital or
physician to plan members at a rate negotiated with the hospital or
physician for the provision of services or according to the lesser of
the following:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 38 OF 166
July 2004 Medicaid HMO Contract
a. The usual and customary charge made to the general public by
the hospital or physician; or
b. The Florida Medicaid reimbursement rate established for the
hospital or physician.
The plan shall reimburse all out-of-plan providers pursuant to
section 641.3155, F.S.
20.10 EMERGENCY CARE REQUIREMENTS
The plan shall make provisions for and advise all members of the
provisions governing emergency use. Emergency services are defined in
section 100.0, Glossary of this contract. In accordance with section
743.064, F.S., the plan shall not deny claims for emergency medical
treatment in a hospital due to lack of parental consent.
Pursuant to section 409.9128, F.S., requirements for the plan to
provide emergency services and care are as follows:
a. In providing for emergency services and care as a covered
service, the plan shall not:
1. Require prior authorization for the receipt of
pre-hospital transport or treatment or for emergency
services and care.
2. Indicate that emergencies are covered only if care is
secured within a certain period of time.
3. Use terms such as "life threatening" or "bona fide"
to qualify the kind of emergency that is covered.
4. Deny payment based on the member's or the hospital's
failure to notify the plan in advance or within a
certain period of time after the care is given.
b. The plan shall provide pre-hospital and hospital-based trauma
services and emergency services and care to a member of the
plan as required under sections 395.1041, 395.4045, and
401.45, F.S.
c. Pursuant to section 409.9128, F.S., when a member is present
at the hospital seeking emergency services and care, the
determination as to whether an emergency medical condition (as
defined in section 409.901, F.S., and provided in section
100.0, Glossary) exists shall be made, for the purpose of
treatment, by a physician of the hospital or, to the extent
permitted by applicable law, by other appropriate personnel
under the supervision of the hospital physician. The physician
or the appropriate personnel shall indicate in the patient's
chart the results of the screening, examination, and
evaluation. The plan shall compensate the provider for the
screening, evaluations and examination that is reasonably
calculated to assist the health care provider in arriving at a
determination as to whether the patient's condition is an
emergency medical condition. The plan shall compensate the
provider for emergency services and care. If a determination
is made that an emergency medical condition does not exist,
the plan is not responsible for payment for services rendered
subsequent to that determination.
d. If a determination has been made that an emergency medical
condition exists and the member has notified the hospital, or
the hospital emergency personnel otherwise has knowledge, that
the patient is a member of the plan, the hospital must make a
reasonable attempt to notify the member's primary care
physician, if known, or the plan, if the plan has previously
requested in writing that the notification be made directly to
the plan, of the existence of the emergency medical condition.
If the primary care physician is not known, or has not been
contacted, the hospital must:
1. Notify the plan as soon as possible prior to
discharge of the member from the emergency care area;
or
2. Notify the plan within 24 hours or on the next
business day after admission of the member as an
inpatient to the hospital.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 39 OF 166
July 2004 Medicaid HMO Contract
If the notification required by this paragraph is not
accomplished, the hospital must document its attempt(s) to
notify the plan or document the circumstances that precluded
attempts to notify the plan. The plan shall not deny payment
for emergency services and care based on a hospital's failure
to comply with the notification requirements of this
paragraph.
e. If the member's primary care physician responds to the
notification, the hospital physician and the primary care
physician may discuss the appropriate care and treatment of
the member. The plan may have a member of the hospital staff
with whom it has a contract participate in the treatment of
the member within the scope of the physician's hospital staff
privileges. The member may be transferred, in accordance with
state and federal law, to a hospital that has a contract with
the plan and has the service capability to treat the member's
emergency medical condition. Notwithstanding any other state
law, a hospital may request and collect insurance or financial
information from a patient in accordance with federal law,
which is necessary to determine if the patient is a member of
the plan, if emergency services and care are not delayed.
f. In accordance with 42 CFR 438.114, the plan must also cover
post-stabilization services without authorization, regardless
of whether the beneficiary obtains the service within or
outside the plan's network, for the following situations:
1. Post-stabilization care services that were
pre-approved by the plan; or were not pre-approved by
the plan because the plan did not respond to the
treating provider's request for pre-approval within
one hour after being requested to approve such care,
or could not be contacted for pre-approval.
2. Post stabilization services are services subsequent
to an emergency that a treating physician views as
medically necessary after an emergency medical
condition has been stabilized. These are not
emergency services, but are non-emergency services
that the plan could choose not to cover out-of-plan
except in the circumstances described above.
g. In accordance with section 409.9128, F.S., reimbursement for
services provided to a member of a plan under this section by
a provider that does not have a contract with the plan shall
be the lesser of:
1. The provider's charges;
2. The usual and customary provider charges for similar
services in the community where the services were
provided;
3. The charge mutually agreed to by the plan and the
provider within 60 calendar days after submittal of
the claim; or
4. The Medicaid rate.
The plan shall not deny emergency services claims for claims
submitted by a non-contracting provider solely based on the
period between the date of service and the date of clean claim
submission unless that period exceeds 365 days.
h. Notwithstanding the requirements stated above, payment by the
plan for claims for emergency services rendered by a
non-contract provider shall be made pursuant to section
641.3155, F.S. If third party liability exists, payment of
claims shall be determined in accordance with section 70.20,
Third Party Resources.
i. The plan must review and approve or disapprove emergency
service claims based on the definition of emergency services
and care, and emergency medical condition, specified in
section 100.0, Glossary.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 40 OF 166
July 2004 Medicaid HMO Contract
20.11 GRIEVANCE SYSTEM REQUIREMENTS
The plan must have an enrollee grievance system in place that includes
a grievance process, an appeal process, and access to the Medicaid fair
hearing system. The plan must develop, implement and maintain a
grievance system that complies with the requirements in s. 641.511,
F.S., and with federal laws and regulations, including 42 CFR 431.200
and 438, Subpart F, "Grievance System." The system must include written
policies and procedures that are approved by the Agency. The plan shall
refer all enrollees and providers who are dissatisfied with the plan or
its action to the grievance/appeal coordinator for processing and
documentation in accordance with this contract and the approved
policies and procedures. The nature of the expression of
dissatisfaction determines which of the processes the plan must follow.
The grievance process is the procedure for addressing enrollee
grievances, which are expressions of dissatisfaction about any matter
other than an action, as "action" is defined in section 100.0,
Glossary. The appeal process is the procedure for addressing enrollee
appeals, which are requests for review of an action, as "action" is
defined in section 100.0, Glossary.
The plan must give enrollees reasonable assistance in completing forms
and other procedural steps, including but not limited to providing
interpreter services and toll-free numbers with TTY/TDD and interpreter
capability. The plan must acknowledge receipt of each grievance and
appeal in writing. The plan must ensure that decision makers on
grievances and appeals were not involved in previous levels of review
or decision-making and are health care professionals with clinical
expertise in treating the enrollee's condition or disease when deciding
any of the following:
a. An appeal of a denial that is based on lack of medical
necessity.
b. A grievance regarding denial of expedited resolution of an
appeal.
c. A grievance or appeal that involves clinical issues.
The plan must provide information on grievance, appeal, and fair
hearing, and their respective policies, procedures, and time frames, to
all providers and subcontractors at the time they enter into a
contract. Procedural steps must be clearly specified in the member
handbook for members and the provider manual for providers, including
the address, telephone number, and office hours of the grievance
coordinator. The information must include:
a. Enrollee rights to Medicaid fair hearing, the method for
obtaining a hearing, the rules that govern representation at
the hearing, and the DCF address for pursuing a fair hearing,
which is Office of Appeals Hearings, 1317 Winewood Boulevard,
Building 5, Room 203, Tallahassee, Florida 32399-0700.
b. Enrollee rights to file grievances and appeals and
requirements and time frames for filing.
c. The availability of assistance in the filing process.
d. The toll-free numbers to file oral grievances and appeals.
e. Enrollee rights to request continuation of benefits during an
appeal or Medicaid fair hearing process and, if the plan's
action is upheld in a hearing, the fact that the enrollee may
be liable for the cost of any continued benefits.
f. Enrollee rights to appeal to the Agency and the Subscriber
Assistance Program, formerly named the Statewide Provider and
Subscriber Assistance Panel (Panel) after exhausting the
plan's appeal or grievance process in accordance with s.
408.7056 and 641.511, F.S., with the following exception: a
grievance taken to Medicaid fair hearing will not be
considered by the Panel. The information must explain that a
request for Panel review must be made by the enrollee within
one year of receipt of the final decision letter from the
plan, must explain how to initiate such a review, must include
the Panel's address and telephone number as follows: Agency
for Health Care Administration, Bureau of Managed Health Care,
Building 1, Room 339, 2727 Mahan Drive, Tallahassee, Florida
32308, (850) 921-5458.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 41 OF 166
July 2004 Medicaid HMO Contract
g. Notice that the plan must continue enrollee benefits if:
1. The appeal is filed timely, meaning on or before the
later of the following:
(a) Within 10 days of the date on the notice of
action (Add 5 days if the notice is sent via
U.S. mail).
(b) The intended effective date of the plan's
proposed action.
2. The appeal involves the termination, suspension, or
reduction of a previously authorized course of
treatment;
3. The services were ordered by an authorized provider;
4. The authorization period has not expired; and
5. The enrollee requests extension of benefits.
The plan must maintain records of grievances and appeals in accordance
with the terms of this contract, including a separate log for calls
regarding the Hernandez Settlement, Hernandez, et al. v. Medows, case
number 02-20964 Civ-Gold/Simonton. The `Hernandez' log shall contain at
a minimum the name of the enrollee, the address of the enrollee, a
telephone number for the enrollee, and a brief description of the issue
(including the name of the drug involved.)
20.11.1 APPEAL PROCESS
An appeal is a request for review of an "action" as defined in section
100.0, Glossary. A beneficiary may file an appeal, and a provider,
acting on behalf of the beneficiary and with the beneficiary's written
consent, may file an appeal. The appeal procedure must be the same for
all beneficiaries.
a. Filing Requirements
The beneficiary or provider may file an appeal within 30 days
of the date of the notice of action. If the plan does not
issue a written notice of action, the enrollee or provider may
file an appeal within one year of the action.
The beneficiary or provider may file an appeal either orally
or in writing and must follow an oral filing with a written,
signed appeal. For oral filings, time frames for resolution
begin on the date the plan receives the oral filing.
b. General Plan Duties
The plan must:
1. Ensure that oral inquiries seeking to appeal an
action are treated as appeals and confirm those
inquiries in writing, unless the beneficiary or the
provider requests expedited resolution.
2. Provide a reasonable opportunity to present evidence,
and allegations of fact or law, in person as well as
in writing.
3. Allow the beneficiary and representative opportunity,
before and during the appeals process, to examine the
beneficiary's case file, including medical records,
and any other documents and records.
4. Consider the beneficiary, representative, or estate
representative of a deceased beneficiary as parties
to the appeal.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 42 OF 166
July 2004 Medicaid HMO Contract
5. Resolve each appeal, and provide notice, as
expeditiously as the beneficiary's health condition
requires, within State-established time frames not to
exceed 45 days from the day the plan receives the
appeal.
6. Continue the enrollee's benefits if:
(a) The appeal is filed timely, meaning on or
before the later of the following:
Within 10 days of the date on the notice of
action (Add 5 days if the notice is sent via
U.S. mail).
The intended effective date of the plan's
proposed action.
(b) The appeal involves the termination,
suspension, or reduction of a previously
authorized course of treatment;
(c) The services were ordered by an authorized
provider;
(d) The authorization period has not expired;
and
(e) The beneficiary requests extension of
benefits.
7. Provide written notice of disposition that includes
the results and date of appeal resolution and for
decisions not wholly in the beneficiary's favor that
includes:
(a) Notice of the right to request a Medicaid
fair hearing.
(b) Information about how to request a Medicaid
fair hearing, including the DCF address for
pursuing a fair hearing, which is Office of
Public Assistance Appeals Hearings, 1317
Winewood Boulevard, Building 1, Room 309,
Tallahassee, Florida 32399-0700.
(c) Notice of the right to continue to receive
benefits pending a hearing.
(d) Information about how to request the
continuation of benefits.
(e) Notice that if the plan's action is upheld
in a hearing, the enrollee may be liable for
the cost of any continued benefits.
(f) Notice that if the appeal is not resolved to
the satisfaction of the beneficiary, the
beneficiary has one year in which to request
review of the plan's decision concerning the
appeal by the Subscriber Assistance Program,
formerly named the Statewide Provider and
Subscriber Assistance Program, as provided
in s. 408.7056, F.S. The notice must explain
how to initiate such a review and must
include the addresses and toll-free
telephone numbers of the Agency and the
Subscriber Assistance Program.
8. Provide the Agency with a copy of the written notice
of disposition upon request.
9. Ensure that punitive action is not taken against a
provider who files an appeal on a beneficiary's
behalf or supports a beneficiary's appeal.
The plan may extend the resolution time frames by up to 14
calendar days if the beneficiary requests the extension or the
plan documents that there is need for additional information
and that the delay is in the beneficiary's interest. If the
extension is not requested by the beneficiary the plan must
give the beneficiary written notice of the reason for the
delay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 43 OF 166
July 2004 Medicaid HMO Contract
If the plan continues or reinstates beneficiary benefits while
the appeal is pending, the benefits must be continued until
one of following occurs:
1. The beneficiary withdraws the appeal.
2. 10 days pass from the date of the plan's
adverse plan decision and the beneficiary
has not requested a Medicaid fair hearing
with continuation of benefits until a
Medicaid fair hearing decision is reached.
(Add 5 days if the notice is sent via U.S.
mail.)
3. A Medicaid fair hearing decision adverse to
the beneficiary is made.
4. The authorization expires or authorized
service limits are met.
If the final resolution of the appeal is adverse to the
beneficiary, the plan may recover the cost of the services
furnished while the appeal was pending, to the extent that
they were furnished solely because of the requirements of this
section.
The plan must authorize or provide the disputed services
promptly, and as expeditiously as the beneficiary's health
condition requires, if the services were not furnished while
the appeal was pending and the disposition reverses a decision
to deny, limit, or delay services.
The plan must pay for disputed services, in accordance with
State policy and regulations, if the services were furnished
while the appeal was pending and the disposition reverses a
decision to deny, limit, or delay services.
c. Expedited Process
Each plan must establish and maintain an expedited review
process for appeals when the plan determines (if requested by
the beneficiary) or the provider indicates (in making the
request on the enrollee's behalf or supporting the
beneficiary's request) that taking the time for a standard
resolution could seriously jeopardize the enrollee's life or
health or ability to attain, maintain, or regain maximum
function.
The beneficiary or provider may file an expedited appeal
either orally or in writing. No additional beneficiary
follow-up is required.
The plan must:
1. Inform the beneficiary of the limited time
available for the enrollee to present
evidence and allegations of fact or law, in
person and in writing.
2. Resolve each expedited appeal and provide
notice, as expeditiously as the
beneficiary's health condition requires,
within State-established time frames not to
exceed 72 hours after the plan receives the
appeal.
3. Provide written notice of disposition.
4. Make reasonable efforts to also provide oral
notice of disposition.
5. Ensure that punitive action is not taken
against a provider who requests an expedited
resolution on the beneficiary's behalf or
supports a beneficiary's request for
expedited resolution.
The plan may extend the resolution time frames by up to 14 calendar
days if the beneficiary requests the extension or the plan documents
that there is need for additional information and that the delay is in
the beneficiary's interest. If the extension is not requested by the
beneficiary, the plan must give the enrollee written notice of the
reason for the delay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 44 OF 166
July 2004 Medicaid HMO Contract
If the plan denies a request for expedited resolution of an appeal, the
plan must:
1. Transfer the appeal to the standard time frame of no
longer than 45 days from the day the receives the
appeal with a possible 14-day extension.
2. Make reasonable efforts to provide prompt oral notice
of the denial
3. Provide written notice of the denial within two
calendar days.
4. Fulfill all general plan duties listed above.
20.11.2 GRIEVANCE PROCESS
A grievance is an expression of dissatisfaction about any matter other
than an action, as "action" is defined in 100.0, Glossary. An enrollee
may file a grievance, and a provider, acting on behalf of the
beneficiary and with the beneficiary's written consent, may file a
grievance.
a. Filing Requirements
The beneficiary or provider may file a grievance within one
year after the date of occurrence that initiated the
grievance.
The beneficiary or provider may file a grievance either orally
or in writing. An oral request may followed up with a written
request, but the time frame for resolution begins the date the
plan the oral filing.
b. General Plan Duties
The plan must:
1. Resolve each grievance, and provide notice, as
expeditiously as the beneficiary's health requires,
within State-established time frames not to exceed 90
days from the day the plan the grievance.
2. Provide written notice of disposition that includes
the results and date of grievance resolution for
decisions not wholly in the beneficiary's favor that
includes:
(a) Notice of the right to request a Medicaid
fair hearing.
(b) Information about how to request a Medicaid
fair hearing, including the DCF address for
pursuing a fair hearing, which is Office of
Public Assistance Appeals Hearings, 1317
Winewood Boulevard, Building 5, Room 203,
Tallahassee, Florida 32399-0700.
(c) Notice of the right to continue to receive
benefits pending a hearing.
(d) Information about how to request the
continuation of benefits.
(e) Notice that if the plan's action is upheld
in a hearing, the beneficiary may be liable
for cost of any continued benefits.
3. Provide the Agency with a copy of the written notice
of disposition upon request.
4. Ensure that punitive action is not taken against a
provider who files a grievance on a behalf or
supports an enrollee's grievance.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 45 OF 166
July 2004 Medicaid HMO Contract
The plan may extend the resolution time frames by up to 14 calendar
days if the beneficiary requests the extension or the plan documents
that there is need for additional information and that the delay is in
the enrollee's interest. If the extension is not requested by the
beneficiary, the plan must give the beneficiary written notice of the
reason for the delay.
20.11.3 MEDICAID FAIR HEARING SYSTEM
The Medicaid fair hearing policy and process is detailed in Rule
65-2.042, F.A.C. The plan's grievance system policy and appeal and
grievance processes shall state that the beneficiary has the right to
request a Medicaid fair hearing in addition to pursuing the plan's
grievance process. A provider acting on behalf of the beneficiary and
with the beneficiary's written consent may request a Medicaid fair
hearing. Parties to the Medicaid fair hearing include the plan, as well
as the beneficiary and his or her representative or the representative
of a deceased enrollee's estate.
a. Request Requirements
The beneficiary or provider may request a Medicaid fair
hearing within 90 days of the date of the notice of action.
The beneficiary or provider may request a Medicaid fair
hearing by contacting DCF at the Office of Public Assistance
Appeals Hearings, 1317 Winewood Boulevard, Building 5, Room
203, Tallahassee, Florida 32399-0700.
b. General Plan Duties
The plan must:
1. Continue the beneficiary's benefits while Medicaid
fair hearing is pending if:
(a) The Medicaid fair hearing is filed timely,
meaning on or before the later of the
following:
Within 10 days of the date on the notice of
action (Add 5 days if the notice is sent via
U.S. mail).
The intended effective date of the plan's
proposed action.
(b) The Medicaid fair hearing involves the
termination, suspension, or reduction of a
previously authorized course of treatment;
(c) The services were ordered by an authorized
provider;
(d) The authorization period has not expired;
and
(e) The beneficiary requests extension of
benefits.
2. Ensure that punitive action is not taken against a
provider who requests a Medicaid fair hearing on the
beneficiary's behalf or supports an enrollee's
request for a Medicaid fair hearing.
If the plan continues or reinstates beneficiary benefits while
the Medicaid fair hearing is pending, the benefits must be
continued until one of following occurs:
1. The beneficiary withdraws the request for Medicaid
fair hearing.
2. 10 days pass from the date of the plan's adverse plan
decision and the beneficiary has not requested a
Medicaid fair hearing with continuation of benefits
until a Medicaid fair hearing decision is reached.
(Add 5 days if the notice is sent via U.S. mail.)
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 46 OF 166
July 2004 Medicaid HMO Contract
3. A Medicaid fair hearing decision adverse to the
beneficiary is made.
4. The authorization expires or authorized service
limits are met.
The plan must authorize or provide the disputed services
promptly, and as expeditiously as the beneficiary's health
condition requires, if the services were not furnished while
the Medicaid fair hearing was pending and the Medicaid fair
hearing officer reverses a decision to deny, limit, or delay
services.
The plan must pay for disputed services, in accordance with
State policy and regulations, if the services were furnished
while the Medicaid fair hearing was pending and the Medicaid
fair hearing officer reverses a decision to deny, limit, or
delay services.
20.12 QUALITY IMPROVEMENT
The plan shall have an ongoing quality improvement (QI) program that
objectively and systematically monitors and evaluates the quality and
appropriateness of care and services rendered, thereby promoting
quality of care and quality patient outcomes in service performance to
its Medicaid population. The plan's written policies and procedures
shall address components of effective health care management including
but not limited to anticipation, identification, monitoring,
measurement, evaluation of enrollee's health care needs, and effective
action to promote quality of care. The plan shall define and implement
improvements in processes that enhance clinical efficiency, provide
effective utilization, and focus on improved outcome management
achieving the highest level of success. The plan and its quality
improvement program shall demonstrate in their care management how
specific interventions better manage the care and impact healthier
patient outcomes. The goal shall be to provide comprehensive, high
quality, accessible, cost effective, and efficient health care to
Medicaid beneficiaries.
The plan shall provide a written descriptive QI program that identifies
FTE staff specifically trained to handle the Medicaid business and
delineates how staffing is organized to interact and resolve problems,
define measures and expectations, and demonstrate the process for
decision making (i.e. projects selection, interventions) and
reevaluation.
The plan shall cooperate with the Agency and the External Quality
Review Organization (EQRO) vendor. The Agency will set methodology and
standards for QI performance improvement with advice from the EQRO.
Prior to implementation, the Agency and/or the EQRO shall review the QI
program. The quality improvement program must be approved, in writing,
by the Agency no later than three months following the effective date
of this contract. If the plan has submitted and received approval for
the present calendar year, an extension may be granted for the
submission of new projects.
The quality improvement program shall be based on the minimum
requirements listed below.
a. The plan's QI governing body shall monitor, evaluate, and
oversee results to improve care. The governing body shall have
written guidelines and standards defining their
responsibilities for:
- Supervision and maintenance of an active QI
committee,
- Ensuring ongoing QI activity coordination with other
management activity, demonstrated through written,
retrievable documentation from meetings or
activities,
- Planning, decisions, interventions, and assessment of
results to demonstrate coordination of QI processes,
- Oversight of QI program activities, and
- A written diagram that demonstrates the QI system
process.
b. The plan shall have a quality improvement review authority
which shall:
- Direct and review quality improvement activities;
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 47 OF 166
July 2004 Medicaid HMO Contract
- Assure that quality improvement activities take place
throughout the plan;
- Review and suggest new or improved quality
improvement activities;
- Direct task forces/committees in the review of
focused concern;
- Designate evaluation and study design procedures;
- Publicize findings to appropriate staff and
departments within the plan;
- Report findings and recommendations to the
appropriate executive authority; and
- Direct and analyze periodic reviews of members'
service utilization patterns.
c. The plan shall provide for quality improvement staff
specifically trained to handle the Medicaid business which
have the responsibility for: identifying their Medicaid
beneficiaries' needs and problems related to quality of care
for covered health care and professional services, measuring
how well these needs are met, and improving processes to meet
these needs. The plan shall evaluate ways in which care is
provided, identify outliers to specific indicators, determine
what shall be accomplished, ascertain how to determine if a
change is an improvement, and initiate interventions that will
result in an improved quality of care for covered health care
and professional services. The plan shall prioritize problem
areas for resolution and design strategies for change;
implement improvement activities and measure success.
d. The systematic process of quality assessment and improvement
shall be objective in systematically monitoring and evaluating
the quality and appropriateness of care and service delivery
(or the failure of delivery) to the Medicaid population
through quality of care projects and related activities.
Opportunities for improvement shall be on an ongoing basis.
The plan shall assess, evaluate, decrease inappropriate care,
decrease inappropriate service denials, and increase
coordination of care. The plan shall document in its QI
program that it is monitoring the range of quality of care
across services and all treatment modalities. This review of
the range of care shall be carried out over multiple review
periods and not only on a concurrent basis.
e. At least four Agency-approved quality-of-care projects must be
performed by the plan. Each study/project must include a
statistically significant sample of Medicaid lives. One of the
four projects must be a (QAPI) Project on Language and
Culture: Clinical Health Care Disparities or Culturally and
Linguistically Appropriate Services, initiated by January 31,
2005. The plan shall provide notification to the Agency prior
to implementation. The notification shall include the general
description, justification, and methodology for each project
and document the potential for meaningful improvement. The
plan shall report quarterly to the Agency within 30 days of
the reporting quarter. The report shall include the current
status of the project, including but not limited to goals,
anticipated outcomes, and ongoing interventions. The results
shall be reported no less than annually. Each project shall
have been through the plan's quality process, including
reporting and assessments by the quality committee and
reporting to the board of directors:
Pursuant to 42 CFR 438.240, the project shall focus on
clinical care and non-clinical areas (i.e. health services
delivery). These projects must be designed to achieve, through
ongoing measurements and intervention, significant
improvement, sustained over time, in clinical care and
non-clinical care areas that are expected to have a favorable
effect on health outcomes and enrollee satisfaction. Each
performance improvement project must be completed in a
reasonable time period so as to generally allow information on
the success of performance improvement projects in the
aggregate to produce new information on quality of care every
year. The Centers for Medicare and Medicaid Services (CMS), in
consultation with states and other stakeholders, may specify
performance measures and topics for performance improvement
projects. If CMS specifies performance improvement projects,
the plan will participate and this will count towards the
Agency-approved quality-of-care projects. Each individual CMS
project can be counted as one of the Agency-approved quality
of care projects. The quality-of-care projects used to measure
performance improvement projects shall include diagrams (e.g.
algorithms and /or flow charts) for monitoring and shall:
1. Target specific conditions and specific health service
delivery issues for focused individual practitioner and
system-wide monitoring and evaluation.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 48 OF 166
July 2004 Medicaid HMO Contract
2. Use clinical care standards or practice guidelines to
objectively evaluate the care the entity delivers or
fails to deliver for the targeted clinical
conditions.
3. Use appropriate quality indicators derived from the
clinical care standards or practice guidelines to
screen and monitor care and services delivered.
4. Implement system interventions to achieve improvement
in quality.
5. Evaluate the effectiveness of the interventions.
6. Provide sufficient information to plan and initiate
activities for increasing or sustaining improvement.
7. Monitor the quality and appropriateness of care
furnished to enrollees with special health care
needs.
8. Reflect the population served in terms of age groups,
disease categories, and special risk status.
9. Ensure that appropriate health professionals analyze
data.
10. Ensure that multi-disciplinary teams will address
system issues.
11. Include objectives and quantifiable measures based on
current scientific knowledge and clinical experience
and have an established goal or benchmark.
12. Identify and use quality indicators that are
measurable and objective.
13. Validate the design to assure that the data to be
abstracted during the QI project is accurate,
reliable and developed according to generally
accepted principles of scientific research and
statistical analysis.
14. Maintain a system for tracking issues over time to
ensure that actions for improvement are effective.
The plan's quality improvement information shall be used in such
processes as recredentialing, recontracting, and annual performance
ratings of individuals. It shall also be coordinated with other
performance monitoring activities, including utilization management,
risk management, and resolution and monitoring of member grievances.
There shall also be a link between other management activities such as
network changes, benefits redesign, medical management systems (e.g.,
precertification), practice feedback to physicians, patient education,
and member services.
The plan's quality improvement program shall have a peer review
component with the authority to review practice methods and patterns of
individual physicians and other health care professionals,
morbidity/mortality, and all grievances related to medical treatment;
evaluate the appropriateness of care rendered by professionals;
implement corrective action when deemed necessary; develop policy
recommendations to maintain or enhance the quality of care provided to
Medicaid enrollees; conduct a review process which includes the
appropriateness of diagnosis and subsequent treatment, maintenance of
medical records requirements, adherence to standards generally accepted
by professional group peers, and the process and outcome of care;
maintain written minutes of the meetings; receive all written and oral
allegations of inappropriate or aberrant service; and educate
recipients and staff on the role of the peer review authority and the
process to advise the authority of situations or problems.
f. Pursuant to 42 CFR 438.208(c)(1), the plan shall implement
mechanisms to identify persons with special health care needs,
as those persons are defined by the Agency.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 49 OF 166
July 2004 Medicaid HMO Contract
g. Plan Service Performance
The following table designates the weight assigned to each performance
measure in Agency-defined categories.
(MINIMUM OF 3) QUALITY
IMPROVEMENT &
ON-SITE AUDIT PERFORMANCE
CAHPS CHCUP COMPLIANCE INDICATORS ACCREDITATION
- ----- ----- ------------- ---------------------- -------------
15% 20% 15% 35% 15%
The External Quality Review Organization vendor (EQRO) may recommend
how items will be scored to get these ratings. Overall scoring will
apply until modified by the EQRO and would be measured as:
RATING SCORE
- ------ -----
Excellent 91-100
Commendable 81-90
Passing 71-80
Provisional 61-70
Failed <60
1. CONSUMER ASSESSMENT OF HEALTH PLANS STUDY (CAHPS)
SURVEY results in yearly conducted survey data
regarding the member's assessment of their
satisfaction with health care services. See section
20.12.2. Starting with the 2004 HMO report, the plans
will be rated in five areas based on the latest CAHPS
survey:
Overall Plan Satisfaction
Ease in Getting to See A Specialist
Ease in Getting Needed Care, Tests, or
Treatment
How Well Providers Communicate with Members
Getting Help from Customer Service
All of the above items correspond to one question in
the consumer survey except for "How Well Providers
Communicate with Members." It contains the combined
results to four survey questions about how well
providers communicate.
Possible ratings are 0 to 5 stars in each area. The plan
performance scoring is based on the value given by the CAHPS
survey and is converted to stars. The CAHPS survey stars will
be equated to points for this section of the contract. The
points are totaled and averaged into a composite overall
rating for this section. For example, if two categories scored
five stars (= 2 x 15 points), two categories scored four stars
(= 2 x 12 points), and one scored three stars (= 1 x 8
points), the total score is 62 points averaged by the number
of categories (rounded to the nearest whole number). The
example's composite plan performance score in this section of
the contract is 12 points.
PLAN PERFORMANCE POINTS AWARDED
- ---------------- --------------
***** 15
**** 12
*** 8
** 4
* 1
No Stars 0
2. CHCUP PARTICIPATION GOAL OF 80 PERCENT. Plan
performance should be measured in improvement and
statutory benchmarks using federal definitions and
audited data.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 50 OF 166
July 2004 Medicaid HMO Contract
POINTS
PLAN PERFORMANCE AWARDED
80% or above 20
Equal to or greater than 66% and <80% 18
15% annual improvement 16
10-14% annual improvement 14
7-9% annual improvement 12
5-6% annual improvement 10
>3% annual improvement 8
>1% annual improvement 5
3. In the On-Site Compliance Audit by the Agency's
Bureau of Managed Care, contract compliance is
assessed, reviewed, and evaluated. This scoring is
used to measure plan performance by recording the
"percentage met" of all the standards currently
contained in the Medicaid HMO contract. This is
considered a critical element and failure to meet
partial compliance may require immediate corrective
action. This audit is conducted every year by the
Agency. The EQRO may monitor the survey results and
may advise the Agency to modify weights.
PLAN POINTS
PERFORMANCE COMPLIANCE AWARDED
- ----------- ---------- -------
95-100% Total Compliance 15
94-90% Substantial Compliance 10
89-85% Partial Compliance 5
80-84% Minimal Compliance 1
<80% Non-Compliance 0
4. QUALITY IMPROVEMENT AND PERFORMANCE INDICATORS are a
combination of (2) HEDIS measurements and (1) plan
selected indicator, Maternity Care. The two HEDIS
measures will be based on those for which the most
plans reported and show the greatest overall
improvement. Benchmarks will be based on national or
regional Medicaid rates. Improvement in HEDIS
measurement shall be measured using baseline data.
The HEDIS 2004 contains measurement year 2003 data
and HEDIS 2005 contains measurement year 2004 data.
Health plans will be reporting to AHCA October 1,
2004, measurement year 2003 data that will be
published in the 2005 HMO REPORT (Choosing A Quality
Health Plan). Health plans will be reporting to AHCA
October 1, 2005, measurement year 2004 data that will
be published in the 2006 HMO REPORT (Choosing a
Quality Health Plan).
POINTS
PLAN PERFORMANCE AWARDED
- ---------------- -------
Meet/exceed benchmarks - 3 indicators 35
Meet/exceed benchmarks - 2 of 3 indicators 30
Substantial improvement demonstrated - 3 of 3 25
Substantial improvement demonstrated - 2 of 3 20
Substantial improvement demonstrated -1 of 3 15
Minimal improvement demonstrated - 3 of 3 10
Interventions implemented - 3 of 3 0
Interventions in place without success and/or noncompliance 0
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 51 OF 166
July 2004 Medicaid HMO Contract
DEFINITIONS FOR BENCHMARKS
PLAN PERFORMANCE DEFINITION
- ---------------- -----------
Meet/exceed benchmarks >5% increase from prior year
Substantial improvement demonstrated >3% increase from prior year
Minimal improvement demonstrated
Interventions implemented >1% increase from prior year
Interventions in place without success and/or
noncompliance No Improvement
Indicators:
a. HEDIS measures pursuant to Agency rule.
b. A HEDIS measure for Maternity Care.
5. ACCREDITATION is performed and scored by a national
accrediting body, pursuant to section 40.6, every 1
to 3 years depending on the outcome of previous audit
and accrediting body program. The accrediting
organization ascertains the plan's capability in
assessing, measuring, demonstrating, and providing
comprehensive, effective, and efficient care.
PLAN PERFORMANCE POINTS AWARDED
- ---------------- --------------
EXCELLENT 15
COMMENDABLE 10
PROVISIONAL 5
CONDITIONAL 0
PLAN
PERFORMANCE JCAHO URAC AAAHC NCQA SCORE
- ----------- ----- ---- ----- ---- -----
Full Full
Full compliance compliance compliance Excellent
EXCELLENT 3 years 2 Years 3 years 3 years 15
Accreditation with
requirements for Conditional One Year Commendable 10
COMMENDABLE improvement
Corrective
PROVISIONAL Provisional Action 6 months Accredited 5
CONDITIONAL Conditional Provisional 0
Denied Denied Denied Denied 0
20.12.1 UTILIZATION MANAGEMENT
The plan's quality improvement program shall have a utilization
management component that includes the following:
a. The plan must develop and have in place utilization management
policies and procedures that include protocols for prior
approval and denial of services, hospital discharge planning,
physician profiling, and retrospective review of both
inpatient and ambulatory claims meeting pre-defined criteria.
b. The plan must develop procedures for identifying patterns of
over-and under-utilization of members and for addressing
potential problems identified as a result of these analyses.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 52 OF 166
July 2004 Medicaid HMO Contract
c. The plan's internal utilization management policies and
procedures must be consistent with the utilization control
program requirements in 42 CFR 456.
d. The plan shall report fraud and abuse information identified
through the utilization management program to the Agency in
accordance with 42 CFR 455.1(a)(1).
e. The plan shall have a procedure for members to obtain a second
medical opinion and shall be responsible for payment of such
services. The plan shall clearly state its procedure for
obtaining a second medical opinion in the member handbook. The
plan's second opinion procedure shall comply with section
641.51, F.S.
f. The plan's service authorization systems shall provide
authorization numbers, effective dates for the authorization,
and written confirmation to the provider of denials, as
appropriate. Pursuant to 42 CFR 438.210(b)(3), any decision to
deny a service authorization request or to authorize a service
in an amount, duration, or scope that is less than requested,
must be made by a health care professional who has appropriate
clinical expertise in treating the enrollee's condition or
disease. Pursuant to 42 CFR 438.210(c), the plan must notify
the requesting provider of any decision to deny a service
authorization request or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to
the provider need not be in writing. The plan must notify the
enrollee in writing of any decision to deny a service
authorization request or to authorize a service in an amount,
duration, or scope that is less than requested.
Pursuant to 42 CFR 438.404(a), 42 CFR 438.404(c) and 42 CFR
438.210(b) and (c), the plan must give the enrollee written
notice of any "action" as defined in section 100.0, Glossary,
within the time frames for each type of action. Pursuant to 42
CFR 438.404(b) and 42 CFR 438.210(c), the notice must explain:
1. The action the plan has taken or intends to take.
2. The reasons for the action.
3. The enrollee's or the provider's right to file a
grievance/appeal.
4. The enrollee's right to request a Medicaid Fair
Hearing.
5. Procedures for exercising enrollee rights to appeal
or grieve.
6. Circumstances under which expedited resolution is
available and how to request it.
7. Enrollee rights to request that benefits continue
pending the resolution of the appeal, how to request
that benefits be continued, and the circumstances
under which the enrollee may be required to pay the
costs of these services.
Pursuant to 42 CFR 438.404 (a) and (c), the notice must be in
writing and must meet the language and format requirements of
42 CFR 438.10(c) and (d) to ensure ease of understanding.
The plan must mail the notice within the following time
frames:
1. For termination, suspension, or reduction of
previously authorized Medicaid-covered services,
within the time frames specified in 42 CFR 431.211,
431.213, and 42 CFR 431.214.
2. For denial of payment, at the time of any action
affecting the claim.
3. For standard service authorization decisions that
deny or limit services, within the time frame
specified in 42 CFR 438.210(d)(1).
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 53 OF 166
July 2004 Medicaid HMO Contract
4. If the plan extends the time frame in accordance with
42 CFR 438.210(d)(1), it must:
Give the enrollee written notice of the reason for
the decision to extend the time frame and inform the
enrollee of the right to file a grievance if he or
she disagrees with that decision.
Issue and carry out its determination as
expeditiously as the enrollee's health condition
requires and no later than the date the extension
expires.
5. For service authorization decisions not reached
within the time frames specified in 42 CFR 438.210(d)
(which constitutes a denial and is thus an adverse
action), on the date that the time frames expire.
6. For expedited service authorization decisions, within
the time frames specified in 42 CFR 438.210(d).
20.12.2 INDEPENDENT MEMBER SATISFACTION SURVEY
The plan shall participate in enhanced managed care quality improvement
including at least the following:
a. The plan shall participate in an independent survey of member
satisfaction, currently the Consumer Assessment of Health
Plans Study survey (CAHPS), conducted by the Agency on an
annual basis in accordance with section 409.912, F.S.
b. The plan shall use the results of the annual member
satisfaction survey to develop and implement plan wide
activities designed to improve member satisfaction. These
activities shall include, but not be limited to, analyses of
the following: formal and informal member complaints, claims
timely payment, disenrollment reasons, policies and
procedures, and any pertinent internal improvement plan
implemented to improve member satisfaction. Activities
pertaining to improving member satisfaction resulting from the
annual member satisfaction survey must be reported to the
Agency on a quarterly basis within 30 days after the end of a
reporting quarter
20.13 MEDICAL RECORDS REQUIREMENTS
The plan shall ensure medical records are maintained for each member
enrolled under this contract in accordance with this section. The
record shall include the quality, quantity, appropriateness and
timeliness of services performed under this contract.
a. The following medical record standards must be
included/followed in each member's records as appropriate:
1. Identifying information on the member, including
name, member identification number, date of birth and
sex, and legal guardianship.
2. Each record must be legible and maintained in detail.
3. A summary of significant surgical procedures, past
and current diagnosis or problems, allergies,
untoward reactions to drugs and current medications.
4. All entries must be dated and signed.
5. All entries must indicate the chief complaint or
purpose of the visit; the objective findings of
practitioner; diagnosis or medical impression.
6. All entries must indicate studies ordered, for
example: lab, x-ray, EKG, and referral reports.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 54 OF 166
July 2004 Medicaid HMO Contract
7. All entries must indicate therapies administered and
prescribed.
8. All entries must include the name and profession of
practitioner rendering services, for example: M.D.,
D.O., O.D., including signature or initials of
practitioner.
9. All entries must include the disposition,
recommendations, instructions to the patient,
evidence whether there was follow-up, and outcome of
services.
10. All records must contain an immunization history.
11. All records must contain information on Smoking/ETOH
(ethyl alcohol)/substance abuse.
12. All records must contain record of emergency care and
hospital discharge summaries.
13. All records must reflect the primary language spoken
by the member and translation needs of the member.
14. All records must identify members needing
communication assistance in the delivery of health
care services.
15. All records must contain documentation that the
member was provided written information concerning
the member's rights regarding advanced directives
(written instructions for living will or power of
attorney), and whether or not the member has executed
an advance directive. The provider shall not, as a
condition of treatment, require the member to execute
or waive an advance directive in accordance with
section 765.110, F.S. The plan must comply with the
requirements 42 CFR 422.128 for maintaining written
policies and procedures for advance directives.
b. The plan shall have a policy to ensure the confidentiality of
patient records in accordance with 42 CFR, Part 431, Subpart
F. This policy shall also include confidentiality of a minor's
consultation, examination, and treatment for a sexually
transmissible disease in accordance with section 384.30, F.S.
c. The plan shall have a policy to ensure compliance with the
Privacy and Security provisions of the Health Insurance
Portability and Accountability Act (HIPAA).
d. The plan shall have a procedure to capture in its medical
records, services provided to its members by non-plan
providers. Such services must include, but not necessarily be
limited to, family planning services, preventive services, and
services for the treatment of sexually transmitted diseases.
20.14 MEDICAL RECORD REVIEW
If the plan is not accredited under the provisions of 641.512, F.S. or
if the plan is accredited by an entity that does not review the medical
records of the plan's primary care physicians, then the plan shall
conduct medical record reviews of Medicaid members to ensure that
practitioners provide high quality health care that is documented
according to established standards. These standards, which must include
all medical record documentation requirements addressed in this
contract, must be distributed to all providers. The plan must conduct
these reviews at all primary care practice sites that serve 50 members
or more. Practice sites include both individual offices and large group
facilities. Each practice site meeting these criteria must be reviewed
at least once during the two-year contract period. The plan must review
a reasonable number of records at each site to determine compliance.
Five to 10 records per site is a generally-accepted target, though
additional reviews must be completed for large group practices or when
additional data is necessary in specific instances. The plan shall
report the results of all medical record reviews to the plan analyst
within 30 calendar days of the review.
The plan must maintain a written strategy for conducting these reviews.
This strategy must include designated staff who will perform this duty,
the method of case selection, the anticipated number of reviews by
practice site, and the tool that will be used. The plan must also
indicate how the compiled
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 55 OF 166
July 2004 Medicaid HMO Contract
information will be linked to other plan functions, such as quality
improvement, credentialing, and peer review.
20.15 QUALITY AND PERFORMANCE MEASURES
Quality and performance measures shall be evaluated at least once
annually at dates to be determined by the Agency or as otherwise
specified by this contract. The plan will implement an enhanced quality
improvement and performance measurement system to provide for the
delivery of quality care with the primary goal of improving the health
status of members.
The plan in conjunction with the Agency will participate in workgroups
to plan further quality improvement strategies and learning to use best
practice methods for enhancing quality of health care.
If CAHPS, the AHCA quality indicators, the annual medical record audit
or the external quality review indicate that the plan's performance is
not acceptable, then the Agency may restrict the plan's enrollment
activities including but not limited to termination of mandatory
assignments.
For plan performance that is not acceptable, the Agency shall require
the plan to submit a corrective action plan. Failure to provide a
corrective action plan within the time specified shall be cause for the
Agency to immediately terminate all enrollment activities and mandatory
assignment. When considering whether to impose a limitation on
enrollment activities or mandatory assignment, the Agency may consider
the HMOs cumulative performance on all quality and performance
measures.
20.16 ANNUAL MEDICAL RECORD AUDIT
The Agency may conduct an annual medical record audit of the plan. The
plan shall furnish specific data requested by the Agency in order to
conduct the audit. If the medical audit indicates that quality of care
is not acceptable pursuant to contractual requirements, the Agency may
restrict the plan's enrollment activities pending attainment of
acceptable quality of care.
20.17 INDEPENDENT MEDICAL REVIEW (EXTERNAL QUALITY REVIEW)
The Agency shall provide for an independent review of Medicaid services
provided or arranged by the provider. The plan shall provide
information necessary for the review based upon the requirements of the
Agency or the Agency's independent peer review contractor. The
information shall include quality outcomes concerning timeliness of and
access to services covered under the contract. The review shall be
performed at least once annually by an entity outside state government.
