EXHIBIT 10.1
JANUARY 2002 - DECEMBER 2003
CONTRACT FOR MEDICAID/BADGERCARE HMO SERVICES
BETWEEN
HMO
AND
WISCONSIN DEPARTMENT OF
HEALTH AND FAMILY SERVICES
TABLE OF CONTENTS
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ARTICLE I ................................................................................... 1
I. DEFINITIONS ...................................................................... 1
ARTICLE II ....................................... .......................................... 7
II. DELEGATIONS OF AUTHORITY......................................................... 7
ARTICLE III ................................................................................. 8
III. FUNCTIONS AND DUTIES OF THE HMO ................................................ 8
A. Statutory Requirement .................................................... 8
B. Provision of Contract Services............................................ 8
C. Time Limit for Decision on Certain Referrals.............................. 19
D. Emergency Care ........................................................... 19
E. 24-Hour Coverage ......................................................... 20
F. Thirty Day Payment Requirement............................................ 20
G. HMO Claim Retrieval System ............................................... 21
H. Appeals to the Department for HMO Payment/Denial of Providers ............ 21
I. Payments for Diagnosis of Whether an Emergency Condition Exists........... 22
J. Memoranda of Understanding for Emergency Services......................... 22
K. Provision of Services..................................................... 23
L. Open Enrollment........................................................... 23
M. Pre-Existing Conditions................................................... 23
N. Hospitalization at the Time of Enrollment or Disenrollment................ 24
O. Non-Discrimination ....................................................... 24
P. Affirmative Action Plan .................................................. 25
Q. Cultural Competency....................................................... 26
R. Health Education and Prevention........................................... 26
S. Enrollee Handbook and Education and Outreach for Newly Enrolled
Recipients................................................................ 28
T. Approval of Marketing Plans and Informing Materials ...................... 30
U. Conversion Privileges..................................................... 32
V. Choice of Health Professional ............................................ 32
W. Quality Assessment/Performance Improvement (QAPI) ........................ 32
X. Access to Premises ....................................................... 52
Y. Subcontracts ............................................................. 52
Z. Compliance with Applicable Laws, Rules or Regulations .................... 52
AA. Use of Providers Certified By Medicaid Program .......................... 52
BB. Reproduction and Distribution of Materials .............................. 53
CC. Provision of Interpreters................................................ 53
DD. Coordination and Continuation of Care ................................... 53
EE. HMO ID Cards ............................................................ 54
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FF. Federally Qualified Health Centers and Rural Health Centers
(FQHCs and RHCs) ............................................................. 54
GG. Coordination with Prenatal Care Services, School-Based Services,
Targeted Case Management Services, a Child Welfare Agencies, and
Dental Managed Care Organizations............................................. 55
HH. Physician Incentive Plans..................................................... 56
II. Advance Directives............................................................ 57
JJ. Ineligible Organizations...................................................... 57
KK. Clinical Laboratory Improvement Amendments ................................... 59
LL. Limitation on Fertility Enhancing Drugs....................................... 59
MM. Reporting of Communicable Diseases ........................................... 60
NN. Medicaid/BadgerCare HMO Advocate Requirements................................. 60
OO. HMO Designation of Staff Person as Contract Representative ................... 63
PP. Subcontracts with Local Health Departments.................................... 63
QQ. Subcontracts with Community-Based Health Organizations........................ 64
RR. Prescription Drugs............................................................ 64
SS. HMO Attestation............................................................... 65
TT. Fraud and Abuse Investigations ............................................... 65
ARTICLE IV ....................................................................................... 66
IV. FUNCTIONS AND DUTIES OF THE DEPARTMENT ............................................... 66
A. Eligibility Determination ..................................................... 66
B. Enrollment .................................................................... 67
C. Disenrollment ................................................................. 67
D. HMO Enrollment Reports ........................................................ 67
E. Utilization Review and Control................................................. 68
F. HMO Review .................................................................... 68
G. HMO Review of Study or Audit Results .......................................... 68
H. Vaccines....................................................................... 68
I. Coordination of Benefits....................................................... 69
J. Wisconsin Medicaid Provider Reports............................................ 69
K. Enrollee Health Status and Primary Language Report ............................ 69
L. Fraud and Abuse Training....................................................... 69
M. Provision of Data to HMOs...................................................... 69
N. Special Procedures for Retroactive Payments Adjustments for
Pregnant BadgerCare Enrollees.................................................. 69
ARTICLE V ........................................................................................ 70
V. PAYMENT TO THE HMO .................................................................... 70
A. Capitation Rates............................................................... 70
B. Actuarial Basis ............................................................... 70
C. Renegotiation.................................................................. 70
D. Reinsurance.................................................................... 70
E. Neonatal Intensive Care Unit Risk-Sharing...................................... 70
F. Payment Schedule .............................................................. 72
G. Capitation Payments For Newborns .............................................. 72
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H. Coordination of Benefits (COB) .............................................. 73
I. Recoupments ................................................................. 75
J. Payment for Aids, HIV-Positive, and Ventilator Dependent..................... 76
ARTICLE VI ..................................................................................... 79
VI. REPORTS, DATA, AND COMPUTER/DATA REPORTING SYSTEM .................................. 79
A. Disclosure................................................................... 79
B. Periodic Reports ............................................................ 79
C. Access to and Audit of Contract Records ..................................... 80
D. Records Retention ........................................................... 80
E. Special Reporting and Compliance Requirements ............................... 81
F. Reporting of Corporate and Other Changes .................................... 81
G. Computer/Data Reporting System............................................... 82
ARTICLE VII .................................................................................... 83
VII. ENROLLMENT AND DISENROLLMENTS ..................................................... 83
A. Enrollment .................................................................. 83
B. Third Trimester Pregnancy Disenrollment ..................................... 84
C. Ninth Month Pregnancy Disenrollment ......................................... 84
D. Exemptions from Enrollment in any HMO and Disenrollment for
Patients of Certified Nurse Midwives or Nurse Practitioners ................. 84
E. Exemption from Enrollment in any HMO and Disenrollment For
AIDS HIV-Positive with Anti Retroviral Drug Treatment ....................... 85
F. Exemptions from Enrollment in any HMO and Disenrollment for
Patients of Federally Qualified Health Centers Federally Qualified
Health Centers .............................................................. 85
G. Native American Disenrollment ............................................... 86
H. Special Disenrollments....................................................... 86
I. Exemptions from Enrollment in any HMO and Disenrollment for
Recipients With Commercial HMO Insurance or Commercial
Insurance With a Restricted Provider Network ................................ 86
J. Exemption from Enrollment in any HMO and Disenrollment for
Families Where One or More Members are receiving SSI benefits ............... 86
K. Voluntary Disenrollment ..................................................... 87
L. Section 1115(A) Waiver and State Plan Amendment.............................. 87
M. Additional Services.......................................................... 87
N. Enrollment/Disenrollment Practices .......................................... 87
O. Enrollee Lock-In Period ..................................................... 88
ARTICLE VIII ................................................................................... 88
VIII. GRIEVANCE PROCEDURES.............................................................. 88
A. Procedures .................................................................. 88
B. Recipient Appeals of HMO Formal Grievance Decisions/Formal
Grievance Process. .......................................................... 90
C. Notifications of Denial, Termination, Suspension, or Reduction of
Benefits to Enrollees ....................................................... 91
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D. Notifications of Denial of New Benefits to Enrollees .................... 93
E. Reporting of Grievances to the Department ............................... 94
ARTICLE IX ................................................................................. 94
IX. REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT ................. 94
A. Suspension of New Enrollment ............................................ 94
B. Department-Initiated Enrollment Reductions .............................. 94
C. Other Enrollment Reductions ............................................. 95
D. Withholding of Capitation Payments and Orders to Provide Services ....... 95
E. Inappropriate Payment Denials ........................................... 98
F. Sanctions ............................................................... 99
G. Sanctions and Remedial Actions........................................... 99
ARTICLE X .................................................................................. 99
X. TERMINATION AND MODIFICATION OF CONTRACT......................................... 99
A. Mutual Consent .......................................................... 99
B. Unilateral Termination................................................... 99
C. Obligations of Contracting Parties ...................................... 100
D. Where this Contract is terminated for any reason......................... 101
E. Where this Contract is terminated on any basis not given
including non-renewal of the contract for a given contract period ....... 101
F. Modification............................................................. 102
ARTICLE XI ................................................................................. 102
XI. INTERPRETATION OF CONTRACT LANGUAGE............................................. 102
A. Interpretations ......................................................... 102
ARTICLE XII ................................................................................ 102
XII. CONFIDENTIALITY OF RECORDS .................................................... 102
ARTICLE XIII ............................................................................... 103
XIII. DOCUMENTS CONSTITUTING CONTRACT............................................... 103
A. Current Documents........................................................ 103
B. Future Documents ........................................................ 104
ARTICLE XIV ................................................................................ 105
XIV. MISCELLANEOUS ................................................................. 105
A. Indemnification ......................................................... 105
B. Independent Capacity of Contractor ...................................... 105
C. Omissions ............................................................... 105
D. Choice of Law ........................................................... 105
E. Waiver................................................................... 105
F. Severability ............................................................ 106
G. Force Majeure............................................................ 106
H. Headings ................................................................ 106
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I. Assignability............................................................. 106
J. Right to Publish.......................................................... 106
ARTICLE XV .................................................................................. 107
XV. HMO SPECIFIC CONTRACT TERMS...................................................... 107
A. Initial Contract Period .................................................. 107
B. Renewals.................................................................. 107
C. Specific Terms of the Contract ........................................... 107
SUBCONTRACT FOR CHIROPRACTIC SERVICES ............................................... 108
ADDENDUM I .................................................................................. 109
SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING.......................................... 109
ADDENDUM II ................................................................................. 118
POLICY GUIDELINES FOR MENTAL HEALTH/SUBSTANCE ABUSE AND
COMMUNITY HUMAN SERVICE PROGRAMS..................................................... 118
ADDENDUM III (DELETED)
RISK-SHARING FOR INPATIENT HOSPITAL SERVICES
ADDENDUM IV ................................................................................. 126
CONTRACT SPECIFIED REPORTING REQUIREMENTS............................................ 126
PART A. REPORTS AND DUE DATES........................................................ 126
PART B. WISCONSIN MEDICAID/BADGERCARE HMO SUMMARY AND
ENCOUNTER DATA SET .......................................................... 130
PART C. PROVIDER LIST ON TAPE ....................................................... 131
PART D. AIDS COST SUMMARY / VENTILATOR COST SUMMARY.................................. 133
ADDENDUM V .................................................................................. 135
STANDARD ENROLLEE HANDBOOK LANGUAGE ................................................. 135
ADDENDUM VI ................................................................................. 147
MEDICAID/BADGERCARE HMO REPORT ON COORDINATION
OF BENEFITS.......................................................................... 147
ADDENDUM VII ................................................................................ 149
ACTUARIAL BASIS...................................................................... 149
ADDENDUM VIII................................................................................ 150
COMPLIANCE AGREEMENT - AFFIRMATIVE ACTION/CIVIL RIGHTS............................... 150
ADDENDUM IX ................................................................................. 153
MODEL MEMORANDUM OF UNDERSTANDING BETWEEN
HEALTH MAINTENANCE ORGANIZATION AND PRENATAL CARE
COORDINATION AGENCY ................................................................. 153
</Table>
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ADDENDUM X ......................................................................................... 154
MEMORANDUM OF UNDERSTANDING BETWEEN MILWAUKEE
COUNTY HMOS AND BUREAU OF MILWAUKEE CHILD WELFARE .......................................... 154
ADDENDUM XI ........................................................................................ 157
HEALTHCHECK WORKSHEET ...................................................................... 157
HMO RATE REGIONS AND ESTABLISHED COUNTIES .................................................. 158
Region 1: Duluth/Superior................................................................... 158
Region 2: Wausau/Rhinelander ............................................................... 158
Region 3: Green Bay......................................................................... 158
Region 4: Twin Cities ...................................................................... 158
Region 5: Marshfield/Stevens Point ......................................................... 158
Region 6: Appleton/Oshkosh ................................................................. 158
Region 7: LaCrosse ......................................................................... 158
Region 8: Madison/South Central............................................................. 158
Region 9: Southeast Wisconsin............................................................... 158
Established Counties ....................................................................... 158
ADDENDUM XII ....................................................................................... 159
COMMON CARRIER TRANSPORTATION MEMORANDUM OF
UNDERSTANDING BETWEEN MILWAUKEE COUNTY MEDICAID/
BADGERCARE HMOS AND MILWAUKEE COUNTY DEPARTMENT
OF HUMAN SERVICES .......................................................................... 159
ADDENDUM XIII....................................................................................... 161
MODEL MEMORANDUM OF UNDERSTANDING BETWEEN .................................................. 161
HEALTH MAINTENANCE ORGANIZATION AND SCHOOL DISTRICT
OR CESA MEDICAID-CERTIFIED FOR THE SCHOOL BASED SERVICES
BENEFIT .................................................................................... 161
ADDENDUM XIV ....................................................................................... 162
GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS,
TARGETED CASE MANAGEMENT (TCM) AGENCIES, AND CHILD
WELFARE AGENCIES............................................................................ 162
ADDENDUM XV ........................................................................................ 164
PERFORMANCE IMPROVEMENT PROJECT OUTLINE..................................................... 164
ADDENDUM XVI ....................................................................................... 166
TARGETED PERFORMANCE IMPROVEMENT MEASURES DATA SET.......................................... 166
ADDENDUM XVII....................................................................................... 167
MEDICAID/BADGERCARE HMO NEWBORN REPORT ..................................................... 167
ADDENDUM XVIII (DELETED)
RECOMMENDED CHILDHOOD IMMUNIZATION SCHEDULE
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ADDENDUM XIX
REPORTING REQUIREMENTS FOR NEONATAL INTENSIVE CARE UNIT RISK-SHARING ....................... 170
ADDENDUM XX (DELETED)
SPECIFIC TERMS OF THE MEDICAID/BADGERCARE HMO CONTRACT
ADDENDUM XXI-A...................................................................................... 173
FORMAL GRIEVANCE EXPERIENCE SUMMARY REPORT ................................................. 173
ADDENDUM XXI-B ..................................................................................... 174
HMO REPORTING FORM FOR INFORMAL GRIEVANCES ................................................. 174
ADDENDUM XXII....................................................................................... 175
GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN
MEDICAID HMOS AND COUNTY BIRTH TO THREE (B-3) AGENCIES...................................... 175
ADDENDUM XXIII...................................................................................... 181
WISCONSIN MEDICAID HMO REPORT ON AVERAGE BIRTH COSTS BY COUNTY ............................. 181
ADDENDUM XXIV....................................................................................... 184
LOCAL HEALTH DEPARTMENTS AND COMMUNITY-BASED HEALTH ORGANIZATIONS - A RESOURCE FOR HMOs .... 184
ADDENDUM XXV ....................................................................................... 187
GENERAL INFORMATION ABOUT THE WIC PROGRAM, SAMPLE
HMO-TO-WIC REFERRAL FORM, AND STATEWIDE LIST OF WIC AGENCIES................................ 187
ADDENDUM XXVII...................................................................................... 206
STATEWIDE LIST OF LOCAL WIC AGENCIES ....................................................... 206
ADDENDUM XXVII ..................................................................................... 214
STATEWIDE LIST OF LOCAL WIC AGENCIES........................................................ 214
</Table>
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CONTRACT FOR SERVICES
Between
Department of Health and Family Services
and
HMO
The Wisconsin Department of Health and Family Services and HMO, an insurer with
a certificate of authority to do business in Wisconsin, and an organization
which makes available to enrolled participants, in consideration of periodic
fixed payments, comprehensive health care services provided by providers
selected by the organization and who are employees or partners of the
organization or who have entered into a referral or contractual arrangement with
the organization, for the purpose of providing and paying for
Medicaid/BadgerCare contract services to recipients enrolled in the HMO under
the State of Wisconsin Medicaid Plan approved by the Secretary of the United
States Department of Health and Human Services pursuant to the provisions of the
Social Security Act and for the further specific purpose of promoting
coordination and continuity of preventive health services and other medical care
including prenatal care, emergency care, and HealthCheck services, do herewith
agree:
ARTICLE I
I. DEFINITIONS
The term "ABUSE" means provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in an unnecessary cost
to Medicaid/BadgerCare, in reimbursement for services that are not
medically necessary, or in services that fail to meet professionally
recognized standards for health. Abuse also includes client or member
practices that result in unnecessary costs to Medicaid.
The term "ACTION" means the denial or limited authorization of a requested
service, including the type or level of service; the reduction, suspension
or termination of a previously authorized service; the denial, in whole or
in part, of payment for a service.
The term "APPEAL" means a request for review of an action.
The term "BADGERCARE" means part of the Wisconsin Medical Assistance
Program operated by the Wisconsin Department of Health and Family Services
under Title XIX and Title XXI of the Federal Social Security Act, s.
49.655, Wis. Stats., and related State and Federal rules and regulations.
This term will be used throughout this contract.
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The term "CESA" means Cooperative Educational Service Agencies, which are
cooperatives that include multiple school districts that work together for
purchasing and other coordinated functions. There are twelve (12) CESAs in
Wisconsin.
The term "CHILDREN WITH SPECIAL HEALTH CARE NEEDS" means children who have
or are at increased risk for chronic physical, developmental, behavioral,
or emotional conditions and who also require health and related services of
a type or amount beyond that required by children generally and who are
enrolled in a Children with Special Health Care Needs program operated by a
Local Health Department or a local Title V funded Maternal and Child Health
Program.
The term "COMMUNITY BASED HEALTH ORGANIZATIONS" means non-profit agencies
providing community based health services. These organizations provide
important health care services such as HealthCheck screenings, nutritional
support, and family planning, targeting such services to high-risk
populations.
The term "CONTINUING CARE PROVIDER" means (as stated in 42 CFR 441.60(a)) a
provider who has an agreement with the Medicaid agency to provide:
A. any reports that the Department may reasonably require, and
B. at least the following services to eligible HealthCheck recipients
formally enrolled with the provider as enumerated in 42 CFR
441.60(a)(1)-(5):
1. screening, diagnosis, treatment, and referrals for follow-up
services,
2. maintenance of the recipient's consolidated health history,
including information received from other providers,
3. physician's services as needed by the recipient for acute,
episodic or chronic illnesses or conditions,
4. provision or referral for dental services, and
5. transportation and scheduling assistance.
The term "CONTRACT" means the agreement executed between the HMO and the
Department to accomplish the duties and functions, in accordance with the
rules and arrangements specified in this document.
The term "CONTRACT SERVICES" means those services that the HMO is required
to provide under this contract.
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The term "CONTRACTOR" means the HMO(s) awarded the contract resulting from
the HMO Certification process to provide capitated managed care in
accordance with the contract.
The term "CULTURAL COMPETENCY" means a set of congruent behaviors,
attitudes, practices and policies that are formed within an agency, and
among professionals that enable the system, agency, and professionals to
work respectfully, effectively and responsibly in diverse situations.
Essential elements of cultural competence include understanding diversity
issues at work, understanding the dynamic of difference, institutionalizing
cultural knowledge, and adapting to and encouraging organizational
diversity.
The term "DEPARTMENT" means the Wisconsin Department of Health and Family
Services.
The term "EMERGENCY MEDICAL CONDITION" means---
A. A medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result
in:
1. placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn child) in
serious jeopardy,
2. serious impairment of bodily functions, or
3. serious dysfunction of any bodily organ or part; or
B. With respect to a pregnant woman who is in active labor---
1. where there is inadequate time to effect a safe transfer to
another hospital before delivery; or
2. where transfer may pose a threat to the health or safety of the
woman or the unborn child.
C. A psychiatric emergency involving a significant risk of serious harm
to oneself or others.
D. A substance abuse emergency exists if there is significant risk of
serious harm to an enrollee or others, or there is likelihood of
return to substance abuse without immediate treatment.
E. Emergency dental care is defined as an immediate service needed to
relieve the patient from pain, an acute infection, swelling, trismus,
fever, or trauma. In all emergency situations, the HMO must document
in the recipient's dental records the nature of the emergency.
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The term "ENCOUNTER" shall include the following:
1. A service or item provided to a patient through the health care
system. Examples include but are not limited to:
a. Office visits
b. Surgical procedures
c. Radiology, including professional and/or technical components
d. Prescribed drugs
e. Durable medical equipment
f. Emergency transportation to a hospital
g. Institutional stays (inpatient hospital, rehabilitation stays)
h. HealthCheck screens
2. A service or item not directly provided by the HMO, but for which the
HMO is financially responsible. An example would include an emergency
service provided by an out-of-network provider or facility.
3. A service or item not directly provided by the HMO, and one for which
no claim is submitted but for which the HMO may supplement its
encounter data set. Such services might include HealthCheck screens
for which no claims have been received and if no claim is received,
the HMO's medical chart. Examples of services or items the HMO may
include are:
a. HealthCheck services
b. Lead Screening and Testing
c. Immunizations
The terms "SERVICES" or "ITEMS" as used above include those services and
items not covered by the Wisconsin Medicaid Program, but which the HMO
chooses to provide as part of its Medicaid managed care product. Examples
include educational services, certain over-the-counter drugs, and delivered
meals.
The term "ENCOUNTER RECORD" means an electronically formatted list of
encounter data elements per encounter as specified in the Wisconsin
Medicaid 2002-2003 HMO Encounter Data User Manual. An encounter record may
be prepared from a single detail line from a claim such as the HCFA 1500 or
UB-92.
The terms "ENROLLEE" and "PARTICIPANT" mean a Medicaid/BadgerCare recipient
who has been certified by the State as eligible to enroll under this
Contract, and whose name appears on the HMO Enrollment Reports which the
Department will transmit to the HMO every month in accordance with an
established notification schedule. Children who are reported to the
certifying agency within 100 days of birth shall be enrolled in the HMO
their mother is enrolled in from their date of birth if the mother was an
enrollee on the date
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of birth. Children who are reported to the certifying agency after the
100th day but before their first birthday may be eligible for
Medicaid/BadgerCare on a fee-for-service (FFS) basis.
The term "ENROLLMENT AREA" means the geographic area within which
recipients must reside in order to enroll, on a mandatory basis, in the HMO
under this Contract.
The term "EXPERIMENTAL SURGERY AND PROCEDURES" means experimental services
that meet the definition of HFS 107.035(1) and (2) Wis. Adm. Code. as
determined by the Department.
The term "FORMALLY ENROLLED WITH A CONTINUING CARE PROVIDER" (as cited in
42 CFR 441.60(d)) means that a recipient (or recipient's guardian) agrees
to use one continuing care provider as the regular source of a described
set of services for a stated period of time.
The term "FRAUD" means an intentional deception or misrepresentation made
by a person or entity with the knowledge that the deception could result in
some unauthorized benefit to him/herself, itself or to some other person or
entity. It includes any act that constitutes fraud under applicable Federal
or State law.
The term "GRIEVANCE" means an expression of dissatisfaction about any
matter other than an action. The term is also used to refer to the overall
system that includes grievances and appeals handled by the HMO. 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.
The term "HMO" means the health maintenance organization or its parent
corporation with a certificate of authority to do business in Wisconsin,
that is obligated under this Contract.
The term "HMO ENCOUNTER TECHNICAL WORKGROUP" means a workgroup composed of
HMO technical staff, contract administrators, claims processing,
eligibility, and/or other HMO staff, as necessary; Department staff from
the Division of Health Care Financing; and staff from the Department's
fiscal agent contractor.
The term "LOCAL HEALTH DEPARTMENT" (LHD) means an agency of local
government established according to Chapter 251, Wis. Stats. Local health
departments have statutory obligation to perform certain core functions,
which include assessment, assurance, and policy development for the purpose
of protecting and promoting the health of their communities.
The term "MEDICAID" means the Wisconsin Medical Assistance Program operated
by the Wisconsin Department of Health and Family Services under Title XIX
of the Federal Social Security Act, Ch. 49, Wis. Stats., and related State
and Federal rules and
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regulations. This will be the term used consistently in this Contract.
However, other expressions or words equivalent to Medicaid are "MA,"
"Medical Assistance," and "WMAP."
The term "MEDICAL STATUS CODE" means the two digit (alphanumeric) code that
the Department uses in its computer system to define the type of Medicaid
eligibility a recipient has: the code identifies the basis of eligibility,
whether cash assistance is being provided, and other aspects of Medicaid.
The medical status code is listed on the HMO enrollment reports. Please
refer to Article IV. A. for a list of HMO eligible medical status codes.
The term "MEDICALLY NECESSARY" means a medical service that meets the
definition of HFS 101.03(96m) Wis. Adm. Code.
The term "NEWBORN" means an enrollee who is less than 100 days old.