If the medical audit indicates that quality of care is not acceptable
pursuant to contractual requirements, the Agency may restrict the
plan's enrollment activities pending attainment of acceptable quality
of care.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 56 OF 166
July 2004 Medicaid HMO Contract
30.0 MARKETING AND ENROLLMENT
30.1 MARKETING, PRE-ENROLLMENT MATERIALS AND POST-ENROLLMENT MATERIALS
The plan shall ensure that all marketing, pre-enrollment, member,
disenrollment, and grievance materials developed for the Medicaid
population adhere to the following policies and procedures:
a. All materials developed for the Medicaid population must be at
or near the fourth-grade comprehension level so that the
materials are understandable (in accordance with section
1932(a)(5) of the Social Security Act as enacted by section
4701 of the Balanced Budget Act of 1997), and be available in
alternative communication methods (such as large print, video
or audio recordings, or Braille) appropriate for persons with
disabilities.
b. The plan shall assure that appropriate foreign language
versions of all materials are developed and available to
members and potential members. The plan shall provide
interpreter services in person where practical, but otherwise
by telephone, for applicants or members whose primary language
is a foreign language. Foreign language versions of materials
are required if, as provided annually by the Agency, the
population speaking a particular foreign (non-English)
language in a county is greater than five percent.
c. For each new contract period, the plan shall submit to the
Agency for written approval, pursuant to section 409.912,
F.S., its marketing strategy and all marketing and
pre-enrollment materials no later than 60 calendar days prior
to contract renewal, and for any changes in marketing and
pre-enrollment materials during the re-contracting and renewal
period, no later than 60 calendar days prior to
implementation. The marketing materials must be distributed in
the plan's entire service area in accordance with section 4707
of the Balanced Budget Act of 1997.
d. Marketing materials include, but are not limited to, all
solicitation materials; forms; brochures; fact sheets;
posters; lectures; Medicaid recruitment materials and
presentations; pre-enrollment applications, etc.
e. To announce a specific event, the plan shall submit a request
to market pursuant to section 30.2.2.1, Approval Process, and
include the announcement of the event that will be given out
to the public.
f. General advertising materials and general marketing materials
used by an HMO to solicit both non-Medicaid and Medicaid
beneficiaries are not subject to prior approval of the Agency.
30.2 MARKETING ACTIVITIES
The plan shall be responsible for developing and implementing a written
plan designed to solicit enrollment from Medicaid eligible persons and
to control the actions of its marketing staff. All of the marketing
policies set forth in this contract apply to staff, subcontractors,
plan volunteers and all persons acting for or on behalf of the plan.
All materials developed shall be governed by the following
requirements.
a. Market Area. The plan shall limit its market area to residents
identified in section 90.0, Payment and Maximum Authorized
Enrollment Levels, or in any amendment of this contract. The
plan shall not solicit applications for enrollment from
residents of a service area which is not authorized by the
contract.
b. Marketing Practices. The plan is not authorized to make any
presentations or engage in any recruitment activities that are
not approved, in writing, by the Agency.
Violations of any of the policies listed below shall subject
the plan to rescission of its authorization to market in all
or specific locations, or through any or all methods, as
determined by the Agency. The plan may dispute rescission of
marketing authorization for a period in excess of one month
pursuant to section 70.10, Disputes.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 57 OF 166
July 2004 Medicaid HMO Contract
30.2.1 PROHIBITED ACTIVITIES
The plan is prohibited from engaging in any of the following practices
or activities:
a. In accordance with section 409.912, F.S., practices that are
discriminatory, including, but not limited to, attempts to
discourage enrollment or reenrollment on the basis of actual
or perceived health status.
b. In accordance with section 409.912, F.S., activities that
could mislead or confuse beneficiaries, or misrepresent the
organization, its marketing representatives, or the Agency. No
fraudulent, misleading, or misrepresentative information shall
be used in marketing including information regarding other
governmental programs.
c. Overly aggressive solicitation, such as repeated telephoning,
continued recruitment after an offer for enrollment is
declined by a beneficiary, or similar techniques. Plan
representatives shall not directly solicit individuals for the
purpose of enrolling in the plan except as provided in section
30.2.2, Permitted Activities.
d. In accordance with section 409.912, F.S., granting or offering
of any monetary or other valuable consideration for
enrollment, except as authorized by section 409.912, F.S.
e. Direct or indirect cold call marketing for solicitation of
Medicaid beneficiaries, either by door-to-door, telephone or
other, in accordance with section 4707 of the Balanced Budget
Act of 1997, and section 409.912, F.S. Cold call marketing is
defined as any unsolicited personal contact with a potential
enrollee by an employee or agent of a managed care entity for
the purpose of influencing the individual to enroll with the
entity.
f. Offers of insurance, such as but not limited to, accidental
death, dismemberment, disability or life insurance.
g. Enlisting the assistance of any employee, officer, elected
official or agent of the state in recruitment of Medicaid
beneficiaries except as authorized in writing by the Agency.
h. In accordance with section 409.912, F.S., false or misleading
claims that the state or county recommends that a Medicaid
beneficiary enroll with the plan.
i. In accordance with section 409.912, F.S., claims that a
Medicaid beneficiary will lose benefits under the Medicaid
program or any other health or welfare benefits to which the
beneficiary is legally entitled, if the beneficiary does not
enroll with the plan.
j. In accordance with 42 CFR 438.104(b)(2)(i), any assertion or
statement (whether written or oral) that the beneficiary must
enroll in the plan in order to obtain benefits or in order to
not lose benefits.
k. In accordance with section 409.912, F.S. and 42 CFR
438.104(b)(2)(ii), false or misleading claims that the entity
is recommended or endorsed by any federal, state or county
government, the Agency, CMS, or any other organization which
has not certified its endorsement in writing to the plan.
l. In accordance with section 409.912, F.S., false or misleading
claims that marketing representatives are employees or
representatives of the state or county, or of anyone other
than the entity or the organization by whom they are
reimbursed.
m Offers of material or financial gain to any persons
soliciting, referring or otherwise facilitating beneficiary
enrollment except for authorized licensed marketing
representatives. The plan shall ensure that only licensed
marketing representatives market the plan to beneficiaries.
n. Giving away promotional items in excess of a $1.00 retail
value to attract attention. Items to be given away shall bear
the plan's name and shall only be given away at health fairs
or other general public
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 58 OF 166
July 2004 Medicaid HMO Contract
events. In addition, such promotional items must be offered to
the general public and shall not limited to persons who
indicate they will enroll in the plan.
o. The plan may not market prior to enrollment the incentives
that shall be offered to the member as described in section
10.10, Incentive Programs. Marketing may describe the programs
(not the incentives) that shall be offered (e.g., prenatal
classes). The plan may inform members once they are actually
enrolled in the plan about the specific incentives available.
No incentives shall be of a gambling or controlled substance
nature (e.g., lottery tickets, tobacco products, drugs,
alcohol, etc).
p. In accordance with section 409.912, F.S., marketing Medicaid
recipients in state offices unless approved in writing and
approved by the affected state Agency when solicitation occurs
in the another state Agency. The Agency shall ensure that
marketing representatives stationed in state offices market
their managed care plans to Medicaid beneficiaries only in
designated areas and in such a way as to not interfere with
the beneficiaries' activities in the state office. The plan
shall not use any other state facility, program, or procedure
in the recruitment of Medicaid beneficiaries except as in
writing by the Agency. Request for approval of activities at
state offices must be submitted to the plan analyst at least
30 calendar days prior to the activity.
q. Marketing face-to-face to assigned members unless the member
contacts the plan and requests a marketing interview. The plan
shall keep documentation of such contacts and visits in the
member's file. However, upon the effective date of enrollment,
plan marketing staff or other plan staff may visit members in
order to obtain completed new member materials. All such
visits must be documented the member's file.
r. Providing any gift, commission, or any form of compensation to
the enrollment and disenrollment services contractor,
including the contractor's full-time, part-time or temporary
employees and subcontractors. The Agency shall sanction any
such actions as provided for in section 70.17, Sanctions.
s. All activities included in section 641.3903, F.S.
30.2.2 PERMITTED ACTIVITIES
The plan may engage in the following activities under the supervision
and with the approval of the Agency:
a. The plan upon notifying the Agency may have a marketer in
provider offices as long as the provider approves and the
marketer provides information to the beneficiary only upon
request. In addition, the plan and the provider shall not
require the beneficiary to visit the marketer, nor shall the
marketer approach the beneficiary. No sales activities (i.e.,
enrollment applications) will be allowed in provider offices.
However, the plan may leave Agency approved referral cards in
provider offices, at public events and health fairs. These
cards may be completed by Medicaid beneficiaries and delivered
to the plan or turned in at the provider office. Information
on the card is limited to name, address and telephone number
of the prospective member and space for a signature. A space
to note a contact may be provided. A follow up visit to the
beneficiary's home may not occur prior to the referral being
logged by the plan's regional or headquarters member services
office. Twenty-four hours or the next business day must elapse
after the request is logged before the home visit may occur.
b. The plan may market at state offices, health fairs and public
events and contact thereafter, in person potential enrollees
who request further information about the plan in accordance
with section 4707 of the Balanced Budget Act of 1997. The plan
shall submit, for review and approval by the Agency, its
intent to market at health fairs and public events at least
two weeks prior to the event. The plan shall obtain a
completed Agency approved disclosure form from each
organization participating in a health fair or public event
prior to the event. The disclosure form is only required when
the plan is the primary organizer of the health fair or public
event. If the plan has been invited by a community
organization to be a sponsor of an event, the plan shall
provide the Agency with a copy of the
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 59 OF 166
July 2004 Medicaid HMO Contract
invitation in lieu of the disclosure form. All completed
disclosure forms must be sent to the Agency with the plan's
request for approval of the event.
c. A "health fair" means an event conducted in a setting which is
open to the public or a segment of the public (such as the
"elderly" or "school children") at which information about
health care services, facilities, research, preventive
techniques, or other health care information is disseminated.
At least two health related organizations must actively
participate in the health fair.
d. A "public event" is an event sponsored for the public or
segment of the public by two or more actively participating
organizations, one of which may be a health organization.
e. The main purpose of a health fair or a public event shall not
be Medicaid plan marketing, but Medicaid plan marketing may be
provided at these events, subject to Agency rules and
oversight.
f. Marketing face-to-face to Medicaid beneficiaries may be
allowed if the Medicaid beneficiary contacts the plan's
headquarters or regional member services office directly to
request a home visit. The plan shall not allow the visit to
the Medicaid beneficiary's home to occur before the next
business day or 24 hours have elapsed since the request for
the visit. The plan must be able to provide evidence to the
Agency that the 24-hour or next business day requirement has
been met. The plan will be required upon request by the Agency
to provide a log that shows how initial contact with the
beneficiary was made. Only Agency registered marketing
representatives shall be allowed to make home visits. Each
plan shall make available to the Agency as requested a report
of the number of home visits made by each Agency registered
marketing representative to Medicaid beneficiary's homes.
30.2.2.1 APPROVAL PROCESS
Health Fairs and public events shall be approved or denied by the
Agency using the following process:
a. A plan shall submit its bi-monthly marketing schedule to the
Agency, two weeks in advance of each month. The marketing
schedule may be revised if a plan provides notice to the
Agency one week prior to the public event or the health fair.
The Agency may expedite this process as needed.
b. The Agency shall approve or deny the plan's bi-monthly
marketing schedule and revision request no later than the
following working day.
c. The Agency shall establish a standard form that shall be used
by the plan. The form shall include minimum requirements for
necessary information. The Agency shall explain in writing
what is sufficient information for each requirement.
d. The Agency shall establish a statewide log to track the
approval and disapproval of health fairs, public events, and
events in provider offices, and state offices.
e. The Agency may provide verbal approvals or disapprovals to
meet the next working day requirement, but the Agency shall
follow up in writing with specific reasons for disapprovals.
30.2.3 SUBCONTRACTOR'S COMPLIANCE
The plan shall ensure its health care providers comply with the
following marketing requirements:
a. Health care providers may give out plan brochures at health
fairs or in their own offices comparing the benefits of
different plans with which they contract. However, they cannot
orally compare benefits among plans unless marketing
representatives from each plan are present.
b. Health care providers may co-sponsor events, such as health
fairs and cooperatively market and advertise with the plan in
indirect ways; such as, television, radio, posters, fliers,
and print advertisements.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 60 OF 166
July 2004 Medicaid HMO Contract
c. Health care providers may announce a new affiliation with a
plan or give a list of plans they contract with to their
patients.
d. Health care providers cannot furnish lists of their
fee-for-service beneficiaries to plans with which they
contract, nor can providers furnish other HMOs' membership
lists to any plan, nor can providers take applications in
their offices.
30.3 MARKETING REPRESENTATIVES
The plan shall not subcontract with any brokerage firm or independent
agent for purposes of marketing or pre-enrollment activities.
The plan shall, prior to allowing the marketing representative to
pre-enroll beneficiaries, verify with the DFS that all marketing
representatives are properly licensed pursuant to the requirements of
chapter 641, F.S. The plan shall also verify the marketing
representative is in good standing with the DFS.
The plan shall be required to register each marketing representative
with the Agency. The registration shall consist of providing the Agency
with the representative's name; address; telephone number; cellular
telephone number; DFS license number; the names of all Medicaid plans
with which the representative was previously employed; and the name of
the Medicaid plan with which the agent is presently employed. The plan
shall provide the Agency on a monthly basis information on terminations
of all marketing representatives. The plan shall maintain and make
available to the Agency upon request evidence of current licensure and
contractual agreements with all marketing representatives used by the
plan to recruit beneficiaries.
The plan shall report to the Department of Financial Services and the
Agency any marketing representative who violates any of these contract
requirements, within 15 calendar days of knowledge of such violation.
While marketing, authorized marketing representatives shall wear
picture identification that includes their DFS license number and
identifies the plan represented.
The marketing representative shall inform the beneficiary that the
representative is not an employee of the state, but is a representative
of the plan.
The plan shall not pay commission compensation, or shall recoup
commissions paid, to marketing representatives for new members whose
voluntary disenrollment is effective within the first three months of
their initial enrollment, unless the disenrollment is due to the member
moving out of the county in which the plan has been authorized to
operate. In addition, the plan shall not pay commission compensation,
or shall recoup commissions paid, to marketing representatives for
Medicaid ineligible beneficiaries outlined in section 10.3, Ineligible
Beneficiaries, who were enrolled in error. A marketing representative's
monthly commission cannot exceed 40 percent of the marketing
representative's total monthly compensation, excluding benefits.
The plan shall instruct and provide initial and periodic training to
its marketing representatives regarding the marketing, pre-enrollment,
and general service provisions requirements of the contract.
The plan shall implement procedures for background and reference checks
for use in its marketing representative hiring practices.
30.4 MARKETING AND PRE-ENROLLMENT GRIEVANCES
The plan shall develop and maintain procedures to log and resolve
marketing and pre-enrollment grievances, including procedures that
address the resolution of repeated grievances against marketing staff.
The procedures shall contain a provision that a plan employee outside
the marketing department must handle the resolution of all repeated
marketing grievances.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 61 OF 166
July 2004 Medicaid HMO Contract
30.5 PRE-ENROLLMENT ACTIVITIES
The plan shall refer beneficiaries interested in enrolling in the plan
to the enrollment and disenrollment services contractor. However, the
plan may perform pre-enrollment under the supervision of the Agency or
its designee pursuant to Agency pre-enrollment and marketing
guidelines. Pursuant to section 409.912, F.S., pre-enrollment means the
provision of marketing and educational materials to a Medicaid
recipient and assistance in completing the pre-enrollment application,
but shall not include actual enrollment into a managed care plan. A
request for enrollment shall not be deemed complete until the Agency or
its agent verifies that the recipient made an informed, voluntary
choice.
Upon approval of the Agency, the plan may assist the beneficiary with
the completion of a pre-enrollment application, also known as request
to enroll (RTE), in accordance with section 409.912, F.S., and Agency
pre-enrollment and marketing guidelines.
Pre-enrollment applications may be for an individual or for a family.
For voluntary members, all such applications must contain at least the
following information for each applicant: name; address (home and
mailing); county of residence; telephone number; Medicaid ID number;
social security number; date of birth; date of application; applicant's
signature or signature of parent or guardian; and marketing
representative's signature and DFS license number. No health status
information may be asked on the pre-enrollment application.
The plan shall furnish the beneficiary, at the time of application,
with a copy of the completed pre-enrollment application.
For pre-enrollment including assignment, the plan shall accept the
beneficiary in the health condition the beneficiary is in at the time
of pre-enrollment.
The plan shall accept pre-enrollment applications only from
beneficiaries who reside within the authorized service area. In
addition, the plan shall enroll beneficiaries using the provider number
associated with the county in which the beneficiary resides.
The plan shall provide a release form, in new member materials or in
another format acceptable to the Agency, to each applicant authorizing
the plan to release medical information to the federal and state
governments or their duly appointed agents.
If the voluntary applicant is recognized to be in foster care by the
plan, and is dependent, prior to enrollment the plan must receive
written authorization from (1) a parent, (2) a legal guardian, or (3)
the Department of Children and Families (DCF), or DCF's delegate. If a
parent is unavailable, the plan shall obtain authorization from the
DCF.
The plan must provide a reasonable written explanation of the plan to
the beneficiary prior to accepting the pre-enrollment application. The
information must comply with CFR 438.10, to ensure that, before
enrolling, the beneficiary receives, from the plan or the enrollment
and disenrollment services contractor, accurate oral and written
information he or she needs to make an informed decision on whether to
enroll.
The plan shall explain to all applicants that the family may choose to
have all members served by the same primary care provider or they may
choose different primary care providers based on each member's needs.
The plan shall not market to mandatory assigned beneficiaries prior to
the effective enrollment date of the beneficiary, unless the
beneficiary calls and requests a visit.
30.6 ENROLLMENT
The Agency or its designee, upon receipt of the pre-enrollment
transmission and upon receipt of Title XXI MediKids voluntary
enrollment information from the Agency's MediKids' enrollment
contractor, shall be responsible for:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 62 OF 166
July 2004 Medicaid HMO Contract
a. Determining the applicant's eligibility for enrollment in the
plan.
b. Forwarding to the plan a list of all new members on a monthly
basis, which shall include any voluntary MediKids enrollees to
be enrolled by the plan.
The plan shall provide to the Agency's enrollment and disenrollment
services contractor complete Medicaid voluntary pre-enrollment
application data in the agreed upon format and transmission method.
Pre-enrollment application information shall be submitted to the
Agency's enrollment and disenrollment services contractor as often as
daily, according to the Agency-approved data rules for pre-enrollment
application submissions. Error-free applications will remain pending up
to 60 days awaiting beneficiary confirmation. Applications that are not
confirmed and processed within 60 days of the pre-enrollment
application date will be cancelled and must be retaken by the
applicant.
Plan enrollment may be temporarily suspended upon the plan's written
request if approved by the Agency or as provided for in section 70.17
Sanctions.
Membership begins at 12:01 a.m. on the first day of the calendar month
that the member's name appears on the automated enrollment report.
However, if the Agency requests the enrollment of a specific
beneficiary, enrollment begins immediately upon notification.
Membership is in whole months unless otherwise specified.
If the plan's contract is renewed, the enrollment status of all members
shall continue uninterrupted.
The Agency, after processing the enrollment transmission from the
enrollment and disenrollment services contractor and determining the
applicant's eligibility for enrollment in the plan, shall forward to
the plan a list of all new members and their respective plan primary
care providers on a monthly basis. Additional enrollment data collected
by the enrollment and disenrollment services contractor shall be
provided to the plan upon the Agency taking into consideration any plan
requests regarding transmittal items or formats. The Agency shall be
responsible for informing the plan of resulting items and formats.
New eligibles and existing beneficiaries subject to open enrollment who
change from their current Medicaid managed health care plan shall
remain enrolled in their plan for 12 months. Additionally,
beneficiaries who are reinstated or regain eligibility within 60 days
during their 12-month enrollment period shall remain "locked-in" until
the date for the next open enrollment period. Members that move to a
new county shall remain a member of their current plan if the plan
operates in the new county. Beneficiaries will only be allowed to
disenroll from plans outside of the annual open enrollment period if
they meet a "good cause change" reason. The Agency shall forward to the
plan the open enrollment status of the plan's current enrollees
monthly.
Pursuant to 1932(a)(4)(A) and (B) of the Social Security Act, the
enrollment and disenrollment services contractor shall permit an
individual eligible for medical assistance under the State plan who is
enrolled with the plan to terminate (or change) such enrollment for
good cause at any time (consistent with section 1903(m)(2)(A)(vi)), and
without cause during the 90-day period following the date of the
beneficiary's initial enrollment or the date the State sends the
beneficiary notice of the enrollment, whichever is later, and at least
every 12 months thereafter. The enrollment and disenrollment services
contractor shall provide for notice to each enrollee of opportunity to
terminate (or change) enrollment under such conditions. Such notice
shall be provided at least 60 days before each annual enrollment
opportunity.
The plan accepts individuals eligible for enrollment in the order in
which they apply without restriction (unless authorized by the CMS
Regional Administrator), up to the limits set under the contract. The
plan will not discriminate against individuals eligible to enroll on
the basis of race, color, or national origin, and will not use any
policy or practice that has the effect of discriminating on any basis
including but not limited to race, color, or national origin.
Enrollment is voluntary, except in the case of mandatory enrollment
programs that comply with 42 CFR 438.50(a).
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 63 OF 166
July 2004 Medicaid HMO Contract
30.6.1 BEHAVIORAL HEALTH ENROLLMENT
To the maximum extent possible, the plan shall distribute to members in
Agency areas, where behavioral health care has been implemented, to the
plan's direct service behavioral health care providers based upon
member choice and proximity of the member's residence to the plan
service provider's location.
For children in the care and custody of the DCF Foster Care, the plan
shall consult with the appropriate DCF Family Safety and Preservation
worker in order for the plan to identify an appropriate plan direct
service behavioral health care provider who shall be responsible for
monitoring all aspects of the beneficiary's behavioral health care.
Upon new enrollment or re-enrollment of a member, in addition to the
requirements of section 30.7, Member Notification, the plan shall
provide the following information to the plan member:
a. Procedures for obtaining required behavioral health services,
including any additional plan phone numbers to be used for
obtaining services;
b. List of plan's behavioral health service centers (including
city and county);
c. Member Handbook that shall include the following:
1. A notice that clearly states that the member may
select an alternative behavioral health care
coordinator or direct service behavioral health care
provider within the plan, if one is available;
2. Description of behavioral health services provided,
including limitations, exclusions and out-of-plan
use;
3. Description of emergency behavioral health services
and procedures both in and out of the plan's service
area;
4. Information to assist the member in assessing a
potential behavioral health problem.
Upon the initial request for services, the plan shall provide the
member with the name of the assigned behavioral health provider and an
appointment with the provider that is within the required access times
indicated in this section.
30.7 MEMBER NOTIFICATION
The plan shall develop and implement written enrollment procedures,
which shall be used to notify members of enrollment. The plan must give
each beneficiary written notice of any change in the information
required by this section, 42 CFR 438.10(f)(6), and 42 CFR 438.10(g) and
(h), at least 30 days before the intended effective date of the change.
a. Prior to, or upon enrollment, the plan shall provide the
following information to all new members:
1. A written notice providing the actual or estimated
date of enrollment, and the name, telephone number
and address of the member's primary care physician.
2. Termination of a contracted provider, within 15 days
after receipt or issuance of the termination notice,
to each enrollee who received his or her primary care
from, or was seen on a regular basis, by the
terminated provider. The plan must make a good faith
effort to give written notice of such termination to
the enrollee.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 64 OF 166
July 2004 Medicaid HMO Contract
3. An explanation that assigned members or applicants
may choose to have all family members served by the
same primary care provider or they may choose
different primary care providers based on each
member's needs.
4. An explanation of the applicable restrictions of the
plan, especially that the beneficiary must use the
plan providers and secure appropriate referrals to
receive care from providers outside the plan.
b. The plan shall have procedures advising applicants and members
of plan service delivery and provider network changes
including the following:
1. Restrictions on provider access, including providers
who are not taking new patients. Current members
shall be advised on at least a six-month basis.
2. Termination of their assigned primary care physicians
within five business days after the effective date of
the termination.
3. Termination of hospital agreements within the service
area within five business days after the effective
date of the termination.
4. Providers' objections to counseling and referral
services based on moral or religious grounds within
90 calendar days after the plan's change in policy
regarding such a counseling or referral service as
required by section 1932(b)(3), Social Security Act
(enacted by section 4704 of the Balanced Budget Act
of 1997).
5. Members' option to change primary care providers.
6. Members' responsibility to notify the plan if they
change county of residence, and to request a
disenrollment if moving out of the service area, or
choose a new primary care doctor if the member shall
remain in the plan service area.
c. Pursuant to 42 CFR 422.208 and 42 CFR 422.210, the plan shall
provide information on the plan's physician incentive plans or
on the plan's structure and operation to any Medicaid
recipient, upon request.
30.7.1 MEMBER SERVICES HANDBOOK
The member services handbook shall include the following information:
Terms and conditions of enrollment including the reinstatement process;
a description of the open enrollment process; description of services
provided, including limitations and general restrictions on provider
access, exclusions and out-of-plan use; procedures for obtaining
required services, including second opinions; the toll-free telephone
number of the statewide Consumer Call Center; emergency services and
procedures for obtaining services both in and out of the plan's service
area; the extent to which, and how, after-hours and emergency coverage
are provided; procedures for enrollment, including member rights and
procedures ; grievance system components; member rights and procedures
for disenrollment; procedures for filing a "good cause change" request,
including the Agency's toll-free telephone number for the enrollment
and disenrollment services contractor; information regarding newborn
enrollment, including the mother's responsibility to notify the plan
and the mother's DCF caseworker of the newborn's birth and assignment
of pediatricians and other appropriate physicians; member rights and
responsibilities; including the extent to which, and how, enrollees may
obtain benefits from out-of-network providers and the right to obtain
family planning services from any participating Medicaid provider
without prior authorization for such services; the choices of approved
nursing facilities (Frail/Elderly); information on emergency
transportation and non-emergency transportation, counseling and
referral services available under the plan and how to access these;
information that interpretation services and alternative communications
systems are available, free of charge for all foreign languages, and
how to access these services; information that post-stabilization
services are provided without prior authorization; and other post
stabilization care services rules set forth in 42 CFR 422.113(c);
information that services will continue upon appeal of a suspended
authorization and
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 65 OF 166
July 2004 Medicaid HMO Contract
that the enrollee may have to pay in case of an adverse ruling;
information regarding the health care advance directives pursuant to
chapter 765, F.S., 42 CFR 422.128; cost sharing, if any; and
information that enrollees may obtain from the plan information
regarding quality performance indicators, including aggregate enrollee
satisfaction data; and how and where to access any benefits that are
available under the State plan but are not covered under the contract,
including any cost sharing, and how transportation is provided. For a
counseling or referral service that the plan does not cover because of
moral or religious objections, the plan need not furnish information on
how and where to obtain the service. Written information regarding
advance directives provided by the plan must reflect changes in state
law as soon as possible, but no later than 90 days after the effective
date of the change.
The plan will provide enrollee information in accordance with 42 CFR
438.10(f). In accordance with 42 CFR 438.10(f)(2), the plan must notify
enrollees at least on an annual basis of their right to request and
obtain information.
30.7.2 PROVIDER DIRECTORY
The provider directory shall identify all service sites, pharmacies,
hospitals, specialists, certified nurse midwives and licensed midwives,
and ancillary providers. The directory shall include location addresses
and telephone numbers for all primary care providers. For pharmacies,
specialists, certified nurse midwives and licensed midwives, and
ancillary providers, the directory shall include the providers' names
and cities. If all pharmacy providers, within the plan's service area,
in a chain are under contract with the plan, the provider directory
need only list the chain name. In addition, pursuant to section
409.912, F.S., any lists of providers made available to Medicaid
recipients shall be arranged alphabetically, showing the provider's
name and specialty and, separately, by specialty, in alpha order. In
accordance with section 1932(b)(3) of the Social Security Act (enacted
in section 4704 of the Balanced Budget Act of 1997), the provider
directory must include an advisement that some providers may not
perform certain services based on religious or moral beliefs.
30.7.3 MEMBER INFORMATION
In accordance with section 641.54, F.S., the plan shall make available
the following items to members upon request:
a. A detailed description of the plan's authorization and
referral process for health care services which shall include
reasons for denial of services based on moral or religious
grounds as required by section 1932(b)(3), Social Security Act
(enacted in section 4704 of the Balanced Budget Act of 1997).
b. A detailed description of the plan's process used to determine
whether health care services are medically necessary.
c. A description of the plan's quality improvement program.
d. Policies and procedures relating to the plan's prescription
drug benefits program.
e. Policies and procedures relating to the confidentiality and
disclosure of the member's medical records.
f. The decision-making process used for approving or denying
experimental or investigational medical treatments.
g. A detailed description of the plan's credentialing process.
30.7.4 NEW MEMBER MATERIALS
Immediately upon the assigned beneficiaries' and the Title XXI
Medikids' enrollment, the plan shall mail to the new member materials
as required in section 30.7, Member Notification, and the following
additional materials:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 66 OF 166
July 2004 Medicaid HMO Contract
a. A request for the following information, including updates to
this information: assigned member's name, address (home and
mailing), county of residence, telephone number, social
security number; a completed, signed and dated release form
authorizing the plan to release medical information to the
federal and state governments or their duly appointed agents;
and, for beneficiaries in Agency areas where behavioral health
care has been implemented, current behavioral health care
provider information as described in section 10.11, Behavioral
Health Care.
b. A notice that members who lose eligibility and are disenrolled
shall be automatically reenrolled in the plan if eligibility
is regained within 60 days.
c. Each mailing shall include a postage paid, pre-addressed
return envelope. The mailing envelope shall include a request
for address correction.
d. The initial mailing may be combined with the primary care
physician assignment notification specified in section 20.6,
Physician Choice. Each mailing shall be documented in the
plan's records.
30.7.4.1 UNDELIVERABLE MATERIALS
For voluntary members, if new member materials are sent via mail and
the envelope is returned as undeliverable to the plan, the plan shall
note such in member's file. The plan shall then make another reasonable
effort to provide the required materials to the member such as
contacting the member by phone to obtain a more current address.
For assigned beneficiaries whose new member materials are returned
undeliverable to the plan, the plan shall keep the returned envelope in
the members' files and may use any of the following methods during the
members' first three-month enrollment period to contact the members and
document such methods in the members' files.
a. Telephone contact at the telephone number obtained from the
local telephone directory, directory assistance, city
directory or other directory.
b. Telephone contact with the DCF Economic Self-Sufficiency
Services office staff to determine if they have updated
address information and telephone number.
c. Routine checks (at least once a month for the first three
months of enrollment) on services or claims authorized or
denied by the plan to determine if the member has received
services, and to locate updated address and telephone number
information.
If a new address is secured and the plan materials requiring signature
have not been received by the plan or are returned unsigned, the plan
must mail the materials to the new address within ten working days of
the receipt of the new address.
The plan may use other methods to locate assigned members. The plan
shall maintain policies and procedures on the methods used to locate
assigned members and to document such members use of plan services.
30.8 ENROLLMENT REINSTATEMENTS
Pre-enrollment applications and new member materials are not required
for a former member who was disenrolled because of the loss of Medicaid
eligibility and who regains his/her eligibility within 60 days and is
automatically reinstated as a plan member. In addition, unless
requested by the beneficiary, pre-enrollment and new member materials
are not required for a former member subject to open enrollment who was
disenrolled because of the loss of Medicaid eligibility, who regains
his/her eligibility within 6 months of his/her managed care enrollment,
and is reinstated as a plan member. The plan is responsible for
assigning all reinstated beneficiaries to the primary care physician
who was treating them prior to loss
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 67 OF 166
July 2004 Medicaid HMO Contract
of eligibility, unless the beneficiary specifically requests another
primary care physician, the primary care physician no longer
participates in the plan or is at capacity, or the member has changed
geographic areas. A notation of the effective date of the reinstatement
is to be made on the most recent application or conspicuously
identified in the member's administrative file. Beneficiaries, who were
previously enrolled in a managed care plan, lose and regain eligibility
after 60 days, will be treated as new eligibles.
The plan shall notify, in writing, each person who is to be reinstated,
of the effective date of the reinstatement and the assigned primary
care physician. The notifications shall distinguish between
beneficiaries subject to open enrollment and beneficiaries not subject
to open enrollment and shall include information regarding good cause
change procedures or general plan change procedures through the
Agency's toll-free enrollment and disenrollment services contractor
telephone number as appropriate. The notification shall also instruct
the beneficiary to contact the plan if a new member card and/or a new
member handbook are needed. The plan shall provide such notice to each
affected person by the first day of the month following the plan's
receipt of the notice of reinstatement.
30.9 NEWBORN ENROLLMENT
All Medicaid eligible newborns of members are the responsibility of the
plan and the plan is responsible for payment of medically necessary and
well child care regardless of lack of notification by DCF of the
newborn's Medicaid identification number. The plan remains responsible
for the newborn, regardless of the mother's Medicaid eligibility or HMO
enrollment status, for the birth month and the next two consecutive
months. Newborn enrollment shall occur through the following
procedures, or in another format acceptable to the Agency:
a. Upon identification of a member's pregnancy, the plan shall
immediately notify the DCF of the unborn beneficiary. The plan
must provide this notification by completing and submitting to
DCF the Form DCF-ES 2039. In addition, the plan must indicate
its name and address as the entity initiating referral;
b. The plan shall use the DCF-ES 2039 completed form to identify
the unborn's Medicaid identification number and inactive
enrollment in Medicaid;.
c. Upon birth or upon the hospital notifying the plan of such
birth, the plan shall initiate the Unborn Activation Process,
either electronically or by faxing the correctly completed
form to the Agency's fiscal agent. The electronic Unborn
Activation Process is described in the AHCA/ACS 834 companion
guide. This process results in the activation of the Medicaid
identification number, the update of demographic information,
retroactive enrollment of the newborn in mother's HMO for no
more than three months, and retroactive and appropriate
payment of capitation;
d. The plan shall inform the hospital and the newborn's attending
and consulting physicians that the newborn is a plan member
and that they must seek reimbursement from the plan;
e. The plan shall reimburse the Agency for any fee-for-service
claims the Agency has paid for covered services provided to
plan newborns that occurred within the first three months of
life, unless the plan provides documentation that the services
were already reimbursed by the plan.
30.10 ENROLLMENT LEVELS
The plan is assigned enrollment levels for the operational area(s)
indicated in section 90.0, Payment and Maximum Authorized Enrollment
Levels, of this contract. The number of Medicaid beneficiaries enrolled
in the plan may not exceed the maximum authorized enrollment level per
county. The cost of care for any Medicaid beneficiaries enrolled over
the maximum level per county is a liability for the plan and shall not
be charged to the Agency or the enrolled beneficiary. The plan shall
notify the enrollment and disenrollment services contractor when
enrollment has reached the maximum number authorized.
The plan must request a contract amendment for an enrollment level
increase.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 68 OF 166
July 2004 Medicaid HMO Contract
30.11 DISENROLLMENT
The Agency shall be responsible for processing disenrollments.
a. The plan's responsibility is to:
1. At the time of enrollment for new members, notify
each member of the right to disenroll without cause
during the open enrollment period or at any time for
"good cause" and how to initiate the disenrollment
process through the Agency's enrollment and
disenrollment services contractor. Such notification
must adhere to approved wording specifications
provided by the Agency;
2. Ensure that disenrollees who wish to file an appeal
are afforded the opportunity to do so.
b. Except for the following reasons for proposed disenrollment,
all members must be afforded the right to file an appeal:
disenrollments due to moving out of the service area;
disenrollments due to loss of Medicaid eligibility; and
disenrollments due to death.
30.11.1 VOLUNTARY DISENROLLMENTS
For voluntary disenrollments, the plan shall comply with the following
requirements:
a. The effective date for disenrollment shall be the last day of
the month in which disenrollment was effectuated by the
Agency, unless the Agency requests an earlier or later date;
b. The plan shall ensure that it does not restrict the member's
right to disenroll voluntarily in any way;
c. The plan and its agents shall not provide or assist in the
completion of a disenrollment request form or assist the
Agency's enrollment and disenrollment services contractor in
the disenrollment process, except for their own members at
those members' request;
d. The plan shall ensure that all written and oral disenrollment
requests are promptly referred to the Agency's enrollment and
disenrollment services contractor helpline as follows:
1. For oral requests, the plan shall immediately refer
the member to contact the enrollment and
disenrollment services contractor helpline number;
and
2. The plan shall send, within three business days of
the plan's receipt of any written request, a letter
to the member advising the member to call the
enrollment and disenrollment services contractor
helpline.
e. The plan shall keep a daily written log or electronic
documentation of all oral and written disenrollment requests
and the disposition of such requests. The log shall include
the following: the date the request was received by the plan;
the date the member was referred to the enrollment and
disenrollment services contractor or the date of the letter
advising them of the disenrollment procedure, as appropriate;
and the reason that the member is requesting disenrollment;
f. A beneficiary may request disenrollment as follows:
1. For good cause, at any time.
2. Without cause, at the following times:
(a) During the 90 days following the beneficiary's
initial enrollment or the date the Agency sends the
beneficiary notice of the enrollment, whichever is
later;
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 69 OF 166
July 2004 Medicaid HMO Contract
(b) At least every 12 months thereafter;
(c) Upon enrollment reinstatement according to
section 30.8, Enrollment Reinstatements, of this
contract, if the temporary loss of Medicaid
eligibility has caused the beneficiary to miss the
annual disenrollment opportunity;
(d) When the Agency grants the beneficiary the right
to terminate enrollment without cause as an
intermediate sanction specified in 42 CFR
438.702(a)(3).
g. If a disenrollment request is not reviewed by the Agency
within the time frames specified in this section, the
disenrollment is considered approved.
30.11.2 INVOLUNTARY DISENROLLMENTS
With proper written documentation, the following are acceptable reasons
for which the plan shall submit involuntary disenrollments to the
Agency: member death; fraudulent use of the beneficiary ID card;
beneficiaries moving outside the plan's authorized service area; or the
plan discovers that the member is ineligible for enrollment based on
the criteria specified in section 10.3, Ineligible Beneficiaries. The
plan shall promptly submit such disenrollments to the Agency. In no
event shall the plan submit such disenrollment at such a date as would
cause the disenrollment to be effective later than 59 calendar days
after the plan's receipt of the reason for involuntary disenrollment.
The plan shall ensure that involuntary disenrollment documents are
maintained in an identifiable member record.
a. If the plan discovers that an ineligible beneficiary has been
enrolled, then it must notify the beneficiary in writing that
the beneficiary shall be disenrolled the next contract month
or earlier if necessary. Until the beneficiary is disenrolled,
the plan shall be responsible for the provision of services to
that beneficiary.
b. On a monthly basis, the plan shall review its ongoing
enrollment report (FLMR 8200-R004) to ensure that all members
are residing in the plan's authorized service area. For
beneficiaries with out-of-service area addresses on the
enrollment report, the plan shall notify the beneficiary in
writing that the beneficiary should contact the enrollment and
disenrollment services contractor to choose another managed
care option and that the member will be disenrolled. The plan
shall involuntarily disenroll the beneficiary during the next
available transmission.
c. For beneficiaries who have elected services through a hospice
program, the plan shall submit a disenrollment request to the
Agency for the beneficiary immediately upon obtaining notice
that the beneficiary has been or shall receive hospice
services. The disenrollment shall be effective upon the date
of admission to the hospice program. Capitation payment made
to the plan shall be reduced on a prorated basis for members
whose disenrollment is effective after the first day of a
month in accordance with section 409.912, F.S.
d. For those beneficiaries admitted to an institution, including
nursing home admittance for a member who has been assessed at
a nursing home level of care, the plan shall submit a
disenrollment request for the beneficiary to the Agency
immediately upon obtaining notice that the beneficiary has
been or shall be admitted. The disenrollment shall be
effective upon the first day of the month following the date
the disenrollment transmission was sent to the Agency.
e. The plan may submit an involuntary disenrollment request to
the Agency plan analyst after providing to the member at least
one verbal and at least one written warning of the full
implications of his/her failure of actions:
1. For a member who continues not to comply with a
recommended plan of health care or misses three
consecutive appointments within a continuous six
month period. Such requests must be submitted at
least 60 calendar days prior to the requested
effective date.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 70 OF 166
July 2004 Medicaid HMO Contract
2. For a member whose behavior is disruptive, unruly,
abusive or uncooperative to the extent that his or
her membership in the plan seriously impairs the
organization's ability to furnish services to either
the member or other members.
The analyst may approve such requests provided the plan
documents that attempts were made to educate the member
regarding his/her rights and responsibilities, assistance
which would enable the member to comply was offered through
case management, and it has been determined that the member's
behavior is not related to the member's medical or behavioral
condition. Beneficiaries who are disenrolled through this
section are not eligible for re-enrollment without the
permission of the plan.
f. The plan shall submit involuntary disenrollment requests to
the Agency for assigned members that meet both of the
following requirements:
The plan was unable to contact the member by mail, phone, or
personal visit within the first four months of enrollment, and
The plan was unable to document the use of plan services by
the member, or another family unit member, within the first
four months of enrollment. Such disenrollments shall be
submitted through the Agency approved transmission medium
specified in section 60.0, Reporting Requirements on the first
available transmission after the end of the members' fourth
month of enrollment. The plan shall keep documentation of its
inability to contact the member and that it has no record of
providing services to the member, or to another family unit
member, in the member's file.
g. The following are unacceptable reasons for the plan, on its
own initiative, to request disenrollment of a member:
pre-existing medical condition; changes in health status;
volume of utilization, and periodically missed appointments.
h. For all involuntary disenrollments submitted by the plan, the
plan shall document its reason for the involuntary
disenrollment in the member's file.
i. The plan shall promptly provide involuntary disenrollment data
via an Agency approved transmission medium, on the first
available transmission after receiving the Agency's approval
of such request or, for assigned members, by the timeframe
indicated in f. of this subsection.
j. For involuntary disenrollments, documentation must contain the
following minimum information: name; address; telephone
number; reason for disenrollment with brief explanation; date;
signature by plan staff and an indication as to whether or not
the member wishes to file a grievance.
k. The plan shall send to the Agency a monthly summary report of
all plan submitted involuntary disenrollments pursuant to
section 60.2.2, Medicaid Disenrollment Summary. This report
must specify the reason for such disenrollments. It will be
reconciled to the Disenrollment Report processed by the Agency
for the applicable month and shall be reviewed by the Agency
for compliance with acceptable reasons for disenrollment. The
Agency may reinstate enrollment for any member whose reason
for disenrollment is not consistent with established
guidelines.
30.11.2.1 FRAIL/ELDERLY DISENROLLMENT
The plan may request the Agency to disenroll the member at the
beginning of a recontracting period if it can be demonstrated the
member would benefit from disenrollment, or if the member is
institutionalized in a long term nursing facility at the conclusion of
the state fiscal year and the plan furnishes written documentation
based upon a CARES assessment or written assurance from the member's
primary care physician or the administrator of the nursing facility
where the member is placed that the nursing home placement is permanent
and not temporary. All disenrollments for institutionalized members
must have written prior approval by the Agency and be submitted as
involuntary disenrollments on the first available
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 71 OF 166
July 2004 Medicaid HMO Contract
transmission to the fiscal agent after receiving Agency approval of the
request. Such approval shall not be unreasonably withheld.
30.12 ENROLLMENT/DISENROLLMENT VERIFICATION
The Agency shall arrange for the plan to receive a monthly list of
eligible members and a list of those members ineligible or disenrolled
from the HMO. The plan shall be responsible for notifying, in writing,
enrollees involuntarily disenrolled by the plan of the disenrollment
effective date and the reason for disenrollment, in accordance with
section 30.11.2 d. and e., Involuntary Disenrollments.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 72 OF 166
July 2004 Medicaid HMO Contract
40.0 ASSURANCES AND CERTIFICATIONS
40.1 MONITORING PROVISIONS
In addition to the monitoring requirements specified in the Agency's
core contract, section I.E.2., Monitoring, the plan shall permit the
Agency, entities authorized by the Agency, and DHHS to evaluate,
through inspection or other means, the quality, appropriateness and
timeliness of services provided under the contract.
40.2 CERTIFICATION OF LABORATORIES AND PORTABLE X-RAY COMPANIES
All independent laboratory testing sites providing services under this
contract must be freestanding clinical laboratories certified under the
Clinical Laboratory Improvement Amendments of 1988 (CLIA). The
laboratory may provide only those specific laboratory test specialties
and subspecialties covered by CLIA certification.
All portable x-ray companies providing services to members at their
place of residence must have been certified by the Agency in accordance
with Title XVIII (Medicare) standards.
40.3 GOOD FAITH EFFORT WITH SCHOOL DISTRICTS
In accordance with section 409.9122, F.S., the plan assures it shall
make a good faith effort to execute agreements (refer to section 110.5,
Memorandum of Agreement) with school districts participating in the
certified match program regarding the coordinated provision of
school-based services pursuant to sections 236.0812 and 409.908(21),
F.S.; and to ensure that duplication of services does not occur.
40.4 GOOD FAITH EFFORT WITH COUNTY HEALTH DEPARTMENTS
The plan assures it shall make a good faith effort to execute memoranda
of agreement (refer to section 110.2 for a model Memorandum of
Agreement) with the local county health departments to provide services
which may include, but are not limited to, family planning services,
services for the treatment of sexually transmitted diseases, other
public health related diseases, tuberculosis, immunizations, DCF foster
care emergency shelter medical screenings, school-based services
pursuant to section 409.9122., and services related to Healthy Start
prenatal and postnatal screenings. Refer to section 20.13, Medical
Records Requirements, and sections 10.8.11, Physician Services, and
10.8.10, Independent Laboratory and Portable X-ray Services.
40.5 GOOD FAITH EFFORT WITH MIDWIVES
THE PLAN ASSURES IT SHALL MAKE A GOOD FAITH EFFORT TO EXECUTE CONTRACTS
WITH CERTIFIED NURSE MIDWIVES TO PROVIDE SERVICES IN ACCORDANCE WITH
SECTION 641.31, F.S., FOR LOW RISK PATIENTS.
40.6 ACCREDITATION
Commercially licensed plans shall achieve accreditation by an external
accreditation organization approved in accordance with section 641.512,
F.S.
40.7 MINORITY RECRUITMENT AND RETENTION PLAN
The plan shall implement and maintain a minority recruitment and
retention plan in accordance with section 641.217, F.S. The plan shall
have policies and procedures for the implementation and maintenance of
such a plan. The minority recruitment and retention plan may be
company-wide for all product lines.
40.8 OWNERSHIP AND MANAGEMENT DISCLOSURE
Federal and state laws require full disclosure of ownership, management
and control of Medicaid HMOs.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 73 OF 166
July 2004 Medicaid HMO Contract
a. Disclosure shall be made on forms prescribed by the Agency for
the areas of ownership and control interest (42 CFR 455.104
Form CMS 1513), business transactions (42 CFR 455.105), public
entity crimes (section 287.133(3)(a), F.S.), and disbarment
and suspension (52 Fed. Reg., pages 20360-20369, and section
4707 of the Balanced Budget Act of 1997). The forms are
available through the Agency and are to be submitted to the
Agency with the initial application for a Medicaid HMO and
then submitted on an annual basis. The plan shall disclose any
changes in management as soon as those occur. In addition, the
plan shall submit to the Agency full disclosure of ownership
and control of Medicaid HMOs at least 60 calendar days before
any change in the plan's ownership or control occurs.
b. The following definitions apply to ownership disclosure:
1. A person with an ownership interest or control
interest means a person or corporation that:
Owns, indirectly or directly 5 percent or
more of the plan's capital or stock, or
receives 5 percent or more of its profits;
Has an interest in any mortgage, deed of
trust, note, or other obligation secured in
whole or in part by the plan or by its
property or assets and that interest is
equal to or exceeds 5 percent of the total
property or assets; or
Is an officer or director of the plan if
organized as a corporation, or is a partner
in the plan if organized as a partnership.
2. The percentage of direct ownership or control is
calculated by multiplying the percent of interest
which a person owns, by the percent of the plan's
assets used to secure the obligation. Thus, if a
person owns 10 percent of a note secured by 60
percent of the plan's assets, the person owns 6
percent of the plan.
3. The percent of indirect ownership or control is
calculated by multiplying the percentage of ownership
in each organization. Thus, if a person owns 10
percent of the stock in a corporation, which owns 80
percent of the plan stock, the person owns 8 percent
of the plan.
c. The following definitions apply to management disclosure:
Changes in management are defined as any change in the
management control of the plan. Examples of such changes are
those listed below or equivalent positions by another title.
1. Changes in the board of directors or officers of the
plan, medical director, chief executive officer,
administrator, and chief financial officer.
2. Changes in the management of the plan where the plan
has decided to contract out the operation of the plan
to a management corporation. The plan shall disclose
such changes in management control and provide a copy
of the contract to the Agency for approval at least
60 calendar days prior to the management contract
start date.
d. In accordance with section 409.912, F.S., the plan shall
annually conduct a background check with the Florida
Department of Law Enforcement on all persons with five percent
or more ownership interest in the plan, or who have executive
management responsibility for the managed care plan, or have
the ability to exercise effective control of the plan. The
plan shall submit information to the Agency for such persons
who have a record of illegal conduct according to the
background check. The plan shall keep a record of all
background checks to be available for Agency review upon
request.
1. In accordance with section 409.907, F.S., plans with
an initial contract beginning on or after July 1,
1997, shall submit, prior to execution of a contract,
complete sets of fingerprints of principals of the
plan to the Agency for the purpose of conducting a
criminal history record check.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 74 OF 166
July 2004 Medicaid HMO Contract
2. Principals of the plan shall be as defined in section
409.907, F.S.
e. The plan shall submit to the Agency, within five working days,
any information on any officer, director, agent, managing
employee, or owner of stock or beneficial interest in excess
of five percent of the plan who has been found guilty of,
regardless of adjudication, or who entered a plea of nolo
contendere or guilty to, any of the offenses listed in section
435.03, F.S.
f. In accordance with section 409.912, F.S., the Agency shall not
contract with a plan that has an officer, director, agent,
managing employee, or owner of stock or beneficial interest in
excess of five percent of the plan, who has committed any of
the above listed offenses. In order to avoid termination, the
plan must submit a corrective action plan, acceptable to the
Agency, that ensures that such person is divested of all
interest and/or control and has no role in the operation and
management of the plan.
40.9 INDEPENDENT PROVIDER
It is expressly agreed that the plan and any subcontractors and agents,
officers, and employees of the plan or any subcontractors, in the
performance of this contract shall act in an independent capacity and
not as officers and employees of the Agency or the State of Florida. It
is further expressly agreed that this contract shall not be construed
as a partnership or joint venture between the plan or any subcontractor
and the Agency and the State of Florida.
40.10 GENERAL INSURANCE REQUIREMENTS
The plan shall obtain and maintain at all times adequate insurance
coverage including general liability insurance, professional liability
and malpractice insurance, fire and property insurance, and directors'
omission and error insurance. All insurance coverage must comply with
the provisions set forth in Rule 690-191.069, F.A.C.; excepting that
the reporting, administrative, and approval requirements shall be to
the Agency rather than to the Department of Financial Services. All
insurance policies must be written by insurers licensed to do business
in the State of Florida and in good standing with the Department of
Financial Services. All policy declaration pages must be submitted to
the Agency annually. Each certificate of insurance shall provide for
notification to the Agency in the event of termination of the policy.
40.11 WORKER'S COMPENSATION INSURANCE
The plan shall secure and maintain during the life of the contract,
worker's compensation insurance for all of its employees connected with
the work under this contract. Such insurance shall comply with the
Florida Worker's Compensation Law, chapter 440, F.S. Policy declaration
pages must be submitted to the Agency annually.
40.12 STATE OWNERSHIP
The Agency shall have the right to use, disclose, or duplicate all
information and data developed, derived, documented, or furnished by
the plan resulting from this contract. Nothing herein shall entitle the
Agency to disclose to third parties data or information which would
otherwise be protected from disclosure by state or federal law.
40.13 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT COMPLIANCE
The plan assures that it will be in compliance with the HIPAA
regulations.
40.14 SYSTEMS COMPLIANCE
The plan warrants that each item of hardware, software, and/or firmware
required for the provision of service under this contract shall be able
to accurately process date data (including, but not limited to,
calculating, comparing, and sequencing) including leap year
calculations, when used in accordance with the
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 75 OF 166
July 2004 Medicaid HMO Contract
item documentation provided by the plan, provided that all
items (e.g., hardware, software, firmware) used in combination
with other designated items properly exchange date data with
it.
40.15 CERTIFICATION OF REPORTED DATA
Data reported as provided in section 60.0, Reporting Requirements, and
data specified in 42 CFR 438.604, must be certified by one of the
following: the plan's chief executive officer, the chief financial
officer, or an individual who has delegated authority to sign for and
who reports directly to the plan's chief executive officer or chief
financial officer.
Based on best knowledge, information, and belief, the certification
must attest to the accuracy, completeness, and truthfulness of the data
and of the documents specified by the Agency. The plan must submit the
certification concurrently with the certified data.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 76 OF 166
July 2004 Medicaid HMO Contract
50.0 FINANCIAL REQUIREMENTS
50.1 INSOLVENCY PROTECTION
The plan shall establish a restricted insolvency protection account
with a federally guaranteed financial institution licensed to do
business in Florida in accordance with section 1903(m)(1) of the Social
Security Act (amended by section 4706 of the Balanced Budget Act of
1997), and section 409.912, F.S. The plan shall deposit into that
account five percent of the capitation payments made by the Agency each
month until a maximum total of two percent of the annualized total
current contract amount is reached. No interest may be withdrawn from
this account until the maximum contract amount is reached. This
provision shall remain in effect as long as the plan continues to
contract with the Agency. The restricted insolvency protection account
may be drawn upon with the authorized signatures of two persons
designated by the plan and two representatives of the Agency. The
signature card shall be resubmitted when a change in authorized
personnel occurs. If the authorized persons remain the same, the plan
shall submit an attestation to this effect annually. A sample form
(Multiple Signature Verification Agreement) may be found as section
110.3. All such agreements or other signature cards must be approved in
advance by the Agency.
a. In the event that a determination is made by the Agency that
the plan is insolvent, as defined in section 100.0, Glossary,
the Agency may draw upon the amount solely with the two
authorized signatures of representatives of the Agency and
funds may be disbursed to meet financial obligations incurred
by the plan under this contract. A statement of account
balance shall be provided by the plan within 15 calendar days
of request of the Agency.
b. If the contract is terminated, expired, or not continued, the
account balance shall be released by the Agency to the plan
upon receipt of proof of satisfaction of all outstanding
obligations incurred under this contract.
c. In the event the contract is terminated or not renewed and the
plan is insolvent, the Agency may draw upon the insolvency
protection account to pay any outstanding debts the plan owes
the Agency including, but not limited to, overpayments made to
the plan, and fines imposed under the contract or section
641.52, F.S., for which a final order has been issued. In
addition, if the contract is terminated or not renewed and the
plan is unable to pay all of its outstanding debts to health
care providers, the Agency and the plan agree to the court
appointment of an impartial receiver for the purpose of
administering and distributing the funds contained in the
insolvency protection account. Should a receiver be appointed,
he shall give outstanding debts owed to the Agency priority
over other claims.
50.2 INSOLVENCY PROTECTION ACCOUNT WAIVER
Pursuant to section 409.912, the Agency may waive the insolvency
protection account requirement, in writing, when evidence of adequate
insolvency insurance and reinsurance are on file with the Agency which
shall protect members in the event the plan is unable to meet its
obligations.
50.3 SURPLUS START UP ACCOUNT
All new plans, after initial contract execution but prior to initial
member enrollment, shall submit to the Agency, if a private entity,
proof of working capital in the form of cash or liquid assets excluding
revenues from Medicaid premium payments equal to at least the first
three months of operating expenses or $200,000, whichever is greater.
This provision shall not apply to plans that have been providing
services to members for a period exceeding three continuous months.
50.4 SURPLUS REQUIREMENT
In accordance with section 409.912, F.S., the plan shall maintain at
all times in the form of cash, investments that mature in less than 180
calendar days allowable as admitted assets by the Department of
Financial Services, and restricted funds of deposits controlled by the
Agency (including the plan's
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 77 OF 166
July 2004 Medicaid HMO Contract
insolvency protection account) or the Department of Financial Services,
a surplus amount equal to one and one half times the plan's monthly
Medicaid prepaid revenues. In the event that the plan's surplus (as
defined in section 100.0, Glossary) falls below an amount equal to one
and one half times the plan's monthly Medicaid prepaid revenues, the
Agency shall prohibit the plan from engaging in marketing and
pre-enrollment activities, shall cease to process new enrollments until
the required balance is achieved, or may terminate the plan's contract.
50.5 INTEREST
Interest generated through investments made by the plan under this
contract shall be the property of the plan and shall be used at the
plan's discretion.
50.6 SAVINGS
The plan shall retain any savings realized under this contract after
all bills, charges, and fines are paid.
50.7 FIDELITY BONDS
The plan shall secure and maintain during the life of this contract a
blanket fidelity bond from a company doing business in the State of
Florida on all personnel in its employment. The bond shall be issued in
the amount of at least $250,000 per occurrence. Said bond shall protect
the Agency from any losses sustained through any fraudulent or
dishonest act or acts committed by any employees of the provider and
subcontractors, if any. Proof of coverage must be submitted to the
Agency's contracting officer within 60 calendar days after execution of
the contract and prior to the delivery of health care. To be acceptable
to the Agency for fidelity bonds, a surety company shall comply with
the provisions of chapter 624, F.S. Proof of the fidelity bond shall be
submitted to the Agency annually during the re-contracting and renewal
period.
50.8 INSPECTION AND AUDIT OF FINANCIAL RECORDS
The state and DHHS may inspect and audit any financial records of the
plan or its subcontractors. Pursuant to section 1903(m)(4)(A) of the
Social Security Act and State Medicaid Manual 2087.6(A-B),
non-federally qualified plans must report to the state, upon request,
and to the Secretary and the Inspector General of DHHS, a description
of certain transactions with parties of interest as defined in section
1318(b) of the Social Security Act.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 78 OF 166
July 2004 Medicaid HMO Contract
60.0 REPORTING REQUIREMENTS
60.1 FISCAL AGENT REPORTS
THE FOLLOWING INFORMATION WILL BE PROVIDED BY THE MEDICAID FISCAL AGENT
TO THE CONTRACT MEDICAID HMO:
1. Transaction Input Summary Report (FLMR 8200-R005) - Indicates
the errors that were made in the enrollment/disenrollment data
submitted.
2. New Enrollee Report (FLMR 8200-R001) - Lists the new enrollees
as of the report's effective date.
3. Cancellation Report (FLMR 8200-R002) - Lists those persons who
were previously enrolled erroneously and are being removed.
Their effective cancellation dates are the same as their
enrollment dates.
4. Disenrollment Report (FLMR 8200-R003) - Lists those persons
who are no longer eligible for Medicaid or who have been
disenrolled from the plan as of the report's effective date.
5. New Enrollees Under 21 (FLMR 8200-R007) - Lists those eligible
members newly enrolled.
6. Disenrollment under 21 (FLMR 8200-R006) - Lists those eligible
members newly disenrolled.
7. Ongoing Report (FLMR 8200-R004) - Lists all persons who are
enrolled in the plan as of the report's effective date.
8. HMO Reinstatement Report (FLMR 8200-R009) - Lists those
persons who were re-enrolled in the plan, because they lost
and then regained eligibility within a 60-day window.
Reinstatements are processed and reported twice each month,
during the primary processing cycle called "monthly magic" and
again during month-end processing.
The plan shall review these reports for accuracy and will notify the
agency if discrepancies are found. The fiscal agent will make a full
conversion to the use of HIPAA-compliant standard transactions. At that
time, all beneficiary enrollment maintenance and reporting will be done
using the X12N 834 transaction. The plan must be capable of receiving
and processing the 834 transaction. Additionally, during the transition
period from proprietary to standard formats, the plan must
cooperatively participate in the transition process, including formal
testing, when asked to do so by the Agency.
60.2 HMO REPORTING REQUIREMENTS
The plan is responsible for complying with all the reporting
requirements established by the Agency. The plan is responsible for
assuring the accuracy, completeness, and timely submission of each
report. Deadlines for report submission referred to in this contract
specify the actual time of receipt at the Agency, not the date the file
was postmarked or transmitted. Before October 1 of each contract year,
the plans shall deliver to the Agency certifications by an Agency
approved independent auditor that the CHCUP screening rate reports in
Tables 10 and 11 have been fairly and accurately presented. In
addition, before October 1, the plans shall deliver to the Agency a
certification by an Agency approved independent auditor that the
quality indicator data reported for the previous calendar year have
been fairly and accurately presented. If a reporting due date falls on
a weekend, the report will be due to the Agency on the following
Monday. The Agency will furnish the plan with the appropriate reporting
formats, instructions, submission timetables and technical assistance
as required.
The Agency requires certification of data as provided in 42 CFR
438.606. The data that must be certified include but are not limited to
enrollment information, encounter data, and other information required
by the Agency.
The Agency reserves the right to modify the reporting requirements to
which the plan must adhere but will allow the plan 90 calendar days to
complete the implementation, unless otherwise required by law. The
Agency shall provide the plan written notification of modified
reporting requirements. The reporting requirements specifications are
outlined in this section. Failure of the plan to submit required
reports accurately and within the time frames specified may result in
sanctions being levied.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 79 OF 166
July 2004 Medicaid HMO Contract
During fiscal year 2003/04, the Agency contracted with Thomson Medstat
to develop a strategic plan for the implementation of a Medicaid
Encounter Data System, referred to as MEDS. The Agency will continue
its work towards the development, installation and initial operation of
MEDS during fiscal year 2004/05. Once a comprehensive MEDS design and
implementation plan has been finalized, it will be available to the
plans for review. From this design plan, the Agency, in collaboration
with the plan, will define the stages of implementation for MEDS, along
with a specific timeframe for completion.
During FY2004/05, the plan must provide the Agency with a strategic
plan that outlines the steps the plan will take to achieve system
readiness for participation in MEDS. The plan shall be prepared to meet
all system requirements, to submit encounter data, and to conform to
the technical enhancements required by the Agency for full
participation in MEDS.
The Agency shall provide instruction and guidance to the plan during
each stage of development. Once MEDS installation requirements specific
to the plan have been defined, the Agency shall work with the plan to
establish a deadline for plan readiness.
TABLE 1. SUMMARY OF REPORTING REQUIREMENTS FOR MEDICAID CONTRACTED
HEALTH MAINTENANCE ORGANIZATIONS
MEDICAID HMO REPORTS REQUIRED BY AHCA
REPORT NAME LEVEL OF ANALYSIS FREQUENCY SUBMISSION MEDIA
- -----------------------------------------------------------------------------------------------------------------------------
'Proprietary' Enrollment and Location Level Monthly File Transfer to fiscal agent via a secure
DisenrollmentUploaded File Table Internet
2 site.
- -----------------------------------------------------------------------------------------------------------------------------
Medicaid HMO/PHP Location Level Monthly, within Electronic mail or diskette submission
Disenrollment Summary 15 days from
Table 3 the beginning of
the reporting
month
- -----------------------------------------------------------------------------------------------------------------------------
Frail Elderly Disenrollment Location Level Annually, due Electronic mail or diskette submission
Summary by June 1
- -----------------------------------------------------------------------------------------------------------------------------
Service Utilization Summary Plan Level Quarterly, Electronic mail or diskette submission
Tables4 and 5 within 45 days
of end of
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Appeals Reporting Individual Level Quarterly, Electronic mail or diskette submission
Table 6 within 45 days
of end of
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Inpatient Discharge Report Individual Level Quarterly, Electronic mail or diskette submission
Table 7 within 30 days
of the end of
the
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Claims Inventory Summary Report Plan Level Quarterly, Electronic mail on diskette submission
within 45 days
of the end of
the
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Marketing Rep. Report Plan Level Monthly, within Electronic mail or diskette submission AHCA
Table 8 30 days from supplied spreadsheet template
the end of the
reporting month
- -----------------------------------------------------------------------------------------------------------------------------
Provider Network Report Location Level At least Electronic submission to enrollment and
Table 9 monthly disenrollment services contractor in format
specified by enrollment and disenrollment
contractor
- -----------------------------------------------------------------------------------------------------------------------------
Child Health Check-Up Reporting Plan Level Annually, for Electronic mail or diskette submission of
Table 10 previous federal completed Child Health Check-Up Reporting
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 80 OF 166
July 2004 Medicaid HMO Contract
fiscal year (oct- spreadsheet file
Sept) due by
January 15.
Audited report
is due by Oct 1.
- -----------------------------------------------------------------------------------------------------------------------------
Child Health Check-Up Reporting, Plan Level Annually, for Electronic mail or diskette submission of
Table 11 previous federal completed spreadsheet file
fiscal year (Oct-
Sept) due by
January 15. As
required by
Section 10.8.1 f.
of this contract.
Audited report
is due by Oct.1
- -----------------------------------------------------------------------------------------------------------------------------
AHCA Quality Plan Level Annually, for Electronic mail, CD ROM or diskette
Indicators previous submission
calendar year,
due October 1.
- -----------------------------------------------------------------------------------------------------------------------------
Frail/Elderly Care Service Individual Level Quarterly, Electronic mail, CD ROM or diskette
Utilization Report within 45 days submission
of end of
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Financial Reporting Plan Level Quarterly, AHCA supplied spreadsheet template on
within 45 days diskette
of end of
reporting
quarter
- -----------------------------------------------------------------------------------------------------------------------------
Audited Financial Report Plan Level Annually, Electronic mail or diskette submission
within 90 days
of end of plan
Fiscal Year
- -----------------------------------------------------------------------------------------------------------------------------
Minority Business Enterprise Individual Level Monthly by the Electronic mail
Contract Reporting fifteenth
Suspected Fraud Reporting Plan Level As required by As required by section 60.2.14
section 60.2.14
- -----------------------------------------------------------------------------------------------------------------------------
Behavioral Health Quarterly Area 1 and Area 6 and Quarterly, Electronic mail or diskette
Report upon implementation of within 45 days submission of completed agency-supplied
prepaid mental health of the end of the template
in other Areas quarter
Location Level
- -----------------------------------------------------------------------------------------------------------------------------
FARS/CFARS Area 1 and Area 6 and Annually, due As required by section 10.11.5
upon implementation of no later than
prepaid mental health August 15.
in other Areas
- -----------------------------------------------------------------------------------------------------------------------------
Behavioral Health: Annual Area 6 and Area 1 and Annually, due Electronic mail or diskette submission of
Expenditure Report upon implementation of no later than completed agency-supplied template
prepaid mental health April 1.
in other Areas
Plan Level
- -----------------------------------------------------------------------------------------------------------------------------
Emergency Management Plan Plan Level Annually, due As required by Section 70.11
by May 31
All plans must use the same naming convention for all submitted
reports. Unless otherwise noted, each report will have an 8-digit file
name, constructed as follows:
Digit 1 Report Identifier Indicates the report type. Use H for hospital
discharge data, G for grievance report, M for
Medicaid disenrollment, F for Frail Elder
Disenrollment, S for Service utilization.
- ----------------------------------------------------------------------------------------------------
Digits 2, 3, and 4 Plan Identifier Indicates the specific plan submitting the data by
the use of 3 unique alpha digits. Comports to the
plan identifier used in exchanging data with the
enrollment broker.
- ----------------------------------------------------------------------------------------------------
Digits 5 and 6 Year Indicates the year. For example, reports submitted
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 81 OF 166
July 2004 Medicaid HMO Contract
in 2004 should indicate 04.
---------------------------------------------------------------------------------------------------
Digits 7 and 8 Time Period For reports submitted on a quarterly basis, use Q1,
Q2, Q3 or Q4. For reports submitted monthly, use
the appropriate month, such as 01, 02, 03, etc.
These files can be put on a diskette and mailed to the following
address:
Agency for Health Care Administration
Bureau of Managed Health Care
Data Analysis Unit
Mail Stop Code #26
2727 Mahan Drive
Tallahassee, FL 32308
OR
Attached to an Internet e-mail message and electronically mailed to the
Agency for Health Care Administration at the following address:
MMCDATA@FDHC.STATE.FL.US
AHCA SUPPLIED SPREADSHEET TEMPLATES ON DISKETTE. The agency will
provide templates to the plans for financial and CHCUP reporting. These
templates can be used with Excel spreadsheet applications. The
spreadsheets are to be completed and the diskette mailed to the address
indicated above or attached to an Internet e-mail message and
electronically mailed to the Agency for Health Care Administration at
the email address noted above. Financial reports only must be sent to
the following e-mail address:
MMCFIN@FDHC.STATE.FL.US
60.2.1 `PROPRIETARY' ENROLLMENT AND DISENROLLMENT UPLOADED FILE
Until the transition to the use of the 834 transaction has been
completed, this report is to be submitted monthly to the Florida
Medicaid fiscal agent for every person who is to be involuntarily
disenrolled (using an action code 2 transaction), or transferred to a
different county of operation within the plan (using an action code 2
transaction with the old provider number county and an action code 1
with the new provider number county). No enrollment transactions should
be submitted, since all enrollment transactions are completed by the
agency-contracted enrollment broker. The file uploaded to the Medicaid
fiscal agent's secure Internet site will be a fixed record length ASCII
file (80 bytes)
TABLE 2. FILE LAYOUT
MONTHLY ENROLLMENT, DISENROLLMENT, AND CANCELLATION REPORT FOR PAYMENT FILE SPECIFICATION
- ------------------------------------------------------------------------------------------------------------------
FIELD START END CHARACTER
DATA ELEMENT NAME LENGTH COLUMN COLUMN OR NUMERIC
- ------------------------------------------------------------------------------------------------------------------
1=enrollment transfer, Action Code 1 1 1 N
2=disenrollment,
7=unable to locate
- ------------------------------------------------------------------------------------------------------------------
Valid 9 digit provider number Provider Number 9 2 10 N
- ------------------------------------------------------------------------------------------------------------------
Valid 10 digit Medicaid recipient Recipient Medicaid 10 11 20 N
I.D. number Number
- ------------------------------------------------------------------------------------------------------------------
Recipient's last name Recipient Last Name 12 21 32 C
- ------------------------------------------------------------------------------------------------------------------
Recipient's first name Recipient First Name 9 33 41 C
- ------------------------------------------------------------------------------------------------------------------
Recipient's date of birth Recipient Date of Birth - 8 42 49 N
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 82 OF 166
July 2004 Medicaid HMO Contract
(MMDDYYYY) MMDDYYYY
- ------------------------------------------------------------------------------------------------------------------
HMO/PHP assigned recipient I.D. HMO Recipient ID 9 50 58 C
- ------------------------------------------------------------------------------------------------------------------
HMO location, assigned by plan HMO Location 9 59 67 C
- ------------------------------------------------------------------------------------------------------------------
Reserved for Fiscal Agent Use Filler 1 68 68
- ------------------------------------------------------------------------------------------------------------------
Inactive field, zero fill Filler 8 69 76 C
- ------------------------------------------------------------------------------------------------------------------
Transaction date (MMYY) This HMO Transaction Date- 4 77 80 C
should reflect the date the transaction MMYY
will be effective. Must be the month
following the submission of the file.
ONCE THE TRANSITION TO THE EXCLUSIVE USE OF THE 834 TRANSACTION IS
COMPLETE, THE PLANS MUST COMPLY WITH ALL THE FEDERAL REQUIREMENTS OF
ADMINISTRATIVE SIMPLIFICATION, AS DOCUMENTED IN THE NATIONAL ELECTRONIC
DATA INTERCHANGE TRANSACTION SET IMPLEMENTATION GUIDE FOR THE BENEFIT
ENROLLMENT AND MAINTENANCE ASC X12N 834 TRANSACTION, AS WELL AS THE
ACS/AHCA ANSI ASC X12N 834 COMPANION GUIDE.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 83 OF 166
July 2004 Medicaid HMO Contract
60.2.2 MEDICAID HMO DISENROLLMENT SUMMARY(M***YYMM.DBF)
This report provides a uniform means of reporting each HMO's monthly
involuntary disenrollments and transfers from one county of plan
operation to another. This is a summary report of the number of
transactions submitted to the fiscal agent for processing. The report
is required to enable the agency to assess the reasons for each HMO and
to assure that members are disenrolled in compliance with contract
guidelines.
The plan will submit one record per location (unique 9 digit Medicaid
provider number) in the M***YYMM.dbf file format.
The plan will submit this report monthly, by the 15th day of the month
being reported. The M***YYMM.dbf file will be submitted to the agency
via Internet e-Mail to MMCDATA@FDHC.STATE.FL.US or on a high density
3.5" diskette (IBM compatible, 1.44 Mb) received by the due date at the
address given in Section 60.2.
Agency staff will perform site reviews of disenrollee files to assess
the accuracy of these reports and to review the documentation of
reasons for disenrollment. On a random basis, transactions submitted by
the plan directly to the fiscal agent will also be compared to the
reported number of transactions for a given month.
TABLE 3. FILE LAYOUT FOR MEDICAID HMO DISENROLLMENT SUMMARY REPORTING FILE
FIELD NAME DESCRIPTION TYPE WIDTH
- -------------------------------------------------------------------------------------------------------
PLAN_ID 9 digit provider code (includes 2 digit location) Character 9
- -------------------------------------------------------------------------------------------------------
FROM_DATE The beginning date of the reporting period Date 8
- -------------------------------------------------------------------------------------------------------
TO_DATE The ending date of the reporting period Date 8
- -------------------------------------------------------------------------------------------------------
I1 Missed 3 consecutive appointments in continuous 6 month period Numeric 7
- -------------------------------------------------------------------------------------------------------
I2 Moved out of service area Numeric 7
- -------------------------------------------------------------------------------------------------------
I3 Admitted to long term care facility Numeric 7
- -------------------------------------------------------------------------------------------------------
I4 Fraudulent use of Medicaid or plan ID card Numeric 7
- -------------------------------------------------------------------------------------------------------
I5 Death of enrollee Numeric 7
- -------------------------------------------------------------------------------------------------------
I6 Loss of Medicaid eligibility Numeric 7
- -------------------------------------------------------------------------------------------------------
I7 Resident of state hospital or correctional institution Numeric 7
- -------------------------------------------------------------------------------------------------------
I8 Unable to locate Numeric 7
- -------------------------------------------------------------------------------------------------------
I9 Resident of an ICF/DD Numeric 7
- -------------------------------------------------------------------------------------------------------
I10 Hospice Numeric 7
- -------------------------------------------------------------------------------------------------------
I11 Participants of the Project AIDS Care waiver program Numeric 7
- -------------------------------------------------------------------------------------------------------
I12 Participants of the assisted living waiver Numeric 7
- -------------------------------------------------------------------------------------------------------
I13 Residents of a prescribed pediatric extended care center Numeric 7
- -------------------------------------------------------------------------------------------------------
I14 Members of the Florida Assertive Community Treatment Team (FACT) Numeric 7
- -------------------------------------------------------------------------------------------------------
I15 Enrolled in Medicare HMO Numeric 7
- -------------------------------------------------------------------------------------------------------
I16 Major medical third party coverage Numeric 7
- -------------------------------------------------------------------------------------------------------
I17 Enrolled in + receiving services through Children's Med. Services. Numeric 7
- -------------------------------------------------------------------------------------------------------
I18 Admission to a DJJ residential commitment program/facility Numeric 7
- -------------------------------------------------------------------------------------------------------
Tin Number of Transfers Into This County of Plan Operation Numeric 7
- -------------------------------------------------------------------------------------------------------
Tout Number of Transfers Out of This County of Plan Operation Numeric 7
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 84 OF 166
July 2004 Medicaid HMO Contract
60.2.3 FRAIL/ELDERLY ANNUAL DISENROLLMENT SUMMARY REPORT (E***YY06.dbf)
This report provides a uniform means of reporting disenrollments from
the frail/elderly program.
The plan will submit one record per location (unique 9 digit Medicaid
provider number) in the F***YY06.dbf file format defined in this
section.
The plan will submit this report annually, by June 1. The file will be
submitted to the agency via Internet e-Mail to MMCDATA@FDHC.STATE.FL.US
or on a high density 3.5" diskette (IBM compatible, 1.44 Mb) received
by the due date at the address given in Section 60.2.
Agency staff will perform site reviews of disenrollee files to assess
the accuracy of these reports and to review the documentation of
reasons for disenrollment. These reviews will include a review of
disenrollment due to patient deaths and disenrollments for reasons
reported as other.
FILE LAYOUT FOR FRAIL/ELDERLY DISENROLLMENT SUMMARY REPORTING FILE
FILED NAME DESCRIPTION TYPE WIDTH
- -------------------------------------------------------------------------------------------------------
PLAN_ID 9 digit provider code (includes 2 digit location) Character 9
- -------------------------------------------------------------------------------------------------------
FROM_DATE The beginning date of the reporting period (mm/dd/yy) Date 8
- -------------------------------------------------------------------------------------------------------
TO_DATE The ending date of the reporting period (mm/dd/yy) Date 8
- -------------------------------------------------------------------------------------------------------
V1 Expects to move Numeric 7
- -------------------------------------------------------------------------------------------------------
V2 Wishes to see private M.D, or practitioner, or attend another clinic Numeric 7
- -------------------------------------------------------------------------------------------------------
V3 Dissatisfied with plan policies or procedures Numeric 7
- -------------------------------------------------------------------------------------------------------
V4 Enrolled/Enrolling in MediPass Numeric 7
- -------------------------------------------------------------------------------------------------------
V5 Marketing representative complaint or misrepresentation of plan Numeric 7
- -------------------------------------------------------------------------------------------------------
V6 Enrolled/Enrolling in other Medicaid HMO Numeric 7
- -------------------------------------------------------------------------------------------------------
V7 Other Voluntary Numeric 7
- -------------------------------------------------------------------------------------------------------
V8 Participants of the Assistive Care Services Program Numeric 7
- -------------------------------------------------------------------------------------------------------
I1 Missed 3 consecutive appointments in continuous 6 month period Numeric 7
- -------------------------------------------------------------------------------------------------------
I2 Moved out of service area Numeric 7
- -------------------------------------------------------------------------------------------------------
I3 Admitted to long term care facility Numeric 7
- -------------------------------------------------------------------------------------------------------
I4 Fraudulent use of Medicaid or plan ID card Numeric 7
- -------------------------------------------------------------------------------------------------------
I5 Death of enrollee Numeric 7
- -------------------------------------------------------------------------------------------------------
I6 Loss of Medicaid eligibility Numeric 7
- -------------------------------------------------------------------------------------------------------
I7 Other involuntary Numeric 7
- -------------------------------------------------------------------------------------------------------
I9 Resident of an ICF/DD Numeric 7
- -------------------------------------------------------------------------------------------------------
I10 Hospice Numeric 7
- -------------------------------------------------------------------------------------------------------
I11 Participants of the Project AIDS Care waiver program Numeric 7
- -------------------------------------------------------------------------------------------------------
I12 Participants of the Assisted Living Waiver Numeric 7
- -------------------------------------------------------------------------------------------------------
I14 Members of the Florida Assertive Community Treatment Team Numeric 7
(FACT)
- -------------------------------------------------------------------------------------------------------
I15 Enrolled in Medicare HMO Numeric 7
- -------------------------------------------------------------------------------------------------------
I16 Major medical third party coverage Numeric 7
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 85 OF 166
July 2004 Medicaid HMO Contract
60.2.4 SERVICE UTILIZATION SUMMARY (S***YYQ*.dbf)
The plan will submit service utilization reports to the agency in the
format defined below. This data includes services provided to MediKids
members. This report is due within 45 calendar days after the end of
the quarter being reported. For reporting purposes, calendar year
quarters end as follows: Quarter 1, March; Quarter 2, June; Quarter 3,
September; Quarter 4, December. The agency reserves the right to
modify information and format.
The plan will submit quarterly service utilization reports in the
format of the dBASE III+ compatible file (S***YYQ*.dbf) defined below.
1. Medicaid ID: The 7 digit Medicaid provider number for
a Medicaid contracted plan.
2. Report Type: Fill in the field rept_type with the
value SUT to indicate the service utilization report.
3. Reporting Period: Complete the from_date and to_date
fields with the beginning and ending dates of the
quarter you are reporting. All date fields must be
completed in traditional dbf format of mm/dd/yy.
4. Service Utilization Measures:
Each Service Utilization measure described below will
be reported by recipient eligibility category as
defined on Table 4. These categories are AFDC related
(AFDC, foster care, SOBRA), SSI with no Medicare, SSI
with Medicare part B, SSI with Medicare part A and B,
and persons served under the Frail Elderly program.
Please note that only those plans that operate an
Agency-approved Frail Elder expanded benefit should
include Frail Elderly program data in this report.
A) Hospital Inpatient (Days): Enrollee inpatient days
provided in the quarter. Do not report the number of
stays or visits.
B) Emergency Center (Visits): Enrollee visits emergency
centers (e.g., hospital emergency rooms and emergency
clinics).
C) Physician Office (Visits): Enrollee visits to
physician's offices (e.g., primary or specialty care
by medical doctor or doctor of osteopathic medicine).
D) Non-Physician Office (Visits): Enrollee visits to
non-physicians' offices for a variety of treatment
reasons, modalities and services, including:
Physicians Assistant; Advanced Registered Nurse
Practitioner.
E) Prescribed Medicine: Enter the number of
prescriptions. If a prescription is refillable, each
refill is counted separately. Include all services
for which the plan paid, whether provided in house,
contracted, or community pharmacies.
F) Nursing Home Days: Enter the number of nursing home
days experienced by plan enrollees. Do not enter the
number of stays or visits.
G) Live Births: Number of children born to members of
your health plan.
H) Outpatient Center (Visits): Enrollee visits to
outpatient centers (e.g. hospital outpatient
agencies, ambulatory surgery centers and diagnostic
centers).
I) Community Mental Health Services: Number of Community
Mental Health Services provided by the plan to
enrollees in your Medicaid contracted plan. These
services include procedure codes 90801, 90825, 90843,
90844, 90853, 90862, 90887, 99214, W1023, W1027,
W1044, W1046, W1058, W1059, W1060, W1061, W1064,
W1067 through W1075.
J) Targeted Case Management Services: Number of mental
health targeted case management services provided by
the plan. Included services are: mental health case
management for children under 18 (Medicaid procedure
code W9891), mental health case management for adults
(W9892), intensive team mental health case management
(W9899).
K) Transportation Services: Number of trips provided by
your plan to plan enrollees. Count a round trip as
two trips.
L) Dental Services (if covered): Number of Dental
Services provided by your plan to your plan members.
Report all dental categories of service (D0100-D9999)
provided. These services comprise CPT codes 10060
through 99285.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 86 OF 166
July 2004 Medicaid HMO Contract
M) Total Enrollee Months: The number multiplied by the
number of months served during the quarter. For
example, if a person is enrolled in your plan for the
entire quarter, then that corresponds to 3 months
multiplied by 1 enrollee, that is a 3 enrollee
months. This information can be obtained by summing
the enrollee months for the quarter by eligibility
category from the summary page of each month's final
HMO Ongoing Report.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 87 OF 166
July 2004 Medicaid HMO Contract
TABLE 4. FIELD NAMES FOR SERVICE UTILIZATION SUMMARY FILE (S***YYQ*.dbf)
HMO SERVICE UTILIZATION REPORT LAYOUT
MEDICAID ID: PLAN ID REPT_TYPE: SUT REPORTING PERIOD: FROM FROM DATE TO TO DATE
UTILIZATION MEASURES ELIGIBILITY CATEGORIES
- -----------------------------------------------------------------------------------------------------------------------------------
AFDC / FOSTER SSI - NO SSI-PART B SSI-PART FRAIL
SERVICES UNIT OF MEASURE MEDICARE MEDICARE A&B ELDERLY**
CARE / SOBRA MEDICARE
- -----------------------------------------------------------------------------------------------------------------------------------
Hospital Inpatient Days AFDC_HI SSI_HI SSIB_HI SSIAB_HI FE_HI**
- -----------------------------------------------------------------------------------------------------------------------------------
Emergency Center Visits AFDC_EC SSI_EC SSIB_EC SSIAB_EC FE_EC**
- -----------------------------------------------------------------------------------------------------------------------------------
Physician Office Visits AFDC_PO SSI_PO SSIB_PO SSIAB_PO FE_PO**
- -----------------------------------------------------------------------------------------------------------------------------------
Non-Physician Office Visits AFDC_NO SSI_NO SSIB_NO SSIAB_NO FE_NO**
- -----------------------------------------------------------------------------------------------------------------------------------
Prescribed Medicines Number of Prescriptions AFDC_RX SSI_RX SSIB_RX SSIAB_RX FE_RX**
- -----------------------------------------------------------------------------------------------------------------------------------
Nursing Home Days AFDC_NH SSI__NH SSIB_NH SSIAB_NH FE_NH**
- -----------------------------------------------------------------------------------------------------------------------------------
Live Births Number of Births AFDC_LB SSI_LB SSIB_LB SSIAB_LB FE_LB**
- -----------------------------------------------------------------------------------------------------------------------------------
Outpatient/Ambulatory Surgeries Number of Outpatient Surgeries AFDC_AS SSI_AS SSIB_AS SSIAB_AS FE_AS**
- -----------------------------------------------------------------------------------------------------------------------------------
Community Mental Health Number of Community Mental AFDC_MH SSI_MH SSIB_MH SSIAB_MH FE_MH**
Services Health Services
- -----------------------------------------------------------------------------------------------------------------------------------
Targeted Case Management Number of Targeted Case AFDC_CM SSI_CM SSIB_CM SSIAB_CM FE_CM**
Services Management Services
- -----------------------------------------------------------------------------------------------------------------------------------
Transportation Services Number of Trips AFDC_TR SSI_TR SSIB_TR SSIAB_TR FE_TR**
- -----------------------------------------------------------------------------------------------------------------------------------
Dental Services Number of Services Provided AFDC_DN SSI_DN SSIB_DN SSIAB_DN FE_DN**
- -----------------------------------------------------------------------------------------------------------------------------------
Total Enrollee Months AFDC_EM SSI_EM SSIB_EM SSIAB_EM FE_EM**
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 88 OF 166
July 2004 Medicaid HMO Contract
TABLE 5. STRUCTURE FOR SERVICE UTILIZATION SUMMARY REPORTING FILE (S***YYQ*.DBF)
FIELD FIELD NAME TYPE WIDTH FIELD FIELD NAME TYPE WIDTH FIELD FIELD NAME TYPE WIDTH
- ----------------------------------------------------------------------------------------------------------
1 PLAN_ID Character 7 24 FE_NO Numeric 9 47 SSIB_MH Numeric 9
- ----------------------------------------------------------------------------------------------------------
2 FROM_DATE Date 8 25 AFDC_RX Numeric 9 48 SSIAB_MH Numeric 9
- ----------------------------------------------------------------------------------------------------------
3 TO_DATE Date 8 26 SSI_RX Numeric 9 49 FE_MH Numeric 9
- ----------------------------------------------------------------------------------------------------------
4 REPT_TYPE Character 5 27 SSIB_RX Numeric 9 50 AFDC_CM Numeric 9
- ----------------------------------------------------------------------------------------------------------
5 AFDC_HI Numeric 9 28 SSIAB_RX Numeric 9 51 SSI_CM Numeric 9
- ----------------------------------------------------------------------------------------------------------
6 SSI_HI Numeric 9 29 FE_RX Numeric 9 52 SSIB_CM Numeric 9
- ----------------------------------------------------------------------------------------------------------
7 SSIB_HI Numeric 9 30 AFDC_NH Numeric 9 53 SSIAB_CM Numeric 9
- ----------------------------------------------------------------------------------------------------------
8 SSIAB_HI Numeric 9 31 SSI_NH Numeric 9 54 FE_CM Numeric 9
- ----------------------------------------------------------------------------------------------------------
9 FE_HI Numeric 9 32 SSIB_NH Numeric 9 55 AFDC_TR Numeric 9
- ----------------------------------------------------------------------------------------------------------
10 AFDC_EC Numeric 9 33 SSIAB_NH Numeric 9 56 SSI_TR Numeric 9
- ----------------------------------------------------------------------------------------------------------
11 SSI_EC Numeric 9 34 FE_NH Numeric 9 57 SSIB_TR Numeric 9
- ----------------------------------------------------------------------------------------------------------
12 SSIB_EC Numeric 9 35 AFDC_LB Numeric 9 58 SSIAB_TR Numeric 9
- ----------------------------------------------------------------------------------------------------------
13 SSIAB_EC Numeric 9 36 SSI_LB Numeric 9 59 FE_TR Numeric 9
- ----------------------------------------------------------------------------------------------------------
14 FE_EC Numeric 9 37 SSIB_LB Numeric 9 60 AFDC_DN Numeric 9
- ----------------------------------------------------------------------------------------------------------
15 AFDC_PO Numeric 9 38 SSIAB_LB Numeric 9 61 SSI_DN Numeric 9
- ----------------------------------------------------------------------------------------------------------
16 SSI_PO Numeric 9 39 FE_LB Numeric 9 62 SSIB_DN Numeric 9
- ----------------------------------------------------------------------------------------------------------
17 SSIB_PO Numeric 9 40 AFDC_AS Numeric 9 63 SSIAB_DN Numeric 9
- ----------------------------------------------------------------------------------------------------------
18 SSIAB_PO Numeric 9 41 SSI_AS Numeric 9 64 FE_DN Numeric 9
- ----------------------------------------------------------------------------------------------------------
19 FE_PO Numeric 9 42 SSIB_AS Numeric 9 65 AFDC_EM Numeric 9
- ----------------------------------------------------------------------------------------------------------
20 AFDC_NO Numeric 9 43 SSIAB_AS Numeric 9 66 SSI_EM Numeric 9
- ----------------------------------------------------------------------------------------------------------
21 SSI_NO Numeric 9 44 FE_AS Numeric 9 67 SSIB_EM Numeric 9
- ----------------------------------------------------------------------------------------------------------
22 SSIB_NO Numeric 9 45 AFDC_MH Numeric 9 68 SSIAB_EM Numeric 9
- ----------------------------------------------------------------------------------------------------------
23 SSIAB_NO Numeric 9 46 SSI_MH Numeric 9 69 FE_EM Numeric 9
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 89 OF 166
July 2004 Medicaid HMO Contract
60.2.5 APPEALS REPORT (A***YYQ*.DBF)
The Appeals Report provides the agency with detailed information about
the plan's ability to handle member appeals through its internal
grievance system. Please refer to Section 100.0 of this contract for
the definitions of grievances, actions and appeals.