The term "POST STABILIZATION SERVICES" means medically necessary
non-emergency services furnished to an enrollee after he or she is
stabilized following an emergency medical condition.
The term "PROVIDER" means a person who has been certified by the Department
to provide health care services to recipients and to be reimbursed by
Medicaid for those services.
The term "PUBLIC INSTITUTION" means an institution that is the
responsibility of a governmental unit or over which a governmental unit
exercises administrative control as defined by federal regulations
including but not limited to prisons and jails.
The term "RECIPIENT" means any individual entitled to benefits under Title
XIX and XXI of the Social Security Act, and under the Medicaid State Plan
as defined in Chapter 49, Wis. Stats.
The term "RISK" means the possibility of monetary loss or gain by the HMO
resulting from service costs exceeding or being less than payments made to
it by the Department.
The term "SERVICE AREA" means an area of the State in which the HMO has
agreed to provide Medicaid services to Medicaid enrollees. The Department
will monitor enrollment levels of HMOs by the service areas of the HMO, and
HMO will indicate whether they will provide dental or chiropractic services
by service area. A service area may be as small as a zip code, may be a
county, a number of counties, or the entire State.
The term "STATE" means the State of Wisconsin.
The term "SUBCONTRACT" means any written agreement between the HMO and
another party to fulfill the requirements of this Contract. However, such
term does not include
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insurance purchased by the HMO to limit its loss with respect to an
individual enrollee, provided the HMO assumes some portion of the
underwriting risk for providing health care services to that enrollee.
The term "WISCONSIN TRIBAL HEALTH DIRECTORS ASSOCIATION (WTHDA)" means the
coalition of all Wisconsin American Indian Tribal Health Departments.
Terms that are not defined above shall have their primary meaning
identified in the Wisconsin Administrative Code, Chs. HFS 101-108.
ARTICLE II
II. DELEGATIONS OF AUTHORITY
The HMO shall oversee and remain accountable for any functions and
responsibilities that it delegates to any subcontractor. For all major or
minor delegation of function or authority:
A. There shall be a written agreement that specifies the delegated
activities and reporting responsibilities of the subcontractor and
provides for revocation of the delegation or imposition of other
sanctions if the subcontractor's performance is inadequate.
B. Before any delegation, the HMO shall evaluate the prospective
subcontractor's ability to perform the activities to be delegated.
C. The HMO shall monitor the subcontractor's performance on an ongoing
basis and subject the subcontractor to formal review at least once a
year.
D. If the HMO identifies deficiencies or areas for improvement, the HMO
and the subcontractor shall take corrective action.
E. If the HMO delegates selection of providers to another entity, the HMO
retains the right to approve, suspend, or terminate any provider
selected by that entity.
HMO Contract for January 1, 2002 - December 31, 2003
-7-
ARTICLE III
III. FUNCTIONS AND DUTIES OF THE HMO
In consideration of the functions and duties of the Department contained in
this Contract the HMO shall:
A. Statutory Requirement Retain at all times during the period of this
Contract a valid Certificate of Authority issued by the State of
Wisconsin Office of the Commissioner of Insurance.
B. Provision of Contract Services
1. Promptly provide or arrange for the provision of all services
required under Section 49.46(2), Wis. Stats., and HFS 107 Wis.
Adm. Code; as further clarified in all Wisconsin Medicaid Program
Provider Handbooks and Bulletins, and HMO Contract Interpretation
Bulletins (CIBs) and as otherwise specified in this Contract
except:
a. County Transportation by common carrier or private motor
vehicle (except as required in Article III. B (10).
HealthCheck). HMOs are required to arrange for
transportation for HealthCheck visits. When authorized by
the Department, the HMO may provide non-emergency
transportation by common carrier or private motor vehicle
for HealthCheck visits and be reimbursed by the County.
HMOs may negotiate arrangements with local county
Departments of Health and Social Services for common carrier
or private vehicle transportation for HMO services in
general and not just for HealthCheck visits. The Department
will make a list of county transportation contacts available
to HMOs upon request.
The Department will facilitate the development of such
arrangements between the HMO and the county. HMOs interested
in developing a transportation arrangement with one or more
counties and interested in Department assistance should
contact the following office either by mail or phone:
Bureau of Managed Health Care Programs
P.O. Box 309
Madison, WI 53701- 0309
Phone Number: (608) 266-7894 or 267-2170
Fax Number: (608) 261-7792
HMO Contract for January 1, 2002 - December 31, 2003
-8-
b. Milwaukee County HMOs will provide common carrier
transportation to enrollees. Transportation services will be
limited to:
o Transportation of Medicaid/BadgerCare HMO members only.
o Transportation of Medicaid/BadgerCare HMO members to
and from Medicaid covered services.
The HMO is responsible for arranging for the common carrier
transportation and providing monthly costs incurred to
Milwaukee County Department of Human Services (MCDHS), for
common carrier transportation arranged. HMO agrees to submit
costs to the DHS within 15 days following the end of each
month to:
Milwaukee County DHS
Financial Assistant, Division Administrator
1220 W. Vliet Street
Milwaukee, WI 53206
The DHS is responsible for reimbursing the HMO for mileage
and an administration fee. The State Department of Health
and Family Services reserves the right to adjust these
rates.
The HMO shall maintain adequate records for each enrollee
which include all pertinent and sufficient information
relating to common carrier transportation, and make this
information readily available to the Department of Health
and Family Services (DHFS). HMO agrees to report suspected
abuse by enrollees or providers to the DHFS.
c. Dental, unless the HMO is certified to provide dental
services.
d. Prenatal Care Coordination.
e. Targeted Case Management.
f. School-Based Services.
g. Milwaukee Childcare Coordination.
h. Tuberculosis-related Services.
HMO Contract for January 1, 2002 - December 31, 2003
-9-
2. Cover chiropractic services, or in the alternative, enter into a
subcontract for chiropractic services with the State as provided
in Article XV. State law mandates coverage.
3. Remain liable for provision of care for that period for which
capitation payment has been made in cases where medical status
code changes occur subsequent to capitation payment.
4. Be liable, where emergencies and HMO referrals to out-of-area or
non-affiliated providers occur, for payment only to the extent
that Medicaid pays, including Medicare deductibles, or would pay,
its FFS providers for services to the AFDC/BadgerCare population.
For inpatient hospital services, the Department will provide each
HMO per diem rates based on the Medicaid FFS equivalent. This
condition does not apply to: (1) cases where prior payment
arrangements were established; and (2) specific subcontract
agreements.
5. Changes to Medicaid covered services mandated by Federal or State
law subsequent to the signing of this Contract will not affect
the contract services for the term of this Contract, unless (1)
agreed to by mutual consent, or (2) unless the change is
necessary to continue to receive federal funds or due to action
of a court of law.
The Department may incorporate any change in covered services
mandated by Federal or State law into the Contract effective the
date the law goes into effect, if it adjusts the capitation rate
accordingly. The Department will give the HMO 30 days notice of
any such change that reflects service increases, and the HMO may
elect to accept or rejects the service increases for the
remainder of that contract year; the Department will give the HMO
60 days notice of any such change that reflects service
decreases, with a right of the HMO to dispute the amount of the
decrease within that 60 days. The HMO has the right to accept or
reject service decreases for the remainder of the Contract year.
The date of implementation of the change in coverage will
coincide with the effective date of the increased or decreased
funding. This section does not limit the Department's ability to
modify the Medicaid/HMO Contract for changes in the State Budget.
6. Be responsible for payment of all contract services provided to
all Medicaid/BadgerCare recipients listed as ADDs or CONTINUEs on
either the Initial or Final Enrollment Reports (see Article IV. B
and D) generated for the month of coverage. The HMO is also
responsible for payment of services to all newborns meeting the
criteria described in Article V.G, "Capitation Payments for
Newborns." Additionally, the HMO agrees to provide, or authorize
provision of, services to all Medicaid enrollees with valid
Forward cards indicating HMO enrollment without regard to
disputes
HMO Contract for January 1, 2002 - December 31, 2003
-10-
about enrollment status and without regard to any other
identification requirements. Any discrepancies between the cards
and the reports will be reported to the Department for
resolution. The HMO shall continue to provide and authorize
provision of all contract services until the discrepancy is
resolved. This includes recipients who were PENDING on the
Initial Report and held a valid Forward card indicating HMO
enrollment, but did not appear as an CONTINUE on the Final
Report.
7. Transplants: As a general principle, Wisconsin Medicaid does not
pay for items that it determines to be experimental in nature.
a. Procedures that are covered by Medicaid that are no longer
considered experimental are cornea transplants and kidney
transplants. HMOs shall cover these services.
b. There are other procedures that are approved only at
particular institutions, including bone marrow transplants,
liver, heart, heart-lung, lung, pancreas-kidney, and
pancreas transplants. HMOs need not cover the
transplantation because there are no funds in the FFS
experience data (and thus in the HMO capitation rates) for
these services. This relieves the HMO from paying for
expensive follow-up care, as when there are permanent,
expensive requirements for drugs or equipment.
1) The person to get the transplant will be permanently
exempted from HMO enrollment the first of the month in
which surgery is performed.
2) In the case of autologous bone marrow transplants, the
person will be permanently exempted from HMO enrollment
the date the bone marrow was extracted.
c. Enrollees who have had one or more transplant surgeries
referenced in 7 b, prior to enrollment in an HMO will be
permanently exempted the first of the month of their HMO
enrollment.
8. Dental Care: HMOs that agree to accept the dental capitation rate
for the purpose of covering all Medicaid dental services must:
a. Cover all dental services as required under HFS 107.07,
provider handbooks, bulletins, and periodic updates.
HMO Contract for January 1, 2002 - December 31, 2003
-11-
b. Provide diagnostic, preventive, and medically necessary
follow-up care to treat the dental disease, illness, injury
or disability of enrollees while they are enrolled in an
HMO, except as required in sub. (c).
c. Complete orthodontic or prosthodontic treatment begun while
an enrollee is enrolled in an HMO if the enrollee becomes
ineligible or disenrolls from the HMO, no matter how long
the treatment takes. Medicaid/BadgerCare covers such
continuing services for FFS recipients and the costs of
continuing treatment are included in the FFS payment data on
which the HMO capitation rates are based. An HMO will not be
required to complete orthodontic or prosthodontic treatment
on an enrollee who has begun treatment as a FFS recipient
and who subsequently has been enrolled in an HMO.
[Refer to the chart following this page of the Contract for
the specific details of completion of orthodontic or
prosthodontic treatment in these situations.]
d. HMOs who cover dental will be required to do quarterly
progress reports to the Department documenting the outcomes
or current status of activities intended to increase
utilization. These reports are due fifteen (15) days after
the end of each calendar quarter.
HMO Contract for January 1, 2002 - December 31, 2003
-12-
RESPONSIBILITY FOR PAYMENT OF ORTHODONTIC AND PROSTHODONTIC TREATMENT WHEN
THERE IS AN ENROLLMENT STATUS CHANGE DURING THE COURSE OF TREATMENT
<Table>
<Caption>
WHO PAYS FOR COMPLETION OF
ORTHODONTIC AND PROSTHODONTIC
TREATMENT* WHERE THERE IS AN
ENROLLMENT STATUS CHANGE
-----------------------------------
FIRST HMO SECOND HMO FFS
--------- ---------- ---
Person converts from one status to another:
1. FFS to an HMO covering dental. N/A X
2a. HMO covering dental to an HMO not covering dental, and person's X
residence remains within 50 miles of the person's residence when in
the first HMO.
2b. HMO covering dental to an HMO not covering dental, and person's X
residence changes to greater than 50 miles of the person's residence
when in the first HMO.
3a. HMO covering dental to the same or another HMO covering dental and X
the person's residence remains within 50 miles of the residence when
in the first HMO.
3b. HMO covering dental to the same or another HMO covering dental and X
the person's residence changes to greater than 50 miles of the
residence when in the first HMO.
4. HMO with dental coverage to FFS because:
a. Person moves out of the HMO service area but the person's X
residence remains within 50 miles of the residence when in the
HMO.
b. Person moves out of the HMO service area, but the person's N/A X
residence changes to greater than 50 miles of the residence when
in the HMO.
c. Person exempted from HMO enrollment. N/A X
d. Person's medical status changes to an ineligible HMO code and the X N/A
person's residence remains within 50 miles of the residence when
in that HMO.
e. Person's medical status changes to an ineligible HMO code and the N/A X
person's residence changes to greater than 50 miles of the
residence when in that HMO.
5a. HMO with dental to ineligible for Medicaid/BC and the X N/A
person's residence remains within 50 miles of the
residence when in that HMO.