The A*** YYQ*.dbf file will be submitted to the Agency for Health Care
Administration via Internet e-Mail to MMCDATA@FDHC.STATE.FL.US or on a
high density 3.5" diskette (IBM compatible, 1.44 Mb) received within 45
calendar days following the end of the reported quarter. An appeals
report must be submitted each quarter by each plan. If no new appeals
have arisen in any counties of plan operation, or if the status of an
unresolved appeal has not changed to 'Resolved,' please submit one
record only. This record must contain the PLAN_ID field only, with the
first 7 digits of the 9-digit Medicaid provider number.
TABLE 6. STRUCTURE FOR APPEAL REPORTING FILE
Field Name Type Width Description
- ----------------------------------------------------------------------------------------------------------
PLAN_ID Character 9 Your nine digit Medicaid provider number.
- ----------------------------------------------------------------------------------------------------------
RECIP_ID Character 9 The recipient's 9 digit Medicaid ID number
- ----------------------------------------------------------------------------------------------------------
LAST_NAME Character 15 he recipient's last name
- ----------------------------------------------------------------------------------------------------------
FIRST_NAME Character 15 he recipient's first name
- ----------------------------------------------------------------------------------------------------------
MID_INIT Character 1 The recipient's middle initial
- ----------------------------------------------------------------------------------------------------------
APP_DATE Date 8 The date of the appeal
- ----------------------------------------------------------------------------------------------------------
EXPED_REQ Character 1 Indicate whether or not the appeal was an expedited request
Y =Yes N = No
- ----------------------------------------------------------------------------------------------------------
APP_TYPE Character 1 Indicate whether the appeal is related to a behavioral health service
Y = Yes N=No
- ----------------------------------------------------------------------------------------------------------
APP_TYPE Numeric 2 The type of appeal:
- ----------------------------------
1. Quality of Care 9. Enrollment/Disenrollment
2. Access to Care 10. Termination of Contract
3. Emergency Services 11. Services after termination
4. Not Medically Necessary 12. Unauthorized out of plan svcs
5. Pre-Existing Condition 13. Unauthorized in-plan svcs
6. Excluded Benefit 14. Benefits available in plan
7. Billing Dispute 15. Experimental/Investigational
8. Contract Interpretation 16. Other
- ----------------------------------------------------------------------------------------------------------
DISP_DATE Date 8 The date of the disposition (mm/dd/yy)
- ----------------------------------------------------------------------------------------------------------
DISP Numeric 2 The disposition of the appeal:
- ----------------------------------
1. Referral made to specialist 10. In HMO Grievance System
2. PCP Appointment made 11. Referred to Area Office
3. Bill Paid 12. Member sent OLC form
4. Procedure scheduled 13. Lost contact with member
5. Reassigned PCP 14. Hospitalized / Institutionalized
6. Reassigned Center 15. Confirmed original decision
7. Disenrolled Self 16. Reinstated in HMO
8. Disenrolled by plan 17. Other
9. In HMO QA Review
- ----------------------------------------------------------------------------------------------------------
DISP_STAT Character 1 R= Resolved U = Unresolved
Note: Any appeal reported as unresolved must be reported again
when resolved. Appeals that are resolved in the quarter prior to
reporting should be reported for the first time as resolved.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 90 OF 166
July 2004 Medicaid HMO Contract
60.2.6 INPATIENT DISCHARGE REPORT (H***YYQ*.DBF)
The Inpatient Discharge Report provides the agency with detailed
hospital inpatient utilization information. This includes general acute
care and inpatient psychiatric services. The plan must submit a DBF
file with the following record layout to the Agency via Internet e-mail
to MMCDATA@FDHC.STATE.FL.US, on a high density 3.5" diskette (IBM
compatible, 1.44 Mb), or on a CD, quarterly within 30 calendar days
following the end of the reported quarter. During the first year of the
contract period, these data records will be submitted to the fiscal
agent's State Healthcare Clearinghouse using the HIPAA-compliant X12N
837 transaction. The Agency will provide adequate written notice prior
to beginning this conversion.
TABLE 7. STRUCTURE FOR INPATIENT DISCHARGE REPORTING FILE
FIELD NAME TYPE WIDTH DESCRIPTION
- ----------------------------------------------------------------------------------------------------------
PLAN_ID Character 9 9 Digit Medicaid provider number of health plan
- ----------------------------------------------------------------------------------------------------------
RECIP_ID Character 9 9 Digit Medicaid ID number of plan member
- ----------------------------------------------------------------------------------------------------------
RECIP_LAST Character 20 Last name of plan member
- ----------------------------------------------------------------------------------------------------------
RECIP_FIRS Character 10 First name of plan member
- ----------------------------------------------------------------------------------------------------------
RECIP_DOB Date 8 Plan member's date of birth
- ----------------------------------------------------------------------------------------------------------
HOSP_ID Character 9 AHCA ID Number of admitting hospital
- ----------------------------------------------------------------------------------------------------------
HOSP_NAME Character 50 Optional Field if ID not on agency-supplied list; Please use upper
case only.
- ----------------------------------------------------------------------------------------------------------
ADMIT Date 8 Date of Admission
- ----------------------------------------------------------------------------------------------------------
DISCH Date 8 Date of Discharge
- ----------------------------------------------------------------------------------------------------------
ADMIT_TYPE Character 1 Indicates the Type of Admission.
1=General Acute Care
2=Inpatient Psych
- ----------------------------------------------------------------------------------------------------------
TPL Numeric 5 Amount paid by third party (whole dollars)
- ----------------------------------------------------------------------------------------------------------
DIAGI Character 7 Primary ICD-9 Diagnosis
- ----------------------------------------------------------------------------------------------------------
DIAG2 Character 7 Secondary ICD-9 Diagnosis (if applicable)
- ----------------------------------------------------------------------------------------------------------
DIAG3 Character 7 Tertiary ICD-9 Diagnosis (if applicable)
- ----------------------------------------------------------------------------------------------------------
PROC1 Character 5 For an surgical or obstetrical admission, the principal ICD-9
Procedure Code
- ----------------------------------------------------------------------------------------------------------
PROC2 Character 5 For an surgical or obstetrical admission, the secondary ICD-9
Procedure Code
- ----------------------------------------------------------------------------------------------------------
PROC3 Character 5 For an surgical or obstetrical admission, the tertiary ICD-9
Procedure Code
60.2.7 MARKETING REPRESENTATIVE REPORT (R***YYMM.XLS)
The plan shall be required to register each marketing representative
with the agency as outlined in Section 30.3, Marketing Representatives.
The R***YYMM.xls file will be submitted within five days of the
reporting month to the agency at the following e-mail address:
petrieg@fdhc.state.fl.us. The agency-supplied spreadsheet template must
be used. This template contains the following data elements:
TABLE 8: REQUIRED INFORMATION FOR MARKETING REPRESENTATIVE REPORT TEMPLATE()
Plan Information Marketing Representative Information
-----------------------------------------------------------
Plan Name Last Name
-----------------------------------------------------------
Address First Name
-----------------------------------------------------------
Contact Person DOI License Number
-----------------------------------------------------------
Phone Address
-----------------------------------------------------------
Fax City
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 91 OF 166
July 2004 Medicaid HMO Contract
Email Address State
-----------------------------------------------------------
Zip
-----------------------------------------------------------
Office Phone
-----------------------------------------------------------
Cell Phone
-----------------------------------------------------------
Last HMO Employer
60.2.8 PROVIDER NETWORK REPORT
The agency shall collect provider network information from the Medicaid
contracted HMOs. The plan shall submit to the enrollment and
disenrollment services contractor, via FTP, the plan's provider
directory for each county on at least a monthly basis, and in the
format described below. This report serves dual purposes. The
enrollment services contractor loads this information into their BESST
system for use in answering beneficiary questions and to enable primary
care provider (PCP) selection at the time of voluntary plan enrollment.
The agency uses the file to monitor the plan's compliance with required
provider network composition and PCP to member ratios, and for other
uses deemed pertinent. The plan must ensure that this is an electronic
representation of the plan's network of contracted providers, not a
listing of entities for whom claims have been paid.
The file is an ASCII flat file and is a complete refresh of the
provider information. The file must be submitted on the Monday
preceding the second to the last Saturday of each month. If this Monday
deadline falls on a holiday, the file must be submitted on the Friday
before the holiday. Both the enrollment services contractor and the
Agency will use this required file. The plan may also choose to submit
the file a second time each month, on the third business day before the
end of the month. The plan may use this optional file submission
opportunity to ensure that the information presented to beneficiaries
is the most current data available. Updated provider network
information is available to the enrollment specialists two to three
business days after the submission deadline.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 92 OF 166
July 2004 Medicaid HMO Contract
TABLE 9. FILE LAYOUT FOR MEDICAID HMO PROVIDER NETWORKS
Field Required Field
Field Name Length Field Format Justification Comments
- -----------------------------------------------------------------------------------------------------------------------------------
Plan Code 9 X alpha Left with This is the 9 digit Medicaid Provider ID number
leading zeros specific to the county of HMO operation.
- -----------------------------------------------------------------------------------------------------------------------------------
Provider Type 1 X alpha Left Identifies the provider's general area of service with
an alpha character, as follows:
P = Primary Care Provider (PCP)
I = Individual Practitioner other than a PCP
B = Birthing Center
T = Therapy
G = Group Practice (includes FQHCs and RHCs)
H = Hospital
C = Crisis Stabilization Unit
D = Dentist
R = Pharmacy
A = Ancillary Provider (DME providers, Home Health
Care Agencies, etc.)
- -----------------------------------------------------------------------------------------------------------------------------------
Plan Provider 15 X alpha Left with leading Unique number assigned to the provider by the plan.
Number zeros
- -----------------------------------------------------------------------------------------------------------------------------------
Group Affiliation 15 Required for alpha Left with The unique provider number assigned by the HMO to the
all groups and leading zeros group practice. This field is required for all
providers providers who are members of a group, such as PCPs
who are and specialists. The group affiliation number must be
members of a the same for all providers who are members of that
group group. A record is also required for each group
practice being reported. For groups, this
identification number must be the same as the plan
provider number.
- -----------------------------------------------------------------------------------------------------------------------------------
SSN or FEIN 9 X alpha Left with Social Security Number of Federal Identification
.. leading zeros Number for the individual provider or the group
practice.
- -----------------------------------------------------------------------------------------------------------------------------------
Provider last 30 X alpha Left The last name of the provider, or the first
name 30 characters of the name of the group. (Please do
not include courtesy titles such as Dr., Mr., Ms.,
since this titles can interfere with electronic
searches of the data.) This field should also be used
to note hospital name. UPPER CASE ONLY PLEASE.
- -----------------------------------------------------------------------------------------------------------------------------------
Provider first 30 X alpha Left The first name of the provider, or the continuation
name of the name of the group. Please do not include
provider middle name in this field. Middle name field
has been added at the end of the file for this
purpose. UPPER CASE ONLY PLEASE.
- -----------------------------------------------------------------------------------------------------------------------------------
Address line 1 30 X alpha Left Physical location of the provider or practice. Do not
use P.O. Box or mailing address is different from
practice location. UPPER CASE ONLY PLEASE.
- -----------------------------------------------------------------------------------------------------------------------------------
Address line 2 30 alpha Left
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 93 OF 166
July 2004 Medicaid HMO Contract
City 30 X alpha Left Physical city location of the provider or practice.
Left UPPER CASE ONLY PLEASE
- -----------------------------------------------------------------------------------------------------------------------------------
Zip Code 9 X numeric Left with Physical zip code location of the provider or
trailing zeros practice. Accuracy is important, since address
information is one of the standard items used to
search for providers that are located in close
proximity to the member.
- -----------------------------------------------------------------------------------------------------------------------------------
Phone area code 3 numeric Left
- -----------------------------------------------------------------------------------------------------------------------------------
Phone number 7 numeric Left Please note that the format does not allow for use of
a hyphen
- -----------------------------------------------------------------------------------------------------------------------------------
Phone extension 4 numeric Left
- -----------------------------------------------------------------------------------------------------------------------------------
Sex 1 alpha Left The gender of the provider. Valid values: M = male;
F = Female; U = Unknown
- -----------------------------------------------------------------------------------------------------------------------------------
PCP Indicator 1 X alpha Left Used to indicate if an individual provider is a
primary care physician. Valid values: P = Yes, the
provider is a PCP; N = No, the provider is not a PCP.
This field should not be used to note group providers
as PCPs, since members must be assigned to specific
providers, not group practices.
- -----------------------------------------------------------------------------------------------------------------------------------
Provider 1 Required if alpha Left X = Accepting new patients
Limitation PCP Indicator N = Not accepting new patients but remaining a
= P contracted network provider
L = Not accepting new patients; leaving the network
(Please note the "L" designation at
the earliest opportunity)
P = Only accepting current patients
C = Accepting children only
A = Accepting adults only
R = Refer member to HMO member services
F = Only accepting female patients
- -----------------------------------------------------------------------------------------------------------------------------------
HMO/MediPass 1 X alpha Left H = HMO
Indicator This field must be completed with this designation
for each record submitted by the HMO.
- -----------------------------------------------------------------------------------------------------------------------------------
Evening hours 1 alpha Left Y = Yes; N = No
- -----------------------------------------------------------------------------------------------------------------------------------
Saturday hours 1 alpha Left Y = Yes; N = No
- ----------------------------------------------------------------------------------------------------------------------------------
Age restrictions 20 alpha Left Populate this field with free-form text, to identify
any age restriction the provider may have on their
practice.
- -----------------------------------------------------------------------------------------------------------------------------------
Primary Specialty 3 Required if numeric Left with Insert the 3 digit code that most closely describes
Provider leading zeros ------------------------------------------------------
Type = P or I 001 Adolescent Medicine 002 Allergy
------------------------------------------------------
003 Anesthesiology 004 Cardiovascular
Medicine
------------------------------------------------------
005 Dermatology 006 Diabetes
------------------------------------------------------
007 Emergency Medicine 008 Endocrinology
------------------------------------------------------
009 General Family Practice 010 Gastroenterology
------------------------------------------------------
011 General Practice 012 Preventative
Medicine
------------------------------------------------------
013 Geriatrics 014 Gynecology
------------------------------------------------------
015 Hematology 016 Immunology
------------------------------------------------------
017 Infectious Diseases 018 Internal Medicine
-----------------------------------------------------
019 Neonatal/Perinatal 020 Neoplastic
Diseases
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 94 OF 166
July 2004 Medicaid HMO Contract
021 Nephrology 022 Neurology
------------------------------------------------------
023 Neurology/Children 024 Neuropathology
------------------------------------------------------
025 Nutrition 026 Obstetrics
------------------------------------------------------
027 OB-GYN 028 Occupational
Medicine
------------------------------------------------------
029 Oncology 030 Ophthalmology
------------------------------------------------------
031 Otolaryngology 032 Pathology
------------------------------------------------------
033 Pathology, Clinical 034 Pathology, Forensic
------------------------------------------------------
035 Pediatrics 036 Pediatric Allergy
------------------------------------------------------
037 Pediatric Cardiology 038 Pediatric Oncology
&Hematology
------------------------------------------------------
039 Pediatric Nephrology 040 Pharmacology
------------------------------------------------------
041 Physical Medicine 042 Psychiatry
and Rehab
------------------------------------------------------
043 Psychiatry, Child 044 Psychoanalysis
------------------------------------------------------
045 Public Health 046 Pulmonary Diseases
------------------------------------------------------
047 Radiology 048 Radiology,
Diagnostic
------------------------------------------------------
049 Radiology, Pediatric 050 Radiology,
Therapeutic
------------------------------------------------------
051 Rheumatology 052 Surgery, Abdominal
------------------------------------------------------
053 Surgery, Cardiovascular 054 Surgery, Colon /
Rectal
------------------------------------------------------
055 Surgery, General 056 Surgery, Hand
------------------------------------------------------
057 Surgery, Neurological 058 Surgery, Orthopedic
------------------------------------------------------
059 Surgery, Pediatric 060 Surgery, Plastic
------------------------------------------------------
061 Surgery, Thoracic 062 Surgery, Traumatic
------------------------------------------------------
063 Surgery, Urological 064 Family Planning
------------------------------------------------------
065 Maternal/Fetal 066 Therapeutic
Comprehensive
Assessment
------------------------------------------------------
067 Physical Therapist 068 Therapeutic
Foster Care
------------------------------------------------------
069 UNUSED 070 Adult Dentures Only
------------------------------------------------------
071 General Dentistry 072 Oral Surgeon
(Dentist)
------------------------------------------------------
073 Pedodontist 074 Other Dentist
------------------------------------------------------
075 Adult Primary Care 076 Clinical Nurse
Nurse Practitioner Spec. Psych Mental
with Nurse
------------------------------------------------------
077 College Health Nurse 078 Diabetic Nurse
Practitioner Practitioner
------------------------------------------------------
079 UNUSED 080 Family Nurse
Practitioner
------------------------------------------------------
081 Family Planning Nurse 082 Geriatric Nurse
Practitioner Practitioner
------------------------------------------------------
083 Maternal/Child Family 084 Cert. Reg.
Planning Nurse Practitioner Nurse Anesthetist
------------------------------------------------------
085 Certified Registered 086 OB/GYN Nurse
Nurse Midwife Practitioner
------------------------------------------------------
087 Pediatric Nurse 088 Orthodontist
Practitioner
------------------------------------------------------
089 Assisted Living for 090 Occupational
the Elderly Therapist
------------------------------------------------------
091 Physical Therapist 092 Speech Therapist
------------------------------------------------------
093 Respiratory Therapist 094 Katie Beckett
------------------------------------------------------
095 Aged/Disabled Adults 096 Developmental
Services Disability
------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 95 OF 166
July 2004 Medicaid HMO Contract
097 Channeling 098 Community Supported Living
Arrangement
----------------------------------------------------------
099 Project AIDS Care 100 Chiropractor
----------------------------------------------------------
101 Optometrist 102 Podiatrist
----------------------------------------------------------
103 Urologist
----------------------------------------------------------
Specialty 2 3 numeric Left with Use codes listed above.
leading
- ------------------------------------------------------------------------------------------------------------------------------------
Specialty 3 3 numeric Left with Use codes listed above.
leading
- ------------------------------------------------------------------------------------------------------------------------------------
Language 1 2 numeric Left with 01 = English
leading 02 = Spanish
03 = Haitian Creole
04 = Vietnamese
05 = Cambodian
06 = Cambodian
07 = Cambodian
08 = Polish
09 = French
10 = Other
- ------------------------------------------------------------------------------------------------------------------------------------
Language 2 2 numeric Use codes listed above.
- ------------------------------------------------------------------------------------------------------------------------------------
Language 3 2 numeric Use codes listed above.
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital 9 numeric Left with Hospital with which the provider isaffiliated
Affiliation 1 leading zeros Use the AHCA ID for accurate identification,
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital 9 numeric Left with as above
Affiliation 2 leading zeros
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital 9 numeric Left with as above
Affiliation 3 leading zeros
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital 9 numeric Left with as above
Affiliation 4 leading zeros
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital 9 numeric Left with as above
Affiliation 5 leading zeros
- ------------------------------------------------------------------------------------------------------------------------------------
Wheel Chair 1 alpha Indicates if the provider's office is wheelchair Use Y = Yes or N = No.
Access accessible.
- ------------------------------------------------------------------------------------------------------------------------------------
# of HMO 4 X numeric Left with Information must be provided for PCPs only.Indicates the total number
Members leading zeros of patients who are enrolled in submitting plan.For providers who
practice at multiple locations, the number of HMO members specific to
each physical location must be specified.
- ------------------------------------------------------------------------------------------------------------------------------------
Active Patient 4 X numeric Left with Total Active Patient Load, as defined in contract
Load leading zeros
- ------------------------------------------------------------------------------------------------------------------------------------
Professional 10 X alpha/ Must be included for all health care professionals. License number is
formatted with up
- ------------------------------------------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 96 OF 166
July 2004 Medicaid HMO Contract
License Number numeric to 3 alpha characters followed by up to 7 numeric digits.
- ------------------------------------------------------------------------------------------------------------------------------------
AHCA Hospital 8 Required if numeric Left with The number assigned by the Agency to uniquely identify each
ID Provider leading zeros specific hospital by physical location. Any out of state
Type = "H" hospital for which an AHCA ID is not included should be
designated with the pseudo-number 99999999.
- ------------------------------------------------------------------------------------------------------------------------------------
County Health 1 X alpha Used to designate whether the individual or group provider is
Department associated only with a county health department.Y = Yes; N =
(CHD)Indicator field must be completed for all PCP and
No. This specialty providers.
- ------------------------------------------------------------------------------------------------------------------------------------
Filler 47 X
- ------------------------------------------------------------------------------------------------------------------------------------
Trailer Record
The trailer record is used to balance the number of recordsreceived with the
number loaded on BESST. The data from the Trailer Record is not loaded on BESST.
RECORD LENGTH: 76
Field Field
Field Name Length Format Values
- --------------------------------------------------------------------------------------------------
Trailer Record Text 36 Alpha 'TRAILER RECORD DATA'
- --------------------------------------------------------------------------------------------------
Record Count 7 Numeric Total number of records on file
excluding the trailer record (right
justified, zero filled)
- --------------------------------------------------------------------------------------------------
System Process date 8 Alpha Mmddyyyy
- --------------------------------------------------------------------------------------------------
Filler 25
- --------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 97 OF 166
July 2004 Medicaid HMO Contract
60.2.9 CHILD HEALTH CHECK-UP REPORTING
This annual EPSDT (CHCUP-CMS 416) report provides basic information on
participation in the Medicaid Child Health Check-Up program. The
information is used to comply with Federal EPSDT (CMS 416) reporting
requirements and allows the state to assess the effectiveness of EPSDT
programs operated by the plans. Child health screening services are
defined for purposes of reporting on this form as initial or periodic
screens required to be provided according to Florida's screening
periodicity schedule.
THIS REPORT IS DUE BY THE JANUARY 15TH FOLLOWING THE END OF THE
REPORTING PERIOD. THE REPORTING PERIOD IS FROM OCTOBER 1 THROUGH
SEPTEMBER 30. For example, the report covering October 1, 2002 through
September 30, 2002 will be due on or before January 2003. A reporting
template will be provided with all formulas entered. The method of
calculation is provided in the detailed instructions below for your
information. By October 1 of the following year, the plans shall
deliver to the Agency a certification by an Agency approved independent
auditor that the Child Health Checkup data have been fairly and
accurately presented.
DETAILED INSTRUCTIONS - For each of the following line items, report
total counts by the age groups indicated. In cases where calculations
are necessary, perform separate calculations for the total column and
each age group. Report age BASED UPON THE CHILD'S AGE AS OF SEPTEMBER
30 OF THE FEDERAL FISCAL YEAR.
MEDICAID PROVIDER ID NUMBER - Enter the plan's seven digit Medicaid
Provider ID number
PLAN NAME. Enter the name of your Health Plan.
FISCAL YEAR. Enter the federal fiscal year being reported. Example
October 1, 2001 - September 30, 2002 is Federal Fiscal year 2001-2002.
LINE 1 - TOTAL INDIVIDUALS ELIGIBLE FOR EPSDT (CHCUP) - Enter the total
unduplicated number of all individuals under the age of 21 enrolled in
the plan, distributed by age and by basis of Medicaid eligibility.
Unduplicated means that an eligible person is reported only once
although he or she may have had more than one period of eligibility
during the year. Medicaid-eligible individuals under age 21 are
considered eligible for EPSDT (CHCUP) services, regardless of whether
they have been informed about the availability of EPSDT (CHCUP)
services or whether they accept EPSDT (CHCUP) services at the time of
informing.
DO NOT COUNT YOUR MEDIKIDS POPULATIONS.
LINE 2a - STATE PERIODICITY SCHEDULE - Given.
LINE 2b - NUMBER OF YEARS IN AGE GROUP - Given
LINE 2c - ANNUALIZED STATE PERIODICITY SCHEDULE - Given
LINE 3a - TOTAL MONTHS ELIGIBILITY - Enter the total months of
eligibility for the individuals in each age group in line 1 during the
reporting year.
LINE 3b - AVERAGE PERIOD OF ELIGIBILITY - Calculated by dividing the
total months of eligibility by line 1. Divide that number by 12 and
enter the quotient. This number represents the portion of the year that
individuals remain Medicaid eligible during the reporting year,
regardless of whether eligibility was maintained continuously.
LINE 4 - EXPECTED NUMBER OF SCREENINGS PER ELIGIBLE MULTIPLIED -
Calculated by multiplying line 2c by line 3b. Enter the product. This
number reflects the expected number of initial or periodic screenings
per child per year based on the number required by the state-specific
periodicity schedule and the average period of eligibility.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 98 OF 166
July 2004 Medicaid HMO Contract
LINE 5 - EXPECTED NUMBER OF SCREENINGS - Calculated by multiplying line
4 by line 1. Enter the product. This reflects the total number of
initial or periodic screenings expected to be provided to the eligible
individuals in line 1.
LINE 6 - TOTAL SCREENS RECEIVED - Enter the total number of initial or
periodic screens furnished to eligible individuals under either
fee-for-service or managed care arrangements. This includes those
initial screens billed to Medicaid's fiscal agent in accordance with
Section 80.1 a. of this contract. USE THE CPT CODES LISTED BELOW OR ANY
PLAN-SPECIFIC EPSDT (CHCUP) CODES YOU MAY HAVE DEVELOPED IN THE PLAN
FOR THESE SCREENS. USE OF THESE PROXY CODES IS FOR REPORTING PURPOSES
ONLY. PLANS MUST CONTINUE TO ENSURE THAT ALL FIVE AGE-APPROPRIATE
ELEMENTS OF AN EPSDT (CHCUP) SCREEN, AS DEFINED BY LAW, ARE PROVIDED TO
EPSDT (CHCUP) RECIPIENTS.
NOTE: This number should not reflect sick visits or episodic visits
provided to children unless an initial or periodic screen was also
performed during the visit. However, it may reflect a screen outside of
the normal state periodicity schedule that is used as a "catch-up"
EPSDT (CHCUP) screening. (A catch-up EPSDT (CHCUP) screening is defined
as a complete screening that is provided to bring a child up-to-date
with the State's screening periodicity schedule.) Use data reflecting
DATE OF SERVICE within the fiscal year for such screening services or
other documentation of such services furnished under capitated
arrangements. The codes to be used to document the receipt of an
initial or periodic screen are as follows: .
CPT-4 CODES: PREVENTIVE MEDICINE SERVICES
99381 New Patient under one year
99382 New Patient (ages 1-4 years)
99383 New Patient (ages 5-11 years)
99384 New Patient (ages 12-17 years)
99385 New Patient (ages 18-39 years)
99391 Established patient under one year
99392 Established patient (ages 1-4 years)
99393 Established patient (ages 5-11 years)
99394 Established patient (ages 12-17 years)
99395 Established patient (ages 18-39 years)
99431 Newborn care (history and examination)
99432 Normal newborn care
99435 Newborn Care (history and examination)
or
CPT-4 codes: Evaluation and Management Codes
99201-99205 New Patient
99211-99215 Established Patient
(NOTE: THESE CPT-4 EVALUATION AND MANAGEMENT CODES MUST BE USED IN
CONJUNCTION WITH V CODES V20-V20.2 AND/OR V70.0 AND/OR V70.3-70.9.)
DO NOT COUNT MEDIKIDS POPULATION WHO HAVE HAD A CHECK-UP.
LINE 7 - SCREENING RATIO - Calculated by dividing the actual number of
initial and periodic screening services received (line 6) by the
expected number of initial and periodic screening services (line 5).
This ratio indicates the extent to which EPSDT (CHCUP) eligibles
receive the number of initial and periodic screening services required
by the state's periodicity schedule, adjusted by the proportion of the
year for which they are Medicaid eligible. THIS RATIO SHOULD NOT BE
OVER 100%. ANY DATA SUBMITTED WHICH EXCEEDS 100% WILL BE REFLECTED AS
100% ON THE FINAL REPORT. The plan shall adopt annual screening goals
to achieve at least 80% EPSDT (CHCUP) screening ratio pursuant to
Section 5360, Annual Participation Goals, of the State Medicaid Manual.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 99 OF 166
July 2004 Medicaid HMO Contract
LINE 8 - TOTAL ELIGIBLES WHO SHOULD RECEIVE AT LEAST ONE INITIAL OR
PERIODIC SCREEN - The number of persons who should receive at least one
initial or periodic screen is dependent on the state's periodicity
schedule. Use the following calculations:
1. Look at the number entered in line 4 of this form. If that
number is greater than 1, use the number 1. If the number in
line 4 is less than or equal to 1, use the number in line 4.
(This procedure will eliminate situations where more than one
visit is expected in any age group in a year.)
2. Multiply the number from calculation 1 above by the number in
line 1 of the form. Enter the product on line 8.
LINE 9 - TOTAL ELIGIBLES RECEIVING AT LEAST ONE INITIAL OR PERIODIC
SCREEN - Enter the unduplicated count of individuals, including those
enrolled in managed care arrangements, who received at least one
documented initial or periodic screen during the year. Refer to codes
in line 6.
DO NOT COUNT MEDIKIDS POPULATION WHO HAVE HAD A CHECK-UP.
LINE 10 - PARTICIPANT RATIO - Calculated by dividing line 9 by line 8.
This ratio indicates the extent to which eligibles are receiving any
initial and periodic screening services during the year. The plan shall
adopt annual participating goals to achieve at least 80% EPSDT (CHCUP)
participating ratio pursuant to Section 5360, Annual Participation
Goals, of the State Medicaid Manual.
LINE 11 - TOTAL ELIGIBLES REFERRED FOR CORRECTIVE TREATMENT - Enter the
unduplicated number of individuals, including those in managed care
arrangements, who, as the result of at least one health problem
identified during an initial or periodic screening service, INCLUDING
VISION AND HEARING SCREENINGS, were scheduled for another appointment
with the screening provider or referred to another provider for further
needed diagnostic or treatment services. This element does not include
correction of health problems during the course of a screening
examination. This element is required. For reporting on the EPSDT
(CHCUP) only count the referral codes "T" and "V".
The new federally required referral codes are:
U Complete Normal
Indicator is used when there are no referrals made.
2 Abnormal, Treatment Initiated
Indicator is used when a child is currently under treatment for
referred diagnostic or corrective health problem.
T Abnormal, Recipient Referred
Indicator is used for referrals to another provider for
diagnostic or corrective treatments or scheduled for another
appointment with check-up provider for diagnostic or corrective
treatment for at least one health problem identified during an
initial or periodic check-up (not including dental referrals)
V Patient Refused Referral
Indicator is used when the patient refused a referral.
LINE 12a - TOTAL ELIGIBLES RECEIVING ANY DENTAL SERVICES - Enter the
unduplicated number of children receiving any dental service as defined
by HCPC codes D0100 - D9999 (ADA codes 00100 - 09999). Include
Procedure Code W5301.
LINE 12b - TOTAL ELIGIBLES RECEIVING PREVENTIVE DENTAL SERVICES - Enter
the unduplicated number of children receiving a preventive dental
service as defined by HCPC codes D1000 - D1999 (ADA codes 01000 -
01999). Include Procedure Code W5301.
LINE 12c - TOTAL ELIGIBLES RECEIVING DENTAL TREATMENT SERVICES - Enter
the unduplicated number of children receiving treatment services as
defined by HCPC codes D2000 - D9999 (ADA codes 02000 - 09999).
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 100 OF 166
July 2004 Medicaid HMO Contract
NOTE: For purposes of reporting the information on dental services,
unduplicated means that each child is counted once for each line of
data requested. For example, a child would be counted once on line 12a
for receiving any dental service and would be counted again for line
12b and/or 12c if the child received a preventive and/or treatment
dental service. These numbers should reflect services received in
fee-for-service and managed care arrangements. Lines 12b and 12c do not
equal to total services reflected on line 12a.
LINE 13 - TOTAL ELIGIBLES ENROLLED IN MANAGED CARE - This number is
reported for informational purposes only. This number represents all
individuals eligible for EPSDT (CHCUP) services in the plan who were
enrolled at any time during the reporting year. These individuals
should be included in the total number of unduplicated eligibles on
line 1 and the number of initial or periodic screenings provided to
these individuals should be included in lines 6 and 8 for purposes of
determining the state's screening and participation rates. The number
of individuals referred for corrective treatment and receiving dental
services should be reflected in lines 11 and 12, respectively.
DO NOT COUNT YOUR MEDIKIDS POPULATIONS.
LINE 14 - TOTAL NUMBER OF SCREENING BLOOD LEAD TESTS - Enter the total
number of screening blood lead tests furnished to eligible individuals
enrolled in your plan. Blood lead tests done on persons who have been
diagnosed or treated for lead poisoning should not be counted. This is
a required element. Do not make entries in the shaded columns.
To report number of screening blood lead tests do the following: Count
the number of times CPT code 83655 ("lead") or any state-specific
(local) codes including W9979 used for a blood lead tests reported with
any ICD-9-CM except with diagnosis codes 984 (.0-.9)("Toxic Effects of
Lead and Its Compounds"), E861.5 ("Accidental Poisoning by Petroleum
Products, Other Solvents and Their Vapors NEC: Lead Paints"), and
E866.0 ("Accidental Poisoning by Other Unspecified Solid and Liquid
Substances: Lead and Its Compounds and Fumes"). These specific ICD-9-CM
diagnosis codes are used to identify people who are lead poisoned.
Blood lead tests done in these individuals should not be counted as a
screening blood lead test. This is a federally mandated test for ages
12 months, 24 months and between the ages of 36 - 72 months for those
who have not been previously screened for lead poisoning.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 101 OF 166
July 2004 Medicaid HMO Contract
TABLE 10. SAMPLE OF CHILD HEALTH CHECK-UP REPORTING TEMPLATE
ENTER DATA IN BLUE COLORED OUT-LINED CELLS CHILD HEALTH CHECK-UP REPORT
ONLY (CHCUP)
SEVEN DIGIT MEDICAID PROVIDER NUMBER : THIS REPORT IS DUE TO THE
PLAN NAME : AGENCY NO LATER THAN JANUARY 15.
FEDERAL FISCAL YEAR : THE AUDITED REPORT
IS DUE OCTOBER 1.
AGE GROUPS
LESS THAN 1-2 3-5 6-9 10-14 15-18 19-20 TOTAL
1 YEAR YEARS * YEARS YEARS YEARS YEARS YEARS ALL YEARS
- ---------------------------------------------------------------------------------------------------------------------------
1. TOTAL INDIVIDUALS ELIGIBLE FOR CHCUP
(UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
2A. STATE PERIODICITY SCHEDULE 6 4 3 2 5 4 2 26
- ---------------------------------------------------------------------------------------------------------------------------
2B. NUMBER OF YEARS IN AGE GROUP 1 2 3 4 5 4 2 21
- ---------------------------------------------------------------------------------------------------------------------------
2C. ANNUALIZED STATE PERIODICITY SCHEDULE 6.00 2.00 1.00 0.50 1.00 1.00 1.00 1.24
- ---------------------------------------------------------------------------------------------------------------------------
3A. TOTAL MONTHS OF ELIGIBILITY
- ---------------------------------------------------------------------------------------------------------------------------
3B. AVERAGE PERIOD OF ELIGIBILITY
- ---------------------------------------------------------------------------------------------------------------------------
4. EXPECTED NUMBER OF SCREENINGS
PER ELIGIBLE
- ---------------------------------------------------------------------------------------------------------------------------
5. EXPECTED NUMBER OF SCREENINGS
- ---------------------------------------------------------------------------------------------------------------------------
6. TOTAL SCREENS RECEIVED
- ---------------------------------------------------------------------------------------------------------------------------
7. SCREENING RATIO
- ---------------------------------------------------------------------------------------------------------------------------
8. TOTAL ELIGIBLE WHO SHOULD RECEIVE
AT LEAST ONE
INITIAL OR PERIODIC SCREENING
- ---------------------------------------------------------------------------------------------------------------------------
9. TOTAL ELIGIBLES RECEIVING AT LEAST
ONE INITIAL OR
PERIODIC SCREEN (UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
10. PARTICIPATION RATIO
- ---------------------------------------------------------------------------------------------------------------------------
11. TOTAL ELIGIBLES REFERRED FOR
CORRECTIVE TREATMENT (UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
12A. TOTAL ELIGIBLES RECEIVING ANY DENTAL
SERVICES
(UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 102 OF 166
July 2004 Medicaid HMO Contract
12B. TOTAL ELIGIBLES RECEIVING
PREVENTATIVE DENTAL SERVICES
(UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
12C. TOTAL ELIGIBLES RECEIVING DENTAL
TREATMENT SERVICES (UNDUPLICATED)
- ---------------------------------------------------------------------------------------------------------------------------
13. TOTAL ELIGIBLES ENROLLED IN PLAN
- ---------------------------------------------------------------------------------------------------------------------------
14. TOTAL NUMBER OF SCREENING BLOOD
LEAD TESTS
- ---------------------------------------------------------------------------------------------------------------------------
* INCLUDES 12-MONTH VISIT
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 103 OF 166
July 2004 Medicaid HMO Contract
TABLE 11. CHILD HEALTH CHECK-UP REPORT - FLORIDA 60 %
SCREENING RATIO TEMPLATE FILING INSTRUCTIONS
This report is due by January 15th following the end of the reporting
period. The reporting period is from October 1 through September 30.
The Agency will supply a reporting template that includes all formulas
already entered. By October 1 of the following year, the plan shall
deliver to the Agency a certification by an Agency approved independent
auditor that the Child Health Checkup data has been fairly and
accurately presented.
DETAILED INSTRUCTIONS: For each of the following line items, report
total counts by the age groups indicated. In cases where calculations
are necessary, perform separate calculations for the total column and
each age group. Report age BASED UPON THE CHILD'S AGE AS OF SEPTEMBER
30 OF THE FEDERAL FISCAL YEAR.
MEDICAID PROVIDER ID NUMBER: Enter the plan's seven digit Medicaid
Provider ID number.
PLAN NAME: Enter the name of the managed health care plan.
FISCAL YEAR: Enter the Federal Fiscal year being reported. Example:
October 1, 1999 - September 30, 2000 would be Federal fiscal year
1999-2000.
LINE 1 - TOTAL INDIVIDUALS ELIGIBLE FOR CHILD HEALTH CHECK-UP (EPSDT):
Enter the total UNDUPLICATED number of all individuals under the age of
21 enrolled in the health plan CONTINUOUSLY FOR 8 MONTHS, distributed
by age and by basis of Medicaid eligibility. Unduplicated means that an
eligible person is REPORTED ONLY ONCE although he or she may have had
more than one period of eligibility during the year. Medicaid eligible
individuals under age 21 are considered eligible for EPSDT (CHCUP)
services, regardless of whether they have been informed about the
availability of EPSDT services or whether they accept EPSDT (CHCUP)
services at the time of the informing.
DO NOT COUNT YOUR MEDIKIDS POPULATIONS.
LINE 2A - STATE PERIODICITY SCHEDULES - Given.
LINE 2B - NUMBER OF YEARS IN AGE GROUP - Given.
LINE 2C - ANNUALIZED STATE PERIODICITY SCHEDULE - Given.
LINE 3A - TOTAL MONTHS ELIGIBILITY - Enter the total months of
eligibility for the individuals in each age group in Line 1 during the
reporting year.
LINE 3B - AVERAGE PERIOD OF ELIGIBILITY - Calculated by dividing the
total months of eligibility by Line 1, then by dividing that number by
12. This number represents the portion of the year that individuals
remain Medicaid eligible during the reporting year, regardless of
whether eligibility was maintained continuously.
LINE 4 - EXPECTED NUMBER OF SCREENINGS PER ELIGIBLE MULTIPLY -
Calculated by multiplying Line 2c by Line3 b. This number reflects the
expected number of initial or periodic screenings per child per year
based on the number required by the state-specific periodicity schedule
and the average period of eligibility.
LINE 5 - EXPECTED NUMBER OF SCREENINGS - Calculated by multiplying Line
4 by Line 1. This reflects the total number of initial or periodic
screenings expected to be provided to the eligible individuals in Line
1.
LINE 6 - TOTAL SCREENINGS RECEIVED - Enter the total number of initial
or periodic screens furnished to eligible individuals under managed
care arrangements. USE THE CPT CODES LISTED BELOW OR ANY PLAN-SPECIFIC
EPSDT (CHCUP) CODES THE PLAN MAY HAVE DEVELOPED FOR THESE SCREENS. USE
OF THESE PROXY CODES IS FOR REPORTING PURPOSES ONLY. PLANS MUST
CONTINUE TO ENSURE THAT ALL FIVE AGE-APPROPRIATE ELEMENTS OF AN EPSDT
(CHCUP) SCREEN, AS DEFINED BY LAW, ARE PROVIDED TO EPSDT (CHCUP)
RECIPIENTS.
NOTE: This number should not reflect sick visits or episodic visits
provided to children unless an initial or periodic screen was also
performed during the visit. However, it may reflect a screen outside of
the normal state periodicity schedule that is used as a "catch-up"
EPSDT (CHCUP) screening. (A catch-up EPSDT
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 104 OF 166
July 2004 Medicaid HMO Contract
screening is defined as a COMPLETE screening that is provided to bring
a child up-to-date with the State's screening periodicity schedule.)
Use data reflecting DATE OF SERVICE within the fiscal year for such
screening services or other documentation of such services furnished
under capitated arrangements. The codes to be used to document the
receipt of an initial or periodic screen are as follows:
Medicaid locally assigned procedure code W9881
CPT-4 codes Preventive Medicine Services
99381 New Patient under one year
99382 New Patient (ages 1-4 years)
99383 New Patient (ages 5-11 years)
99384 New Patient (ages 12-17 years)
99385 New Patient (ages 18-39 years)
99391 Established patient under one year
99392 Established patient (ages 1-4 years)
99393 Established patient (ages 5-11 years)
99394 Established patient (ages 12-17 years)
99395 Established patient (ages 18-39 years)
99431 Newborn care (history and examination)
99432 Normal newborn care
99435 Newborn Care (history and examination)
or
CPT-4 Codes, Evaluation and Management Codes
99201-99205 New Patient
99211-99215 Established Patient
NOTE: THESE CPT-4 CODES MUST BE USED IN CONJUNCTION WITH V CODES
V20-V20.2 AND/OR V70.0 AND/OR V70.3-V70.9.
DO NOT COUNTY YOUR MEDIKIDS POPULATION WHO HAVE HAD A CHECK-UP.
LINE 7-SCREENING RATIO - Calculated by dividing the actual number of
initial and periodic screening services received (Line 6) by the
expected number of initial and periodic screening services (Line 5).
This ratio indicates the extent to which EPSDT (CHCUP) eligibles
receive the number of initial and periodic screening services required
by the state's periodicity schedule, adjusted by the proportion of the
year for which they are Medicaid eligible. THIS RATIO SHOULD NOT BE
OVER 100%. ANY DATA SUBMITTED WHICH EXCEEDS 100% WILL BE REFLECTED AS
100% ON THE FINAL REPORT.
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 105 OF 166
July 2004 Medicaid HMO Contract
TABLE 11. SAMPLE OF CHILD HEALTH CHECK-UP REPORT - FLORIDA 60%
SCREENING RATIO TEMPLATE
ENTER DATA IN BLUE COLORED OUT-LINED CELLS
CHILD HEALTH CHECKUP REPORT (EPSDT) -
60% SCREENING RATIO
SEVEN DIGIT MEDICAID PROVIDER THIS REPORT IS DUE TO THE AGENCY NO
ID NUMBER : LATER THAN JANUARY.
PLAN NAME : THIS REPORT REFLECTS ONLY THOSE
ELIGIBLES THAT HAVE AT LEAST 8
MONTHS OF CONTINUOUS
ENROLLMENT
FEDERAL FISCAL YEAR : 409.912(26),
AGE GROUPS
LESS THAN 1-2 3-5 6-9 10-14 15-18 19-20 TOTAL
1 YEAR YEARS * YEARS YEARS YEARS YEARS YEARS ALL YEARS
1. TOTAL INDIVIDUALS ELIGIBLE FOR EPSDT
(UNDUPLICATED)
2A. STATE PERIODICITY SCHEDULE 6 4 3 2 5 4 2 26
2B. NUMBER OF YEARS IN AGE GROUP 1 2 3 4 5 4 2 21
2C. ANNUALIZED STATE PERIODICITY SCHEDULE 6.00 2.00 1.00 0.50 1.00 1.00 1.00 1.24
3A. TOTAL MONTHS OF ELIGIBILITY
3B. AVERAGE PERIOD OF ELIGIBILITY
4. EXPECTED NUMBER OF SCREENINGS PER ELIGIBLE
5. EXPECTED NUMBER OF SCREENINGS
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 106 OF 166
July 2004 Medicaid HMO Contract
AGE GROUPS
LESS THAN 1-2 3-5 6-9 10-14 15-18 19-20 TOTAL
1 YEAR YEARS * YEARS YEARS YEARS YEARS YEARS ALL YEARS
6. TOTAL SCREENS RECEIVED 0
7. SCREENING RATIO - F.S. 409.912(26)
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 107 OF 166
July 2004 Medicaid HMO Contract
60.2.10 AHCA QUALITY INDICATORS
Completion of AHCA Quality Indicators
The AHCA Quality Indicators will be calculated for each calendar year;
that is from January 1 through December 31. The AHCA Quality
Indicators are due by October 1 subsequent to the measurement year.