5b. HMO with dental to ineligible for Medicaid/BC and the person's N/A X
residence changes to greater than 50 miles of the residence when in
that HMO.
6. HMO without dental to ineligible for Medicaid/BC. N/A X
</Table>
- ----------
* Orthodontic treatment is only covered by Medicaid/BadgerCare for children
under 21 as a result of a HealthCheck referral (HFS 107.07(3)).
HMO Contract for January 1, 2002 - December 31, 2003
-13-
9. The following provision refers to payments made by the HMO. HMO
covered primary care and emergency care services provided to a
recipient living in a Health Professional Shortage Area (HPSA) or
by a provider practicing in a HPSA must be paid at an enhanced
rate of 20 percent above the rate the HMO would otherwise pay for
those services. Primary care providers are defined as nurse
practitioners, nurse midwives, physician assistants, and
physicians who are Medicaid-certified with specialties of general
practice, OB-GYN, family practice, internal medicine, or
pediatrics. Specified HMO-covered obstetric or gynecological
services (see the Wisconsin Medicaid and BadgerCare Physicians
Services Handbook) provided to a recipient living in a HPSA or by
a provider practicing in a HPSA must be paid at an enhanced rate
of 25 percent above the rate the HMO would otherwise pay
providers in HPSAs for those services.
However, this does not require the HMO to pay more than the
enhanced Medicaid FFS rate or the actual amount billed for these
services. The HMO shall ensure that the money for HPSA payments
are paid to the physicians and are not used to supplant funds
that previously were used for payment to the physicians. The
Department will supply a list of the services affected by this
provision, the maximum FFS rates, and HPSAs. The HMO must develop
written policies and procedures to ensure compliance with this
provision. These policies must be available for review by the
Department, upon request.
10. HealthCheck
a. HMO Responsibilities:
Provide services as a continuing care provider as defined in
Article I, and according to policies and procedures in Part
D of the Wisconsin Medicaid Provider Handbook related to
covered services.
Provide HealthCheck screens upon request. For enrollees over
1 year of age, if an enrollee, parent or guardian of an
enrollee requests a HealthCheck screen, HMO shall provide
such screen within 60 days, if a screen is due according to
the periodicity schedule. If the screen is not due within 60
days, then the HMO shall schedule the appointment in
accordance with the periodicity schedule. For enrollees up
to one (1) year of age, if a parent or guardian of an
enrollee's requests a HealthCheck screen, HMO shall provide
such screen within 30 days, if a screen is due according to
the periodicity schedule. If the screen is not due
HMO Contract for January 1, 2002 - December 31, 2003
-14-
within 30 days, then the HMO shall schedule the appointment
in accordance with the periodicity schedule.
Provide HealthCheck screens at a rate equal to or greater
than 80 percent of the expected number of screens. The rate
of HealthCheck screens will be determined by the calculation
in the HealthCheck Worksheet in Addendum XI. The HMO may
complete the worksheet on its own, periodically, as a means
to monitor its HealthCheck screening performance.
HealthCheck data provided by the HMO must agree with its
medical record documentation. For the purpose of the
HealthCheck recoupment process the Department will not
include any additional HealthCheck encounter records that
are received after January 16, 2004 and 2005 for the year
under consideration. (Please note: This is a thirteen-month
period of time from the end of the years under
consideration. (For example, for dates of service in 2002
the cut-off period will be January 16, 2004).
b. Department Responsibilities:
If the HMO provides fewer screens in the contract year than
80 percent, the Department will:
1) recoup the funds provided to the HMO for the provision
of the remaining screens. The following formula will be
used:
(0.80 x A - B) x (C - D), where
A = Expected number of screens (Line 6 of HealthCheck
Worksheet)
B = Number of screens paid in the contract year as
reported in the HMO's Encounter Data Set as of
January 16, 2004 and January 16, 2005. (This is a
total of a thirteen-month period following the
year under consideration.
C = *FFS maximum allowable fee (Line 11 of the
HealthCheck Worksheet). The FFS maximum allowable
fee is the average maximum fee for the year.
For example, if the maximum allowable fee for
HealthCheck is $50 from January through June, and
$52 from July through December, then the average
maximum allowable fee for the year is $51.
D = HMO discount, if applicable.
HMO Contract for January 1, 2002 - December 31, 2003
-15-
2) determine the amount of the HMO's HealthCheck
recoupment, by Rate Region, excluding Dane, Eau Claire,
Kenosha, Milwaukee and Waukesha counties, which will be
determined separately. Rate Regions are defined in
Addendum XI.
3) determine the actual number of screens completed, for
the recoupment calculation (Line 8 of the Worksheet),
by using the number of screens reported in the HMO's
Encounter Database for calendar years 2002 and 2003 by
Rate Region, except for Dane, Eau Claire, Kenosha,
Milwaukee and Waukesha counties which will be
determined separately. The Department will identify and
retrieve the HealthCheck screening data from the
Encounter Database.
When assigning HealthCheck screens to an age category,
the Department will use the member's age on the first
day of the month in which the screening occurred. If
a newborn enrollee is screened in the month of their
birth, the newborn's screen will be assigned to the
<1 age category.
4) determine the number of eligible months and
unduplicated enrollees (Lines 1 and 2 of the Worksheet)
per HMO per year, for the HealthCheck recoupment
calculation, by using the Medicaid Management
Information System Recipient Eligibility File according
to specifications contained in Article III B 10 b.
When calculating member months for each age category,
the Department will use the member's age on the first
day of the month except for newborns. Newborns
enrolled in an HMO in the month of their birth will be
counted as eligible from their date of birth.
5) inform the HMO in writing of its preliminary analysis
of the HealthCheck data and allow the HMO 30 business
days to review and respond to the calculations. If the
HMO responds within 30 business days, the Department
will review the HMO's concerns and notify the HMO of
its final decision. If an HMO does not respond within
30 business days, the Department will send a "Notice of
Intent to Recover" letter 40 days after the initial
letter.
HMO Contract for January 1, 2002 - December 31, 2003
-16-
11. The HMO must adequately fund physician services
provided to pregnant women and children under age 19,
so that they are paid at rates sufficient to ensure
that provider participation and services are as
available to the Medicaid/BadgerCare population as to
the general population in the HMO service area(s).
12. The actual provision of any service is subject to the
professional judgment of the HMO providers as to the
medical necessity of the service, except that the HMO
must provide assessment and evaluation services ordered
by a court. Decisions to provide or not to provide or
authorize medical services shall be based solely on
medical necessity and appropriateness as defined in HFS
101.03(96m). Disputes between HMOs and recipients about
medical necessity can be appealed through an HMO
grievance system, and ultimately to the Department for
a binding determination; the Department's
determinations will be based on whether Medicaid would
have covered that service on a FFS basis (except for
certain experimental procedures discussed in Article
III, B. 7). Alternatively, disputes between HMOs and
enrollees about medical necessity can be appealed
directly to the Department.
HMOs are not restricted to providing Wisconsin Medicaid
covered services. Sometimes, HMOs find that other
treatment methods may be more appropriate than
Medicaid covered services, or result in better
outcomes.
None of the provisions of this contract that are
applicable to Wisconsin Medicaid covered services
apply to other services that an HMO may choose to
provide, except that abortions, hysterectomies and
sterilizations must comply with 42 CFR 441 Subpart E
and 42 CFR 441 Subpart F.
If a service provided is an alternative or replacement
to a Wisconsin Medicaid covered service, then the HMO
or HMO provider is not allowed to bill the enrollee for
the service.
13. HMO and its providers and subcontractors shall not bill
a Medicaid/ BadgerCare enrollee for medically necessary
services covered under this Contract and provided
during the enrollee's period of HMO enrollment. HMO and
its providers and subcontractors shall not bill a
Medicaid/ BadgerCare enrollee for copayments and/or
premiums for medically necessary services covered under
this Contract and provided during the enrollee's period
of HMO enrollment. Any provider who knowingly and
willfully bills a Medicaid/BadgerCare enrollee for an
MA covered service shall be guilty of a felony and upon
conviction shall be fined, imprisoned, or both, as
defined in Section 1128B.(d)(1) [42 U.S.C. 1320a-7b] of
the
HMO Contract for January 1, 2002 - December 31, 2003
-17-
Social Security Act. This provision shall continue to
be in effect even if the HMO becomes insolvent.
However, if an enrollee agrees in advance in writing
to pay for a non-Medicaid/ BadgerCare covered service,
then the HMO, HMO provider, or HMO subcontractor may
bill the enrollee. The standard release form signed by
the enrollee at the time of services does not relieve
the HMO and its providers and subcontractors from the
prohibition against billing an enrollee in the absence
of a knowing assumption of liability for a
non-Medicaid/BadgerCare covered service. The form or
other type of acknowledgment relevant to an enrollee's
liability must specifically state the admissions,
services, or procedures that are not covered by
Medicaid/BadgerCare.
14. The HMO must operate a program to promote full
immunization of enrollees. The HMO shall be responsible
for administration of immunizations including payment
of an administration fee for vaccines provided by the
Department. For vaccines that are newly approved during
the term of the Contract and not yet part of the
Vaccine for Children program, the HMO will report usage
for reimbursement from the Department. The Department
will identify vaccines that meet these criteria to the
HMO.
The HMO, as a condition of their certification as a
Medicaid/ BadgerCare provider, shall share enrollee
immunization status with Local Health Departments and
other non-profit HealthCheck providers upon request of
those providers without the necessity of enrollee
authorization. The Department is also requiring that
Local Health Departments and other non-profit
HealthCheck providers share that equivalent
information with HMOs upon request. This provision is
made to ensure proper coordination of immunization
services and to prevent duplication of services.
15. Services required under Section 49.46(2), Wis. Stats.,
and HFS 107 Wis. Adm. Code, include (without limitation
due to enumeration) private duty nursing services,
nurse-midwife services, and independent nurse
practitioner services; physician services, including
primary care services, are not only services performed
by physicians, but services under the direct,
on-premises supervision of a physician performed by
other providers such as physician assistants and nurses
of various levels of certification.
16. Provision of Family Planning Services and
Confidentiality of Family Planning Information: Give
enrollees the opportunity to have their own primary
physician for the provision of family planning services
whether that provider is in-plan or out-of-plan. If the
enrollee chooses an out-of-plan provider, those family
planning services will be paid FFS. The physician
HMO Contract for January 1, 2002 - December 31, 2003
-18-
does not replace the primary care provider chosen by or
assigned to the enrollee. All such information and
medical records relating to family planning shall be
kept confidential including those of a minor.
C. Time Limit for Decision on Certain Referrals
Pay for covered services provided by a non-HMO provider to a
disabled participant less than three (3) years of age, or to any
participant pursuant to a court order (for treatment), effective
with the receipt of a written request for referral from the
non-HMO provider, and extending until the HMO issues a written
denial of referral. This requirement does not apply if the HMO
issues a written denial of referral within seven (7) days of
receiving the request for referral.
D. Emergency Care
Promptly provide or pay for needed contract services for
emergency medical conditions and post-stabilization services as
defined in Article I. Nothing in this requirement mandates HMOs
to reimburse for post-stabilization services that were not
authorized by the HMO.
1. Payments for qualifying emergencies (including services at
hospitals or urgent care centers within the HMO service
area(s)) are to be based on the medical signs and symptoms
of the condition upon initial presentation. The
retrospective findings of a medical work-up may legitimately
be the basis for determining how much additional care may be
authorized, but not for payment for dealing with the initial
emergency.
2. All HMOs, regardless of whether dental care is included in
their contract, are responsible for paying all ancillary
charges relating to dental emergencies with the only
exception being the dentist's or oral surgeon's direct and
office charges. These ancillary charges would include, but
are not limited to, physician, anesthesia, pharmacy and
emergency room in a hospital or freestanding ambulatory care
setting.
Ambulance Services
1. HMOs may require submission of a trip ticket with ambulance
claims before paying the claim. Claims submitted without a
trip ticket need only be paid at the service charge rate.
2. HMOs will pay a service fee for ambulance response to a call
in order to determine whether an emergency exists,
regardless of the HMO's determination to pay for the call.
HMO Contract for January 1, 2002 - December 31, 2003
-19-
3. HMOs will pay for emergency ambulance services based on
established Medicaid criteria for claims payment of these
services.
4. HMO will either pay or deny payment of a complete claim for
ambulance services within 45 days of receipt of the claim.
5. HMOs will respond to appeals from ambulance companies within
the time frame described in Article III. H. Failure will
constitute HMO agreement to pay the appealed claim in full.