The measures will constitute a subset of the HEDIS and will be based
on the current recommendation of the National Committee for Quality
Assurance (NCQA) for Medicaid HMO HEDIS reporting. Detailed
instructions and valuable information for calculating these measures
can be found in the HEDIS documentation available from NCQA. Technical
specification for the quality indicators can be found in the current
HEDIS Technical Specifications Manual available from the National
Committee for Quality Assurance, 2000 L Street NW, Suite 500,
Washington, DC 20036. (800) 839-6487.
Plans shall refer to and comply with Rule Chapter 59B-13, Florida
Administrative Code, for reporting instructions regarding the report
format, electronic reporting and other information pertaining to
Medicaid membership reporting for these quality indicators.
Do not include Florida Healthy Kids or MediKids with your Medicaid
data for the AHCA Quality Indicators.
60.2.11 FRAIL/ELDERLY CARE SERVICE UTILIZATION REPORTING (F***YYQ*.dbf)
Any plan that operates an Agency-approved Frail Elder expanded benefit
must submit recipient-specific service utilization data in the
electronic format specified below. The services reported represent the
comprehensive array of services that might be necessary to maintain a
member at home while avoiding nursing home placement, including acute
and long-term care services.
These reports must be provided as ASCII, fixed length text files, with
two files, per recipient, per month. There will be one file for
long-term care services and one file for acute care services. For
example, if a recipient were enrolled for an entire quarter, you would
have three separate records in each of two separate files that are
submitted once for the entire quarter. These two files, the LTC
Services file and the Acute Care Services file, must be submitted once
every quarter to your DOEA/AHCA contract manager. You will have up to
three months after the last month in a specific quarter to submit the
quarterly report.
Right justify all fields unless noted otherwise. For amount paid,
include the sum of Medicaid and Medicare crossover claims (deductibles
and co-pays for Medicare claims).* If you have questions about the
definitions of these services please reference the appropriate
Medicaid coverage and limitations handbook for Medicaid state plan
services. Note: Please do not use commas between fields. Round
currency to the nearest dollar amount.
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 108 OF 166
July 2004 Medicaid HMO Contract
FILE 1: LONG-TERM CARE SERVICES
FIELD START
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
SSN SOCIAL SECURITY NUMBER (LEFT JUSTIFY) 000000000 9 1 9 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MEDICAID MEDICAID ID NUMBER 0000000000 10 10 19 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ENROL INITIAL DATE OF PROGRAM ENROLLMENT MMYYYY 6 20 25 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DISENROL DATE OF DISENROLLMENT, IF APPLICABLE MMYYYY 6 26 31 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
REINST REINSTATE DATE MMYYYY 6 32 37 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ALF ALF RESIDENT INDICATOR 1=YES; 2=NO 1 38 38 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MONTH REPORT MONTH MMYYYY 6 39 44 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
LTC
SERVICES DESCRIPTION UNIT OF SERVICE/
COST
- ------------------------------------------------------------------------------------------------------------------------------------
ADCOMP Adult Companion Services 15 MINUTE UNIT 4 45 48 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ADAYHLTH ADULT DAY HEALTH SERVICES 15 MINUTE UNIT 4 49 52 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ALFSVS ASSISTED LIVING SERVICES DAYS 2 53 54 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ALFSVS$$ ASSISTED LIVING SERVICES AMOUNT PAID 6 55 60 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ATTCARE ATTENDANT CARE SERVICES 15 MINUTE UNIT 4 61 64 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CASEAID CASE AIDE 15 MINUTE UNIT 4 65 68 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CASEMGMT Case Management (Internal) 15 MINUTE UNIT 4 69 72 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CHORE CHORE SERVICES 15 MINUTE UNIT 2 73 74 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
COM_MH COMMUNITY MENTAL HEALTH VISIT 2 75 76 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CNMS_$$ CONSUMABLE MEDICAL SUPPLIES AMOUNT PAID 6 77 82 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
COUNSEL COUNSELING 15 MINUTE UNIT 4 83 86 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DME_$$ DURABLE MEDICAL EQUIPMENT AMOUNT PAID 6 87 92 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ENVIRAA ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS JOB 2 93 94 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ESCORT ESCORT SERVICES 15 MINUTE UNIT 4 95 98 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FAMT_I FAMILY TRAINING SERVICES (INDIVIDUAL) 15 MINUTE UNIT 2 99 100 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FAMT_G FAMILY TRAINING SERVICES (GROUP) 15 MINUTE UNIT 2 101 102 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FINARRS FINANCIAL ASSESSMENT/RISK REDUCTION SERVICES 15 MINUTE UNIT 4 103 106 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FINM_RRS FINANCIAL MAINTENANCE/RISK REDUCTION SERVICES 15 MINUTE UNIT 4 107 110 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
HDMEAL HOME DELIVERED MEALS MEAL 2 111 112 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
HOMESRVS HOMEMAKER SERVICES 15 MINUTE UNIT 4 113 116 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MH_CM MENTAL HEALTH CASE MANAGEMENT 15 MINUTE UNIT 4 117 120 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
SNF NURSING FACILITY SERVICES- LONG-TERM DAYS 2 121 122 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
NUTR_RRS NUTRITIONAL ASSESSMENT/RISK REDUCTION SERVICES 15 MINUTE UNIT 4 123 126 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
OT OCCUPATIONAL THERAPY 15 MINUTE UNIT 4 127 130 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PCS PERSONAL CARE SERVICES 15 MINUTE UNIT 4 131 134 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PERS_I PERSONAL EMERGENCY RESPONSE SYSTEM Job 2 NUMERIC
INSTALLATION 135 136
- ------------------------------------------------------------------------------------------------------------------------------------
PERS_M PERSONAL EMERGENCY RESPONSE SYSTEM - DAY 2 137 138 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 109 OF 166
July 2004 Medicaid HMO Contract
FIELD START
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MAINTENANCE
- ------------------------------------------------------------------------------------------------------------------------------------
PEST_I PEST CONTROL - INITIAL VISIT JOB 2 139 140 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PEST_M PEST CONTROL - MAINTENANCE MONTH 1 141 141 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PT PHYSICAL THERAPY 15 MINUTE UNIT 4 142 145 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RISKREDU PHYSICAL RISK ASSESSMENT AND REDUCTION 15 MINUTE UNIT 4 146 149 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PRIVNURS PRIVATE DUTY NURSING SERVICES 15 MINUTE UNIT 4 150 153 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PT_R REGISTERED PHYSICAL THERAPIST VISIT 2 154 155 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RSPTH RESPIRATORY THERAPY 15 MINUTE UNIT 4 156 159 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RESP_HM RESPITE CARE - IN HOME 15 MINUTE UNIT 4 160 163 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RESP_FAC RESPITE CARE - FACILITY-BASED DAYS 2 164 165 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
NURSE SKILLED NURSING VISIT 4 166 169 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
SPTH SPEECH THERAPY 15 MINUTE UNIT 4 170 173 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
TRANSPOR TRANSPORTATION SERVICES (NOT INCLUDED IN ESCORT TRIPS 3 NUMERIC
OR ADULT DAY HEALTH SERVICES) 174 176
- ------------------------------------------------------------------------------------------------------------------------------------
OTH_UNIT OTHER LTC SERVICE NOT LISTED (UNIT) UNIT/ VISIT 6 177 182 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DESCR_1 DESCRIPTION OF OTHER LTC SERVICE 35 183 217 TEXT
- ------------------------------------------------------------------------------------------------------------------------------------
OTH_$$ OTHER LTC SERVICE NOT LISTED (AMOUNT) AMOUNT PAID 6 218 223 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DESCR_2 DESCRIPTION OF OTHER LTC SERVICE 35 224 258 TEXT
- ------------------------------------------------------------------------------------------------------------------------------------
FILE 2: ACUTE CARE SERVICES
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT FIELD START END COL. TEXT/NUMERIC
LENGTH COL.
ACUTE UNITS OF SERVICE/
SERVICES DESCRIPTION COST
- ------------------------------------------------------------------------------------------------------------------------------------
SSN SOCIAL SECURITY NUMBER (LEFT JUSTIFY) 000000000 9 1 9 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MEDICAID MEDICAID ID NUMBER 0000000000 10 10 19 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MONTH REPORT MONTH MMYYYY 6 20 25 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CLINIC CLINIC SERVICES VISIT 2 26 27 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
CLINIC$$ CLINIC SERVICES COSTS VISIT 2 28 29 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DENTAL DENTAL SERVICES VISIT 6 30 35 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DENTAL$$ DENTAL SERVICES COSTS AMOUNT PAID 6 36 41 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DIALYSIS DIALYSIS CENTER VISIT 2 42 43 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DIALYS$$ DIALYSIS CENTER COSTS AMOUNT PAID 6 44 49 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ER EMERGENCY ROOM SERVICES VISIT 2 50 51 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ER_$$ EMERGENCY ROOM SERVICES COSTS AMOUNT PAID 6 52 57 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FQHC FQHC SERVICES VISIT 2 58 59 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
FQHC_$$ FQHC SERVICES COSTS AMOUNT PAID 6 60 65 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
HEAR HEARING SERVICES INCLUDING HEARING AIDS AMOUNT PAID 6 66 71 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 110 OF 166
July 2004 Medicaid HMO Contract
FIELD START
FIELD NAME DESCRIPTION UNIT OF MEASUREMENT LENGTH COL. END COL. TEXT/NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
INPTSVS INPATIENT HOSPITAL SERVICES DAY 3 72 74 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
INPTSV$$ INPATIENT HOSPITAL SERVICES COSTS AMOUNT PAID 6 75 80 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
LAB INDEPENDENT LABORATORY OR PORTABLE X-RAY AMOUNT PAID 6 81 86 NUMERIC
SERVICES
- ------------------------------------------------------------------------------------------------------------------------------------
ARNP NURSE PRACTITIONER SERVICES VISIT 2 87 88 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
ARNP_$$ NURSE PRACTITIONER SERVICES COSTS AMOUNT PAID 6 89 94 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RX_$$ PHARMACEUTICALS AMOUNT PAID 6 95 100 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PA PHYSICAL ASSISTANT VISIT 2 101 102 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PA_$$ PHYSICAL ASSISTANT COSTS AMOUNT PAID 6 103 108 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MD PHYSICIAN SERVICES VISIT 2 109 110 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
MD_$$ PHYSICIAN SERVICES COSTS AMOUNT PAID 6 111 116 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
OUTPT OUTPATIENT HOSPITAL SERVICES ENCOUNTER 3 117 119 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
OUTPT_$$ OUTPATIENT HOSPITAL SERVICES COSTS AMOUNT PAID 6 120 125 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PODIATRY Podiatry VISIT 2 126 127 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
PODIAT$$ Podiatry Costs AMOUNT PAID 6 128 133 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RURAL RURAL HEALTH SERVICES VISIT 2 134 135 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
RURAL$$ RURAL HEALTH SERVICES COSTS AMOUNT PAID 6 136 141 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
SNFREHA$ SKILLED NURSING FACILITY SERVICES- AMOUNT PAID 6 142 147 NUMERIC
REHABILITATION**
- ------------------------------------------------------------------------------------------------------------------------------------
EYE_$$ VISUAL SERVICES INCLUDING EYEGLASSES AMOUNT PAID 6 148 153 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
OTH_UNIT OTHER ACUTE SERVICE NOT LISTED (UNIT) UNIT/ VISIT 6 154 159 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DESCR_1 DESCRIPTION OF OTHER ACUTE SERVICE 35 160 194 TEXT
- ------------------------------------------------------------------------------------------------------------------------------------
OTH_$$ OTHER ACUTE SERVICE NOT LISTED (AMOUNT) AMOUNT PAID 6 195 200 NUMERIC
- ------------------------------------------------------------------------------------------------------------------------------------
DESCR_2 DESCRIPTION OF OTHER ACUTE SERVICE 35 201 235 TEXT
- ------------------------------------------------------------------------------------------------------------------------------------
**Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
clients who are also eligible for Medicare.
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 111 OF 166
July 2004 Medicaid HMO Contract
60.2.12 FINANCIAL REPORTING
GENERAL INFORMATION, DEFINITIONS AND INSTRUCTIONS
The plan is required to submit to the agency annual audited financial
statements and four quarterly unaudited financial statements.
The audited financial statements are due no later than three calendar
months after the end of the provider's fiscal year. The Agency will
accept audited financial statements that have been prepared in
conformity with accounting practices prescribed or permitted by the
Department of Financial Services. The accountant preparing the audited
financial statements must be an independent certified public
accountant. The unaudited quarterly financial statements are to be
prepared on a GAAP basis and are due no later than 45 days after the
calendar quarter and shall include a: Balance Sheet, Statement of
Revenues and Expenses, and Statement of Changes in Financial Position
and Net Worth. These financial statements shall be filed on diskette,
or by Internet e-mail to MMCFIN@FDHC.STATE.FL.US using the agency
supplied spreadsheet template.
Annual and quarterly financial statements shall be specific to the
operation of the Medicaid HMO rather than to a parent or umbrella
organization. If the HMO is under a guarantee agreement, which was
approved by the Agency, then the HMO must also file an audited
financial statement of the guaranteeing organization, which reflects
twelve months of operation.
THE FINANCIAL TEMPLATE CONTAINS THE FOLLOWING (SHEETS/TABS):
Master sheet - this is the balance sheet, consolidated revenue
and expense statement and changes in financial position. This
statement reflects four (4) quarters plus fiscal year totals.
1. Enrollment - consists of quarterly enrollment detailed by
county, and product line.
2. Profit and Loss - tracks operational performance by product
line.
3. Aggregate write-in - tracks any information recorded on the
balance sheet or profit and loss statements, which needs
further explanation.
4. Jurat - shows the plan name, plan address, telephone number,
etc.
5. Claims and IBNR-provides an aging schedule of claims by
quarter and product line.
6. FQHC/RHC- Federally Qualified Health Centers and Rural Health
Clinics summary information.
BALANCE SHEET
1. CASH AND EQUIVALENTS - Cash in the bank or on hand, available
for current use.
2. SHORT-TERM INVESTMENTS - Readily saleable investments acquired
with temporarily unneeded cash. Does not include restricted
securities.
3. PREMIUMS RECEIVABLE - NET - Gross amounts collectible from
groups or individuals who receive from the plan, less the
amount accrued from premiums determined to be uncollectible
for the period.
4. INTEREST RECEIVABLE - Interest earned on investments but not
received.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 112 OF 166
July 2004 Medicaid HMO Contract
5. OTHER RECEIVABLES - NET - Gross amounts collectible from
sources other than plan members or groups, less the amount
accrued for receivables determined to be uncollectible during
the period. Example: fee-for-service. This should NOT include
restricted receivables.
6. PREPAID EXPENSES - Future expenses paid in advance such as
unexpired insurance.
7. AGGREGATE WRITE-INS FOR CURRENT ASSETS - Show non-restricted
current assets, including inventories, not included in the
other Current Assets categories.
8. TOTAL CURRENT ASSETS - Sum total of all current assets.
9. RESTRICTED FUNDS - Assets held for contract (i.e., Medicaid)
grants, reserves including cash, securities, receivables,
other, etc.
10. LOAN ESCROW - Funds for which loan notes have been signed by
the provider but not drawn down. Funds may be held by the
provider or an escrow agent.
11. LONG-TERM INVESTMENTS - Investments held for a period longer
than twelve months.
12. INTANGIBLE ASSETS AND GOODWILL - Net - Assets of no physical
substance. These may include patents, copyrights, licenses,
and franchises. Provide gross amount less amortization.
13. AGGREGATE WRITE-INS FOR OTHER ASSETS - Show non-current assets
not included in the Other Assets categories.
14. TOTAL OTHER ASSETS - Sum total of all other assets.
15. LAND - Real estate owned by the plan.
16. BUILDINGS & IMPROVEMENTS - Buildings owned by the plan and
improvements made to provider-owned buildings.
17. CONSTRUCTION IN PROGRESS - Buildings or improvements in
progress or under construction. These will be capitalized upon
completion or utilization.
18. FURNITURE AND EQUIPMENT - Includes medical equipment, office
equipment and furniture owned by the plan.
19. AGGREGATE WRITE-INS FOR OTHER EQUIPMENT - Include automobiles,
fixtures and other fixed assets not reported in other Property
and Equipment categories.
20. TOTAL PROPERTY AND EQUIPMENT - NET - Total of Property and
Equipment categories, less Accumulated Depreciation - the
cumulative amount of depreciation on property and equipment.
Depreciation is an accounting practice recognizing the
consumption of the value of a fixed asset during the asset's
useful life. Depreciation expenses are charged to the expense
categories representing the cost center to which the fixed
asset is assigned.
21. TOTAL ASSETS - Total of Current Assets, Other Assets and Net
Property and Equipment.
1. ACCOUNTS PAYABLE - Amounts due to creditors for the
acquisition of goods and services (trade and vendors rather
than health care providers) on a credit basis.
2. CLAIMS PAYABLE (Reported) - Claims reported and booked as
payables.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 113 OF 166
July 2004 Medicaid HMO Contract
3. ACCRUED INPATIENT CLAIMS (Not reported) - Hospital and
institutional care claims incurred but not reported and/or
booked as payables.
4. ACCRUED PHYSICIAN CLAIMS (Not reported) - Claims incurred but
not reported and/or booked as payables for physicians and
ancillary (such as lab and x-ray) services by providers under
an arrangement with the HMO. These may include capitation
payments to medical groups or fees to IPAs.
5. ACCRUED REFERRAL CLAIMS (Not reported) - Claims incurred but
not reported and/or booked as payables for consultants and
referrals to providers outside a plan arrangement. These
claims are usually paid on a fee-for-service basis.
6. ACCRUED OTHER MEDICAL (Not Reported) - Other incurred medical
expenses but not reported and/or booked as payables including
emergency room, out-of-area services, payroll, etc.
7. ACCRUED PROVIDER INCENTIVE POOL - Accruals for withholds from
IPAs or capitated medical groups and other such arrangements
in which the provider may return incentive funds to plans.
8. UNEARNED PREMIUMS - Income received or booked in advance of
the period to which it applies. A liability exists to render
service in the future.
9. LOANS AND NOTED PAYABLE - CURRENT - The principal amount on
loans due within one year.
10. AGGREGATE WRITE-INS FOR CURRENT LIABILITIES - Show current
liabilities not included in other Current Liabilities
categories; include accrued payroll and taxes.
11. TOTAL CURRENT LIABILITIES - Total of Current Liability
Categories.
12. LOANS AND NOTES - Loans and notes signed by the plan not
including current portion payable. Includes federal loans.
13. STATUTORY LIABILITY - Reserve required as a liability by
statute (e.g., government purchaser requirements).
14. AGGREGATE WRITE-INS FOR OTHER LIABILITIES - Show other
liabilities of a long-term nature.
15. TOTAL OTHER LIABILITIES - Total of Other Liability Categories.
16. TOTAL LIABILITIES - Sum of current and other liabilities.
17. CONTRIBUTED CAPITAL - Capital donated to an organization.
18. COMMON STOCK-
Ordinary capital shares of the corporation.
19. PREFERRED STOCK- Stock having priority over the corporation's
common stock.
20. PAID IN SURPLUS - Amount over stated value of Line 17.
Reflects actual amount in excess of par or stated value.
21. UNASSIGNED SURPLUS - Unassigned Retained Earnings. Cumulative
earnings or deficit from operations, net of reserves and
restricted funds.
22. AGGREGATE WRITE-INS FOR OTHER NET WORTH ITEMS - May include
statutory reserves, subordinated debt, and accrued interest on
subordinated debt.
23. TOTAL NET WORTH - Total Assets minus Total Liabilities.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 114 OF 166
July 2004 Medicaid HMO Contract
24. TOTAL LIABILITIES AND NET WORTH - Total liabilities plus net
worth,
DETAILS OF WRITE-INS AGGREGATED FOR OTHER NET WORTH ITEMS -
STATEMENT OF REVENUES, EXPENSES AND NET WORTH
1. PREMIUM - Revenue recognized on a prepaid basis from
individuals and groups for provision of a specified range of
health services over a defined period of time, normally three
months. Premium shall be separated by line of business, such
as Commercial, Medicaid and Medicare.
2. FEE-FOR-SERVICE - Revenue recognized by the plan entity for
provision of health services to non-members by plan providers
and to members through provision of health services excluded
from their prepaid benefit packages.
3. COPAYMENTS - Revenue recognized by the plan entity from plan
members on a utilization related basis for certain health
services included in the HMO benefit package.
4. TITLE XVIII - MEDICARE - Revenue as a result of an arrangement
between a provider and the Centers for Medicare and Medicaid
Services for services to a Medicare beneficiary.
5. TITLE XIX - MEDICAID - Revenue as a result of an arrangement
between a plan and a Medicaid State Agency for services to a
Medicaid beneficiary.
6. INTEREST - Interest earned from all sources, including the
federal loan in escrow and reserve accounts.
7. C.O.B. AND INSURANCE RECOVERIES - Income from Coordination of
Benefits and insurance recoveries.
8. REINSURANCE RECOVERIES - Income from the settlement of
stop-loss (reinsurance) claims.
9. AGGREGATE WRITE-INS- Revenue from sources not covered in the
previous revenue accounts, such as recovery of bad debts or
gain on sales of capital assets, etc.
10. TOTAL REVENUE - Total of the revenue accounts.
11. PHYSICIAN SERVICES - Expenses for physician services provided
under contractual arrangement to the plan including the
following: salaries, including fringe benefits, paid to
physicians for delivery of medical services; capitated
payments paid by the plan to physicians for delivery of
medical services to plan subscribers; and fees paid by the
plan to physicians on a fee-for-service basis for delivery of
medical services to plan subscribers.
12. OTHER PROFESSIONAL SERVICES - Compensation, including fringe
benefits, paid by the plan to non-physician providers engaged
in the delivery of medical services and to personnel engaged
in activities in direct support of the provision of medical
services. This includes dentists, psychologists, optometrists,
podiatrists, extenders, nurses, clinical personnel such as
ambulance drivers, technicians, paraprofessionals, janitors,
quality improvement analysts, administrative supervisors,
secretaries to medical personnel, and medical records clerks.
13. OUTSIDE REFERRALS - Expenses for providers not under provider
arrangement such as consultations.
14. EMERGENCY ROOM, OUT-OF-AREA, OTHER - Expenses for other
non-contracted health delivery services incurred by plan
members for which the plan is responsible on a fee-for-service
basis. These include emergency room costs and out-of-area
emergency physician and hospital costs.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 115 OF 166
July 2004 Medicaid HMO Contract
15. OCCUPANCY, DEPRECIATION AND AMORTIZATION - Expenses associated
with medical services including the amount of depreciation and
amortization expense which is directly associated with the
delivery of medical services. The costs of occupancy to the
plan which are directly associated with the delivery of
medical services. Included in occupancy are costs of using a
facility, fire and theft insurance, utilities, maintenance,
lease, etc.
16. INPATIENT - Inpatient hospital costs of routine and ancillary
services for plan members while confined to an acute care
hospital. Does not include out-of-area hospitalization.
Routine hospital service includes regular room and board
(including intensive care units, coronary care units, and
other special inpatient hospital units), dietary and nursing
services, medical and surgical supplies, medical social
services, and the use of certain equipment and facilities for
which the plan does not customarily make a separate charge.
Ancillary services may also include laboratory, radiology,
drugs, delivery room and physical therapy services. Ancillary
services may also include other special items and services for
which charges are customarily made in addition to routine
service charges. Charges for non-plan physician services
provided in a hospital are included in this line item only if
included as an unidentified portion of charges by a hospital
to the plan. (If separately itemized or billed, physician
charges must be included in referrals, above.) Include the
cost of utilizing skilled nursing and intermediate care
facilities. Skilled nursing facilities are primarily engaged
in providing skilled nursing care and related services for
patients who require medical or nursing care or rehabilitation
service. Intermediate care facilities are for individuals who
do not require the degree of care and treatment which a
hospital or nursing care facility provides, but do not require
care and services above the level of room and board.
17. REINSURANCE EXPENSES - Expenses for Reinsurance or "stop-loss"
insurance.
18. OTHER MEDICAL - Costs directly associated with the delivery of
medical services under plan arrangement that are not
appropriately assignable to the medical expense categories
defined above, e.g., costs of medical supplies, medical
administration expense (except compensation), malpractice
insurance, etc.
19. INCENTIVE POOL ADJUSTMENT - A contra category for adjusting
the full medical expenses reported. For example, physician
withholds or hospital volume discounts returned by or to the
provider should be included here. Adjustments should be made
on the annual report only.
20. TOTAL MEDICAL AND HOSPITAL - Total of the above categories.
21. COMPENSATION - All expenses for administrative services
including compensation and fringe benefits for personnel time
devoted to or in direct support of administration. Include
expenses for management contracts. Do not include marketing
expenses. However, when a management company pays rent,
insurance, and other non-salary or non-commission payments,
these amounts should not be reported as compensation.
22. INTEREST EXPENSES - Interest on loans paid during period.
23. OCCUPANCY, DEPRECIATION AND AMORTIZATION - Expenses associated
with administrative services including the costs of occupancy
to the plan entity which are directly associated with plan
administration. Included in occupancy are costs of using a
facility, fire and theft insurance, utilities, maintenance,
lease, etc. Do not include expenses for marketing in this
category.
The amount of depreciation and amortization expense which is
directly associated with administrative services. Depreciation
expense is the incremental consumption of the value of a fixed
asset during the asset's useful life.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 116 OF 166
July 2004 Medicaid HMO Contract
24. MARKETING - Expenses directly related to marketing activities
including advertising, printing, marketing representative
compensation and fringe benefits, commissions, broker fees,
travel, occupancy, and other expenses allocated to the
marketing activity.
25. AGGREGATE WRITE-IN- Costs, which are not appropriately
assignable to the health, plan administration categories
defined above. Included are costs to update member records,
servicing of member inquiries and complaints, claims
adjudication and payment, legal, audit, data processing,
accounting, insurance, bad debts, all taxes except federal
income taxes, etc.
26. TOTAL ADMINISTRATION - Total of the above categories.
27. TOTAL EXPENSES - Total of Medicaid and Hospital and
Administration Expenses.
28. INCOME (LOSS) - Total revenues minus total expenses.
29. EXTRAORDINARY ITEM - A non-recurring gain or loss that meets
the following criteria:
The event must be unusual. It should be highly abnormal and
unrelated to, or only incidentally related to, the ordinary
activities of the entity.
The event must occur infrequently. It should be of a type that
would not reasonably be expected to recur in the foreseeable
future.
The following gains and losses are specifically not
extraordinary: write-down or write off of accounts receivable,
inventory, or intangible assets: gains or losses from changes
in the value of foreign currency; gains or losses on disposal
of a segment of a business; gains or losses from the disposal
of fixed assets; effects of a strike; and adjustments of
accruals on long-term contracts.
30. PROVISION FOR TAXES - State and federal taxes for period
(for-profit organization only).
31. NET INCOME (LOSS) - Total revenues minus total expenses less
extraordinary items and state and federal taxes.
STATEMENT OF CHANGES IN FINANCIAL POSITION AND NET WORTH
SOURCES: Sources of funds used in operations including the following:
1. NET INCOME (LOSS) - Report the figure calculated for this
line.
ADD ITEMS NOT AFFECTING WORKING CAPITAL IN THE CURRENT PERIOD:
Depreciation amortization and deferred taxes are expenses and
affecting working capital. These expenses are added back.
2. DEPRECIATION AND AMORTIZATION
3. DEFERRED TAXES - These are accrued taxes for the period, which
are held for payment to the government during a later period.
4. SHOW OTHER EXPENSES NOT AFFECTING WORKING CAPITAL.
OTHER ADDITIONS TO WORKING CAPITAL: Additions are generally
from borrowing or from liquidating non-current assets and
include the following:
5. PROCEEDS FROM BORROWING - Additions from borrowing which
increase current asset accounts.
6. SHOW OTHER ADDITIONS TO WORKING CAPITAL.
7. TOTAL SOURCES OF FUNDS - Total of the above categories.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 117 OF 166
July 2004 Medicaid HMO Contract
APPLICATIONS: Uses of Working Capital, usually additions to non-current
assets or reductions in long-term liabilities, including the following:
8. ADDITIONS TO PROPERTY AND EQUIPMENT - Increase in property and
equipment from last period.
9. REDUCTIONS IN LONG-TERM DEBT - Decrease in long-term
liabilities from last period.
10. SHOW OTHER USES OF WORKING CAPITAL.
11. TOTAL APPLICATIONS OF FUNDS - Total of the above categories.
12. INCREASE (DECREASE) IN WORKING CAPITAL - Excess or deficiency
of sources over applications of Funds.
NET WORTH:
13. Net Worth Beginning of Period
14. Increase (Decrease) in Donated Capital
15. Increase (Decrease) in Capital - (Current year less previous
year)
16. Increase (Decrease) in Paid in Surplus - (Current year less
previous year)
17. Increase (Decrease) in Reserves and Restricted Funds -
(Current year less previous year)
18. Increase (Decrease) in Unassigned Surplus - (Current year less
previous year)
19. Net Worth End of Period
60.2.13 MINORITY BUSINESS ENTERPRISE CONTRACT REPORTING
The Agency for Health Care Administration encourages the Vendor to use
Minority and Certified Minority businesses as subvendors when procuring
commodities or services to meet the requirements of the contract.
The Agency requires information regarding the Vendor's use of minority
owned businesses as subvendors under this contract. This information
will be used for assessment and evaluation of the Agency's Minority
Business Utilization Plan. During the term of the contract, it will be
necessary to provide this information monthly by the 15th of each
subsequent month. A minority owned business is defined as any business
enterprise owned and operated by the following ethnic groups: African
American (Certified Minority Code H or Non-Certified Minority Code N),
Hispanic American (Certified Minority Code I or Non-Certified Minority
O), Asian American (Certified Minority Code J or Non-Certified Minority
Code P), Native American (Certified Minority Code K or Non-Certified
Minority Code Q), or American Woman (Certified Minority Code M or
Non-Certified Minority Code R).
The Vendor is required to provide the following information on company
letterhead:
1) Minority subvendor's company name and Minority Code (see above);
2) Services subcontracted related to this contract;
3) Dates of services (beginning and ending);
4) Total dollar amount paid to subvendor for services related to this
contract; or
5) A statement that no minority subvendors were used during this
period.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 118 OF 166
July 2004 Medicaid HMO Contract
60.2.14 SUSPECTED FRAUD REPORTING
Upon detection of a potentially or suspected fraudulent claim by a
provider, the plan shall file a report to the agency. At minimum, the
report shall contain the name of the provider, the provider number or
the tax identification number, and a description of the suspected
fraudulent act. This report must be sent in narrative fashion to the
plan analyst.
60.2.15 CLAIMS INVENTORY SUMMARY REPORT
The plan shall file an aging claims summary report quarterly, noting
paid, denied and unpaid claims by provider type. The plan will submit
this report using the CLAIMS AGING TEMPLATE.XLS file supplied by the
agency. This file is an excel spreadsheet and may be submitted to the
following email address: mmcclms@fdhc.state.fl.us.
60.3 BEHAVIORAL HEALTH REPORTING REQUIREMENTS
In all AHCA Areas where the plan is capitated for and provides
behavioral health care services, the agency requires additional
quarterly reporting using an agency-supplied template. The template
must be submitted within 45 days of the end of the quarter being
reported. A separate template must be completed and submitted for each
AHCA Area in which the plan provides behavioral health care services.
All data must be compiled by the plan prior to submitting the template.
Failure of the plan to submit required reports accurately and within
the time frames specified may result in penalties in accordance with
Section 70.17, Sanctions of this contract.
The template contains five separate worksheets that must be completed
each quarter. By completing each worksheet within the template, the
plan will provide a summary of service utilization, caseload reports of
targeted case management and intensive team case management, an report
of allocation of recipients, by age and eligibility category, by
provider, and a summary of all critical incidents.
60.3.1 PATIENT SATISFACTION REPORTING
In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall conduct a behavioral health patient
satisfaction survey in both English and Spanish by March 1, of each
year.
The plan shall report the results of the survey to the agency by May
15, of each year. The sampling for the survey shall be a statistically
significant sample of each category represented for members having
received behavioral health services during the period reflected in the
report.
60.3.2 APPEALS REPORTING
In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall include in its quarterly appeals reports, a
sub-listing of all current behavioral health related appeals and the
status of such appeals to the Agency as required in Section 60.2, HMO
Reporting Requirements, of this contract.
60.3.3 QUALITY IMPROVEMENT REPORTING
In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall submit to the plan analyst, on a quarterly
basis, a summary of the plan's behavioral health quality improvement
activities and findings for that quarter, as well as a summary on the
status of any unresolved prior quarter behavioral health care services
issues. In addition, the plan shall include behavioral health quality
improvement activities and reporting as part of the plan's general
assurance activities as required in Section 20.12, Quality Improvement,
of this contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 119 OF 166
July 2004 Medicaid HMO Contract
60.3.4 INPATIENT DISCHARGE REPORTING
The plan shall report all discharges from acute care hospitals in
Section 60.2.6 Inpatient Discharge report. These discharges are
accompanied by up to three diagnosis codes. The agency will use these
detailed discharge records to evaluate utilization of inpatient
services for behavioral health diagnoses, as well as compare the
utilization patterns and the behavioral health status of members of
contracted plans.
60.3.5 CRITICAL INCIDENT REPORTING
In addition to supplying a summary of critical incidents in the
quarterly reporting template, additional critical incident reporting
must be done in the manner prescribed by the appropriate district's DCF
Alcohol, Drug Abuse Mental Health office, using their reporting forms
and procedures.
60.3.6 BEHAVIORAL HEALTH CARE EXPENDITURE REPORT
By April 1 of each year, plans with members in Areas 1 and 6 and upon
implementation of prepaid mental health in other Areas shall provide a
breakdown of expenditures related to the provision of behavioral health
care, using the spreadsheet template provided by the agency. Pursuant
to Section 409.912(3)(b), F.S., 80 percent of the capitation paid to
the plan shall be expended for the provision of behavioral health care
services. In the event the plan expends less than 80 percent of the
capitation, the difference shall be returned to the agency no later
than May 1 of each year.
For reporting purposes in accordance with this section, `behavioral
health services' are defined as those services that the Plan is
required to provide as listed in the Community Mental Health Services
Coverage and Limitations handbook and the Targeted Case Management
Coverage and Limitations handbook.
For reporting purposes in accordance with this section `expended' means
the total amount, in dollars, paid directly or indirectly to behavioral
health providers solely for the provision of behavioral health services
defined above, not including administrative expenses or overhead of the
plan.
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 120 OF 166
July 2004 Medicaid HMO Contract
70.0 TERMS AND CONDITIONS
70.1 AGENCY CONTRACT MANAGEMENT
The Division of Medicaid within the Agency shall be responsible for
management of the contract. The Division of Medicaid shall make all
statewide policy decision-making or contract interpretation. In
addition, the Division of Medicaid shall be responsible for the
interpretation of all federal and state laws, rules and regulations
governing or in any way affecting this contract. Management shall be
conducted in good faith with the best interest of the state and the
beneficiaries it serves being the prime consideration. The Agency shall
provide final interpretation of general Medicaid policy. When
interpretations are required, the plan shall submit written requests to
the Agency's contract manager.
The terms of this contract do not limit or waive the ability, authority
or obligation of the Office of Inspector General, Bureau of Medicaid
Program Integrity, its contractors, or other duly constituted
government units (state or federal) to audit or investigate matters
related to, or arising out of this contract.
70.2 APPLICABLE LAWS AND REGULATIONS
The plan agrees to comply with all applicable federal and state laws,
rules and regulations including but not limited to: Title 42 Code of
Federal Regulations (CFR) chapter IV, subchapter C; Title 45 CFR, Part
74, General Grants Administration Requirements; chapters 409 and 641,
Florida Statutes; all applicable standards, orders, or regulations
issued pursuant to the Clean Air Act of 1970 as amended (42 USC 1857,
et seq.); Title VI of the Civil Rights Act of 1964 (42 USC 2000d) in
regard to persons served; Title IX of the education amendments of 1972
(regarding education programs and activities); 42 CFR 431, subpart F,
section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C. in
regard to the contractor safeguarding information about beneficiaries;
Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to
employees or applicants for employment; Rule 59G-8.100, F.A.C.; section
504 of the Rehabilitation Act of 1973, as amended, 29 USC. 794, which
prohibits discrimination on the basis of handicap in programs and
activities receiving or benefiting from federal financial assistance;
chapter 641, parts I and III, F.S., in regard to managed care; the Age
Discrimination Act of 1975, as amended, 42 USC. 6101 et. seq., which
prohibits discrimination on the basis of age in programs or activities
receiving or benefiting from federal financial assistance; the Omnibus
Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits
discrimination on the basis of sex and religion in programs and
activities receiving or benefiting from federal financial assistance;
Medicare - Medicaid Fraud and Abuse Act of 1978; the federal Omnibus
Budget Reconciliation Acts; Americans with Disabilities Act (42 USC
12101, et seq.); the Newborns' and Mothers' Health Protection Act of
1996; and the Balanced Budget Act of 1997 and the Health Insurance
Portability and Accountability Act of 1996. The plan is subject to any
changes in federal and state law, rules, or regulations.
70.3 ASSIGNMENT
Except as provided below or with the prior written approval of the
Agency, which approval shall not be unreasonably withheld, this
contract and the monies which may become due are not to be assigned,
transferred, pledged or hypothecated in any way by the plan, including
by way of an asset or stock purchase of the plan and shall not be
subject to execution, attachment or similar process by the plan.
a As provided by section 409.912, F.S., when a merger or
acquisition of a plan has been approved by the Department of
Financial Services pursuant to section 628.4615, F.S., the
Agency shall approve the assignment or transfer of the
appropriate Medicaid HMO contract upon the request of the
surviving entity of the merger or acquisition if the plan and
the surviving entity have been in good standing with the
Agency for the most recent 12 month period, unless the Agency
determines that the assignment or transfer would be
detrimental to the Medicaid recipients or the Medicaid
program. The entity requesting the assignment or transfer
shall notify the Agency of the request 90 days prior to the
anticipated effective date.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 121 OF 166
July 2004 Medicaid HMO Contract
b. To be in good standing, a plan must not have failed
accreditation or committed any material violation of the
requirements of section 641.52, F.S., and must meet the
Medicaid contract requirements.
c. For the purposes of this section, a merger or acquisition
means a change in controlling interest of a plan, including an
asset or stock purchase.
70.4 ATTORNEY'S FEES
In the event of a dispute, each party to the contract shall be
responsible for its own attorneys' fees except as otherwise provided by
law.
70.5 CONFLICT OF INTEREST
The contract is subject to the provisions of chapter 112, Florida
Statutes. The plan must disclose the name of any officer, director, or
agent who is an employee of the State of Florida, or any of its
agencies. Further, the plan must disclose the name of any state
employee who owns, directly or indirectly, an interest of five percent
or more in the offerer's firm or any of its branches. The plan
covenants that it presently has no interest and shall not acquire any
interest, direct or indirect, which would conflict in any manner or
degree with the performance of the services hereunder. The plan further
covenants that in the performance of the contract no person having any
such known interest shall be employed. No official or employee of the
Agency and no other public official of the State of Florida or the
federal government who exercises any functions or responsibilities in
the review or approval of the undertaking of carrying out the contract
shall, prior to completion of this contract, voluntarily acquire any
personal interest, direct or indirect, in this contract or proposed
contract.
70.6 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 the Agency and the plan shall be relieved of all obligations
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 the Agency and the provider shall be
discharged from further obligations created under the terms of the
contract. However, such declaration or finding shall not affect any
rights or obligations of either party to the extent that such rights or
obligations arise from acts performed or events occurring prior to the
effective date of such declaration or finding.
70.7 COURT OF JURISDICTION OR VENUE
For purposes of any legal action occurring as a result of or under this
contract, between the plan and the Agency, the place of proper venue
shall be Leon County.
70.8 CROSSOVER CLAIMS FOR MEDICAID/MEDICARE ELIGIBLE MEMBERS
The plan shall reimburse non-participating providers for Medicare
deductibles and co-insurance payments for Medicare dually eligible
members according to the lesser of the following: the rate negotiated
with the provider or the reimbursement amount as stipulated in section
409.908, F.S.
The plan shall reimburse providers for such services no later than 35
calendar days after submittal of a clean claim which includes an
explanation of Medicare benefits, or, if no explanation of Medicare
benefits is provided, the plan shall comply with the third party payor
requirements in section 70.20, Third Party Resources.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 122 OF 166
July 2004 Medicaid HMO Contract
70.9 DAMAGES FOR FAILURE TO MEET CONTRACT REQUIREMENTS
In addition to any remedies available through this contract, in law or
equity, the plan shall reimburse the Agency for any federal
disallowances or sanctions imposed on the Agency as a result of the
provider's failure to abide by the terms of this contract.
70.10 DISPUTES
The plan may request in writing an interpretation of the contract from
the contract manager. In the event the plan disputes this
interpretation, the plan may request the dispute be decided by the
Division of Medicaid. Any disputes that arise out of or relate to this
contract shall be decided by the Agency's Division of Medicaid which
shall reduce the decision to writing and serve a copy on the plan. The
written decision of the Agency's Division of Medicaid shall be final
and conclusive. The division will render its final decision based upon
the written submission of the plan and the Agency, unless, at the sole
discretion of the Division director, the division allows an oral
presentation by the plan and the Agency. If such a presentation is
allowed, the information presented will be considered in rendering the
division's decision. Should the plan challenge an Agency decision
through arbitration as provided below, the action shall not be stayed
except by order of an arbitrator. Thereafter, a plan shall resolve any
controversy or claim arising out of or relating to the contract, or the
breach thereof, by arbitration. Said arbitration shall be held in the
City of Tallahassee, Florida, and administered by the American
Arbitration Association in accordance with its applicable rules and the
Florida Arbitration Code (chapter 682, F.S.). Judgment upon any award
rendered by the arbitrator may be entered by the Circuit Court in and
for the Second Judicial Circuit, Leon County, Florida. The chosen
arbitrator must be a member of the Florida Bar actively engaged in the
practice of law with expertise in the process of deciding disputes and
interpreting contracts in the health care field. Any arbitration award
shall be in writing and shall specify the factual and legal bases for
the award. Either party may appeal a judgment entered pursuant to an
arbitration award to the First District Court of Appeal. The parties
shall bear their own costs and expenses relating to the preparation and
presentation of a case in arbitration. The arbitrator shall award to
the prevailing party all administrative fees and expenses of the
arbitration, including the arbitrator's fee. This contract with
numbered attachments represents the entire agreement between the plan
and the agency with respect to the subject matter in it and supersedes
all other contracts between the parties when it is duly signed and
authorized by the plan and the Agency. Correspondence and memoranda of
understanding do not constitute part of this contract. In the event of
a conflict of language between the contract and the attachments, the
provisions of the contract shall govern. However, the Agency reserves
the right to clarify any contractual relationship in writing with the
concurrence of the plan and such clarification shall govern. Pending
final determination of any dispute over an Agency decision, the plan
shall proceed diligently with the performance of the contract and in
accordance with the Agency's Division of Medicaid direction.
70.11 FORCE MAJEURE
The Agency shall not be liable for any excess cost to the plan if the
Agency's failure to perform the contract arises out of causes beyond
the control and without the result of fault or negligence on the part
of the Agency. In all cases, the failure to perform must be beyond the
control without the fault or negligence of the Agency. The plan shall
not be liable for performance of the duties and responsibilities of the
contract when its ability to perform is prevented by causes beyond its
control. These acts must occur without the fault or negligence of the
plan. These include destruction to the facilities due to hurricanes,
fires, war, riots, and other similar acts. Annually by May 31, the plan
shall submit to the Agency for approval an emergency management plan
specifying what actions the plan shall conduct to ensure the ongoing
provisions of health services in a disaster or man-made emergency.
70.12 LEGAL ACTION NOTIFICATION
The plan shall give the Agency by certified mail immediate written
notification (no later than 30 calendar days after service of process)
of any action or suit filed or of any claim made against the plan by
any subcontractor, vendor, or other party which results in litigation
related to this contract for disputes or damages exceeding the amount
of $50,000. In addition, the plan shall immediately advise the Agency
of
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 123 OF 166
July 2004 Medicaid HMO Contract
the insolvency of a subcontractor or of the filing of a petition in
bankruptcy by or against a principal subcontractor.
70.13 LICENSING
In accordance with section 409.912, F.S., all entities that provide
Medicaid prepaid health care services must be commercially licensed in
accordance with the provisions of Part I and Part III of chapter 641,
F.S.
70.14 MISUSE OF SYMBOLS, EMBLEMS, OR NAMES IN REFERENCE TO MEDICAID
No person or plan may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other
communication, or a broadcast, telecast, or other production, alone or
with other words, letters, symbols or emblems the words "Medicaid," or
"Agency for Health Care Administration," except as required in the
Agency's core contract, page 2, unless prior written approval is
obtained from the Agency. Specific written authorization from the
Agency is required to reproduce, reprint, or distribute any Agency
form, application, or publication for a fee. State and local
governments are exempt from this prohibition. A disclaimer that
accompanies the inappropriate use of program or Agency terms does not
provide a defense. Each piece of mail or information constitutes a
violation.