E. 24-Hour Coverage
Provide all emergency contract services and post-stabilization
services as defined in this Contract twenty-four (24) hours each
day, seven (7) days a week, either by the HMO's own facilities or
through arrangements approved by the Department with other
providers. The HMO shall have one (1) toll-free phone number that
enrollees or individuals acting on behalf of an enrollee can call
at any time to obtain authorization for emergency transport,
emergency, or urgent care. (Authorization here refers to the
requirements defined in Addendum V, in the Standard Enrollee
Handbook Language, regarding the conditions under which an
enrollee must receive permission from the HMO prior to receiving
services from a non-HMO affiliated provider in order for the HMO
to reimburse the provider: e.g., for urgent care, for ambulance
services for non-emergency care, for extended emergency services,
and other situations.) This number must have access to
individuals with authority to authorize treatment as appropriate.
A response to such call must be provided within 30 minutes
(except that response to ambulance calls shall be within 15
minutes) or the HMO will be liable for the cost of subsequent
care related to that illness or injury incident whether treatment
is in- or out-of-plan and whether the condition is emergency,
urgent, or routine.
The HMO must be able to communicate with a caller in the language
spoken by the caller or the HMO will be liable for the cost of
subsequent care related to that illness or injury incident
whether treatment is in- or out-of-plan and whether the condition
is emergency, urgent, or routine.
These calls must be logged with time, date and any pertinent
information related to persons involved, resolution and follow-up
instructions.
The HMO shall notify the Department of any changes of this one
toll-free phone number for emergency calls within seven (7)
working days of change.
F. Thirty Day Payment Requirement
Pay at least 90% (ninety percent) of adjudicated (clean) claims
from subcontractors for covered medically necessary services
within thirty (30) days of
HMO Contract for January 1, 2002 - December 31, 2003
-20-
receipt of a clean claim , and 99% (ninety-nine percent) within
ninety (90) days and 100 percent of the claims within 180 days of
receipt, except to the extent subcontractors have agreed to later
payment. HMO agrees not to delay payment to subcontractors
pending subcontractor collection of third party liability unless
the HMO has an agreement with their subcontractor to collect
third party liability.
G. HMO Claim Retrieval System
Maintain a claim retrieval system that can on request identify
date of receipt, action taken on all provider claims (i.e., paid,
denied, other), and when action was taken. HMO shall date stamp
all provider claims upon receipt. In addition, maintain a claim
retrieval system that can identify, within the individual claim,
services provided and diagnoses of enrollees with nationally
accepted coding systems: HCPCS including level I CPT codes and
level II and level III HCPCS codes with modifiers, ICD-9-CM
diagnosis and procedure codes, and other national code sets such
as place of service, type of service, and EOB codes. Finally, the
claim retrieval system must be capable of identifying the
provider of services by the appropriate Wisconsin Medicaid
provider ID number assigned to all in-plan providers. Refer to
Article III, section AA for use of providers certified by the
Medicaid program.
H. Appeals to the Department for HMO Payment/Denial of Providers
Provide the name of the person and/or function at the HMO to whom
provider appeals should be submitted.
Provide written notification to providers of HMO payment/denial
determinations which includes:
1. A specific explanation of the payment amount or a specific
reason for the payment denial.
2. A statement regarding the provider's rights and
responsibilities in appealing to the HMO about the HMO's
initial determination by submitting a separate letter or
form:
a. clearly marked "appeal"
b. which contains the provider's name, date of service,
date of billing, date of rejection, and reason(s) claim
merits reconsideration
c. for each appeal
d. to the person and/or function at the HMO that handles
Provider Appeals within sixty (60) days of the initial
denial or partial payment.
HMO Contract for January 1, 2002 - December 31, 2003
-21-
3. A statement advising the provider of the provider's right to
appeal to the Department if the HMO fails to respond to the
appeal within forty-five (45) days or if the provider is not
satisfied with the HMO's response to the request for
reconsideration, and that all appeals to the Department must
be submitted in writing within sixty (60) days of the HMO's
final decision.
4. Accept written appeals from providers who disagree with the
HMO's payment/denial determination, if the provider submits
the dispute in writing and within sixty (60) days of the
initial payment/denial notice. The HMO has forty-five (45)
days from the date of receipt of the request for
reconsideration to respond in writing to the provider. If
the HMO fails to respond within that time frame, or if the
provider is not satisfied with the HMO's response, the
provider may seek a final determination from the Department.
5. Accept the Department's determinations regarding appeals of
disputed claims. In cases where there is a dispute about an
HMO's payment/ denial determination and the provider has
requested a reconsideration by the HMO according to the
terms described above, the Department will hear appeals and
make final determinations. These determinations may include
the override of the HMO's time limit for submission of
claims in exceptional cases. The Department will not
exercise its authority in this regard unreasonably. The
Department will accept written comments from all parties to
the dispute prior to making the decision. Appeals must be
submitted to the Department within sixty (60) days of the
date of written notification of the HMO's final decision
resulting from a request for reconsideration. The Department
has forty-five (45) days from the date of receipt of all
written comments to respond to these appeals. HMOs will pay
provider(s) within forty-five (45) days of receipt of the
Department's final determination.
I. Payments for Diagnosis of Whether an Emergency Condition Exists
Pay for appropriate, medically necessary, and reasonable
diagnostic tests utilized to determine if an emergency exists.
Payment for emergency services continue until the patient is
stabilized and can be safely discharged or transferred.
J. Memoranda of Understanding for Emergency Services
HMOs may have a contract or an MOU with hospitals or urgent care
centers within the HMO's service area(s) to ensure prompt and
appropriate payment for emergency services. For situations where
a contract or MOU is not possible, HMOs must identify for
hospitals and urgent care centers procedures that ensure prompt
and appropriate payment for emergency services.
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1. Such MOUs shall provide for:
a. The process for determining whether an emergency
exists.
b. The requirements and procedures for contacting the HMO
before the provision of urgent or routine care.
c. Agreements, if any, between the HMO and the provider
regarding indemnification, hold harmless, or any other
deviation from malpractice or other legal liability
which would attach to the HMO or provider in the
absence of such an agreement.
d. Payments for appropriate, medically necessary, and
reasonable diagnostic tests to determine if an
emergency exists.
e. Assurance of timely and appropriate provision of and
payment for emergency services.
2. Unless a contract or MOU specifies otherwise, HMOs are
liable to the extent that FFS would have been liable for the
emergency situation. The Department reserves the right to
resolve disputes between HMOs, hospitals and urgent care
centers regarding emergency situations based on FFS
criteria.
K. Provision of Services
Provide contract services to Medicaid/BadgerCare enrollees under
this Contract in the same manner as those services are provided
to other members of the HMO.
L. Open Enrollment
Conduct a continuous open enrollment period during which the HMO
shall accept recipients eligible for coverage under this Contract
in the order in which they are enrolled without regard to health
status of the recipient or any other factor(s).
M. Pre-Existing Conditions
Assume responsibility for all covered medical conditions of each
enrollee as of the effective date of coverage under the Contract.
The aforementioned responsibility shall not apply in the case of
persons hospitalized at the time of initial enrollment, as
provided for in this article.
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N. Hospitalization at the Time of Enrollment or Disenrollment
1. The HMO will not assume financial responsibility for
enrollees who are hospitalized at the time of enrollment
(effective date of coverage) until an appropriate hospital
discharge.
2. The Department will be responsible for paying on a FFS basis
all Medicaid covered services for such hospitalized
enrollees during hospitalization.
3. Enrollees, including newborn enrollees, who are hospitalized
at the time of disenrollment from the HMO shall remain the
financial responsibility of the HMO. The financial liability
of the HMO shall encompass all contract services. The HMO's
financial liability shall continue for the duration of the
hospitalization, except where (1) loss of Medicaid/
BadgerCare eligibility occurs; (2) disenrollment occurs
because there is a voluntary disenrollment from the HMO as a
result of one of the conditions in Addendum II, in which
case HMO liability shall terminate upon disenrollment being
effective; and (3) except where disenrollment is due to
medical status change to a code indicating SSI, 503 case, or
institutionalized eligibility. 503 cases are SSI cases that
continue Medicaid eligibility in spite of social security
cost of living increases that cause an SSI recipient to lose
SSI eligibility. In these three exceptions, the HMO's
liability shall not exceed the period for which it is
capitated.
4. Discharge from one hospital and admission to another within
twenty-four (24) hours for continued treatment shall not be
considered discharge under this section. Discharge is
defined here as it is in the UB-92 Manual.
O. Non-Discrimination
Comply with all applicable Federal and State laws relating to
non-discrimination and equal employment opportunity including s.
16.765, Wis. Stats., Federal Civil Rights Act of 1964,
regulations issued pursuant to that Act and the provisions of
Federal Executive Order 11246 dated September 26, 1985, and
assure physical and program accessibility of all services to
persons with physical and sensory disabilities pursuant to
Section 504 of the Federal Rehabilitation Act of 1973, as amended
(29 U.S.C. 794), all requirements imposed by the applicable
Department regulations (45 CFR part 84) and all guidelines and
interpretations issued pursuant thereto, and the provisions of
the Age Discrimination and Employment Act of 1967 and Age
Discrimination Act of 1975.
Chapter 16.765, Wis. Stats. requires that in connection with the
performance of work under this Contract, the Contractor agrees
not to discriminate against any employee or applicant for
employment because of age, race, religion, color, handicap, sex,
physical condition, developmental disability as defined in
HMO Contract for January 1, 2002 - December 31, 2003
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Section 51.01(5), sexual orientation or national origin. This
provision shall include, but not be limited to, the following:
employment, upgrading, demotion or transfer; recruitment or
recruitment advertising; layoff or termination; rates of pay or
other forms of compensation; and selection for training,
including apprenticeship. Except with respect to sexual
orientation, the Contractor further agrees to take affirmative
action to ensure equal employment opportunities. The Contractor
agrees to post in conspicuous places, available for employees and
applicants for employment, notices to be provided by the
contracting officer setting forth the provisions of the
non-discrimination clause. Addendum VIII contains further details
on the requirements of non-discrimination.
With respect to provider participation, reimbursement, or
indemnification - HMO will not discriminate against 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. This shall not be construed to
prohibit an HMO from including providers to the extent necessary
to meet the needs of the Medicaid population or from establishing
any measure designed to maintain quality and control cost
consistent with these responsibilities.
P. Affirmative Action Plan
Comply with State Affirmative Action policies. Contracts
estimated to be twenty-five thousand dollars ($25,000) or more
require the submission of a written affirmation action plan or
have a current plan on file with the State of Wisconsin.
Contractors with an annual work force of less than twenty-five
employees are exempted from this requirement; however, such
contractors shall submit a statement to the Division of Health
Affirmative Action/Civil Rights Compliance Office certifying that
its work force is less than twenty-five employees.
1. "Affirmative Action Plan" is a written document that details
an affirmative action program. Key parts of an affirmative
action plan are:
a. a policy statement pledging nondiscrimination and
affirmative action in employment;
b. internal and external dissemination of the policy;
c. assignment of a key employee as the equal opportunity
officer;
d. a work force analysis that identifies job
classification where representation of women,
minorities and the disabled is deficient;
e. goals and timetables that are specific and measurable,
and that are set to correct deficiencies and to reach a
balance of work force;
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f. revision of all employment practices to ensure that
they do not have discriminatory effects; and
g. establishment of internal monitoring and reporting
systems to measure progress regularly.
2. Within fifteen (15) days after the award of a contract, the
affirmative action plan shall be submitted to the Department
of Health and Family Services Box 7850, Madison, WI
53707-7850. Contractors are encouraged to contact the
Department of Health and Family Services, Affirmative
Action/Civil Rights Compliance Office at (608) 266-9372 for
technical assistance.
3. Addendum VIII contains further details on the requirements
of Affirmative Action Plans.
Q. Cultural Competency
1. HMO shall address the special health needs of enrollees such
as those who are low income or members of specific
population groups needing specific culturally competent
services. HMO shall incorporate in its policies,
administration, and service practice such as (1) recognizing
member's beliefs, (2) addressing cultural differences in a
competent manner, (3) fostering in staff/providers behaviors
and effectively address interpersonal communication styles
which respect enrollees' cultural backgrounds. HMO shall
have specific policy statements on these topics and
communicate them to subcontractors.