70.15 NON-RENEWAL
This contract shall be renewed only upon mutual consent of the parties.
Either party may decline to renew the contract for any reason. Chapter
120, F.S. does not apply to a decision by the Agency not to renew this
contract.
70.16 OFFER OF GRATUITIES
By signing this agreement, the plan signifies that no member of or a
delegate of Congress, nor any elected or appointed official or employee
of the State of Florida, the General Accounting Office, Department of
Health and Human Services, CMS, or any other federal Agency has or
shall benefit financially or materially from this procurement. The
contract may be terminated by the Agency if it is determined that
gratuities of any kind were offered to or received by any officials or
employees from the offeror, his agent, or employees.
70.17 SANCTIONS
In accordance with section 4707 of the Balanced Budget Act of 1997, and
section 409.912, F.S., the Agency may impose any of the following
sanctions against the plan if it determines that the plan has violated
any provision of this contract, or the applicable statutes or rules
governing Medicaid HMOs:
a. Suspension of the plan's voluntary enrollments and
participation in the assignment process for Medicaid
enrollment;
b. Suspension or revocation of payments to the plan for Medicaid
beneficiaries enrolled during the sanction period. If the plan
has violated the contract, the Agency may order the plan to
reimburse the complainant for out-of-pocket medically
necessary expenses incurred or order the plan to pay
non-network plan providers who provide medically necessary
services;
c. Suspension of all marketing activities to Medicaid
beneficiaries;
d. Imposition of a fine for violation of the contract with the
Agency, pursuant to section 409.912, F.S. With respect to any
nonwillful violation, such fine shall not exceed $2,500 per
violation. In no event shall such fine exceed and aggregate
amount of $10,000 for all nonwillful violations arising out of
the same action. With respect to any knowing and willful
violation of section 409.912, F.S. or the contract with the
Agency, the Agency may impose a fine upon the entity in an
amount not to exceed $20,000
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 124 OF 166
July 2004 Medicaid HMO Contract
for each such violation. In no event shall such fine exceed an
aggregate amount of $100,000 for all knowing and willful
violations arising out of the same action.
e. Termination pursuant to paragraph III.B. (3) of the Agency
core contract and section 70.19, Termination Procedures, if
the plan fails to carry out substantive terms of its contract
or fails to meet applicable requirements in sections 1932,
1903(m) and 1905(t) of the Social Security Act. After the
Agency notifies the plan that it intends to terminate the
contract, the Agency may give the plan's enrollees written
notice of the state's intent to terminate the contract and
allow the enrollees to disenroll immediately without cause.
f. The Agency may impose intermediate sanctions in accordance
with 42 CFR 438.702, including:
1. Civil monetary penalties in the amounts specified in
section 409.912, F.S.
2. Appointment of temporary management for the plan.
Rules for temporary management pursuant to 42 CFR
438.706 are as follows:
(a) The State may impose temporary management
only if it finds (through onsite survey,
enrollee complaints, financial audits, or
any other means) that--
(1) There is continued egregious
behavior by the plan, including but
not limited to behavior that is
described in 42 CFR 438.700, or
that is contrary to any
requirements of sections 1903(m)
and 1932 of the Social Security
Act; or
(2) There is substantial risk to
enrollees' health; or
(3) The sanction is necessary to ensure
the health of the plan's
enrollees--
(i) While improvements are made to
remedy violations under 42 CFR
438.700; or
(ii) Until there is an orderly
termination or reorganization
of the plan.
(b) The State must impose temporary management
(regardless of any other sanction that may
be imposed) if it finds that a plan has
repeatedly failed to meet substantive
requirements in section 1903(m) or section
1932 of the Social Security Act or 42 CFR
438.706. The State must also grant enrollees
the right to terminate enrollment without
cause, as described in 42 CFR 438.702(a)(3),
and must notify the affected enrollees of
their right to terminate enrollment.
(c) The State may not delay imposition of
temporary management to provide a hearing
before imposing this sanction.
(d) The State may not terminate temporary
management until it determines that the plan
can ensure that the sanctioned behavior will
not recur.
3. Granting enrollees the right to terminate enrollment
without cause and notifying affected enrollees of
their right to disenroll.
4. Suspension or limitation of all new enrollment,
including default enrollment, after the effective
date of the sanction.
5. Suspension of payment for beneficiaries enrolled
after the effective date of the sanction and until
CMS or the Agency is satisfied that the reason for
imposition of the sanction no longer exists and is
not likely to recur.
6. Denial of payments provided for under the contract
for new enrollees when, and for so long as, payment
for those enrollees is denied by CMS in accordance
with 42 CFR 438.730.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 125 OF 166
July 2004 Medicaid HMO Contract
Before imposing any intermediate sanctions, the state
must give the plan timely notice according to 42 CFR
438.710.
g. In accordance with section 409.912, F.S., if the plan's Child
Health Check-Up screening compliance rate is below 60 percent,
it must submit to the Agency, and implement, an Agency
accepted corrective action plan. If the plan does not meet the
standard established in the corrective action plan during the
time period indicated in the corrective action plan, the
Agency has the authority to impose sanctions in accordance
with this section.
Unless the duration of a sanction is specified, a sanction
shall remain in effect until the Agency is satisfied that the
basis for imposing the sanction has been corrected and is not
likely to recur.
70.18 SUBCONTRACTS
The plan is responsible for all work performed under this contract, but
may, with the written approval of the Agency, enter into subcontracts
for the performance of work required under this contract. All
subcontracts must comply with 42 CFR 438.230. All subcontracts and
amendments executed by the plan must meet the following requirements
and all model provider subcontracts must be approved, in writing, by
the Agency in advance of implementation. All subcontractors must be
eligible for participation in the Medicaid program; however, the
subcontractor is not required to participate in the Medicaid program as
a provider. The Agency encourages use of minority business enterprise
subcontractors. Subcontracts are required with all major providers of
services including all primary care sites.
The plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider's license, or certification under
applicable state law, solely on the basis of such license, or
certification, in accordance with section 4704 of the Balanced Budget
Act of 1997. This paragraph shall not be construed to prohibit a plan
from including providers only to the extent necessary to meet the needs
of the plan's enrollees or from establishing any measure designed to
maintain quality and control costs consistent with the responsibilities
of the organization. If the plan declines to include individual
providers or groups of providers in its network, it must give the
affected providers written notice of the reason for its decision.
In all contracts with health care professionals, the plan must comply
with the requirements specified in 42 CFR 438.214 which includes but is
not limited to selection and retention of providers, credentialing and
recredentialing requirements, and nondiscrimination.
No subcontract which the plan enters into with respect to performance
under the contract shall in any way relieve the plan of any
responsibility for the performance of duties under this contract. The
plan shall assure that all tasks related to the subcontract are
performed in accordance with the terms of this contract. The plan shall
identify in its subcontracts any aspect of service that may be further
subcontracted by the subcontractor.
All model and executed subcontracts and amendments used by the plan
under this contract must be in writing, signed, and dated by the plan
and the subcontractor and meet the following requirements:
a. Identification of conditions and method of payment:
1. The plan agrees to make payment to all subcontractors
pursuant to section 641.3155, F.S. 42 CFR 447.46, 42
CFR 447.45(d)(2), 42 CFR 447.45 (d)(3), 42 CFR 447.45
(d)(5) and 42 CFR 447.45 (d)(6); If third party
liability exists, payment of claims shall be
determined in accordance with section 70.20, Third
Party Resources.
2. Provide for prompt submission of information needed
to make payment.
3. Make full disclosure of the method and amount of
compensation or other consideration to be received
from the plan. The provider shall not charge for any
service provided to the member at a
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 126 OF 166
July 2004 Medicaid HMO Contract
rate in excess of the rates established by the plan's
subcontract with the provider in accordance with
section 1128B(d)(1), Social Security Act (enacted by
section 4704 of the Balanced Budget Act of 1997).
4. Require an adequate record system be maintained for
recording services, charges, dates and all other
commonly accepted information elements for services
rendered to beneficiaries under the contract.
5. Physician incentive plans must comply with 42 CFR
417.479, 42 CFR 438.6(h), 42 CFR 422.208 and 42 CFR
422.210. Plans shall make no specific payment
directly or indirectly under a physician incentive
plan to a physician or physician group as an
inducement to reduce or limit medically necessary
services furnished to an individual enrollee.
Incentive plans must not contain provisions which
provide incentives, monetary or otherwise, for the
withholding of medically necessary care.
The plan must disclose information on provider
incentive plans listed in 42 CFR 417.479(h)(1) and
417.479(I) at the times indicated in 42 CFR
417.479(d)-(g). All such arrangements must be
submitted to the Agency for approval, in writing,
prior to use. If any other type of withhold
arrangement currently exists, it must be omitted from
all subcontracts.
6. Specify whether the plan will assume full
responsibility for third party collections in
accordance with section 70.20, Third Party Resources.
b. Provisions for monitoring and inspections:
1. Provide that the Agency and DHHS may evaluate through
inspection or other means the quality,
appropriateness and timeliness of services performed.
2. Provide for inspections of any records pertinent to
the contract by the Agency and DHHS.
3. Require that records be maintained for a period not
less than five years from the close of the contract
and retained further if the records are under review
or audit until the review or audit is complete.
(Prior approval for the disposition of records must
be requested and approved by the provider if the
subcontract is continuous.)
4. Provide for monitoring and oversight by the plan and
the subcontractor to provide assurance that all
licensed medical professionals are credentialed in
accordance with the plan's and the Agency's
credentialing requirements as found in section
20.5.1, Credentialing and Recredentialing Policies
and Procedures, if the plan has delegated the
credentialing to a subcontractor.
5. Provide for monitoring of services rendered to
beneficiaries sponsored by the provider.
c. Specification of functions of the subcontractor:
1. Identify the population covered by the subcontract.
2. Specify the amount, duration and scope of services to
be provided by the subcontractor, including a
requirement that the subcontractor continue to
provide services through the term of the capitation
period for which the Agency has paid the plan.
3. Provide for timely access to physician appointments
to comply with the following availability schedule:
urgent care - within one day; routine sick care -
within one week; well care - within one month.
Require that the network providers offer hours of
operation that are no less than the hours of
operation offered to commercial beneficiaries or
comparable to Medicaid fee-for-service if the
provider serves only Medicaid beneficiaries.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 127 OF 166
July 2004 Medicaid HMO Contract
4. Provide for submission of all reports and clinical
information required by the plan, including Child
Health Check-Up reporting (if applicable).
5. Provide for the participation in any internal and
external quality improvement, utilization review,
peer review, and grievance procedures established by
the plan.
d. Protective clauses:
1. Require safeguarding of information about
beneficiaries according to 42 CFR, Part 438.224.
2. Require compliance with HIPAA privacy and security
provisions.
3. Require an exculpatory clause, which survives
subcontract termination including breach of
subcontract due to insolvency, that assures that
beneficiaries or the Agency may not be held liable
for any debts of the subcontractor and, in accordance
with 42 CFR 447.15, that the beneficiary is not
liable to the provider for any services for which the
health maintenance organization is liable as
specified in section 641.315, F.S.
4. Contain a clause indemnifying, defending and holding
the Agency and the plan members harmless from and
against all claims, damages, causes of action, costs
or expense, including court costs and reasonable
attorney fees to the extent proximately caused by any
negligent act or other wrongful conduct arising from
the subcontract agreement. This clause must survive
the termination of the subcontract, including breach
due to insolvency. The Agency may waive this
requirement for itself, but not plan members, for
damages in excess of the statutory cap on damages for
public entities if the subcontractor is a public
health entity with statutory immunity. All such
waivers must be approved in writing by the Agency.
5. Require that the subcontractor secure and maintain
during the life of the subcontract worker's
compensation insurance for all of its employees
connected with the work under this contract unless
such employees are covered by the protection afforded
by the plan. Such insurance shall comply with the
Florida's Worker's Compensation Law.
6. Pursuant to section 641.315, F.S., contain no
provision that prohibits the physician from providing
inpatient services in a contracted hospital to a
subscriber if such services are determined by the
organization to be medically necessary and covered
services under the organization's contract with the
contract holder.
7. Contain no provision restricting the provider's
ability to communicate information to the provider's
patient regarding medical care or treatment options
for the patient when the provider deems knowledge of
such information by the patient to be in the best
interest of the health of the patient.
8. Pursuant to section 641.315, contain no provision
requiring providers to contract for more than one HMO
product or otherwise be excluded.
9. Pursuant to section 641.315, F.S., contain no
provision that in any way prohibits or restricts the
health care provider from entering into a commercial
contract with any other plan.
10. Specify that if the subcontractor delegates or
subcontracts any functions of the plan, that the
subcontract or delegation includes all the
requirements of this section and section 20.3.
11. Make provisions for a waiver of those terms of the
subcontract, which, as they pertain to Medicaid
beneficiaries, are in conflict with the
specifications of this contract.
12. Specify procedures and criteria for extension,
renegotiation and termination, and that the provider
must give 60 days' advance written notice to the
plan, and the Office of Insurance Regulation
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 128 OF 166
July 2004 Medicaid HMO Contract
before canceling the contract with the plan for any
reason. Nonpayment for goods or services rendered by
the provider to the plan is not a valid reason for
avoiding the 60-day advance notice of cancellation
pursuant to section 641.315, F.S. A copy of the
notice shall be filed simultaneously with the Agency.
Pursuant to section 641.315, F.S., specify that the
plan will provide 60 days' advance written notice to
the provider and the Office of Insurance Regulation
before canceling, without cause, the contract with
the provider, except in a case in which a patient's
health is subject to imminent danger or a physician's
ability to practice medicine is effectively impaired
by an action by the Board of Medicine or other
governmental Agency, in which case notification shall
be provided to the Agency immediately. A copy of the
notice submitted to the Office of Insurance
Regulation shall be filed simultaneously with the
Agency.
13. Provide for revoking delegation or imposing other
sanctions if the subcontractor's performance is
inadequate.
70.18.1 HOSPITAL SUBCONTRACTS
All hospital subcontracts must meet the requirements outlined in
section 70.18, Subcontracts. In addition such subcontracts must require
that the hospitals notify the plan of births where the mother is a plan
member. The subcontract must also specify which entity (plan or
hospital) is responsible for completing form DCF-ES 2039 and submitting
it to the local DCF Economic Self-Sufficiency Services office. The
subcontract must also indicate that the plan's name must be indicated
as the referring Agency when the form DCF-ES 2039 is completed.
70.19 TERMINATION PROCEDURES
In conjunction with section III.B., Termination, on page 3 of the
Agency's core contract, termination procedures are required. The plan
agrees to extend the thirty (30) calendar days notice found in section
III.B.1., Termination at Will, on page 3 of the Agency's core contract
to ninety (90) calendar days notice. The party initiating the
termination shall render written notice of termination to the other
party by certified mail, return receipt requested, or in person with
proof of delivery, or by facsimile letter followed by certified mail,
return receipt requested. The notice of termination shall specify the
nature of termination, the extent to which performance of work under
the contract is terminated, and the date on which such termination
shall become effective. In accordance with 1932(e)(4), Social Security
Act, the Agency shall provide the plan with an opportunity for a
hearing prior to termination for cause.
Upon receipt of final notice of termination, on the date and to the
extent specified in the notice of termination, the plan shall:
a. Stop work under the contract, but not before the termination
date.
b. Cease enrollment of new beneficiaries under the contract.
c. Terminate all marketing activities and subcontracts relating
to marketing.
d. Assign to the state those subcontracts as directed by the
Agency's contracting officer including all the rights, title
and interest of the plan for performance of those
subcontracts.
e. In the event the Agency has terminated this contract in one or
more Agency areas of the state, complete the performance of
this contract in all other areas in which the plan has not
been terminated.
f. Take such action as may be necessary, or as the Agency's
contracting officer may direct, for the protection of property
related to the contract which is in the possession of the plan
and in which the Agency has been granted or may acquire an
interest.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 129 OF 166
July 2004 Medicaid HMO Contract
g. Not accept any payment after the contract ends unless the
payment is for the time period covered under the contract. Any
payments due under the terms of this contract may be withheld
until the Agency receives from the plan all written and
properly executed documents as required by the written
instructions of the Agency.
h. At least 60 calendar days prior to the termination effective
date, provide written notification to all members of the
following information: the date on which the plan will no
longer participate in the State's Medicaid program; and
instructions on contacting the Agency's enrollment and
disenrollment services help line to obtain information on
members' enrollment options and to request a change in managed
care enrollment.
In addition, through separate written notification, the plan
shall inform the parents or guardians of members enrolled in
the MediKids program that they must contact the MediKids help
line to make another managed care selection in order to
continue to be eligible for the program and receive services.
70.20 THIRD PARTY RESOURCES
The plan shall be responsible for making every reasonable effort to
determine the legal liability of third parties to pay for services
rendered to members under this contract. The plan has the same rights
to recovery of the full value of services as the Agency (See section
409.910, F.S. The following standards govern recovery.
a. If the plan has determined that third party liability exists
for part or all of the services provided directly by the plan
to a member, the plan shall make reasonable efforts to recover
from third party liable sources the value of services
rendered.
b. If the plan has determined that third party liability exists
for part or all of the services provided to a member by a
subcontractor or referral provider, and the third party is
reasonably expected to make payment within 120 calendar days,
the plan may pay the subcontractor or referral provider only
the amount, if any, by which the subcontractor's allowable
claim exceeds the amount of the anticipated third party
payment; or, the plan may assume full responsibility for third
party collections for service provided through the
subcontractor or referral provider.
c. The plan may not withhold payment for services provided to a
member if third party liability or the amount of liability
cannot be determined, or if payment shall not be available
within a reasonable time, beyond 120 calendar days from the
date of receipt.
d. When both the Agency and the plan have liens against the
proceeds of a third party resource, the Agency shall prorate
the amount due to Medicaid to satisfy such liens under section
409.910, F.S., between the Agency and the plan. This prorated
amount shall satisfy both liens in full.
e. The Agency may, at its sole discretion, offer to provide third
party recovery services to the plan. If the plan elects to
authorize the Agency to recover on its behalf, the plan shall
be required to provide the necessary data for recovery in the
format prescribed by the Agency. All recoveries, less the
Agency's cost to recover shall be income to the plan. The cost
to recover shall be expressed as a percentage of recoveries
and shall be fixed at the time the plan elects to authorize
the Agency to recover on its behalf.
f. All funds recovered from third parties shall be treated as
income for the plan.
70.21 WAIVER
No covenant, condition, duty, obligation, or undertaking contained in
or made a part of the contract shall be waived except by written
agreement of the parties, and forbearance or indulgence in any other
form or manner by either party in any regard whatsoever shall not
constitute a waiver of the covenant, condition, duty, obligation, or
undertaking to be kept, performed, or discharged by the party to which
the same may
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 130 OF 166
July 2004 Medicaid HMO Contract
apply. Until complete performance or satisfaction of all such
covenants, conditions, duties, obligations, or undertakings, the other
party shall have the right to invoke any remedy available under law or
equity not withstanding any such forbearance or indulgence.
70.22 WITHDRAWING SERVICES FROM A COUNTY
If the plan intends to withdraw services from a county, it shall
provide written notice to its members in that county at least 60
calendar days prior to the last day of service. The notice shall
contain the same information as required for a notice of termination
according to subsection h. of section 70.19, Termination Procedures.
The plan shall also provide written notice of the withdrawal to all
subcontractors in the county.
70.23 MYFLORIDAMARKETPLACE VENDOR REGISTRATION
Each Vendor doing business with the State of Florida for the sale of
commodities or contractual services as defined in section 287.012,
Florida Statutes, shall register in MyFloridaMarketPlace, in compliance
with Rule 60A-1.030, Florida Administrative Code, unless exempt under
Rule 60A-1.030(3) Florida Administrative Code.
70.23.1 MYFLORIDAMARKETPLACE TRANSACTION FEE
The State of Florida, through the Department of Management Services,
has instituted MyFloridaMarketPlace, a statewide eProcurement system.
Pursuant to section 287.057(23), Florida Statutes (2002), all payments
for commodities and/or contractual services as defined in Section
287.012, Florida Statutes, shall be assessed a Transaction Fee of one
percent (1.0%), which the Vendor shall pay to the State, unless exempt
under Rule 60A-1.032, Florida Administrative Code. Notwithstanding the
provisions of Rule 60A-1.030, et seq., the assessment of a transaction
fee shall be contingent upon Federal approval of the transaction fee
assessment program and continued payment of applicable federal matching
funds.
For payments within the State accounting system (FLAIR or its
successor), the Transaction Fee shall, when possible, be automatically
deducted from payments to the Vendor. If automatic deduction is not
possible, the Vendor shall pay the Transaction Fee pursuant to Rule
60A-1.031(2), Florida Administrative Code. By submission of these
reports and corresponding payments, Vendor certifies their correctness.
All such reports and payments shall be subject to audit by the State or
its designee.
The Vendor shall receive a credit for any Transaction Fee paid by the
Vendor for the purchase of any item(s) if such item(s) are returned to
the Vendor through no fault, act, or omission of the Vendor.
Notwithstanding the foregoing, a Transaction Fee is non-refundable when
an item is rejected or returned, or declined, due to the Vendor's
failure to perform or comply with specifications or requirements of the
agreement.
Failure to comply with these requirements shall constitute grounds for
declaring the Vendor in default and recovering re-procurement costs
from the Vendor in addition to all outstanding fees. VENDORS DELINQUENT
IN PAYING TRANSACTION FEES MAY BE EXCLUDED FROM CONDUCTING FUTURE
BUSINESS WITH THE STATE.
70.23.2 MYFLORIDAMARKETPLACE VENDOR REGISTRATION AND TRANSACTION FEE EXEMPTION
This contract will provide health care services at or below Medicaid
rates and are therefore exempt from the Vendor Registration under Rule
60A-1.030(2)(d)(1), and the one percent (1.0%) Transaction Fee under
Rule 60A-1.032(1)(h) of the Florida Administrative Code.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 131 OF 166
July 2004 Medicaid HMO Contract
80.0 METHOD OF PAYMENT
80.1 PAYMENT TO PLAN BY AGENCY
This is a fixed price unit cost contract. The Agency or its appointed
fiscal agent shall make payment to the plan on a monthly basis for the
plan's satisfactory performance of its duties and responsibilities as
set forth in this contract. To accommodate payments, the plan is
enrolled as an HMO provider with the Medicaid fiscal agent. Section
60.2, HMO Reporting Requirements, details the enrollment reports, the
monthly payment request processing, and service utilization procedures.
a. Plans will be eligible to participate in the Child Health
Check-Up (CHCUP) incentive program when the plan has exceeded
both the federal 80% participation and screening ratio goals
and the 60% state screening ratio as outlined in section
10.8.1. The Agency will determine which plans will participate
based upon the audited CHCUP reports submitted each October 1
as outlined in section 60.2.9.
The amount of the incentive payment shall be calculated as
follows. The ratio of a qualified plan's screenings to the
total of all plans' screenings will be multiplied by the total
amount in the fund for the incentive payment. The ratios will
be based on the plans' audited CHCUP reports. The total amount
in the fund will be determined at the discretion of the Agency
and in no event shall the total monies allotted to the
incentive program be in excess of the funds paid to the plans
for CHCUP fee-for-service claims for the fiscal year ending
June 30, 2003 (this will be the latest complete fiscal year
for which fee-for-service claims have been finalized). In
addition, pursuant to 42 CFR 438.6 (c) (1) (iv) and (5) (iii),
the payment to any one plan shall not be in excess of 5% of
the capitation amount paid for Child Health Check-Up services
pursuant to this contract for the contract year ending June
30, 2005.
b. The Agency shall pay the applicable capitation rate for each
member whose name appears on the HMO ONGOING REPORT (FLMR
8200-R004) and the HMO REINSTATEMENT REPORT (FLMR 8200-R009)
for each month, except that the Agency shall not pay for any
part of the total enrollment that exceeds the maximum
authorized enrollment level(s) expressed in this contract. The
payment amount shall depend upon the number of members in each
capitation category, at a rate as provided for by this
contract, or as adjusted pursuant to the contract when
necessary. The plan is obligated to provide services pursuant
to the terms of this contract for all members for whom the
plan has received capitation payment or for whom the Agency
has assured the plan that capitation payment is forthcoming.
c. The capitation rates to be paid are developed using historical
rates paid by Medicaid fee-for-service for similar services in
the same geographic area, adjusted for inflation, where
applicable and in accordance to 42 CFR 438.6(c). .
d. For plans participating in the frail/elderly program, the plan
is paid a capitation rate for each member who has received the
appropriate CARES assessment based on the Medicaid
fee-for-service claims experience of a like group of similarly
assessed beneficiaries. The rate merges the claims experience
from both the community setting and the nursing home setting
for the rate base group of beneficiaries for the rate base
year. The plan receives the "nursing home" capitation rate for
each member for as long as the member remains a member and
continues to meet the minimum nursing home level of care. If
the member, upon reassessment by CARES, loses the nursing home
level of care, the member reverts back to the standard
community capitation rate applicable to his/her eligibility
group.
e. The capitation rates to be paid shall be as indicated in
section 90.0, Payment and Authorized Enrollment Levels, which
indicates an initial and maximum authorized enrollment levels
and capitation rates applicable to each authorized eligibility
category.
f. At such time as the Agency receives legislative direction to
assess plans for enrollment and disenrollment services costs,
the Agency shall apply assessments, in quarterly installments
each year, against the plan's next capitation payment to pay
for enrollment and disenrollment services contractor costs as
follows:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 132 OF 166
July 2004 Medicaid HMO Contract
1. July 1, for costs estimated for the Agency's
enrollment and disenrollment services contractor
system and contract for July and the following two
months.
2. October 1, for costs related to the third party
enrollment and disenrollment services contract for
October and the following two months.
3. January 1, for costs related to maintaining the third
party enrollment and services contract for January
and the following two months.
4. April 1, for costs related to maintaining the third
party enrollment and disenrollment services contract
for April and the following two months.
g. Unless otherwise specified in this contract, the plan shall
accept the capitation payment received each month as payment
in full by the Agency for all services provided to members
covered under this contract and the administrative costs
incurred by the plan in providing or arranging for such
services. Any and all costs incurred by the plan in excess of
the capitation payment shall be borne in total by the plan.
h. Potentially, several frail/elderly members may be receiving
care from the plan prior to actually being listed on the
monthly enrollment roster. The plan may be eligible to receive
retroactive capitation payments for those members once they
are enrolled and listed on the monthly roster. Retroactive
capitation payments will not be granted due to retroactive
Medicaid eligibility, however. In order to receive the
retroactive capitation payment, the following must be met:
1. The member must meet established Level of Care (LOC)
requirements.
2. The member is eligible for Medicaid, and is
successfully enrolled on the monthly enrollment
roster under the appropriate county's frail/elderly
Medicaid provider number.
3. The member's LOC must be dated prior to the first day
of the month retroactive capitation payment is being
requested.
4. Proof of the care provided must be presented (e.g.,
copy of a paid claim for the care provided in the
retro month).
5. A letter from the plan requesting that the
retroactive capitation payment be considered, with
the required documentation included.
80.2 NEWBORN PAYMENT AND PROCEDURES
The plan is responsible for payment of all covered services provided to
newborns for up to the first three months of life.
a. The agency shall pay a capitation rate for each newborn
enrolled in the plan.
b. The plan shall use the Unborn Activation Process to enroll all
babies born to member mothers.
80.3 RATE ADJUSTMENTS
The plan and the Agency acknowledge that the capitation rates paid
under this contract as specified in section 90.0, Payment and Maximum
Authorized Enrollment Levels, of this contract are subject to approval
by the federal government.
a Adjustments to funds previously paid and to be paid may be
required. Funds previously paid shall be adjusted when
capitation rate calculations are determined to have been in
error, or when capitation
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 133 OF 166
July 2004 Medicaid HMO Contract
payments have been made for beneficiaries who are determined
not to have been eligible for HMO membership during the period
for which the capitation payments were made. In such events,
the plan agrees to refund any overpayment and the Agency
agrees to pay any underpayment.
b. The Agency agrees to adjust capitation rates to reflect
budgetary changes in the Medicaid fee-for-service program. The
rate of payment and total dollar amount may be adjusted with a
properly executed amendment when Medicaid fee-for-service
expenditure changes have been established through the
appropriations process and subsequently identified in the
Agency's operating budget. Legislatively-mandated changes
shall take effect on the dates specified in the legislation.
c. If the Agency has received legislative direction as specified
in section 80.1 e., Payment to Plan by Agency, the Agency
shall annually, or more frequently, determine the actual
expenditures for enrollment and disenrollment services. The
Agency will compare capitation rate assessments to the actual
costs for enrollment and disenrollment services. The following
factors will enter into any cost settlement process:
1. If the amount of capitation assessments are less than
the actual cost of providing enrollment and
disenrollment services, the plan will return the
difference to the Agency within thirty calendar days
of settlement.
2. If the amount of capitation assessments exceeds the
actual cost of providing enrollment, and
disenrollment services, the Agency will make up the
difference to the plan within thirty calendar days of
the settlement.
80.4 ERRORS
Plans are expected to prepare carefully all reports and monthly payment
requests for submission to the Agency. If after preparation and
electronic submission, a plan error is discovered either by the plan or
the Agency, the plan has 30 business days from its discovery of the
error, or 30 business days after receipt of notice by the Agency, to
correct the error and re-submit accurate reports and/or invoices.
Failure to respond within the 30 business day period may result in a
loss of any money due the plan for such errors.
80.5 MEMBER PAYMENT LIABILITY PROTECTION
The plan shall not hold members liable for the following in accordance
with section 1932 (b)(6), Social Security Act (enacted by section 4704
of the Balanced Budget Act of 1997):
a. For debts of the plan, in the event of the plan's insolvency.
b. For payment of covered services provided by the plan if the
plan has not received payment from the Agency for the
services, or if the health care provider, under contract or
other arrangement with the plan, fails to receive payment from
the Agency or the plan.
c. For payments to the health care provider, including referral
providers, that furnished covered services under a contract,
or other arrangement with the plan, that are in excess of the
amount that normally would be paid by the member if the
service had been received directly from the plan.
80.6 COPAYMENTS
The plan shall not require any copayment or cost sharing for services
listed in section 10.4., Covered Services, section 10.5, Optional
Services, if provided, or 10.6, Expanded Services, nor may the plan
charge members for missed appointments.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 134 OF 166
WellCare HMO d/b/a StayWell Health Plan of Florida Medicaid HMO Contract
July 1, 2004
90.0 PAYMENT AND AUTHORIZED ENROLLMENT LEVELS
The plan is assigned an authorized maximum enrollment level for each
operational county, and shall be paid capitation payments for each
Agency operational area, in accordance with the following table. The
plan shall be paid capitation payments based on the Agency operational
area (or rate zone) age group, and gender, in accordance with Table 2;
and Table 3 for areas where behavioral health care has been
implemented.
The authorized maximum enrollment level is in effect on July 1, 2004,
or upon contract execution, whichever is later. The Agency must approve
in writing any increase in the plan's maximum enrollment level for each
operational county. Such approval shall not be unreasonably withheld,
and shall be based on the plan's satisfactory performance of terms of
the contract and approval of the plan's administrative and service
resources, as specified in this contract, in support of each enrollment
level.
The Agency has developed estimated rates, for examination and
evaluation by its actuary, Milliman and Co., to be paid to the
Contractor for services provided in Fiscal Year 2004-2005. These
estimated rates represent the Agency's best efforts to develop accurate
rates. They are included as Attachment VI; entitled "ESTIMATED 04-05
HMO RATES; NOT FOR USE UNLESS APPROVED BY CMS." The Agency may use, or
may amend and use these estimated rates, only after certification by
its actuary and approval by the Centers for Medicare and Medicaid
Services, and by notice in a contract amendment to the Contractor.
Inclusion of these estimated rates is not intended to convey or imply
any rights, duties or obligations of either party, nor is it intended
to restrict, restrain or control the rights of either party that may
have existed independently of this section of the Agreement. By
signature of this document, the parties explicitly agree that this
section shall not independently convey any inherent rights,
responsibilities or obligations of either party, relative to these
rates, and shall not itself be the basis for any cause of
administrative, legal or equitable action brought by either party.
In the event the rates certified by the actuary and approved by CMS are
different from the Agency's estimated rates, the Contractor agrees to
accept a reconciliation performed by the Agency to bring payments to
the Contractor in line with the approved rates.
Upon receipt of CMS approval of 2004-2005 capitation rates, the Agency
shall amend this contract to reflect accepted capitation rates
effective July 1, 2004.
Upon CMS approval of 2005-2006 capitation rates, the Agency shall amend
this contract to reflect CMS approved and actuarially certified
capitation rates effective July 1, 2005.
Table 1 provides the plan's contract enrollment levels.
Table 2 provides capitation rates for all Agency areas, except for
areas where behavioral health care has been implemented.
Table 3 provides capitation rates for Agency areas where behavioral
health care has been implemented, including community mental health and
mental health targeted case management.
TABLE 1 PROJECTED ENROLLMENT
COUNTY MAXIMUM ENROLLMENT LEVEL
BREVARD 14,000
BROWARD 25,000
DADE 25,000
HERNANDO 9,500
HILLSBOROUGH 28,000
LEE 10,000
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 135 OF 166
WellCare HMO d/b/a StayWell Health Plan of Florida Medicaid HMO Contract
July 1, 2004
MANATEE 12,000
ORANGE 38,000
OSCEOLA 12,000
PALM BEACH 15,000
PASCO 7,000
PINELLAS 15,000
POLK 25,000
SARASOTA 4,500
SEMINOLE 5,000
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 136 OF 166
WellCare HMO d/b/a StayWell Health Plan of Florida Medicaid HMO Contract
July 1, 2004
TABLE 2
AREA
Area 03
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 304.04 74.58 47.23 53.30 115.21 132.40 204.22 310.61 310.61
SSI/No Medicare 1722.67 318.21 170.47 178.77 178.77 539.93 539.93 554.25 554.25
SSI/Part B 288.07 288.07 288.07 288.07 288.07 288.07 288.07 288.07 288.07
SSI/Part A & B 261.55 261.55 261.55 261.55 261.55 261.55 261.55 261.55 184.90
Area 04
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 271.14 66.78 42.37 47.98 103.10 118.94 183.29 279.31 279.31
SSI/No Medicare 1595.82 294.29 157.35 165.25 165.25 498.99 498.99 512.40 512.40
SSI/Part B 249.15 249.15 249.15 249.15 249.15 249.15 249.15 249.15 249.15
SSI/Part A & B 265.42 265.42 265.42 265.42 265.42 265.42 265.42 265.42 187.52
Area 05
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 285.33 69.91 44.12 49.85 107.97 123.86 191.30 290.61 290.61
SSI/No Medicare 1640.03 302.32 161.06 169.11 169.11 511.37 511.37 524.95 524.95
SSI/Part B 217.17 217.17 217.17 217.17 217.17 217.17 217.17 217.17 217.17
SSI/Part A & B 276.42 276.42 276.42 276.42 276.42 276.42 276.42 276.42 195.20
Area 07
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 279.36 68.56 43.44 49.09 105.94 121.92 188.01 286.09 286.09
SSI/No Medicare 1590.95 293.73 157.71 165.37 165.37 499.72 499.72 512.25 512.25
SSI/Part B 265.79 265.79 265.79 265.79 265.79 265.79 265.79 265.79 265.79
SSI/Part A & B 259.85 259.85 259.85 259.85 259.85 259.85 259.85 259.85 183.50
Area 08
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 257.19 63.11 40.00 45.22 97.50 112.18 173.06 263.38 263.38
SSI/No Medicare 1611.33 297.66 159.63 167.51 167.51 505.95 505.95 519.07 519.07
SSI/Part B 250.97 250.97 250.97 250.97 250.97 250.97 250.97 250.97 250.97
SSI/Part A & B 253.44 253.44 253.44 253.44 253.44 253.44 253.44 253.44 179.15
Area 09
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 278.08 68.26 43.21 48.86 105.44 121.17 186.89 284.35 284.35
SSI/No Medicare 1801.74 333.04 179.03 187.98 187.98 567.15 567.15 581.73 581.73
SSI/Part B 251.63 251.63 251.63 251.63 251.63 251.63 251.63 251.63 251.63
SSI/Part A & B 290.09 290.09 290.09 290.09 290.09 290.09 290.09 290.09 204.83
Area 10
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 292.87 71.99 45.66 51.65 111.29 128.28 197.65 301.04 301.04
SSI/No Medicare 2177.44 402.11 215.86 226.70 226.70 684.10 684.10 701.42 701.42
SSI/Part B 267.12 267.12 267.12 267.12 267.12 267.12 267.12 267.12 267.12
SSI/Part A & B 319.69 319.69 319.69 319.69 319.69 319.69 319.69 319.69 225.90
Area 11
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 346.97 84.89 53.53 60.41 130.98 150.12 231.97 352.05 352.05
SSI/No Medicare 2343.27 432.47 231.39 242.81 242.81 734.42 734.42 753.18 753.18
SSI/Part B 420.82 420.82 420.82 420.82 420.82 420.82 420.82 420.82 420.82
SSI/Part A & B 357.12 357.12 357.12 357.12 357.12 357.12 357.12 357.12 252.28
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 137 OF 166
WellCare HMO d/b/a StayWell Health Plan of Florida Medicaid HMO Contract
July 1, 2004
TABLE 3
AREA
AREA 6 OR AREA 1 AGE-BANDED CAPITATION RATES, INCLUDING COMMUNITY MENTAL HEALTH
AND MENTAL HEALTH TARGETED CASE MANAGEMENT.
Area 01
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 261.93 64.58 46.91 51.01 104.29 114.62 176.23 267.49 267.49
SSI/No Medicare 1627.19 305.09 213.99 207.65 207.65 549.97 549.97 544.97 544.97
SSI/Part B 289.84 289.84 289.84 289.84 289.84 289.84 289.84 289.84 289.84
SSI/Part A & B 301.66 301.66 301.66 301.66 301.66 301.66 301.66 301.66 218.69
Area 06
<1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64 65+
TANF/FC/SOBRA 279.29 71.17 59.81 65.79 122.52 124.65 190.77 289.28 289.28
SSI/No Medicare 1498.70 293.07 243.27 196.57 196.57 526.87 526.87 511.41 511.41
SSI/Part B 242.93 242.93 242.93 242.93 242.93 242.93 242.93 242.93 242.93
SSI/Part A & B 263.55 263.55 263.55 263.55 263.55 263.55 263.55 263.55 187.50
For plans participating in the frail/elderly program, the community rate shall
be paid for all members in each eligibility category except for those SSI
members who have been determined by an assessment by the Comprehensive
Assessment and Review for Long Term Care (CARES) Unit to be at risk of nursing
home institutionalization. Evidence of such assessments shall be provided to the
Agency by the plan prior to authorization by the Agency of payment of the
institutional rates. Payment of institutional rates for any eligible member
shall continue only so long as the member meets the level of care requirements
for institutionalization, otherwise, the community capitation rate applies.
Notwithstanding the payment amounts which may be computed with the above rate
table, the sum of total capitation payments under this contract shall not exceed
the total contract amount of $634,852,345.00 expressed on page seven of this
contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 138 OF 166
July 2004 Medicaid HMO Contract
100.0 GLOSSARY
The following terms as used in this contract, shall be construed and/or
interpreted as follows, unless the contract otherwise expressly
requires a different construction and/or interpretation. In the event
of a conflict in language between the definitions, attachments and
other sections of the contract, the language in the Standard Contract
and Attachment I shall govern.
ACTION - 42 CFR 438.400 - 1. The denial or limited authorization of a
requested service, including the type or level of service. 2. The
reduction, suspension, or termination of a previously authorized
service. 3. The denial, in whole or in part, of payment for a service.
4. The failure to provide services in a timely manner, as defined by
the state. 5. The failure of the plan to act within the timeframes
provided in Sec. 438.408(b). 6. For a resident of a rural area with
only one managed care entity, the denial of a Medicaid enrollee's
request to exercise his or her right, under Sec. 438.52(b)(2)(ii), to
obtain services outside the network.
ADL - Activities of Daily Living are activities that reflect the
client's ability to perform tasks that are essential for self-care such
as bathing, feeding oneself, dressing, toileting, transferring from a
bed to a chair, etc.
ADM - Alcohol, Drug Abuse, and Mental Health Office of the Florida
Department of Children and Families (also referred to as DCF).
ALF - Assisted Living Facility.
AGENCY - State of Florida, Agency for Health Care Administration.
AGENT - a person or entity who has employment or a contract with the
plan for the provision of items and services that are significant and
material to the plan's contract with the Agency.
ANCILLARY MEDICAL SERVICES - secondary medical services in support of
primary care services, such as laboratory services.
APD - Agency for People with Disabilities (formally the Developmental
Services Program Office of the Florida Department of Children and
Families)
APPEAL - 42 CFR 438.400 - a request for review of action.
BAKER ACT - the Florida Mental Health Act, chapter 394, F.S.
BEHAVIORAL HEALTH SERVICES - services that the plan is required to
provide as listed in the Community Mental Health Services Coverage and
Limitations Handbook and the Targeted Case Management Coverage and
Limitations Handbook.
BEHAVIORAL HEALTH CARE CASE MANAGER - an individual who provides mental
health care case management services directly to or on behalf of a
member on an individual basis, as defined in 65E-15, F.A.C., and the
Medicaid Targeted Case Management Handbook.
BEHAVIORAL HEALTH CARE PROVIDER - a licensed mental health
professional, as defined in section 394.455(2), F.S., or a registered
nurse, licensed under chapter 464, F.S., and qualified due to training
or competency in mental health care, who is responsible for the
provision of mental health care to patients; or a physician licensed
under chapter 458 or chapter 459, F.S.
BENEFICIARY - any individual whom the Department of Children and
Families (DCF), or the Social Security Administration on behalf of DCF,
determines is eligible, pursuant to federal and state law, to receive
medical or allied care, goods, or services for which the Agency may
make payments under the Medicaid program and is enrolled in the
Medicaid program. Also see "Member."
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 139 OF 166
July 2004 Medicaid HMO Contract
BENEFITS - a schedule of health care services to be delivered to
members covered in the plan developed under this contract as set forth
in sections 10.4, Covered Services, 10.5, Optional Services 10.8,
Manner of Service Provision and 10.9, Quality and Benefit Enhancements,
incorporated into and made a part of this contract.
CAPITATION RATE - the monthly fee that is paid by the Agency to a plan
for each Medicaid beneficiary enrolled under a contract for the
provision of Medicaid services during the payment period.
CARE COORDINATION - the manner or practice of planning, directing, and
coordinating the provision and utilization of mental health care
services of enrolled beneficiaries.
CARES - Comprehensive Assessment and Review for Long Term Care
Services.
CASE MANAGEMENT - a process which assesses, plans, implements,
coordinates, monitors, and evaluates the options and services required
to meet an individuals health needs, using communication and available
resources to promote quality cost-effective outcomes and occurs across
a continuum of care, addressing ongoing individual needs rather than
being restricted to a single practice setting.
CERTIFICATION - the process of determining that a facility, equipment,
or an individual meets the requirements of federal or state law, or
whether Medicaid payments are appropriate or shall be made in certain
situations.
CFR - Code of Federal Regulations.
CHCUP (CHILD HEALTH CHECK-UP), the early and periodic screening,
diagnosis and treatment program administered by the Medicaid program
(formerly EPSDT).
CHD - County Health Department, previously known as county public
health unit (CPHU).
CHILDREN/ADOLESCENTS - Medicaid beneficiaries under the age of 21.
CHILDREN AND FAMILIES SERVICES PROGRAM OFFICE - Children and Families
Safety and Preservation Program Office, located in the Department of
Children and Families, is responsible for overseeing programs that
identify and protect abused and neglected children and that prevent
domestic violence.
CLINIC - a facility that is organized and operated independent of any
institution to furnish preventive, diagnostic, therapeutic,
rehabilitative, or palliative Medicaid care, goods, or services to
outpatients.
CLINICAL RECORD - a single complete record kept at the site of the
member's behavioral health care provider, that documents all of the
service implementation plans developed for, and mental health services
received by, the member.
CLOZARIL - the registered trademark of the SANDOZ Corporation for the
drug clozapine.
CMS - Centers for Medicare and Medicaid Services, the unit of the
United States Department of Health and Human Services that provides
administration and funding for Medicare under Title XVIII and Medicaid
under Title XIX of the Social Security Act.
CONTINUOUS QUALITY IMPROVEMENT - a management philosophy that mandates
continually pursuing efforts to improve the quality of products and
services produced by an organization.
CONTRACTING OFFICER - the Secretary of the Agency for Health Care
Administration or his/her delegate.
COVERAGE AND LIMITATIONS HANDBOOK OR PROVIDER MANUAL - a document that
provides information to a Medicaid provider regarding Medicaid
beneficiary eligibility, claims submission and processing, provider
participation, covered care, goods, or services and limitations,
procedure codes and fees, and other matters
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 140 OF 166
July 2004 Medicaid HMO Contract
related to Medicaid program participation. May also be referred to as
provider handbook.
COVERED SERVICES - see "Benefits."