2. HMO shall encourage and foster cultural competency among
providers. HMO shall, when appropriate, permit enrollees to
choose providers from among the HMO's network based on
linguistic/cultural needs. HMO shall permit enrollees to
change primary providers based on the provider's ability to
provide services in a culturally competent manner. Enrollees
may submit grievances to the HMO and/or the Department
related to inability to obtain culturally appropriate care,
and the Department may, pursuant to such grievance, permit
an enrollee to disenroll and enroll into another HMO, or
into FFS in a county where HMOs do not enroll all eligibles.
R. Health Education and Prevention
1. Inform all enrollees of contributions that they can make to
the maintenance of their own health and the proper use of
health care services.
2. Have a program of health education and prevention available
and within reasonable geographic proximity to its enrollees.
The program shall.
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include health education and anticipatory guidance provided
as a part of the normal course of office visits, and in
discrete programming.
3. The program shall provide:
a. An individual responsible for the coordination and
delivery of services in the program.
b. Information on how to obtain these services (locations,
hours, phones, etc.).
c. Health-related educational materials in the form of
printed, audiovisual, and/or personal communication.
d. Information on recommended check-ups and screenings,
and prevention and management of disease states which
affect the general population. This includes specific
information for persons who have or who are at risk of
developing such health problems (e.g., hypertension,
diabetes, STD, asthma, breast and cervical cancer,
osteoporosis and postpartum depression).
e. Health education and prevention programs. Recommended
programs include: injury control, family planning, teen
pregnancy, sexually transmitted disease prevention,
prenatal care, nutrition, childhood immunization,
substance abuse prevention, child abuse prevention,
parenting skills, stress control, postpartum
depression, exercise, smoking cessation, weight gain
and healthy birth, postpartum weight loss, and
breast-feeding promotion and support. Note that any
education and prevention programs for family planning
and substance abuse would supplement the required
family planning and substance abuse health care
services covered in the Medicaid/BadgerCare program.
f. Promotion of the health education and prevention
program, including use of languages understood by the
population served, and use of facilities accessible to
the population served.
g. Information on and promotion of other available
prevention services offered outside of the HMO
including child nutrition programs, parenting classes,
programs offered by local health departments and other
programs.
h. Systematic referrals of potentially eligible women,
infants, and children to the Special Supplemental
Nutrition Program for Women, Infants, and Children
(WIC) and relevant medical
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information to the WIC program. General information
about recipient eligibility requirements for the WIC
program, a statewide list of WIC agencies, as well as
a sample WIC Referral Form that can be used by HMOs,
can be found in Addendum XXV. The Department will
develop a resource manual for information related to
the Medicaid/BadgerCare Program. Specific information
concerning WIC and WIC agencies will be contained in
the resource manual.
4. Health related educational materials produced by the HMO
must be at a sixth (6th ) grade reading comprehension level
and reflect sensitivity to the diverse cultures served.
Also, if the HMO uses material produced by other entities,
the HMO must review these materials for grade level
comprehension level and for sensitivity to the diverse
cultures served. Finally, the HMO must make all reasonable
efforts to locate and use culturally appropriate health
related material.
S. Enrollee Handbook and Education and Outreach for Newly Enrolled
Recipients
1. Within one week of initial enrollment notification to the
HMO, annually thereafter and whenever the enrollee's
requests, mail to each casehead an enrollee handbook which
is at the "sixth (6th ) grade reading comprehension level"
and which at a minimum will include information about:
a. the phone number that can be used for assistance in
obtaining emergency care or for prior authorization for
urgent care;
b. information on contract services offered by the HMO;
c. location of facilities;
d. hours of service;
e. informal and formal grievance procedures, including
notification of the enrollee's right to a fair hearing;
f. grievance appeal procedures;
g. HealthCheck;
h. family planning policies;
i. policies on the use of emergency and urgent care
facilities;
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j. providers and whether the provider is accepting new
"enrollees," and
k. changing HMOs.
2. The HMO must provide periodic updates to the handbook, as
needed explaining changes in the above policies. Such
changes must be approved by the Department prior to
printing.
3. New standard language for the enrollee handbooks required by
this Contract will be included in the handbooks when HMOs
reprint the informing materials
4. Enrollee handbooks (or substitute enrollee information
approved by the Department which explains HMO services and
how to use the HMO) shall be made available in at least the
following languages: Spanish, Lao, Russian and Hmong if the
HMO has enrollees who are conversant only in those
languages. The handbook should direct enrollees who are not
conversant in English to the appropriate resources within
the HMO for obtaining a copy of the handbook with the
appropriate language. The Department will provide
translations of the standard handbook language in Addendum V
for the four specified languages. HMOs may use the
translated standard handbook language as appropriate to its
service area. However, HMOs must utilize local resources to
review the final handbook language. This will assure the
that the appropriate dialect(s) is/are used in the standard
translation. HMOs must arrange for translation into other
dialects if the translation is inappropriate for its
enrollees.
5. HMOs may create enrollee handbook language that they believe
is simpler than the standard language of Addendum V, but
this substitute language must be approved by the Department
and HMOs must independently arrange for the translation of
any non-standard language.
6. HMOs shall submit their enrollee handbook for review and
approval within sixty (60) days of signing the contract for
2002-2003.
7. Standard language on several subjects, including
HealthCheck, family planning, grievance and appeal rights,
conversion rights, and emergency and urgent care shall
appear in all handbooks and is included in Addendum V. Any
exceptions to the standard must be approved in advance by
the Department, and will be approved only for exceptional
reasons. Standard language may change during the course of
the contract period, if there are changes in federal or
state laws, rules or regulations, in which case the new
language will have to be inserted into the enrollee
handbooks as of the effective date of any such change.
HMO Contract for January 1, 2002 - December 31, 2003
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8. In addition to the above requirements sections 1 through 7
for the enrollee handbook, HMOs are required to perform
other education and outreach activities for newly enrolled
recipients. HMOs are to submit to the Department for prior
written approval an education and outreach plan targeted
towards newly enrolled recipients. This outreach plan will
be examined by the Department during pre-contract review.
Newly enrolled recipients are those recipients appearing on
the enrollment reports described in Article IV. D. and
listed as "ADD-NEW." The plan must identify at least two (2)
educational/outreach activities in addition to the enrollee
handbook to be undertaken by the HMO for the purpose of
informing new enrollees of pertinent information necessary
to access services within the HMO network. The plan must
include the frequency (i.e., weekly, monthly, etc.) of the
activity, the person within the HMO responsible for the
activities, and how activities will be documented and
evaluated for effectiveness.
T. Approval of Marketing Plans and Informing Materials
1. Marketing and Informing Materials
As used in this section, "marketing materials, other
marketing activities, and informing materials" include the
production and dissemination of any informing materials,
marketing plans, marketing materials and other marketing
activities that refer to Medicaid, Title XIX, BadgerCare, or
Title XXI or are intended for Medicaid/BadgerCare
recipients. This requirement includes marketing or informing
materials that are produced by providers under contract to
the HMO or owned by the HMO in whole or in part.
2. Department Approval of Marketing and Informing Materials--
HMOs must submit to the Department for prior written
approval all informing materials, marketing plans, and all
marketing materials and other marketing activities that
refer to Medicaid Title XIX, BadgerCare, or Title XXI or are
intended for Medicaid/ BadgerCare recipients. This
requirement includes marketing or informing materials that
are produced by providers under contract to the HMO or owned
by the HMO in whole or in part.
Marketing plans and informing materials must be written at a
"sixth grade comprehensive level" and will be reviewed by
the Department in a manner that does not unduly restrict or
inhibit the HMO's informing or marketing plans. When
applying this provision to specific marketing plans,
informing materials and/or activities, the entire content
and use of the
HMO Contract for January 1, 2002 - December 31, 2003
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informing/marketing materials or activities shall be taken
into consideration. All materials will be reviewed as
follows:
a. The Department will review and either approve, approve
with modifications, or deny all marketing or informing
material within ten (10) working days of receipt of the
informing materials, except that informing, marketing
materials and other marketing activities are deemed
approved if there is no response from the Department
within ten (10) working days
b. Time-sensitive marketing or informing material must be
clearly marked time-sensitive by the HMO and will be
approved, approved with modifications or denied by the
Department within ten business days. The Department
reserves the right to determine whether the material
is, indeed, time-sensitive.
c. The Department will not approve any materials which are
deemed to be confusing, fraudulent, misleading, or do
not accurately reflect the scope and philosophy of the
Medicaid program and/or its covered benefits.
d. Problems and errors subsequently identified by the
Department must be corrected by the HMO when they are
identified. HMO agrees to comply with Ins. 6.07 and
3.27, Wis. Admin. Code, and practices consistent with
the Balanced Budget Amendment of 1997 P.L. 105-33 Sec.
4707(a) [42 U.S.C. 1396v(d)(2)].
3. Prohibited Practices:
The following marketing practices are prohibited:
a. Practices that are discriminatory;
b. Practices that seek to influence enrollment in
conjunction with the sale of any other insurance
product;
c. Direct and indirect cold calls, either door-to-door or
telephonic;
d. Offer of material or financial gain to potential
members as an inducement to enroll;
e. Activities and material that could mislead, confuse or
defraud consumers;
f. Materials that contain false information; and
g. Practices that are reasonably expected to have the
effect of denying or discouraging enrollment.
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4. HMOs Agreement to Abide by Marketing/Informing Criteria
HMO agrees to engage only in marketing activities and
distribute only those informing and marketing materials that
are pre-approved in writing. HMOs that fail to abide by
these marketing requirements may be subject to any and all
sanctions available under Article IX. In determining any
sanctions, the Department will take into consideration any
past unfair marketing practices, the nature of the current
problem and the specific implications on the health and well
being of the Medicaid enrollees. In the event that an HMO's
affiliated provider fails to abide by these requirements,
the Department will evaluate whether the HMO should have had
knowledge of the marketing issue and the HMO's ability to
adequately onitor ongoing future marketing activities of the
subcontractor(s).
U. Conversion Privileges
Offer any enrollee covered under this Contract, whose enrollment
is subsequently terminated due to loss of Medicaid/BadgerCare
eligibility, the opportunity to convert to a private enrollment
contract without underwriting. This time period for conversion
following Medicaid/BadgerCare termination notice will comply with
Wisconsin Stats. 632.897 regarding conversion rights.
V. Choice of Health Professional
Offer each enrollee covered under this Contract the opportunity
to choose a primary health care professional affiliated with the
HMO, to the extent possible and appropriate. If the HMO assigns
recipients to primary care providers, then the HMO shall notify
recipients of the assignment. HMOs must permit Medicaid/
BadgerCare enrollees to change primary providers at least twice
in any calendar year, and to change primary providers more often
than that for just cause, just cause being defined as lack of
access to quality, culturally appropriate, health care. Such just
cause will be handled as a formal grievance. If the HMO has
reason to lock-in an enrollee to one primary provider and/or
pharmacy in cases of difficult case management, the HMO must
submit a written request in advance of such lock-in to the
Department. Requests should be submitted to the Contract Monitor.
Culturally appropriate care in this section means care by a
provider who can relate to the enrollee and who can provide care
with sensitivity, understanding, and respect for the enrollee's
culture.
W. Quality Assessment/Performance Improvement (QAPI)
1. The HMO Quality Assessment/Performance Improvement (QAPI)
program must conform to requirements of 42 CFR, Part 400,
Medicaid Managed Care Requirements, Subpart D, Quality
Assessment and Performance Improvement. The program must
also comply with 42 Code of Federal
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Regulations (CFR) 434.34 which states that the HMO must have
a QAPI system that:
a. Is consistent with the utilization control requirement
of 42 CFR 456;
b. Provides for review by appropriate health professionals
of the process followed in providing health services;
c. Provides for systematic data collection of performance
and patient results;
d. Provides for interpretation of this data to the
practitioners; and
e. Provides for making needed changes.
2. Quality Assessment/Performance Improvement Program
a. The HMO must have a comprehensive Quality Assessment/
Improvement Program (QAPI) program that protects,
maintains, and improves the quality of care provided to
Wisconsin Medicaid program recipients. The HMO must
evaluate the overall effectiveness of its QAPI program
annually to determine whether the program has
demonstrated improvement, where needed, in the quality
of care and service provided to its Medicaid/
BadgerCare population.
The HMO must have documentation of all aspects of the
QAPI program available for Department review upon
request. The Department may perform off-site and
on-site Quality Assessment/ Performance Improvement
audits to ensure that the HMO is in compliance with
contract requirements. The review and audit may
include: on-site visits; staff and enrollee interviews;
medical record reviews; review of all QAPI procedures,
reports, committee activities, including credentialing
and recredentialing activities, corrective actions and
follow-up plans; peer review process; review of the
results of the member satisfaction surveys, and review
of staff and provider qualifications.
b. The HMO must have a written QAPI work plan that is
ratified by the board of directors and outlines the
scope of activity and the goals, objectives, and time
lines for the QAPI program. New goals and objectives
must be set at least annually based on findings from
quality improvement activities and studies and results
of the HMO
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on DHCF enrollee satisfaction surveys and MEDDIC-MS
performance measures.
c. The HMO governing body is ultimately accountable to the
Department for the quality of care provided to HMO
enrollees. Oversight responsibilities of the governing
body include, at a minimum: approval of the overall
QAPI program and an annual QAPI plan; designating an
accountable entity or entities within the organization
to provide oversight of QAPI; review of written reports
from the designated entity on a periodic basis which
include a description of QAPI activities, progress on
objectives, and improvements made; formal review on an
annual basis of a written report on the QAPI program;
and directing modifications to the QAPI program on an
ongoing basis to accommodate review findings and issues
of concern within the HMO.
d. The QAPI committee shall be in an organizational
location within the HMO such that it can be responsible
for all aspects of the QAPI program. The committee
membership must be interdisciplinary and be made up of
both providers and administrative staff of the HMO,
including:
1) a variety of health professions (e.g., pharmacy,
physical therapy, nursing, etc.);
2) qualified professionals specializing in mental
health or substance abuse and dental care on a
consulting basis when an issue related to these
areas arises;
3) a variety of medical disciplines (e.g., medicine,
surgery, radiology, etc.);
4) OB/GYN and pediatric representation; and
5) HMO management or governing body.
6) Enrollees of the HMO must be able to contribute
input to the QAPI Committee. The HMO must have a
system to receive enrollee input on quality
improvement, document the input received, document
the HMO's response to the input, including a
description of any changes or studies it
implemented as the result of the input and
document feedback to enrollees in response to
input received. The HMO response must be timely.
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e. The committee must meet on a regular basis, but not
less frequently than quarterly. The activities of the
QAPI Committee must be documented in the form of
minutes and reports. The QAPI Committee must be
accountable to the governing body.
Documentation of Committee minutes and activities must
be available to the Department upon request.
f. QAPI activities of HMO providers and subcontractors, if
separate from HMO QAPI activities, shall be integrated
into the overall HMO/QAPI program. Requirements to
participate in QAPI activities, including submission of
complete encounter data, are incorporated into all
provider and subcontractor contracts and employment
agreements. The HMO QAPI program shall provide feedback
to the providers/subcontractors regarding the
integration of, operation of, and corrective actions
necessary in provider/subcontractor QAPI efforts. Other
management activities (Utilization Management, Risk
Management, Customer Service, Complaints and
Grievances, etc.) must be integrated with the QAPI
program. Physicians and other health care practitioners
and institutional providers must actively cooperate and
participate in the HMO's quality activities.
The HMO remains accountable for all QAPI functions,
even if certain functions are delegated to other
entities. If the HMO delegates any activities to
contractors the conditions listed in Article II of
this agreement must be met.
g. There is evidence that HMO management representatives
and providers participate in the development and
implementation of the QAPI plan of the HMO. This
provision shall not be construed to require that HMO
management representatives and providers participate in
every committee or subcommittee of the QAPI program.
h. The HMO must designate a senior executive to be
responsible for the operation and success of the QAPI
program. If this individual is not the HMO Medical
Director, the Medical Director must have substantial
involvement in the QAPI program. The designated
individual shall be accountable for the QAPI activities
of the HMO's own providers, as well as the HMO's
subcontracted providers.
i. The qualifications, staffing level and available
resources must be sufficient to meet the goals and
objectives of the QAPI program
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and related QAPI activities. Such activities
include, but are not limited to, monitoring and
evaluation of important aspects of care and
services, facilitating appropriate use of
preventive services, monitoring provider
performance, provider credentialing, involving
members in QAPI initiatives and conducting
performance improvement projects.
Written documentation listing the staffing
resources that are directly under the
organizational control of the person who is
responsible for QAPI (including total FTEs,
percent of time dedicated to QAPI, background and
experience, and role) must be available to the
Department upon request.
3. Monitoring and Evaluation
a. The QAPI program must monitor and evaluate the quality
of clinical care on an ongoing basis. Important aspects
of care (i.e., acute, chronic conditions, high volume,
high-risk preventive care and services) are studied and
prioritized for performance improvement and/or
development of practice guidelines. Standardized
quality indicators must be used to asses improvement,
assure achievement of minimum performance levels (Ref:
MEDDIC-MS Measures and Technical Specifications),
monitor adherence to guidelines, and identify patterns
of over utilization and under utilization. The
measurement of quality indicators selected by the HMO
for areas other than those included in MEDDIC-MS must
be supported by appropriate data collection and
analysis methods to improve clinical care and services.
b. Provider performance must be measured against practice
guidelines and standards adopted by the QAPI Committee.
Areas identified for improvement must be tracked and
corrective actions taken when warranted. The
effectiveness of corrective actions must be monitored
until problem resolution occurs. Reevaluation must
occur to assure that the improvement is sustained.
c. The HMO must use appropriate clinicians to evaluate the
data on clinical performance, and multi disciplinary
teams to analyze and address data on systems issues.
d. The HMO must also monitor and evaluate care and
services in certain priority clinical and non-clinical
areas specified in Article III W 13 c. d.
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e. The HMO must make documentation available to the
Department upon request regarding quality improvement
and assessment studies on plan performance, which
relate to the enrolled population. See reporting
requirements in Article III. W. Section 13,
"Performance Improvement Priority Areas and Projects."
f. Practice guidelines: The HMO must develop or adopt
practice guidelines that are disseminated to providers
and to enrollees as appropriate or upon request. The
guidelines should be based on reasonable medical
evidence or consensus of health professionals; consider
the needs of the enrollees; developed or adopted in
consultation with the contracting health professionals,
and reviewed and updated periodically.
Decisions with respect to utilization management,
enrollee education, coverage of services, and other
areas to which the practice guidelines apply are
consistent with the guidelines. Variations from the
guidelines must be based on the clinical situation.
4. Access
a. The HMO must provide medical care to its
Medicaid/BadgerCare enrollees that is as accessible to
them, in terms of timeliness, amount, duration, and
scope, as those services are to nonenrolled
Medicaid/BadgerCare recipients within the area served
by the HMO.
The HMO must have a Medicaid certified primary care
provider within a 20-mile distance from any enrollee
residing in the HMO service area. A service area for an
HMO will be specified down to the zip code. Therefore,
all portions of each zip code in the HMO service area
must be within 20-miles from a Medicaid certified
primary care provider.
b. Network Adequacy:
The HMO must assure that its delivery network is
sufficient to provide adequate access to all services
covered under this agreement. In establishing the
network, the HMO must consider:
1) The anticipated Medicaid/BadgerCare enrollment.
2) The expected utilization of services, considering
enrollee characteristics and health care needs.
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3) The number and types of providers (in terms of
training experience and specialization) required
to furnish the contracted services.
4) The number of network providers not accepting new
patients.
5) The geographic location of providers and
enrollees, distance, travel time, normal means of
transportation used by enrollees and whether 1
provider locations are accessible to enrollees
with disabilities.
The HMO must also assure the following provisions:
6) In addition to any primary care provider a female
enrollee may have, provide female enrollees with
direct access to a women's health specialist
within the network for covered women's routine
and preventive health care services.
7) Provision for a second opinion from a qualified
network provider upon enrollee request, subject to
referral procedures approved by the Department.
If an appropriately qualified provider is not
available within the network, arrange for a second
opinion outside the network at no charge to the
enrollee.
8) Adequate and timely coverage of services provided
out of network, when the required medical service
is not available within the HMO network.
9) Network providers are credentialed as required by
this contract.
HMO must provide documentation and assurance of the
above network adequacy criteria as required by the
Department for pre-contract certification or upon
request of the Department.
This access standard does not prevent a recipient from
choosing and HMO when the recipient resides in zip code
that does not meet the 20-mile distance standard.
However, the recipient will not be automatically
assigned to that HMO. If by some circumstance the
recipient has been assigned to the HMO or has chosen
the HMO and becomes dissatisfied with access to medical
care, the recipient will be allowed to disenroll from
the HMO for reason of distance.
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Primary care providers are defined to include, but are
not limited to, Physicians and Physician Clinics with
specialties in general practice, family practice,
internal medicine, obstetrics and gynecology, and
pediatrics, FQHCs, RHCs, Nurse Practitioners, Nurse
Midwives, Physician Assistants, and Tribal Health
Centers. HMOs may define other types of providers as
primary care providers. If they do so, the HMOs must
define these other types of primary care providers and
justify their inclusion as primary care providers
during the pre-contract review phase of the HMO
Certification process.
c. The HMO must have written protocols to ensure that
enrollees have access to screening, diagnosis and
referral, and appropriate treatment for those
conditions and services covered under the Wisconsin
Medicaid program.
The HMO's protocols must include methods for
identification, outreach to and screening/assessment of
enrollees with special health care needs.
d. The HMO must also provide medically necessary high risk
prenatal care within two weeks of the enrollee's
request for an appointment, or within three weeks if
the request is for a specific HMO provider.
e. The HMO must have written standards for the
accessibility of care and services that are
communicated to providers and monitored. The standards
must include the following: waiting times for care at
facilities; waiting times for appointments; specify
that providers' hours of operation do not discriminate
against Medicaid/ BadgerCare enrollees; and whether or
not provider(s) speak member's language. The HMO must
take corrective action if its standards are not met.
f. The HMO must have a mental health or substance abuse
provider within a 35-mile distance from any enrollee
residing in the HMO service area or no further than the
distance for non-enrolled recipients residing in the
service area. The HMO must also give consideration to
whether the providers are accepting new patients, and
where full or part-time coverage is available.
g. The HMO must have a dental provider, when appropriate,
within a 35-mile distance from any enrollee residing in
the HMO service area or no further than the distance
for non-enrolled recipients residing in the service
area. The HMO must also give consideration
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to whether the dentist is accepting new patients, and
where full or part-time coverage is available.
5. Health Promotion and Disease Prevention Services
a. The HMO must identify at-risk populations for
preventive services and develop strategies for reaching
Medicaid/ BadgerCare members included in this
population. Local health departments and
community-based health organizations can provide the
HMO with special access to vulnerable and low-income
population groups, as well as settings that reach
at-risk individuals in their communities, schools and
homes. Public health resources can be used to enhance
the HMO's health promotion and preventive care
programs.
b. The HMO must have mechanisms for facilitating
appropriate use of preventive services and educating
enrollees on health promotion. At a minimum, an
effective health promotion and prevention program
includes: tracking of preventive services, practice
guidelines for preventive services, yearly measurement
of performance in the delivery of such services, and
communication of this information to providers and
enrollees.
6. Provider Selection (credentialing) and Periodic Evaluation
(recredentialing)
a. The HMO must have written policies and procedures for
provider selection and qualifications. For each
practitioner, including each member of a contracting
group that provides services to the HMO's enrollees,
initial credentialing must be based on a written
application, primary source verification of licensure,
disciplinary status, eligibility for payment under
Medicaid and certified for Medicaid. The HMO's written
policies and procedures must identify the circumstances
in which site visits are appropriate in the
credentialing process.
b. The HMO must periodically monitor (no less than every
three years) the provider's documented qualifications
to assure that the provider still meets the HMO's
specific professional requirements.
c. The HMO must also have a mechanism for considering the
provider's performance. The recredentialing method must
include updating all the information (except medical
education) utilized in the initial credentialing
process. Performance evaluation must include
information from: the QAPI system, reviewing enrollee
complaints, and the utilization management system.