CPT - the Physicians' Current Procedural Terminology, (CPT), which is a
systematic listing and coding of procedures and services that is
published yearly by the American Medical Association.
CRISIS EMERGENCY HOT-LINE - a crisis emergency hot-line is defined as a
toll-free telephone line that is answered by a mental health care
professional on a 24-hour basis to handle mental health emergencies.
CRISIS SUPPORT - services for persons initially perceived to need
emergency mental health services but upon assessment do not meet the
criteria for such emergency care. These are acute care services that
are available 24 hours a day, seven days a week for intervention.
Examples include: mobile crisis, crisis/emergency screening, crisis
hot-line, and emergency walk-in.
CUSTODIAL CARE - care, which does not provide continued medical or
paramedical attention, given to assist a person in performing daily
living activities.
DCF - Department of Children and Families (formerly the Department of
Health and Rehabilitative Services or "HRS").
DEA - Drug Enforcement Administration.
DIRECT SERVICE BEHAVIORAL HEALTH CARE PROVIDER - an individual
qualified by training or experience to provide direct behavioral health
services under the supervision of the plan's medical director.
DOH - Department of Health.
DHHS - United States Department of Health and Human Services.
DISENROLLMENT - the Agency-approved discontinuance of a member's
membership in an HMO. Also see "Member."
DJJ - Department of Juvenile Justice.
DOWNWARD SUBSTITUTION OF CARE - the use of less restrictive, lower cost
services, than might otherwise have been provided, which are considered
clinically acceptable and necessary to meet specified objectives
outlined in a member's plan of treatment, provided as an alternative to
higher cost State plan services. Downward substitution of care may
include care provided by private practice psychologists and social
workers, inpatient care in institutions for mental disease, community
detoxification and residential substance abuse services, psycho-social
rehabilitation, housing, drop-in centers and other services the plan
considers are clinically appropriate, more cost effective, and less
restrictive than hospital inpatient care, Medicaid community mental
health services, or Medicaid mental health targeted case management
services.
DS - The Developmental Services Program Office of the Florida
Department of Children and Families (DCF). See "APD" definition.
DURABLE MEDICAL EQUIPMENT (DME) - medical equipment that can withstand
repeated use; is primarily and customarily used to serve a medical
purpose; is generally not useful in the absence of illness or injury;
and is appropriate for use in the patient's home.
EMERGENCY MEDICAL CONDITION - pursuant to section 409.901, F.S., an
emergency medical condition is: (a) a medical condition manifesting
itself by acute symptoms of sufficient severity, which may include
severe pain or other acute symptoms, such that a prudent layperson,
pursuant to section 4704 of the 1997 Balanced Budget Act, who possesses
an average knowledge of health and medicine, could reasonably expect
the
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 141 OF 166
July 2004 Medicaid HMO Contract
absence of immediate medical attention could reasonably be expected to
result in any of the following: 1. Serious jeopardy to the health of a
patient, including a pregnant woman or a fetus. 2. Serious impairment
to bodily functions. 3. Serious dysfunction of any bodily organ or
part. (b) With respect to a pregnant woman: 1. That there is inadequate
time to effect safe transfer to another hospital prior to delivery. 2.
That a transfer may pose a threat to the health and safety of the
patient or fetus. 3. That there is evidence of the onset and
persistence of uterine contractions or rupture of the membranes.
EMERGENCY MENTAL HEALTH SERVICES - those services required to meet the
needs of an individual who is experiencing an acute crisis, resulting
from a mental illness, which is at a level of severity that would meet
the requirements for involuntary examination pursuant to section
394.463, F.S., and who, in the absence of a suitable alternative or
psychiatric medication, would require hospitalization.
EMERGENCY SERVICES AND CARE - medical screening, examination, and
evaluation by a physician, or, to the extent permitted by applicable
laws, by other appropriate personnel under the supervision of a
physician, to determine whether an emergency medical condition exists,
and if it does, the care, treatment, or surgery for a covered service
by a physician which is necessary to relieve or eliminate the emergency
medical condition, within the service capability of a hospital.
ENROLLEE - according to 42 CFR 438.10(a) means a Medicaid beneficiary
who is currently enrolled in an HMO as defined in 42 CFR 438.10(a); See
"Member."
ENROLLMENT - the process by which an eligible beneficiary becomes a
member of the HMO.
ENROLLMENT/DISENROLLMENT SERVICES CONTRACTOR - a corporation or other
legal entity that has contracted with the Agency to provide a telephone
helpline and enrollment and disenrollment services, including new
eligible and other enrollment information packet, enrollment,
disenrollment and plan change confirmation, and open enrollment and
other disenrollment reminder notification mailings. The contractor also
maintains the Agency's Medicaid managed care lock-in/Open Enrollment
database. The current enrollment and disenrollment services contractor
is ACS State Healthcare, LLC.
EPSDT - the Early and Periodic Screening, Diagnosis and Treatment
program administered by the Medicaid program.
EXPANDED BENEFIT - a covered service of an HMO that is either not a
Medicaid covered service, or is a Medicaid covered service furnished by
an HMO for which the plan receives no capitation payment.
EXPEDITED APPEAL PROCESS - each MCO and PIHP must establish and
maintain an expedited review process for appeals, when the MCO or PIHP
determines (for a request from the enrollee) or the provider indicates
(in making the request on the enrollee's behalf or supporting the
enrollee's request) that taking the time for a standard resolution
could seriously jeopardize the enrollee's life or health or ability to
attain, maintain, or regain maximum function.
FACILITY - any premises (a) owned, leased, used or operated directly or
indirectly by or for the plan or its affiliates for purposes related to
this contract; or (b) maintained by a sub-contractor to provide
services on behalf of the plan.
FAMILY SERVICES PLANNING TEAM - a multi-agency team comprised of core
members and child-specific members, including the child's parents
and/or foster parents, who convene to assist parents in developing a
holistic service plan and in securing the least restrictive, most
relevant and appropriate services necessary to keep their child living
in the home and community.
FEE-FOR-SERVICE - a method of making payment for medical or allied
care, goods, or services based on fees set by the agency for defined
care, goods or services.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 142 OF 166
July 2004 Medicaid HMO Contract
FISCAL AGENT - any corporation or other legal entity that has
contracted with the agency to receive, process and adjudicate claims
under the Medicaid program. The current fiscal agent for the Medicaid
Program is ACS.
FLORIDA MENTAL HEALTH ACT - chapter 394, F.S., that includes the Baker
Act, that covers involuntary admissions for persons who are considered
in an emergency mental health condition (a threat to themselves or
others).
FQHC - Federally Qualified Health Center - A clinic that is receiving a
grant from the Public Health Service (PHS) under the PHS Act as defined
in section 1905(1)(2)(B) of the Social Security Act. FQHCs provide
primary health care and related diagnostic services. In addition, FQHCs
may provide dental, optometric, podiatry, chiropractic and mental
health services. An FQHC employs, contracts or obtains volunteer
services from licensed health care practitioners to provide the above
services.
FTE - full time equivalent position.
FUNCTIONAL ASSESSMENT OF NEED - an assessment of a person's physical
health, ability to perform activities of daily living, existing social
support and mental functioning.
FURNISHED - means supplied, given, prescribed, ordered, provided, or
directed to be provided in any manner.
GOOD CAUSE - special reasons that allow beneficiaries to change their
managed care option outside their open enrollment period such as: the
enrollee moves out of the plan's service area; the plan does not,
because of moral or religious objections, cover the service the
enrollee seeks; the enrollee needs related services (for example a
cesarean section and a tubal ligation) to be performed at the same
time; not all related services are available within the network; and
the enrollee's primary care provider or another provider determines
that receiving the services separately would subject the enrollee to
unnecessary risk; other reasons, including but not limited to, poor
quality of care, lack of access to services covered under the contract,
or lack of access to providers experienced in dealing with the
enrollee's health care needs.
Note: Federal law uses the term "cause" rather than "good cause." In
the context with beneficiary disenrollment, this contract uses the term
"good cause."
GRIEVANCE - means an expression of dissatisfaction about any matter
other than an action, as "action" is defined in this section. The term
is also used to refer to the overall system that includes grievances
and appeals handled at the plan level and access to the Medicaid fair
hearing process. (Possible subjects for grievances include, but are not
limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee,
or failure to respect the enrollee's rights.) (42 CFR 438.2)
GRIEVANCE PROCEDURE - the procedure for addressing enrollees'
grievances. A grievance is an enrollee's expression of dissatisfaction
with any aspect of their care other than the appeal of actions (which
is an appeal).
GRIEVANCE SYSTEM - the system for reviewing and resolving enrollee
grievances or appeals. Components must include a grievance process, an
appeal process, and access to the Medicaid fair hearing system.
HAL S. MARCHMANN ALCOHOL AND OTHER DRUG ABUSE SERVICES ACT OF 1993 -
chapter 397 F.S. - The chapter of Florida Statutes that regulates
substance abuse services in Florida. This chapter includes provisions
for licensure, standards of care, and other involuntary assessment and
treatment.
HEALTH ASSESSMENT - a complete health assessment combines health
history, physical assessment and the monitoring of physical and
psychological growth and development.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 143 OF 166
July 2004 Medicaid HMO Contract
HEALTH CARE PROFESSIONAL - means a physician or any of the following: a
podiatrist, optometrist, chiropractor, psychologist, dentist, physician
assistant, physical or occupational therapist, therapist assistant,
speech-language pathologist, audiologist, registered or practical nurse
(including nurse practitioner, clinical nurse specialist, certified
registered nurse anesthetist, and certified nurse midwife), licensed
certified social worker, registered respiratory therapist, and
certified respiratory therapy technician.
HEALTH FAIR - an event conducted in a setting which is open to the
public or a segment of the public (such as the "elderly" or "school
children") at which information about health care services, facilities,
research, preventive techniques, or other health care information is
disseminated. At least two health related organizations that are not
affiliated under common ownership must actively participate in the
health fair.
HIPAA - Health Insurance Portability and Accountability Act.
HMO - Health Maintenance Organization as certified pursuant to chapter
64l, F.S., or in accordance with the Florida Medicaid State plan
definition of an HMO. See also "MCO".
HOSPITAL - a facility licensed in accordance with the provisions of
chapter 395, F.S., or the applicable laws of the state in which the
service is furnished.
IADL - Instrumental Activities of Daily Living are activities that
reflect the client's ability to perform household and other tasks
needed to meet his/her needs within the community. Such tasks include
shopping, cooking, cleaning, managing money, and getting around in the
community.
INDIVIDUALS WITH SPECIAL HEALTH CARE NEEDS - November 6, 2000 Report to
Congress - Individuals with special health care needs are adults and
children who daily face physical, mental, or environmental challenges
that place at risk their health and ability to fully function in
society. They include, for example, individuals with mental retardation
or related conditions; individuals with serious chronic illnesses such
as Human Immunodeficiency Virus (HIV), schizophrenia, or degenerative
neurological disorders; individuals with disabilities from many years
of chronic illness such as arthritis, emphysema or diabetes; and
children and adults with certain environmental risk factors such as
homelessness or family problems that lead to the need for placement in
foster care.
INSOLVENCY - a financial condition that exists when an entity or plan
is unable to pay its debts as they become due in the usual course of
business, or when the liabilities of the entity or plan exceed its
assets.
LEIE - List of Excluded Individuals and Entities - a database
maintained by the U.S. Department of Health and Human Services Office
of Inspector General which provides information to the public, health
care providers, patients and others relating to parties excluded from
participation in the Medicare, Medicaid and all Federal health care
programs.
MANAGED BEHAVIORAL HEALTH ORGANIZATION (MBHO) - a behavioral health
care delivery system managing quality, utilization and cost of
services. Additionally, it measures performance in the area of mental
and substance abuse disorders.
MANDATORY ASSIGNMENT - the process the Agency uses to assign Medicaid
beneficiaries to the plan because the beneficiaries did not voluntarily
choose a plan or MediPass in accordance with section 409.9122, F.S.
Such beneficiaries may also be referred to as "assigned" beneficiaries
or "Agency assigned."
MARKETING - any activity conducted by or on behalf of the plan where
information regarding the services offered by the plan is disseminated
in order to encourage eligible beneficiaries to enroll in the HMO
developed under this contract.
MARKET AREA - the geographic area in which the plan is authorized to
market and to conduct pre-enrollment activities.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 144 OF 166
July 2004 Medicaid HMO Contract
MCO (Managed Care Organization) - an entity that has, or is seeking to
qualify for, a comprehensive risk contract under this part (42 CFR,
Part 438.2), and that is --
1. A Federally qualified HMO that meets the advance
directives requirements of subpart I of part 489 of
this chapter; or
2. Any public or private entity that meets the advance
directives requirements and is determined to also
meet the following conditions:
(i) Makes the services it provides to its
Medicaid enrollees as accessible (in terms of
timeliness, amount, duration, and scope) as those
services are to other Medicaid recipients within the
area served by the entity
(ii) Meets the solvency standards of section
438.116. (Also, see definition of "HMO").
MEDICAID - the medical assistance program authorized by Title XIX of
the federal Social Security Act, 42 U.S.C. s.1396 et seq., and
regulations thereunder, as administered in this state by the Agency
under section 409.901 et seq., F.S.
MEDICALLY NECESSARY OR MEDICAL NECESSITY - services provided in
accordance with 42 CFR section 438.210(a)(4) and as defined in section
59G-1.010(166), F.A.C., to include that medical or allied care, good,
or services furnished or ordered must:
(a) Meet the following conditions:
1. Be necessary to protect life, to prevent significant
illness or significant disability, or to alleviate
severe pain;
2. Be individualized, specific, and consistent with
symptoms or confirmed diagnosis of the illness or
injury under treatment, and not in excess of the
patient's needs;
3. Be consistent with the generally accepted
professional medical standards as determined by the
Medicaid program, and not experimental or
investigational;
4. Be reflective of the level of service that can be
safely furnished, and for which no equally effective
and more conservative or less costly treatment is
available, statewide; and
5. Be furnished in a manner not primarily intended for
the convenience of the beneficiary, the beneficiary's
caretaker, or the provider.
(b) "Medically necessary" or "medical necessity" for inpatient
hospital services requires that those services furnished in a
hospital on an inpatient basis could not, consistent with the
provisions of appropriate medical care, be effectively
furnished more economically on an outpatient basis or in an
inpatient facility of a different type.
(c) The fact that a provider has prescribed, recommended, or
approved medical or allied goods, or services does not, in
itself, make such care, goods or services medically necessary,
a medical necessity, or a covered service.
MEDICAL RECORD - those documents corresponding to medical or allied
care, goods, or services furnished in any place of service. The records
may be on paper, magnetic material, film, or other media. In order to
qualify as a basis for reimbursement, the medical records must be
dated, signed or otherwise attested to, as appropriate to the media,
and legible.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 145 OF 166
July 2004 Medicaid HMO Contract
MEDICARE - the medical assistance program authorized by Title XVIII of
the federal Social Security Act, 42 U.S.C. s. 1395 et seq., and
regulations thereunder.
MEDIKIDS - a Title XXI health insurance program that provides certain
children who are not Medicaid eligible with Medicaid benefits provided
a certain premium is paid and provided the children are enrolled in a
Medicaid HMO or MediPass as specified in section 409.8132, F.S.
MEDIPASS - the primary care case management program administered by the
Florida Medicaid Program.
MEMBER - an eligible Medicaid beneficiary who is an enrollee of an HMO.
See "Enrollee."
NEWBORN - a live child born to a member during her membership under
this contract.
NON-COVERED SERVICE - a service that is not a covered service or
benefit. (See Covered Services definition and Benefits definition.)
NURSING FACILITY - an institutional care facility licensed under
chapter 395, F.S., or chapter 400, F.S., that furnishes medical or
allied inpatient care and services to individuals needing such
services.
OPEN ENROLLMENT - the policy wherein Medicaid beneficiaries are
enrolled into a managed care option for 12 months as long as they
retain Medicaid eligibility. Beneficiaries subject to Open Enrollment
are given an annual Open Enrollment period, i.e., 60 days at the end of
their enrollment year wherein they may choose to change plans for the
following enrollment year. Dually eligible individuals, American
Indians, foster children, children in subsidized adoption arrangements,
CMS children, and SSI beneficiaries under age 19 are not subject to
Open Enrollment.
OUTPATIENT - a patient of an organized medical facility or distinct
part of that facility who is expected by the facility to receive and
who does receive professional services for less than a 24-hour period
regardless of the hour of admission, whether or not a bed is used, or
whether or not the patient remains in the facility past midnight.
PAHP-a Prepaid Ambulatory Health Plan is an entity that provides
medical services to enrollees under contract with the State agency, and
on the basis of prepaid capitation payments, or other payment
arrangements that do not use State plan payment rates; does not provide
for or arrange for, and is not otherwise responsible for the provision
of any inpatient hospital or institutional services for its enrollees;
and does not have a comprehensive risk contract.
PDHP - Prepaid Dental Health Plan is the prepaid ambulatory health plan
(PAHP) developed by the Contractor in performance of its duties and
responsibilities under this contract; or a contractual arrangement
between the Agency and a prepaid ambulatory health plan contractor for
the provision of Medicaid care, goods, or services on a prepaid basis
to Medicaid beneficiaries for dental services. PDHPs are classified as
prepaid ambulatory health plans by 42 CFR 438.
PEER REVIEW - an evaluation of the professional practices of a Medicaid
provider by peers of the provider in order to assess the necessity,
appropriateness, and quality of care furnished as such care is compared
to that customarily furnished by the provider's peers and to recognized
health care standards.
PHYSICALLY SECURE FACILITY - Residential Facilities, such as juvenile
boot camps, and high and maximum risk programs, operated by the Florida
Department of Juvenile Justice as hardware secure facilities.
PIHP - a Prepaid Inpatient Health Plan is an entity that provides
medical services to enrollees under contract with the State agency, and
on the basis of prepaid capitation payments, or other payment
arrangements that do not use State plan payment rates; provides,
arranges for, or otherwise has responsibility for the provision of any
inpatient hospital or institutional services for its enrollees; and
does not have a comprehensive risk contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 146 OF 166
July 2004 Medicaid HMO Contract
PLAN - See definition of "Vendor."
PMHP - Prepaid Mental Health Plan.
PORTABLE X-RAY EQUIPMENT - x-ray equipment transported to a setting
other than a hospital, clinic, or office of a physician or other
practitioner of the healing arts.
POTENTIAL ENROLLEE - according to 42 CFR 438.10(a) means a Medicaid
beneficiary who is subject to mandatory enrollment or may voluntarily
elect to enroll in a given managed care program, but is not yet an
enrollee of a specific managed care program.
PRE-ENROLLMENT APPLICATION - also referred to as the Request to Enroll
(RTE) form, completed by a Medicaid beneficiary with the assistance of
a plan representative, and submitted by the plan to the enrollment and
disenrollment services contractor to initiate the enrollment process.
PRIMARY CARE - comprehensive, coordinated and readily-accessible
medical care, including health promotion and maintenance, treatment of
illness and injury, early detection of disease and referral to
specialists when appropriate.
PRIMARY CARE PHYSICIAN - pursuant to sections 641.19, 641.31 and
641.51, F.S., a Medicaid HMO staff or subcontracted physician
practicing as a general or family practitioner, internist,
pediatrician, obstetrician, gynecologist, or other specialty approved
by the Agency, who furnishes primary care and patient management
services to a beneficiary.
PRIOR AUTHORIZATION - the act of authorizing specific services before
they are rendered. Plans with automated authorization systems may not
require paper authorization as a condition of receiving treatment.
PROTOCOLS - written guidelines or documentation outlining steps to be
followed for handling a particular situation, resolving a problem, or
implementing a plan of medical, nursing, psychosocial, developmental
and educational services.
PROVIDER - a person or entity who has a Medicaid provider agreement in
effect with the Agency, or a subcontractual agreement with a
subcontractor, and is in good standing with the Agency.
PUBLIC EVENT - an event sponsored for the public or a segment of the
public by two or more actively participating organizations, one of
which may be a health organization.
PUBLIC PROVIDER - a county health department or a migrant health center
funded under s. 329 of the Public Health Services Act or a community
health center funded under s. 330 of the Public Health Services Act.
QUALITY IMPROVEMENT - the process of assuring that the delivery of
health care is appropriate, timely, accessible, available and medically
necessary.
RECEIVING FACILITY - as defined in Part I of chapter 394, F.S., a
facility designated by the Department of Children and Families (DCF)
that receives patients under emergency conditions or for psychiatric
evaluation and provides short-term treatment. The term "receiving
facility" does not include a county jail.
RECIPIENT OR MEDICAID RECIPIENT - any individual whom the Department of
Children and Families (DCF), or the Social Security Administration on
behalf of DCF, determines is eligible, pursuant to federal and state
law, to receive medical or allied care, goods, or services for which
the Agency may make payments under the Medicaid program and is enrolled
in the Medicaid program. Also see "member or beneficiary."
RESIDENTIAL SERVICES - as applied to Juvenile Justice, refers to the
out-of-home placement for youth in a level 4, 6, 8, or 10 facility as
result of a delinquency disposition order. Also referred to as
residential commitment programs.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 147 OF 166
July 2004 Medicaid HMO Contract
RISK - the potential for loss that is assumed by a plan and that may
arise because the cost of providing care, goods, or services may exceed
the capitation or other payment made by the Agency to the plan under
terms of the contract.
RISK ASSESSMENT - is the process of collecting information from a
person about hereditary, life style and environmental factors to
determine specific diseases or conditions for which the person is at
risk.
RFP - Request for Proposal.
RURAL HEALTH CLINIC (RHC) - a clinic that is located in a rural area
that has a health care provider shortage. An RHC provides primary
health care and related diagnostic services, and may provide
optometric, podiatry, chiropractic and mental health services. An RHC
employs, contracts or obtains volunteer services from licensed health
care practitioners to provide the above services.
SALES ACTIVITIES - actions performed by an agent of an HMO, including
the acceptance of pre-enrollment applications, for the purpose of
enrollment.
SCREEN OR SCREENING - assessment of a beneficiary's physical or mental
condition to determine evidence or indications of problems and need for
further evaluation or services.
SERVICE AREA - the designated geographical area within which the plan
is authorized by contract to furnish covered services to plan members
and within which the members reside.
SERVICE LOCATION - any location at which a member obtains any health
care service provided by the plan under the terms of this contract.
SERVICE SITE - the locations designated by the plan at which members
shall receive primary care physician services.
SHALL - indicates a mandatory requirement or a condition to be met.
SHELTER SERVICES - As applied to Juvenile Justice, refers to the
temporary out-of-home placement of youth in a CINS/FINS shelter.
SICK CARE - non-urgent problems which do not substantially restrict
normal activity, but could develop complications if left untreated
(e.g., chronic disease).
SOBRA - Sixth Omnibus Budget Reconciliation Act
STATE - State of Florida.
SUBCONTRACT - an agreement entered into by a plan for provision of
services on its behalf. Subcontracts include, but are not limited to
the following: agreements with all providers of medical or ancillary
services, unless directly employed by the plan; management or
administrative agreements; third party billing or other indirect
administrative/fiscal services, including provision of mailing lists or
direct mail services; and any contract which benefits any person with a
control interest in the plan.
SUBCONTRACTOR - any person to which a plan has contracted or delegated
some of its functions, services or its responsibilities for providing
medical or allied care, goods, or services; or its claiming or claims
preparation or processing functions or responsibilities. A typical
subcontractor is a hospital.
SURPLUS - net worth, i.e., total assets minus total liabilities.
THIRD PARTY RESOURCES - an individual, entity, or program, excluding
Medicaid, that is, may be, could be, should be, or has been liable for
all or part of the cost of medical services related to any medical
assistance covered by Medicaid. An example is an individual's auto
insurance company, which typically provides
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 148 OF 166
July 2004 Medicaid HMO Contract
payment of some medical expenses related to automobile accidents and
injuries.
TITLE XXI MEDIKIDS - a Title XXI health insurance program that provides
certain children who are not Medicaid eligible with Medicaid benefits
provided a certain premium is paid and provided the children are
enrolled in a Medicaid HMO or MediPass as specified in section
409.8132, F.S.
TRANSPORTATION - an appropriate means of conveyance furnished to a
beneficiary to obtain Medicaid or other authorized services.
URGENT BEHAVIORAL HEALTH CARE - Are those situations that require
immediate attention and assessment within 23 hours though the
individual is not an immediate danger to self and others and is able to
cooperate in treatment.
URGENT CARE - those problems, which, though not life-threatening, could
result in serious injury or disability unless medical attention is
received (e.g., high fever, animal bites, fractures, severe pain) or do
substantially restrict a member's activity (e.g., infectious illnesses,
flu, respiratory ailments, etc.).
URGENT GRIEVANCE - means an adverse determination when the standard
time frame of the grievance procedure would seriously jeopardize the
life or health of a member or would jeopardize the member's ability to
regain maximum function.
VENDOR- - the organizational entity serving as the primary contractor
and with whom this agreement is executed. The term contractor shall
include all employees, subcontractors, agents, volunteers, and anyone
acting on behalf of, in the interest of, or for a contractor. Also
referred to as the plan.
VIOLATION - each determination by the Agency that a plan failed to act
as specified in the contract or in applicable statutes or rules
governing Medicaid HMOs. Each day that an ongoing violation continues
may be considered for the purposes of this contract to be a separate
violation. In addition, each instance of failing to furnish necessary
and/or required medical services or items to beneficiaries is
considered for purposes of this contract to be a separate violation.
VOLUNTARY APPLICANT - an applicant who chooses to enroll in a Medicaid
HMO. May also be referred to as voluntary member.
WELL CARE - a routine medical visit for one of the following: Child
Health Check-Up visit, family planning, routine follow up to a
previously treated condition or illness, adult physicals and any other
routine visit for other than the treatment of an illness.
WIC - the Special Supplemental Nutrition Program for Women, Infants and
Children (WIC), administered by the Department of Health, Bureau of WIC
and Nutrition Services, provides nutrition counseling, nutrition
education, breastfeeding promotion and support and nutritious foods to
pregnant, postpartum, and breastfeeding women, infants, and children up
to the age of five who are determined to be at nutritional risk and who
have a low to moderate income. An individual who is eligible for
Medicaid is automatically income eligible for WIC benefits.
Additionally, WIC income eligibility is automatically provided to a
member of a family which includes a pregnant woman or infant certified
eligible to receive Medicaid. WIC serves as an adjunct to good health
care during critical times of growth and development, in order to
prevent the occurrence of health problems and to improve health and
nutritional status.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 149 OF 166
July 2004 Medicaid HMO Contract
110.0 EXHIBITS
EXHIBIT 110.1
LABORATORY TESTS AND ASSOCIATED OFFICE VISITS TO BE PAID BY PLAN WITHOUT PRIOR
AUTHORIZATION WHEN INITIATED BY COUNTY HEALTH DEPARTMENT
DESCRIPTION CPT CODE
Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury), quantitative, each 83015
Molecular diagnostics; separation 83894
Nucleic acid probe 83896
Poylmerease chain reaction 83898
Interpretation and report 83912
CBC with differential, automated 85025
CBC automated, without differential 85027
Red blood cell count 85041
Reticulocyte 85044
White blood cell count 85048
Platelet (elec tech) 85049
Fluorescent antibody; screen, each antibody 86255
Fluorescent antibody, titer, each antibody 86256
Hemagglutination inhibition test (HAI) 86280
Hepatitis B surface antigen (HBsAg) 86692
Hepatitis B core antibody (HBcAb); IgG and IgM 86704
Hepatitis B core antibody; IgM 86705
Hepatitis B surface antibody (HBsAb) 86706
Immunoassay for infectious agent antigen, qualitative or semiquantitative; multiple step method 83516
Immunoassay for infectious agent antibody, quantitative, not elsewhere specified 83520
Rubella screen 86762
Immunoelectrophoresis; serum 86320
Immunodiffussion; gel diffusion, qualitative (Ouchterlony), each 86331
Neutralization test, viral 86382
Particle agglutination; screen; each antibody 86403
Syphilis test; qualitative (VDRL, RPR, ART) 86592
Syphilis test, quantitative 86593
Antibody; cytomegalovirus (CMV) 86644
Encephalitis, Eastern equine 86652
Encephalitits, St. Louis 86653
Antibody Enterovirus 86658
HIV antibody, confirmatory test 86689
HIV-1 86701
HIV-2 86702
HIV-1 & HIV-2 86703
Rubella 86762
Rubeola 86765
Toxoplasma 86777
Toxoplasma, IgM 86778
Treponema pallidum, confirmatory test 86781
Varicella-zoster 86787
Antibody screen, RBC, each serum technique 86850
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 150 OF 166
July 2004 Medicaid HMO Contract
Blood typing; ABO 86900
Rh (D) 86901
RBC antigens, other than ABO or Rh (D), each 86905
Concentration (any type), for parasites, OVA, or tubercle bacillus (TB, AFB) 87015
Culture, bacterial, definitive; stool 87045
Culture, bacterial, definitive; throat or nose 87060
Culture, definitive, any other source 87070
Culture or direct bacterial identification method, each organism, by commercial kit, any source 87071
except urine
Culture, bacterial, any source, anaerobic (isolation) 87075
Anaerobe identification 87076
Culture, bacterial, screening only, for single organisms 87081
Culture, fungi, isolation (with or without presumptive identification); skin 87101
Culture, fungi, isolation (with or without presumptive identification); other source, (except blood) 87102
Culture, fungi, blood 87103
Culture, fungi, definitive identification of each fungus (use in addition to codes 87101, 87102, or 87106
87103 when appropriate)
Culture, tubercle or other acid-fast bacilli (TB, AFB, mycobacteria); concentration plus isolation 87116
Culture, mycobacteria, definitive identification of each organism 87118
Culture, typing; gas liquid chromatography (GLC) method 87143
Culture, typing; serologic method, agglutination grouping, per antiserum 87147
Culture, typing; serologic method, speciation 87151
Culture, typing; precipitin method, grouping, per antiserum 87155
Culture, any source, additional identification methods required 87163
Endotoxin, bacterial (pyrogens); homogenization, tissue, for culture 87176
OVA and parasites, direct smears, concentration and identification 87177
Microbial identification, nucleic acid probes, each probe used 88365
Microbial identification, nucleic acid probes, each probe used; with amplification, e.g. polymerase 87179
chain reaction (PCR)
Sensitivity studies, antibiotic; agar diffusion method, per antibiotic 87181
Sensitivity studies, antibiotic; tubercle bacillus (TB, AFB), each drug 87190
Smear, primary source, with interpretation; routine stain for bacteria, fungi or cell types 87205
Smear, primary source, with interpretation; fluorescent and/or acid fast stain for bacteria, fungi or 87206
cell types
Smear, primary source, with interpretation; special stain for inclusion bodies or intracellular 87207
parasites (e.g. malaria, kala-azar, herpes)
Smear, primary source, with interpretation; direct or concentrated, dry, for OVA and parasites 87207
Smear, primary source, with interpretation; wet mount with simple stain, for bacteria, fungi, OVA, 87210
and/or parasites
Smear, primary source, with interpretation; wet and dry mount, for OVA and parasites 87211
Tissue examination for fungi (e.g. KOH slide) 87220
Tissue culture inoculation and observation 87252
Tissue culture, additional studies 87253
Flow cytometry 88180
Viral load (AIDS) W1875
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 151 OF 166
July 2004 Medicaid HMO Contract
EXHIBIT 110.2
MODEL MEMORANDUM OF AGREEMENT BETWEEN THE ______________________ DEPARTMENT OF
HEALTH COUNTY HEALTH DEPARTMENT AND THE
______________________________________________________ (HMO).
1. This agreement is entered into between the State of Florida, Department
of Health ,________________________________________________ County Health
Department, hereinafter referred to as the "CHD" and the
____________________________________________________________________________ HMO
hereinafter referred to as the "HMO", for the purpose of improving services to
patients through coordinated, cooperative health care interactions between the
HMO and the CHD, pursuant to section 409.9122, F.S.
2. Power and Authority of the CHD.
Pursuant to chapter 154, F.S., the Department of Health county health
departments of Florida are responsible for the promotion of the public's health,
the control and eradication of preventable diseases, and the provision of
primary health care for special populations. The CHD must comply with
established public health protocols and applicable state law when providing
health care services.
3. Power and Authority of the HMO.
The HMO has contracted with the Agency for Health Care Administration
(hereinafter referred to as the "Agency") as a Medicaid HMO provider. The HMO
must comply with all established requirements and applicable state law when
providing health care services.
4. The HMO agrees to:
A. Reimburse without prior authorization, medical screenings for foster
care children and emergency shelter care children.
B. In accordance with section 381.0407(4), F.S., reimburse without
prior authorization, the CHD for school-based urgent care services; and the
diagnosis and treatment of sexually transmitted disease and other communicable
diseases, such as tuberculosis and human immunodeficiency syndrome. This shall
include the clinical, medical and laboratory services provided by the CHD to an
HMO patient.
C. Offer the Healthy Start prenatal screen to each member who is
pregnant. (Section 383.14, F.S., 10J-8.010, F.A.C.)
D. Refer all pregnant women meeting Healthy Start high risk screening
criteria to the local CHD for Healthy Start care coordination. (Section 383.14,
F.S., 19J-8.010, F.A.C.)
E. Offer the Healthy Start postnatal (infant) screen to each woman for
her newborn. (Section 383.14, F.S., 10J-8.010 F.A.C.)
F. Refer all infants meeting Healthy Start high risk screening criteria
to the local CHD for Healthy Start care coordination. (10J-8.010, F.A.C.)
G. Refer all pregnant women, postpartum women (up to six months after
delivery), breastfeeding women (up to one year after delivery), infants and
children up to the age of five to the Special Supplemental Nutrition Program for
Women, Infants and Children (WIC) available through the local CHD.
H. Reimburse without prior authorization services for a member's
immunizations.
I. Reimburse without prior authorization for family planning services
and related pharmaceuticals.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 152 OF 166
July 2004 Medicaid HMO Contract
5. The CHD agrees to:
A. Attempt to contact the HMO before providing health care services to
their members.
B. Provide the plan with a copy of the member immunization record at
the time that the immunization is provided to the plan member. The CHD shall not
submit a claim for the immunization if the plan documents to the CHD that the
immunization has already been provided.
C. Notify the HMO within _______ hours when HMO patients are treated in
the CHD.
D. Forward to the HMO within _______ days all medical records relating
to an HMO patient being seen at the CHD.
E. Refer HMO patients back to the HMO for ongoing primary care
following provision of services covered in this agreement.
6. Both parties mutually agree to:
A. Make good faith effort to work in a cooperative manner.
B. Forward any unresolved concerns involving the HMO and the CHD to the
Division of Medicaid.
____________________________________________ __________
CHD Director/Administrator - signature Date
____________________________________________
CHD Director/Administrator - type orprint name
____________________________________________ __________
Authorized Representative of HMO - signature Date
____________________________________________
Authorized Representative of HMO - type or print name
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 153 OF 166
July 2004 Medicaid HMO Contract
EXHIBIT 110.3
SAMPLE MULTIPLE SIGNATURE VERIFICATION AGREEMENT
Account Number: ________________
In consideration of the mutual promises and undertakings expressed herein, this
Agreement is entered into between _____________ Bank ("Bank") and ____________
Health plan ("Health plan"), effective as of the ______ day of
_____________,2004.
1. Health plan is opening the Bank business investment account referenced
by number above ("the Account"), pursuant to the conditions contained in the
agreement entered between Health plan and the Office of the Director of
Medicaid, State of Florida Agency for Health Care Administration ("Medicaid")
dated July 1, 2004.
2. Pursuant to its agreement with Medicaid, Health plan desires, and Bank
agrees to provide, a "hold" on the account so that withdrawals may be made only
by properly authorized written request, and upon manual examination of the
requests, which service shall be subject to the terms and restrictions set forth
below.
3. Bank will only honor written requests for withdrawals which bear the
signatures of two authorized representatives of Medicaid and two signatures of
authorized representatives of Health plan. Medicaid and Health plan will provide
to Bank examples of the signatures of the authorized representatives.
4. Health plan will present the written, properly executed requests for
withdrawal to _________________, at Bank, located at _________________________.
_________, Florida, _______, between the hours of 8:00 am and 4:00 pm, EST,
during banking business days. The request will contain the Account number, the
amount of the funds to be withdrawn, a description of the payee who shall
receive the funds, and the signatures of two authorized representatives of
Medicaid and two signatures of authorized representatives of Health plan.
5. Bank agrees to review the requests; draft the Account for the amount of
the requested withdrawal, and prepare a Bank Official Check in the withdrawn
amount, in accordance with the terms of the request. Bank agrees to undertake
the above and make the Check available to Health plan no later than the close of
the banking day following the banking day in which the request was presented to
Bank in accordance with Paragraph 4, above. [Optional language: Health plan
agrees to pay to Bank a fee of $5.00 for each Official Bank Check issued.]
6. Bank shall return to Health plan any request that does not meet the
above-described requirements. Bank shall have the sole discretion to determine
whether the requirements have been met.
7. Pursuant to its agreement with Medicaid, Health plan agrees that in the
event that Medicaid determines Health plan to be insolvent and notifies Bank of
its determination, Medicaid may make withdrawals on the account by two
authorized representatives of Medicaid, without authorized signatures from
Health plan. Bank shall not be responsible or liable for determining insolvency.
Bank shall not be required to permit withdrawals upon the sole order of Medicaid
until written notification is received from Medicaid at the address described in
Paragraph 4, and Bank has had a reasonable time to act thereon but in no event
later than two (2) business days.
8. Except to the extent that Bank is negligent in performing its duties
under this Agreement, Health plan shall indemnify and hold Bank harmless against
any claim, loss, liability, damage, cost or expense (including reasonable
attorneys' fees incurred by Bank) arising out of or in any way relating to
Bank's compliance with the terms of this Agreement.
9. This Agreement shall supplement the Bank Deposit Agreement, any
corporate or other resolution of Health plan relating to the Account, and any
other agreements or terms affecting the Account. All legal rights and
obligations of Health plan and Bank under such other documents and pursuant to
any applicable laws and banking regulations shall remain in effect, except as
expressly modified by this Agreement.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 154 OF 166
July 2004 Medicaid HMO Contract
10. This Agreement shall be executed by all currently authorized signers on
the Account, and it shall continue in effect notwithstanding any subsequent
change of authorized signers, and without any requirement that it be re-executed
or amended.
11. This Agreement may be terminated at any time by Bank or Health plan,
provided Health plan provides Bank written approval from Medicaid, and provided
that the indemnification provision of paragraph 7 above shall continue in effect
after any such termination with respect to any withdrawals or requests handled
by Bank prior to such termination. This Agreement shall be binding upon and
shall inure to the benefit of any successors and assigns of Health plan,
Medicaid, and Bank.
The undersigned parties have executed this Agreement through their duly
authorized representatives as of the date shown above.
BANK
By:_________________
Title:______________
HEALTH PLAN
By:_________________
Title:______________
HEALTH PLAN'S CERTIFICATION OF AUTHORITY
The undersigned hereby certifies that: (1) (s)he is the Secretary of __________
Health plan; and (2) the foregoing Agreement is consistent with any corporate or
other resolution(s) of Health plan previously or contemporaneously provided to
Bank.
By:_________________
Title:______________
Date of Certification:________________
[Affix corporate seal]
AUTHORIZED SIGNATURES
HEALTH PLAN AGENCY FOR HEALTH CARE ADMINISTRATION
____________________________
Title _________________________________________
Print Name:____________________ Director of Medicaid
Print Name:______________________________
_______________________________
Title _________________________________________
Print Name:____________________ Bureau of Managed Health Care, Chief
Print Name:______________________________
_______________________________
Title _________________________________________
Print Name:____________________ Bureau of Managed Health Care, Operations
Administrator
Print Name:______________________________
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 155 OF 166
July 2004 Medicaid HMO Contract
EXHIBIT 110. 4
FRAIL/ELDERLY PROGRAM
110.4.1 FRAIL/ELDERLY PROGRAM (EXPANDED SERVICE)
The purpose of the frail/elderly portion of a Medicaid HMO is to
provide, coordinate and manage services for the frail and elderly who
need services to prevent or delay placement in a nursing home. A
variety of mandatory and supportive services shall be available to
members to achieve this goal. The plan shall also conduct quality of
care projects for the frail/elderly component as required by section
20.12, Quality Improvement. In order to be eligible for the
frail/elderly program, beneficiaries must be:
a. Assessed by CARES as having met nursing home level of
care and in need of a service(s) to live in their
homes or in the homes of relatives or caregivers as
an alternative to being placed in a nursing home
facility
b. 21 years of age or older
c. An SSI beneficiary
d. Ineligibility criteria are listed in Section 10.3,
Ineligible Recipients.
110.4.2 MANDATORY SERVICE REQUIREMENTS (FRAIL/ELDERLY)
The plan shall provide comprehensive and medically necessary health
care services pursuant to this contract. The plan shall maintain a
maximum ratio of 1:40 (case manager to enrollees). A case manager shall
be assigned to each enrollee. A case manager shall be responsible for
arranging all program service provisions and implementing the service
prescription appropriate to the plan of care. For dually eligible plan
members, case managers are responsible for long-term care service
planning and for developing and carrying out strategies to coordinate
the delivery of all acute and long-term care services.
a. Plan of Care - The plan shall perform a needs assessment and
develop a plan of care for each member. The plan of care must
be based on a comprehensive assessment of the enrollee's
health status, physical and cognitive functioning,
environment, and social supports. The plan shall not impose
service limitations based solely on the members' place of
residence. The plan of care must detail all interventions
designed to address specific barriers to independent
functioning. The plan must clearly identify barriers to the
enrollee and caregivers, if applicable. The case manager must
discuss barriers and explore potential solutions with the
enrollee and caregivers when applicable. In developing the
plan of care the plan must:
1. Assess the immediacy of the new enrollee's services
needs and include a description of the member's
condition (e.g., Activities of Daily Living, (ADL)
and Instrumental Activities of Daily Living (IADL)
limitations, incontinence, cognitive impairment,
arthritis, high blood pressure), as identified
through an appropriate comprehensive assessment and a
medical history review.
2. Identify any existing care plans and service
providers and assess the adequacy of current
services.
3. Ensure that the care plan contains, at minimum,
information about the enrollee's medical condition,
the type of services to be furnished, the amount,
frequency and duration of each service, and the type
of provider to furnish each service.
4. Ensure that treatment interventions address
identified problems, needs and conditions in
consultation with the enrollee and, as appropriate,
the enrollee's legal guardian or caregiver.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 156 OF 166
July 2004 Medicaid HMO Contract
5. Ensure that, at minimum, a quarterly review of the
plan of care occurs to determine the appropriateness
and adequacy of services and to ensure that the
services furnished are consistent with the nature and
severity of the enrollee's needs.
6. Ensure that a face-to-face review of the care plan is
performed through contact with the enrollee at least
every six months to determine the appropriateness and
adequacy of services and to ensure that the services
furnished are consistent with the nature and severity
of the enrollee's needs.
7. Ensure that the care plan is reviewed sooner than the
minimum required time frame if, in the opinion of the
medical professionals involved in the care of the
enrollee, there is reason to believe significant
changes have occurred in the enrollee's condition or
in the services the enrollee receives. The care plan
shall also be reviewed if an enrollee or an
enrollee's legal representative requests another
review due to the changes in the enrollee's physical
or mental condition.
8. Primary caregivers, family, neighbors and other
volunteers will be integrated into an enrollee's plan
of care when it is determined through
multi-disciplinary assessment and care planning that
these volunteer services would improve the enrollee's
capability to live safely in the home setting and are
agreed to by the enrollee.
9. Revise the plan of care in consultation with the
enrollee, the caregiver and, when feasible, the
primary care physician. If the member is
dually-eligible and the primary care physician is not
under contract with the plan to deliver services to
the enrollee, an effort must be made to obtain the
physician's input regarding care plan revisions.
Changes in service provision resulting from a care
plan review must be implemented within ten calendar
days of the review date.
b. Coordination of Care/Case Management.
The plan is responsible for assessing, planning, and managing
the care and services provided to members. The plan shall:
1. Develop a systematic process for coordinating care
with organizations which are not part of the plan's
network.
2. Develop procedures that ensure acute care services
and program services for the plan's Medicaid only
members are coordinated with the member's primary
care provider.
3. Develop protocols that ensure acute care services and
program services for beneficiaries who receive their
medical care from the Medicare fee-for-service system
are coordinated to the maximum extent feasible with
the member's treating physicians and other care
providers.
4. Ensure coordination with the medical, nursing or
administrative staff designated by the facility to
ensure that the plan's assisted living or nursing
facility enrolled members have timely and appropriate
access to the plan's providers and to coordinate care
between those providers and the facility's providers.
5. Facilitate and coordinate the enrollee gaining
referral and receiving access to other needed
services and agencies outside the plan's network.
6. Work to ensure the maintenance or creation of an
enrollee's informal network of caregivers and service
providers.
7. Develop a system of case management which the plan
shall use for the identification of the individual
member's needs, development of immediate and
long-term goals, and arrangements and monitoring of
services for as long as necessary to meet the
established goals for the member.
8. Components essential to the case management system
are:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 157 OF 166
July 2004 Medicaid HMO Contract
a. Outreach, including information
distribution;
b. Intake and referral;
c. Diagnosis and evaluation;
d. Needs assessment;
e. Plan of care development;
f. Resource assessment;
g. Plan implementation;
h. Routine monitoring of providers by
appropriate staff;
i. Progress reports;
j. Reassessment and revision of plan; and
k. Routine conferences or meetings of the care
team with formal methods of communicating
changes to all concerned.
c. Adaptive Equipment - These services are physical adaptations
to the home that include grab bars, cushioned grips, ramps,
modification of bathroom facilities and other minor
adaptations and equipment which assist the member's caregiver
in providing supportive care and allow the member to remain
independent, able to perform ADLs, and/or reduces the risk of
falls without which the enrollee's safety in the home may be
at risk.
d. Adult Day Health Care - This is a center-based program which
assures a protective environment for frail elders and disabled
adults. It provides preventive, remedial, and restorative
services, in addition to therapeutic recreation and nutrition
services. For example, physical, occupational, and speech
therapies indicated in the enrollee's plan of care are
furnished as components of this service. In addition,
physician services, nursing services, social work services and
transportation services may also be included.
e. Homemaker/Personal Care - These are services which help the
member manage activities of daily living (ADLs) and
instrumental ADLs. This service includes preparation of meals,
but not the cost of meals themselves. This service may also
include housekeeping chores such as bed making, dusting and
vacuuming, which are incidental to the care furnished or are
essential to the health and welfare of the enrollee rather
than the enrollee's family.
f. Supplies - These include items like disposable diapers, pads,
ointments, or other items as deemed necessary by the plan.
g. Home Health Services - These are services which provide
medically necessary care to an eligible Medicaid recipient
whose medical condition, illness or injury requires the care
to be delivered in the recipient's place of residence.
Physician ordered and maintained under the direction of the
attending physician, home health services must be provided by
qualified staff and consistent with accepted standards of
medical and nursing practice in execution of an
individualized, written physician-approved plan of care. The
medical need for home health care shall be identified with
appropriate nursing interventions resulting in expected health
outcomes. The plan shall contract for their member needs with
a sufficient number of home health agencies licensed in
accordance with Chapter 400, Part IV, F.S. and Chapter 59A-8,
F.A.C.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 158 OF 166
July 2004 Medicaid HMO Contract
110.4.2.1 NURSING FACILITY PLACEMENT (FRAIL/ELDERLY)
The plan shall adequately network with nursing facility providers to
maintain sufficient bed census capable to ensure access to their
enrolled members. The plan shall provide at a minimum choice of two or
more nursing facilities within a 15 mile radius or 30 minute drive
within the enrollee's zip code of residence and service area. The plan
shall also contract with nursing facilities having most recent
Licensure & Certification Survey ratings of satisfactory or above from
the Agency's Division of Health Quality Assurance, and make a good
faith effort to contract with out of network nursing facility
providers where or when necessary. The plan shall disclose the choices
of approved nursing facilities in the Member Services Handbook.
For members who require the level of care provided in a nursing
facility, the plan shall admit the members to a nursing facility which
participates in Medicaid, accepts the members at the appropriate level
of care, has a written agreement with the plan to accept members under
plan sponsorship, agrees to keep the members under plan sponsorship,
and agrees to maintain the members if sponsorship is transferred to
Medicaid fee-for-service nursing facility program.
The plan is responsible for continuing to provide all covered services
which the member needs and which are not included in the nursing home
rate. The plan shall be liable for the costs of the nursing facility
care for the time specified in the contract with the Agency. The
member will continue to be enrolled in the plan for the duration of
the contract and through recontracting, excepting disenrollments as
described in section 30.11.2.1, Frail/Elderly Disenrollment.
110.4.2.2 QUALITY OF CARE (FRAIL/ELDERLY)
a. Quality of Care Projects: The plan is responsible for
operating an ongoing quality management program which includes
quality assessment an performance improvement, in accordance
with federal and State requirements. The plan shall monitor
the quality appropriateness and effectiveness of enrollee home
and community based services. The plan must also participate
in annual external quality reviews conducted by the External
Quality Review Organization vendor. The plan must conduct
quality of care projects to monitor the quality,
appropriateness, and effectiveness of enrollee care in the
Frail/Elderly program. These projects must include quarterly
reviews of long-term care records of enrollees who have
received services during the previous quarter. Review elements
include management of diagnosis, appropriateness and
timeliness of care, comprehensiveness of and compliance with
the plan of care, and evidence of special screening for, and
monitoring of, high-risk persons and conditions.
The projects must:
1. Target specific conditions and health
service delivery issues appropriate to enrollees for
focused monitoring and evaluation.
2. Use clinical care standards or practice
guidelines to objectively evaluate health services
delivery issues and the care the contractor delivers
or rails to deliver for acute and long-term care
conditions.
3. Use quality indicators derived from the
clinical care standards or practice guidelines to
screen and monitor care and services delivered.
4. The selection of conditions and issues to
study should be based on member profile data and
focus on areas of concern in the care of the frail
elders; for example: falls, incontinence, dementia,
depressions, congestive heart failure, inadequate
family care, family caregiver stress, family
conflict, out-of-home placements, alcohol problems,
and problems of compliance in procedures of medical
treatment.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 159 OF 166
July 2004 Medicaid HMO Contract
b. The plan must annually develop at least two specific quality
goals and provide documentation on each project, describing:
1. The objective;
2. The expected outcomes;
3. A brief justification with background on
each objective;
4. How each quality goal will be measured;
5. The target population;
6. The method of evaluating change in the
quality goals;
7. Communication process; and,
8. Documentation requirements.
c. The plan must ensure that sufficient quality management
resources (skilled staff and resources) specifically trained
to handle a quality Frail/Elderly program. The staff shall
have access to people with expertise in the following areas:
1. Quality Management Director: an identified
senior-level director who will oversee all
quality management and
performance-improvement activities. The
quality management director must have
expertise in geriatric care.
2. Medical Director: a medical director with a
current active license by Florida Board of
Medicine with geriatric expertise and
experience in geriatric care.
3. Geriatrician: a qualified geriatrician, with
a current active license by Florida Board of
Medicine and further certified in Geriatric
Medicine, who will be responsible for
establishing and monitoring the
implementation and administration of
geriatric management protocols to support
geriatric practice.
4. Behavioral Health Clinician: a qualified
behavioral health clinician, with expertise
in geriatric service, who will be
responsible for establishing behavioral
health protocols and providing specialized
support to primary care physicians and
primary care therapists.
d. Continuous Quality Improvement: All clinical and non-clinical
aspects of plan management must be based on principles of
Continuous Quality Improvement (CQI). Continuous quality
improvement is defined in section 100.0, Glossary. The quality
management program must:
1. Recognize that opportunities for improvement
are unlimited;
2. Be data driven;
3. Rely heavily on enrollee input;
4. Rely heavily on input from all employees of
the plan and its subcontractors; and
5. Require measurement of effectiveness,
continuing development, and implementation
of improvements as appropriate.
e. The plan shall develop and periodically review written
guidelines, procedures and protocols on areas of concern in
the care of the frail/elderly.
The plan may be granted an extension period for implementing the new
quality requirements.
110.4.3 EXPANDED SUPPORTIVE SERVICES REQUIREMENTS (FRAIL/ELDERLY)
The plan shall provide other supportive services as deemed necessary.
Services which are especially useful with this population include:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 160 OF 166
July 2004 Medicaid HMO Contract
a. Caregiver Training - Services designed to increase the ability
of family and caregivers to care for the member.
b. Emergency Alert Response Services - Such services monitor the
safety of individuals in their own homes which will alert and
dispatch qualified assistance to the member when in need.
c. Expanded Home Health - Services incorporating health and
medical services, including nutrition, occupational, physical,
and speech therapies, supervised by a health professional
including a registered nurse or a medical doctor. Such
services must be provided in compliance with applicable
Florida statutes and rules.
d. Financial Education - Services which include training,
counseling and assistance with personal financial management
particularly to help the member avoid financial exploitation.
e. Identity Bracelets - A bracelet that identifies the member and
includes a phone number to call to get additional information
about the member. This is particularly useful for people with
cognitive deficits, or those who wander and become
disoriented.
f. Pharmaceutical Management - Services provided by an
appropriately trained and licensed practitioner. This service
is designed to help the member and the team gain the most
value from any pharmaceutical regimen and helps the member use
medication correctly. It includes an assessment of
over-the-counter or home remedies the member uses that may
impact on the member's care, treatment, or which may interact
with other prescribed medications.
g. Respite - Services provided to relieve the caregiver
temporarily of the responsibilities of care giving and
supervision. Providers of this service must be licensed as
required under Florida Statutes.
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 161 OF 166
July 2004 Medicaid HMO Contract
EXHIBIT 110.5
FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES
381.026, F.S.
(1) SHORT TITLE. This section may be cited as the "Florida Patient's Bill of
Rights and Responsibilities."
(2) DEFINITIONS. As used in this section, the term:
(a) "Health care facility" means a facility licensed under chapter 395.
(b) "Health care provider" means a physician licensed under chapter
458, an osteopathic physician licensed under chapter 459, or a podiatrist
licensed under chapter 461.
(c) "Responsible provider" means a health care provider who is
primarily responsible for patient care in a health care facility or provider's
office.
(3) PURPOSE. It is the purpose of this section to promote the interests and
well-being of the patients of health care providers and health care facilities
and to promote better communication between the patient and the health care
provider. It is the intent of the Legislature that health care providers
understand their responsibility to give their patients a general understanding
of the procedures to be performed on them and to provide information pertaining
to their health care so that they may make decisions in an informed manner after
considering the information relating to their condition, the available treatment
alternatives, and substantial risks and hazards inherent in the treatments. It
is the intent of the Legislature that patients have a general understanding of
their responsibilities toward health care providers and health care facilities.
It is the intent of the Legislature that the provision of such information to a
patient eliminate potential misunderstandings between patients and health care
providers. It is a public policy of the state that the interests of patients be
recognized in a patient's bill of rights and responsibilities and that a health
care facility or health care provider may not require a patient to waive his
rights as a condition of treatment. This section shall not be used for any
purpose in any civil or administrative action and neither expands nor limits any
rights or remedies provided under any other law.
(4) RIGHTS OF PATIENTS. Each health care facility or provider shall observe the
following standards:
(a) Individual dignity.
1. The individual dignity of a patient must be respected at
all times and upon all occasions.
2. Every patient who is provided health care services retains
certain rights to privacy, which must be respected without regard to the
patient's economic status or source of payment for his care. The patient's
rights to privacy must be respected to the extent consistent with providing
adequate medical care to the patient and with the efficient administration of
the health care facility or provider's office. However, this subparagraph does
not preclude necessary and discreet discussion of a patient's case or
examination by appropriate medical personnel.
3. A patient has the right to a prompt and reasonable response
to a question or request. A health care facility shall respond in a reasonable
manner to the request of a patient's health care provider for medical services
to the patient. The health care facility shall also respond in a reasonable
manner to the patient's request for other services customarily rendered by the
health care facility to the extent such services do not require the approval of
the patient's health care provider or are not inconsistent with the patient's
treatment.
4. A patient in a health care facility has the right to retain
and use personal clothing or possessions as space permits, unless for him to do
so would infringe upon the right of another patient or is medically or
programmatically contraindicated for documented medical, safety, or programmatic
reasons.
(b) Information.
1. A patient has the right to know the name, function, and
qualifications of each health care provider who is providing medical services to
the patient. A patient may request such information from his responsible
provider or the health care facility in which he is receiving medical services.
2. A patient in a health care facility has the right to know
what patient support services are available in the facility.
3. A patient has the right to be given by his health care
provider information concerning diagnosis, planned course of treatment,
alternatives, risks, and prognosis, unless it is medically inadvisable or
impossible to give this information to the patient, in which case the
information must be given to the patient's guardian or a person designated as
the patient's representative. A patient has the right to refuse this
information.
4. A patient has the right to refuse any treatment based on
information required by this paragraph, except as otherwise provided by law. The
responsible provider shall document any such refusal.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 162 OF 166
July 2004 Medicaid HMO Contract
5. A patient in a health care facility has the right to know
what facility rules and regulations apply to patient conduct.
6. A patient has the right to express grievances to a health
care provider, a health care facility, or the appropriate state licensing agency
regarding alleged violations of patients' rights. A patient has the right to
know the health care provider's or health care facility's procedures for
expressing a grievance.
7. A patient in a health care facility who does not speak
English has the right to be provided an interpreter when receiving medical
services if the facility does not have a person readily available who can
interpret on behalf of the patient.
(c) Financial information and disclosure.
1. A patient has the right to be given, upon request, by the
responsible provider, his designee, or a representative of the health care
facility full information and necessary counseling on the availability of known
financial resources for the patient's health care.
2. A health care provider or a health care facility shall,
upon request, disclose to each patient who is eligible for Medicare, in advance
of treatment, whether the health care provider or the health care facility in
which the patient is receiving medical services accepts assignment under
Medicare reimbursement as payment in full for medical services and treatment
rendered in the health care provider's office or health care facility.
3. A health care provider or a health care facility shall,
upon request, furnish a person, prior to provision of medical services, a
reasonable estimate of charges for such services. Such reasonable estimate shall
not preclude the health care provider or health care facility from exceeding the
estimate or making additional charges based on changes in the patient's
condition or treatment needs.
Each licensed facility not operated by the state shall make
available to the public on its Internet website or by other electronic means a
description of and a link to the performance outcome and financial data that is
published by the agency pursuant to s. 408.05(3)(1). The facility shall place a
notice in the reception area that such information is available electronically
and the website address. The licensed facility may indicate that the pricing
information is based on a compilation of charges for the average patient and
that each patient's bill may vary from the average depending upon the severity
of illness and individual resources consumed. The licensed facility may also
indicate that the price of service is negotiable for eligible patients based
upon the patient's ability to pay.
5. A patient has the right to receive a copy of an itemized
bill upon request. A patient has a right to be given an explanation of charges
upon request.
(d) Access to health care.
1. A patient has the right to impartial access to medical
treatment or accommodations, regardless of race, national origin, religion,
physical handicap, or source of payment.
2. A patient has the right to treatment for any emergency
medical condition that shall deteriorate from failure to provide such treatment.
(e) Experimental research.
In addition to the provisions of section 766.103, F.S., a patient has
the right to know if medical treatment is for purposes of experimental research
and to consent prior to participation in such experimental research. For any
patient, regardless of ability to pay or source of payment for his care,
participation must be a voluntary matter; and a patient has the right to refuse
to participate. The patient's consent or refusal must be documented in the
patient's care record.
(f) Patient's knowledge of rights and responsibilities.
In receiving health care, patients have the right to know what their
rights and responsibilities are.
(5) RESPONSIBILITIES OF PATIENTS. Each patient of a health care provider or
health care facility shall respect the health care provider's and health care
facility's right to expect behavior on the part of patients which, considering
the nature of their illness, is reasonable and responsible. Each patient shall
observe the responsibilities described in the following summary.
(6) SUMMARY OF RIGHTS AND RESPONSIBILITIES. Any health care provider who treats
a patient in an office or any health care facility that admits and treats a
patient shall adopt and make public, in writing, a statement of the rights and
responsibilities of patients, including:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 163 OF 166
July 2004 Medicaid HMO Contract
SUMMARY OF THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES
Florida law requires that your health care provider or health care facility
recognize your rights while you are receiving medical care and that you respect
the health care provider's or health care facility's right to expect certain
behavior on the part of patients. You may request a copy of the full text of
this law from your health care provider or health care facility. A summary of
your rights and responsibilities follows:
A patient has the right to be treated with courtesy and respect, with
appreciation of his individual dignity, and with protection of his need for
privacy.
A patient has the right to a prompt and reasonable response to
questions and requests.
A patient has the right to know who is providing medical services and
who is responsible for his care.
A patient has the right to know what patient support services are
available, including whether an interpreter is available if he does not speak
English.
A patient has the right to know what rules and regulations apply to his
conduct.
A patient has the right to be given by his health care provider
information concerning diagnosis, planned course of treatment, alternatives,
risks, and prognosis.
A patient has the right to refuse any treatment, except as otherwise
provided by law.
A patient has the right to be given, upon request, full information and
necessary counseling on the availability of known financial resources for his
care.
A patient who is eligible for Medicare has the right to know, upon
request and in advance of treatment, whether the health care provider or health
care facility accepts the Medicare assignment rate.
A patient has the right to receive, upon request, prior to treatment, a
reasonable estimate of charges for medical care.
A patient has the right to receive a copy of a reasonably clear and
understandable, itemized bill and, upon request, to have the charges explained.
A patient has the right to impartial access to medical treatment or
accommodations, regardless of race, national origin, religion, physical
handicap, or source of payment.
A patient has the right to treatment for any emergency medical
condition that shall deteriorate from failure to provide treatment.
A patient has the right to know if medical treatment is for purposes of
experimental research and to give his consent or refusal to participate in such
experimental research.
A patient has the right to express grievances regarding any violation
of his rights, as stated in Florida law, through the grievance procedure of the
health care provider or health care facility which served him and to the
appropriate state licensing agency.
A patient is responsible for providing to his health care provider, to
the best of his knowledge, accurate and complete information about present
complaints, past illnesses, hospitalizations, medications, and other matters
relating to his health.
A patient is responsible for reporting unexpected changes in his
condition to his health care provider.
A patient is responsible for reporting to his health care provider
whether he comprehends a contemplated course of action and what is expected of
him.
A patient is responsible for following the treatment plan recommended
by his health care provider.
A patient is responsible for keeping appointments and, when he is
unable to do so for any reason, for notifying the health care provider or health
care facility.
A patient is responsible for his actions if he refuses treatment or
does not follow the health care provider's instructions.
A patient is responsible for assuring that the financial obligations of
his health care are fulfilled as promptly as possible.
A patient is responsible for following health care facility rules and
regulations affecting patient care and conduct.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 164 OF 166
July 2004 Medicaid HMO Contract
EXHIBIT 110.6
MEMORANDUM OF UNDERSTANDING BETWEEN SCHOOL DISTRICT AND HMO
I. GENERAL
This agreement is entered into between the ____________________________
County School District, hereinafter referred to as the "School District" and
_________________________________________________, hereinafter referred to as
the "HMO", for the purpose of improving services to students qualified under the
Medicaid certified school match program through coordinated, cooperative health
care interaction between the school district and the HMO.
Both parties understand and agree that coordinating the health care needs and
treatment of Medicaid eligible students is critical to providing quality
services within and outside the school setting, and preventing possible
duplication of medical services. Both parties devote their efforts to continuity
and quality of care in pursuit of the students' needs for health care services
as required by Florida law.
II. POWER AND AUTHORITY OF THE SCHOOL DISTRICT REGARDING THE CERTIFIED SCHOOL
MATCH PROGRAM REIMBURSEMENT THROUGH MEDICAID:
Pursuant to sections 409.9071 and 236.0812, Florida Statutes, and
chapter 59G, Florida Administrative Code, School Districts in the State of
Florida are eligible to receive Medicaid fee-for-service reimbursement for
certain services provided to Medicaid-eligible students under the Medicaid
certified school match program. These health care services are physical therapy,
speech-language pathology, respiratory therapy, augmentative and communicative
devices, nursing, medication administration and behavioral health (psychology,
social work, etc). In addition, Medicaid reimburses transportation as a related
service under the certified school match program.
III. POWER AND AUTHORITY OF THE HMO REGARDING THE CERTIFIED SCHOOL MATCH PROGRAM
REIMBURSEMENT THROUGH MEDICAID:
The HMO has contracted with AHCA as a Medicaid HMO provider. The HMO
must comply with all established contract requirements and applicable state and
federal law when providing health care services. In accordance with section
409.9122, Florida Statutes, the HMO shall make a good faith effort to execute an
agreement with a School District for services authorized by Florida law.
IV. THE SCHOOL DISTRICT AGREES TO THE FOLLOWING:
1. Request parents or legal guardians to sign a release form for the
release of medical records, plan of care and Individual Education Plan (IEP) or
Family Support Plan (FSP) to the HMO for Medicaid certified school match
services.
2. Refer students to the HMO for ongoing primary care services.
3. Provide the HMO with a plan of care regarding the student's plan of
treatment within ___ days of plan of care development, provided the School
District has received the parent's or legal guardian's signed release of
records.
4. Forward to the HMO either a summary of services or the medical
records relating to the health care services provided under the Medicaid
certified school match program to an HMO student member upon request by the HMO
within ___ days after the HMO patient is treated in the school, or on a
quarterly basis, as agreed upon between the School District and the HMO.
5. Forward any unresolved health care concerns regarding the student,
including concerns which require continuity of treatment during school vacation,
to the HMO.
6. Provide a contact person to the HMO for coordinating services.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 165 OF 166
July 2004 Medicaid HMO Contract
7. As appropriate, include a representative of the HMO in
staffing for the IEP or FSP for each student covered under the
Medicaid certified school match program unless there is
objection from a parent/guardian. In instances where the HMO
does not attend the IEP meeting, the School District will
provide other methods of communicating the student's health
care needs.
V. THE MEDICAID HMO AGREES TO THE FOLLOWING:
1. Provide an HMO contact person to the schools who is responsible for
coordination of services.
2. Refer students to primary care providers for ongoing services.
3. As appropriate, participate in IEP or FSP staff meetings,
review documentation received from the School District, and
take action to ensure coordination of care.
4. Release medical records to the school upon receiving the
parent's or guardian's consent for such release.
VI. BOTH PARTIES AGREE TO:
A. Make good faith effort to work in a cooperative manner.
B. Forward any unresolved concerns involving the HMO and the School
District to the appropriate Agency area Bureau of Managed Health Care
office, as appropriate.
VII. THIS AGREEMENT SHALL TAKE EFFECT_________________________ and shall remain
in effect until terminated by either party, by written notice to the other party
upon certified or registered mail received.
___________________________________________
School District
___________________________________________ _________
Authorized Representative of School District Date
___________________________________________
HMO
___________________________________________ _________
Authorized Representative of HMO Date
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 166 OF 166
ATTACHMENT II
FINANCIAL AND COMPLIANCE AUDIT
The administration of resources awarded by the Agency for Health Care
Administration to the recipient may be subject to audits or monitoring by
the Agency as described in this section.
MONITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-133
and Section 215.97, F.S., as revised (see "AUDITS" below), monitoring procedures
may include, but not be limited to, on-site visits by Agency staff, limited
scope audits as defined by OMB Circular A-133, as revised, and/or other
procedures. By entering into this agreement, the recipient agrees to comply and
cooperate with any monitoring procedures/processes deemed appropriate by the
Agency. In the event the Agency determines that a limited scope audit of the
recipient is appropriate, the recipient agrees to comply with any additional
instructions provided by the Agency to the recipient regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews,
investigations, or audits deemed necessary by the Comptroller or Auditor
General.
AUDITS
PART I: FEDERALLY FUNDED
This Attachment is applicable if the recipient is a State or local government or
a non-profit organization as defined in OMB Circular A- 133, as revised .
1. In the event that the recipient expends $300,000 or more in Federal
awards in its fiscal year, the recipient must have a single or
program-specific audit conducted in accordance with the provisions of
OMB Circular A-133, as revised. PART VI of this agreement indicates
Federal resources awarded through the Agency. In determining the
Federal awards expended in its fiscal year, the recipient shall
consider all sources of Federal awards, including Federal resources
received from the Agency. The determination of amounts of Federal
awards expended should be in accordance with the guidelines established
by OMB Circular A-133, as revised. An audit of the recipient conducted
by the Auditor General in accordance with the provisions of OMB
Circular A-133, as revised, will meet the requirements of this part.
2. In connection with the audit requirements addressed in Part I,
paragraph 1., the recipient shall fulfill the requirements relative to
auditee responsibilities as provided in Subpart C of OMB Circular
A-133, as revised.
3. If the recipient expends less than $300,000 in Federal awards in its
fiscal year, an audit conducted in accordance with the provisions of
OMB Circular A-133, as revised, is not required. In the event that the
recipient expends less than $300,000 in Federal awards in its fiscal
year and elects to have an audit conducted in accordance with the
provisions of OMB Circular A- 133, as revised, the cost of the audit
must be paid from non-Federal resources (i.e., the cost of such an
audit must be paid from recipient resources obtained from other than
Federal entities).
4. Information concerning this section can be found on the Federal Office
of Management and Budget Web page at:
http://www.whitehouse.gov/omb/index
PART II: STATE FUNDED
This part is applicable if the recipient is a non-state entity as defined by
Section 215.97(2)(l), Florida Statutes.
1 . In the event that the recipient expends a total amount of State
Financial Assistance (i.e., State financial assistance provided to the
recipient to carry out a State project) equal to or in excess of
$300,000 in any fiscal year of such recipient, the recipient must have
a State single or project-specific audit for such fiscal year in
accordance with Section 215.97, Florida Statutes; applicable rules of
the Executive Office of the Governor and the Comptroller, and Chapters
10.550 (local governmental entities) or 10.650 (nonprofit and
for-profit organizations), Rules of the Auditor General. PART VI of
this agreement indicates State Financial Assistance awarded through the
Agency by this agreement. In determining the State Financial Assistance
expended in its fiscal year, the recipient shall consider all sources
of State Financial Assistance, including State Financial Assistance
received from the Agency, other state agencies, and other non-state
entities. State Financial Assistance does not include Federal direct or
pass-through awards and resources received by the non-state entity for
Federal program matching requirements.
AHCA CONTRACT NO. FA522, ATTACHMENT II, PAGE 1 OF 3
2. In connection with the audit requirements addressed in Part II,
paragraph 1, the recipient shall ensure that the audit complies with
the requirements of Section 215.97(7), Florida Statutes. This includes
submission of a financial reporting package as defined by Section
215.97(2)(d), Florida Statutes, and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for-profit organizations), Rules of
the Auditor General.
3. If the recipient expends less than $300,000 in State Financial
Assistance in its fiscal year, an audit conducted in accordance with
the provisions of Section 215.97, Florida Statutes, is not required. In
the event that the recipient expends less than $300,000 in State
Financial Assistance in its fiscal year and elects to have an audit
conducted in accordance with the provisions of Section 215.97, Florida
Statutes, the cost of the audit must be paid from the nonstate entity's
resources (i.e., the cost of such an audit must be paid from the
recipient's resources obtained from other than State entities).
4. Information concerning this section can be found on the State of
Florida Web page at:
http://www.myflorida.com/myflorida/government/governorinitiatives/fsaa/
PART III: OTHER AUDIT REQUIREMENTS
1. 45 CFR, Part 74.26(d) extends OMB requirements, as stated in Part I
above, to for-profit organizations.
PART IV: REPORT SUBMISSION
1. Copies of reporting packages for audits conducted in accordance with
OMB Circular A-133, as revised, and required by PART I of this
agreement shall be submitted, when required by Section .320 (d), OMB
Circular A-133, as revised, by or on behalf of the recipient directly
to each of the following:
A. The Agency for Health Care Administration at the following
address:
See AHCA Standard Contract document, Section III,C,1
B. The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections
.320 (d)(1) and (2), OMB Circular A-133, as revised, should be
submitted to the Federal Audit Clearinghouse), at the
following address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
C. Other Federal agencies and pass-through entities in accordance
with Sections .320 (e) and (f), OMB Circular A-133, as
revised.
2. Pursuant to Section .320 (f), OMB Circular A-133, as revised, the
recipient shall submit a copy of the financial reporting package
described in Section .320 (c), OMB Circular A-133, as revised, and any
management letters issued by the auditor, to the Agency at the
following address:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III,
C, 1.
B. To the Federal Agency or pass-through entity making the
request for a copy of the reporting package.
3. Copies of financial reporting packages required by PART II of this
agreement shall be submitted by or on behalf of the recipient directly
to each of the following:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III, C,1.
B. The Auditor General's Office at the following address:
Auditor General's Office
Room 401, Pepper Building
111 West Madison Street
Tallahassee, Florida 32399-1450
AHCA CONTRACT NO. FA522, ATTACHMENT II, PAGE 2 OF 3
4. Copies of reports or management letters required by PART III of this
agreement shall be submitted by or on behalf of the recipient directly
to:
A. The Agency for Health Care Administration at the address
indicated in the Standard Contract document,
Section III, C,1.
B. The Federal Department of Health and Human Services
National External Audit Resources Unit
323 West 8th St., Lucas Place-Room 514
Kansas City, MO 64105.
C. The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections
.320 (d)(1) and (2), OMB Circular A-133, as revised, should be
submitted to the following address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville,IN 47132
5. Any reports, management letters, or other information required to be
submitted to the Agency pursuant to this agreement shall be submitted
timely in accordance with OMB Circular A-133, Florida Statutes, and
Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and
for-profit organizations), Rules of the Auditor General, as applicable.
6. Recipients, when submitting financial reporting packages to the Agency
for audits done in accordance with OMB Circular A-133, or Chapters
10.550 (local government entities) or 10.650 (nonprofit and for-profit)
organizations, Rules of the Auditor General, should indicate the date
that the reporting package was delivered from the auditor to the
recipient in correspondence accompanying the reporting package. This
can be accomplished by providing the cover letter from the reporting
package received from the auditor or a cover letter indicating the date
the reporting package was received by the recipient.
PART V: RECORD RETENTION
1. The recipient shall retain sufficient records demonstrating its
compliance with the terms of this agreement for a period of five (5)
years from the date the audit report is issued, and shall allow the
Agency or its designee, Comptroller, or Auditor General access to such
records upon request. The recipient shall ensure that audit working
papers are made available to the Agency or its designee, Comptroller,
or Auditor General upon request for a period of five (5) years from the
date the audit report is issued unless extended in writing by the
Agency.
NOTE: SECTION .400(d) OF THE OMB CIRCULAR A-133, AS REVISED, AND SECTION
215.97(5)(a), FLORIDA STATUTES, REQUIRE THAT THE INFORMATION ABOUT
FEDERAL PROGRAMS AND STATE PROJECTS INCLUDED IN PART VI OF THIS
ATTACHMENT BE PROVIDED TO THE VENDOR ORGANIZATION IF THE VENDOR IS
DETERMINED TO BE A RECIPIENT. IF PART VI IS NOT INCLUDED THE VENDOR HAS
NOT BEEN DETERMINED TO BE A RECIPIENT AS DEFINED BY THE ABOVE
REFERENCED FEDERAL AND STATE LAWS.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA CONTRACT NO. FA522, ATTACHMENT II, PAGE 3 OF 3
PART VI: SCHEDULE OF FEDERAL AND STATE FUNDING
(MANDATORY TO BE COMPLETED BY AGENCY CONTRACT MANAGER AND INCLUDED AS PART OF
ATTACHMENT II, IF VENDOR IS DETERMINED TO BE A RECIPIENT OF EITHER STATE OR
FEDERAL FINANCIAL ASSISTANCE AS DEFINED IN THE OMB CIRCULAR A-133 AS REVISED OR
SECTION 215.97(2)(m) F.S.. CONTRACT MANAGERS SHOULD UTILIZE THE FEDERAL FUNDING
CHECKLIST TO DETERMINE THE VENDOR'S STATUS PER OMB CIRCULAR A-133 OR THE FLORIDA
SINGLE AUDIT ACT CHECKLISTS TO DETERMINE THE APPLICABILITY AND VENDOR'S STATUS
PER SECTION 215.97, F.S.)
1. COMPLIANCE REQUIREMENTS FOR FEDERAL FINANCIAL ASSISTANCE, STATE
MATCHING AND STATE FINANCIAL ASSISTANCE AWARDED PURSUANT TO THIS
AGREEMENT ARE INCLUDED IN THE AGENCY STANDARD CONTRACT DOCUMENT AND THE
ATTACHMENT I, SPECIAL PROVISIONS SECTION.
a) FEDERAL FINANCIAL ASSISTANCE awarded to the recipient pursuant
to this agreement are as follows:
(Check appropriate Federal Program funding source(s) and provide amount
per source.)
Department of Health and Human Services, Center for Medicaid/Medicare
[ ]Medicaid Title 19(CFDA# 93.778) Amount: $
Medical Assistance Payments
[ ]Medicaid Title 21(CFDA# 93.767) Amount: $
Children's Health Insurance program
[ ]Medicaid Title 18,19,CLIA
Survey and Certification(CFDA# 93.777) Amount: $
b) STATE MATCHING FUNDS awarded to the Recipient pursuant to this
agreement are as follows: (Check appropriate Federal Program
funding source and provide State matching amount per source.)
Department of Health and Human Services, Center for
Medicaid/Medicare
[ ]Medicaid Title 19(CFDA# 93.778) Amount: $
Medical Assistance Payments
[ ]Medicaid Title 21(CFDA# 93.767 Amount: $
Children's Health Insurance Program
[ ]Medicaid Title 18,19, CLIA (CFDA# 93.777)
Survey and Certification Amount: $
c) STATE FINANCIAL ASSISTANCE awarded pursuant to Section 215.97,
F.S., Florida Single Audit Act
(If this section is checked provide CSFA #)
[ ]State Project (CSFA# ) Amount: $
State Project
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
AHCA CONTRACT NO. FA522, ATTACHMENT II, PAGE 3 OF 3
ATTACHMENT V
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/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
1. Each Vendor whose contract/subcontract equals or exceeds $25,000 in
federal monies must sign this certification prior to execution of each
contract/subcontract. Additionally, Vendorss who audit federal programs
must also sign, regardless of the contract amount. The Agency for
Health Care Administration cannot contract with these types of Vendorss
if they are debarred or suspended by the federal government.
2. This certification is a material representation of fact upon which
reliance is placed when this contract/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.
3. The Vendor shall provide immediate written notice to the contract
manager at any time the Vendor learns that its certification was
erroneous when submitted or has become erroneous by reason of changed
circumstances.
4. The terms "debarred," "suspended," "ineligible," "person," "principal,"
and "voluntarily excluded," as used in this certification, have the
meanings set out in the Definitions and Coverage sections of rules
implementing Executive Order 12549. You may contact the contract
manager for assistance in obtaining a copy of those regulations.
5. The Vendor 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.
6. The Vendor 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.
7. The Agency for Health Care Administration may rely upon a certification
of a Vendor that it is not debarred, suspended, ineligible, or
voluntarily excluded from contracting/subcontracting unless it knows
that the certification is erroneous.
8. This signed certification must be kept in the contract manager's
contract file. Subcontractor's certifications must be kept at the
contractor's business location.
CERTIFICATION
(1) The prospective Vendor certifies, by signing this certification, that
neither he nor his principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this contract/subcontract by any federal
department or agency.
(2) Where the prospective Vendor is unable to certify to any of the
statements in this certification, such prospective Vendor shall attach
an explanation to this certification.
______________________________________________ ____________
Signature Date
__________________________________________________________________
Name and Title of Authorized Signer
AHCA CONTRACT NO. FA522, ATTACHMENT V, PAGE 1 OF 1
ATTACHMENT III
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 Vendor 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 Vendor from or on behalf of the Agency.
2. Limits on Use and Disclosure of Protected Health Information.
The Vendor shall not use or disclose Protected Health
Information other than as permitted by this Contract or by
federal and state law. The Vendor 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 Vendor will not
divulge, disclose, or communicate Protected Health Information
to any third party for any purpose not in conformity with this
contract without prior written approval from the Agency. The
Vendor will report to the Agency, within ten (10) business
days of discovery, any use or disclosure of Protected Health
Information not provided for in this Contract of which the
Vendor 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 Vendor is
permitted to use and disclose Protected Health Information
received from the Agency for the proper management and
administration of the Vendor or to carry out the legal
responsibilities of the Vendor, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where
required by law, or where the Vendor 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 Vendor of any
instance of which it is aware in which the confidentiality of
the Protected Health Information has been breached.
4. Disclosure to Agents. The Vendor agrees to enter into an
agreement with any agent, including a subcontractor, to whom
it provides Protected Health Information received from, or
created or received by the Vendor on behalf of, the Agency.
Such agreement shall contain the same terms, conditions, and
restrictions that apply to the Vendor with respect to
Protected Health Information.
5. Access to Information. The Vendor 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.
6. Amendment and Incorporation of Amendments. The Vendor 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 Vendor shall make Protected
Health Information available as required to provide an
accounting of disclosures in accordance with 45 C.F.R. Section
164.528. The Vendor shall document all disclosures of
Protected Health Information as needed for the Agency to
respond to a request for an accounting of disclosures in
accordance with 45 C.F.R. Section 164.528.
8. Access to Books and Records. The Vendor 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
AHCA CONTRACT NO. FA522, ATTACHMENT III, PAGE 1 OF 2
Vendor on behalf of the Agency, available 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 Vendor
shall return all Protected Health Information that the Vendor
still maintains in any form, including any copies or hybrid or
merged databases made by the Vendor; or with prior written
approval of the Agency, the Protected Health Information may
be destroyed by the Vendor after its use. If the Protected
Health Information is destroyed pursuant to the Agency's prior
written approval, the Vendor must provide a written
confirmation of such destruction to the Agency. If return or
destruction of the Protected Health Information is determined
not feasible by the Agency, the Vendor agrees to protect the
Protected Health Information and treat it as strictly
confidential.
CERTIFICATION
The Vendor has caused this Certification to be signed and
delivered by its duly authorized representative, as of the
date set forth below.
Vendor Name:
__________________________________ __________________
Signature Date
__________________________________
Name and Title of Authorized Signer
REMAINDER OF PAGE INTENTIONALLY LEFT BLAK
AHCA CONTRACT NO. FA522, ATTACHMENT III, PAGE 2 OF 2
10/01/02
ATTACHMENT IV
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 sub-awards at all tiers
(including subcontracts, sub-grants, and contracts under grants, loans,
and cooperative agreements) and that all sub-recipients shall certify
and disclose accordingly.
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
_________________________________ ________________________________
Signature Date Date
_________________________________ _________________________________
Name of Authorized Individual Application or Contract Number
__________________________________________________________________________
Name and Address of Organization
AHCA CONTRACT NO. FA522, ATTACHMENT IV, PAGE 1 OF 1
ATTACHMENT V
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/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
1. Each Vendor whose contract/subcontract equals or exceeds $25,000 in federal
monies must sign this certification prior to execution of each
contract/subcontract. Additionally, Vendors who audit federal programs must
also sign, regardless of the contract amount. The Agency for Health Care
Administration cannot contract with these types of Vendors if they are
debarred or suspended by the federal government.
2. This certification is a material representation of fact upon which reliance
is placed when this contract/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.
3. The Vendor shall provide immediate written notice to the contract manager
at any time the Vendor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
4. The terms "debarred," "suspended," "ineligible," "person," "principal," and
"voluntarily excluded," as used in this certification, have the meanings
set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549. You may contact the contract manager for assistance
in obtaining a copy of those regulations.
5. The Vendor 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.
6. The Vendor 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.
7. The Agency for Health Care Administration may rely upon a certification of
a Vendor that it is not debarred, suspended, ineligible, or voluntarily
excluded from contracting/subcontracting unless it knows that the
certification's erroneous.
8. This signed certification must be kept in the contract manager's contract
file. Subcontractor's certifications must be kept at the contractor's
business location.
- --------------------------------------------------------------------------------
CERTIFICATION
(1) The prospective Vendor certifies, by signing this certification, that
neither he nor his principals is presently debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily excluded from
participation in this contract/subcontract by any federal department or
agency.
(2) Where the prospective Vendor is unable to certify to any of the statements
in this certification, such prospective Vendor shall attach an explanation
to this certification.
---------------------------------- -------------------
Signature Date
--------------------------------------------------------
Name and Title of Authorized Signer
AHCA CONTRACT NO. FA522, ATTACHMENT V, PAGE 1 OF 1
ATTACHMENT VI
ESTIMATED 2004-2005 HMO RATES;
NOT FOR USE UNLESS APPROVED BY CMS
STAYWELL Medicaid HMO Contract
July 1, 2004 contract Number :FA522
Table 2.
Area wide Age-banded Capitation Rates for all agency areas of the state other
than Area 6 and Area 1.
Area 03 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 350.25 78.21 48.48 54.04 112.13 135.75 209.08 290.80
290.80
SSI/No Medicare 3239.83 391.28 203.50 212.95 212.95 609.10 609.10 588.30
588.30
SSI/Part B 297.27 297.27 297.27 297.27 297.27 297.27 297.27 297.27
297.27
SSI/Part A & B 257.35 257.35 257.35 257.35 257.35 257.35 257.35 257.35
222.33
Area 04 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 315.46 70.86 44.29 49.27 101.52 123.97 190.08 265.50
265.50
SSI/No Medicare 3104.98 374.20 193.48 202.59 202.59 580.40 580.40 559.85
559.85
SSI/Part B 268.53 268.53 268.53 268.53 268.53 268.53 268.53 268.53
268.53
SSI/Part A & B 262.61 262.61 262.61 262.61 262.61 262.61 262.61 262.61
225.74
Area 05 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 344.75 77.20 47.92 53.39 110.51 134.26 206.44 287.43
287.43
SSI/No Medicare 3312.84 399.97 207.73 217.58 217.58 622.27 622.27 600.49
600.49
SSI/Part B 262.11 262.11 262.11 262.11 262.11 262.11 262.11 262.11
262.11
SSI/Part A & B 279.92 279.92 279.92 279.92 279.92 279.92 279.92 279.92
240.03
Area 07 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 336.57 75.50 47.25 52.60 108.28 132.13 202.76 283.08
283.08
SSI/No Medicare 3320.10 402.55 211.07 220.72 220.72 631.77 631.77 609.58
609.58
SSI/Part B 261.32 261.32 261.32 261.32 261.32 261.32 261.32 261.32
261.32
SSI/Part A & B 251.20 251.20 251.20 251.20 251.20 251.20 251.20 251.20
217.86
Area 08 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 295.59 66.21 41.16 45.89 94.88 115.33 177.31 247.08
247.08
SSI/No Medicare 3101.85 374.62 194.07 203.31 203.31 582.39 582.39 561.96
561.96
SSI/Part B 239.50 239.50 239.50 239.50 239.50 239.50 239.50 239.50
239.50
SSI/Part A & B 253.81 253.81 253.81 253.81 253.81 253.81 253.81 253.81
219.39
Area 09 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 315.38 70.51 43.83 48.82 101.05 122.63 188.58 262.53
262.53
SSI/No Medicare 3369.20 408.36 212.88 222.97 222.97 638.43 638.43 615.96
615.96
SSI/Part B 262.75 262.75 262.75 262.75 262.75 262.75 262.75 262.75
262.75
SSI/Part A & B 285.85 285.85 285.85 285.85 285.85 285.85 285.85 285.85
244.68
Area 10 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 327.60 73.59 46.05 51.31 105.60 128.95 197.71 276.31
276.31
AHCA CONTRACT NO. FA522, ATTACHMENT VI, PAGE 1 OF 3
ATTACHMENT VI
ESTIMATED 2004-2005 HMO RATES;
NOT FOR USE UNLESS APPROVED BY CMS
SSI/No Medicare 4270.73 518.41 272.09 283.90 283.90 812.87 812.87 784.90
784.90
SSI/Part B 282.31 282.31 282.31 282.31 282.31 282.31 282.31 282.31
282.31
SSI/Part A & B 307.18 307.18 307.18 307.18 307.18 307.18 307.18 307.18
266.50
Area 11 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 409.11 91.47 56.55 63.18 131.14 158.74 244.35 339.65
339.65
SSI/No Medicare 4672.23 570.26 296.44 310.78 310.78 892.56 892.56 858.50
858.50
SSI/Part B 446.27 446.27 446.27 446.27 446.27 446.27 446.27 446.27
446.27
SSI/Part A & B 338.41 338.41 338.41 338.41 338.41 338.41 338.41 338.41
308.91
AHCA CONTRACT NO. FA522, ATTACHMENT VI, PAGE 2 OF 3
ATTACHMENT VI
ESTIMATED 2004-2005 HMO RATES;
NOT FOR USE UNLESS APPROVED BY CMS
STAYWELL Medicaid HMO Contract
July 1, 2004 contract Number : FA522
Table 3.
Area 6 or Area 1 Age-banded Capitation Rates, Including Community Mental
Health and Mental Health Targeted Case Management.
Area 01 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 308.27 69.09 48.50 52.47 103.55 119.04 183.31 253.56
253.56
SSI/No Medicare 3001.88 347.10 206.42 205.08 205.08 509.98 509.98 474.26
474.26
SSI/Part B 324.70 324.70 324.70 324.70 324.70 324.70 324.70 324.70
324.70
SSI/Part A & B 293.20 293.20 293.20 293.20 293.20 293.20 293.20 293.20
257.76
Area 06 <1 year 1-5 6-13 14-20 Male 14-20 Female 21-54 Male 21-54 Female 55-64
65+
TANF/FC/SOBRA 329.30 75.87 61.50 67.73 122.33 133.79 202.90 279.50
279.50
SSI/No Medicare 3062.53 377.38 271.33 247.10 247.10 657.23 657.23 596.37
596.37
SSI/Part B 238.18 238.18 238.18 238.18 238.18 238.18 238.18 238.18
238.18
SSI/Part A & B 255.15 255.15 255.15 255.15 255.15 255.15 255.15 255.15
222.29
AHCA CONTRACT NO. FA522, ATTACHMENT VI, PAGE 3 OF 3