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d. The selection process must not discriminate against
providers such as those serving high-risk populations,
or specialize in conditions that require costly
treatment. The HMO must have a process for receiving
advice on the selection criteria for credentialing and
recredentialing practitioners in the HMO's network.
e. If the HMO delegates selection of providers to another
entity, the organization retains the right to approve,
suspend, or terminate any provider selected by that
entity.
f. The HMO must have a formal process of peer review of
care delivered by providers and active participation of
the HMO's contracted providers in the peer review
process. This process may include internal medical
audits, medical evaluation studies, peer review
committees, evaluation of outcomes of care, and systems
for correcting deficiencies. The HMO must supply
documentation of its peer review process upon request.
g. The HMO must have written policies that allow it to
suspend or terminate any provider for quality
deficiencies. There must also be an appeals process
available to the provider that conforms to the
requirements of the HealthCare Quality Improvement Act
of 1986 (42 USCss.11101 etc. Seq.).
h. In addition to the requirements in this section, the
names of individual practitioners and institutional
providers who have been terminated from the HMO
provider network as a result of quality issues must be
immediately forwarded to the Department and reported to
other entities as required by law (42 USC Section 11101
et. Seq.).
i. Institutional Provider Selection--For each provider,
other than an individual practitioner, the HMO
determines, and verifies at specified intervals, that
the provider is:
1) licensed to operate in the State, if licensure is
required, and in compliance with any other
applicable State or Federal requirements; and
2) the HMO verifies if the provider claims
accreditation, or is determined by the HMO to meet
standards established by the HMO itself.
j. Exceptions to Credentialing and recredentialing
requirements:
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These standards do not apply to:
1) Providers who practice only under the direct
supervision of a physician or other provider, and;
2) Hospital-based providers such as emergency room
physicians, anesthesiologists, and other providers
who provide services only incident to hospital
services.
These exceptions do not apply if the provider contracts
independently with the HMO.
7. Enrollee Feedback on Quality Improvement
a. The HMO must have a process to maintain a relationship
with its enrollees that promotes two way communication
and contributes to quality of care and service. The HMO
must show a commitment to treating members with respect
and dignity.
b. Annually, DHCF will conduct a satisfaction of care
survey of a representative sample of enrolled Medicaid/
BadgerCare recipients.
The Department will work with HMOs to develop the
survey instrument and plan. The HMO shall have systems
in place for acting on survey results and shall report
to the Department any quality management projects
planned in response to survey results.
c. The HMO is encouraged to find additional ways to
involve Medicaid/BadgerCare enrollees in quality
improvement initiatives and in soliciting enrollee
feedback on the quality of care and services the HMO
provides. Other ways to bring enrollees into the HMO's
efforts to improve the health care delivery system
include but are not limited to: focus groups, consumer
advisory councils, enrollee participation on the
governing board, the QAPI committees or other
committees, or task forces related to evaluating
services. All efforts to solicit feedback from
enrollees must be approved by the Department.
8. Medical Records
a. The HMO must have policies and procedures for
participating provider medical records content and
documentation that have been communicated to providers
and a process for evaluating its providers' medical
records based on the HMO's policies. These policies
must address patient confidentiality, organization
and
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completeness, tracking, and important aspects of
documentation such as accuracy, legibility, and
safeguards against loss, destruction, or unauthorized
use. The HMO must also have confidentiality policies
and procedures that are applicable to administrative
functions that are concerned with confidential patient
information. Those policies must include information
with respect to disclosure of enrollee-identifiable
medical record and/or enrollment information and
specifically provide:
1. The enrollees may review and obtain copies of
medical records information that pertain to them.
2. The policies above must be made available to
enrollees upon request.
b. Patient medical records must be maintained in an
organized manner (by the HMO, and/or by the HMO's
subcontractors) that permits effective patient care,
they must reflect all aspects of patient care and be
readily available for patient encounters, for
administrative purposes, and for Department review.
c. Because HMOs are considered contractors of the State
and are therefore (only for the limited purpose of
obtaining medical records of its enrollees) entitled to
obtain medical records according to Wisconsin
Administrative Code, HFS 104.01(3), the Department will
require Medicaid-certified providers to release
relevant records to the HMO to assist in compliance
with this section. Where HMOs have not specifically
addressed photocopying expenses in their provider
contracts or other arrangements, the HMOs are liable
for charges for copying records only to the extent that
the Department would reimburse on a FFS basis.
d. The HMO must have written confidentiality policies and
procedures in regard to confidential patient
information. Policies and procedures must be
communicated to HMO staff, members, and providers. The
transfer of medical records to out-of-plan providers or
other agencies not affiliated with HMO (except for the
Department) are contingent upon the receipt by the HMO
of written authorization to release such records signed
by the enrollee or, in the case of a minor, by the
enrollee's parent, guardian, or authorized
representative.
e. The HMO must have written quality standards and
performance goals for participating provider medical
record documentation and be able to demonstrate, upon
request of the DHFS, that the
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standards and goals have been communicated to
providers. The HMO must actively monitor established
standards and provide documentation of standards and
goals upon request of the Department.
f. Medical records must be readily available for HMO-wide
Quality Assessment/Performance Improvement (QAPI) and
Utilization Management (UM) activities and provide
adequate medical and other clinical data required for
(QAPI)/UM, and Department use.
g. The HMO must have adequate policies in regard to
transfer of medical records to ensure continuity of
care when enrollees are treated by more than one
provider. This may include transfer to local health
departments subject to the receipt of a signed
authorization form as specified in Article III. W. 8
(d) above (with the exception of immunization status
information described in Article III. B. 14., which
doesn't require enrollee authorization).
h. Requests for completion of residual functional capacity
evaluation forms and other impairment assessments, such
as queries as to the presence of a listed impairment,
shall be provided within ten (10) working days of
request (at the discretion of the individual provider
and subject to the provider's medical opinion of its
appropriateness) and according to the other
requirements listed above; the HMO and its providers
and subcontractor may charge the enrollee, authorized
representative, or other third party a reasonable rate
for the completion of such forms and other impairment
assessments. Such rates may be reviewed by the
Department for reasonableness and may be modified based
on this review.
i. Minimum medical record documentation per chart entry or
encounter must conform to the Wisconsin Administrative
Code, Chapter HFS 106.02, (9)(b) Medical record
content.
9. Utilization Management (UM)
a. The HMO must have documented policies and procedures
for all UM activities that involve determining medical
necessity, and the approval or denial of medical
services. Qualified medical professionals must be
involved in any decision-making that requires clinical
judgment. The decision to deny, reduce or authorize a
service that is less than requested must be made by a
health professional with appropriate clinical expertise
in treating the affected enrollee's condition(s).
Criteria used to determine medical necessity and
appropriateness must be communicated to providers.
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The criteria for determining medical necessity may not
be more stringent than HFS 101.03 (96m) Wisconsin
Administrative Code.
b. If the HMO delegates any part of the UM program to a
third party, the delegation must meet the requirements
in Article II Delegations of Authority.
c. If the HMO utilizes phone triage, nurse lines or other
demand management systems, the HMO must document review
and approval of qualification criteria of staff and of
clinical protocols or guidelines used in the system.
The system's performance will be evaluated annually in
terms of clinical appropriateness.
d. The policies specify time frames for responding to
requests for initial and continued service
determinations, specify information required for
authorization decisions, provide for consultation with
the requesting provider when appropriate, and provide
for expedited responses to requests for authorization
of urgently needed services. In addition, the HMO must
have in effect mechanisms to ensure consistent
application of review criteria for authorization
decisions (interrater reliability).
Within the timeframes specified, the HMO must give the
enrollee and the requesting provider written notice of:
1) the decision to deny, limit, reduce, delay or
terminate a service along with the reasons for the
decision.
2) the enrollee's right to file a grievance or request
a state fair hearing.
Authorization decisions must be made within the
following time frames and in all cases as expeditiously
as the enrollee's condition requires:
1) within 14 days of the receipt of the request, or
2) within 3 working days if the physician indicates or
the HMO determines that following the ordinary time
frame could jeopardize the enrollee's health or
ability to regain maximum function.
One extension of up to 14 days may be allowed if the
enrollee requests it or if the HMO justifies the need
for more information.
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e. Criteria for decisions on coverage and medical
necessity are clearly documented, are based on
reasonable medical evidence, current standards of
medical practice, or a consensus of relevant health
care professionals, and are regularly updated.
f. The HMO oversees and is accountable for any functions
and responsibilities that it delegates to any
subcontractor. (See Article II Delegations of
Authority).
g. Postpartum discharge policy for mothers and infants
must be based on medical necessity determinations. This
policy must include all follow-up tests and treatments
consistent with currently accepted medical practice and
applicable federal law. The policy must allow at least
a 48-hour hospital stay for normal spontaneous vaginal
delivery, and 96 hours for a cesarean section delivery,
unless a shorter stay is agreed to by both the
physician and the enrollee. HMOs may not deny coverage,
penalize providers, or give incentives or payments to
providers or enrollees. Post hospitalization follow-up
care must be based on the medical needs and
circumstances of the mother and infant. The Department
may request documentation demonstrating compliance with
this requirement.
10. External Quality Review Contractor
a. The HMO must assist the Department and the external
quality review organization under contract with the
Department in identification of provider and enrollee
information required to carry out on-site or off-site
medical chart reviews. This includes arranging
orientation meetings for physician office staff
concerning medical chart review, and encouraging
attendance at these meetings by HMO and physician
office staff as necessary. The provider of service may
elect to have charts reviewed on-site or off-site.
b. When the professional review organization under
contract with the Department identifies an adverse
health situation in which follow-up is needed to
determine whether appropriate care was provided, the
HMO will be responsible for the following tasks:
1) Assign a staff person(s) to conduct follow-up with
the provider(s) concerning each adverse health
situation identified by the Department's
professional review organization, including
informing the provider(s) of the finding and
monitoring the provider's resolution of the finding;
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2) Inform the HMO's QAPI Committee of the final finding
and involve the QAPI Committee in the development,
implementation and monitoring of the corrective
action plan; and
3) Submit a corrective action plan or an opinion in
writing to the Department within 60 days that
addresses the measures that the HMO and the provider
intend to take to resolve the finding. The HMO's
final resolution of all cases must be completed
within six (6) months of HMO notification. A case is
not considered resolved by the Department until the
Department approves the response provided by the
HMO and provider.
c. The HMO will facilitate training provided by the
Department to its providers.
11. Dental Services Quality Improvement (Applies only to HMOs
covering dental services.)
a. The HMO QAPI Committee and QAPI coordinator will review
subcontracted dental programs quarterly to assure that
quality dental care is provided and that the HMO and
the contractor comply with the following:
1) The HMO or HMO affiliated dental provider must
advise the enrollee within 30 days of effective
enrollment of the name of the dental provider and
the address of the dental provider's site. The HMO
or HMO affiliated dental provider must also inform
the enrollee in writing how to contact his/her
dentist (or dental office), what dental services
are covered, when the coverage is effective, and
how to appeal denied services.
2) An HMO or HMO affiliated dental provider who assigns
all or some Medicaid/BadgerCare HMO enrollees to
specific participating dentists must give enrollees
at least 30 days after assignment to choose another
dentist. Thereafter, in accordance with Article III.
V., the HMO and/or affiliated provider must permit
enrollees to change dentists at least twice in any
calendar year and more often than that for just
cause.
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3) HMO-affiliated dentists must provide a
routine dental appointment to an assigned
enrollee within 90 days after the request.
Enrollee requests for emergency treatment
must be addressed within 24 hours after the
request is received.
4) Dental providers must maintain adequate
records of services provided. Records must
fully disclose the nature and extent of each
procedure performed and should be maintained
in a manner consistent with standard dental
practice.
5) The HMO affirms by execution of this Contract
that the HMO's peer review systems are
consistently applied to all dental
subcontractors and providers.
6) The HMO must document, evaluate, resolve, and
follow up on all verbal and written
complaints they receive from
Medicaid/BadgerCare enrollees related to
dental services.
12. Accreditation
a. The Department encourages the HMO to actively pursue
accreditation by the National Committee for Quality
Assurance (NCQA), the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) or other recognized
accrediting body approved by the Department.
b. The achievement of full accreditation by an
accreditation body approved by the department and
satisfaction of the requirements of the HMO
Accreditation Incentive Program as specified by the
Department will result in the HMO qualifying for the
Accreditation Incentive.
Where accreditation standards conflict with the standard set
forth in this agreement, the agreement prevails unless the
accreditation standard is more stringent.
13. Performance Improvement Priority Areas and Projects:
a. The HMO must develop and ensure implementation of
program initiatives to address the specific clinical
needs that have a higher prevalence in the HMO's
enrolled population served under this agreement. These
priority areas must include clinical and non-clinical
Performance Improvement projects. The Department
strongly advocates the development of collaborative
relationships among HMOs, Local Health Departments,
community based
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behavioral health treatment agencies (both public and
private), and other community health organizations to
achieve improved services in priority areas and must
report complete encounter data for all services
provided. Linkages between managed care organizations
and public health agencies is an essential element for
the achievement of the public health objectives,
potentially reducing the quantity and intensity of
services the HMO needs to provide. The Department and
the HMO are jointly committed to on-going collaboration
in the area of service and clinical care improvements
by the development and sharing of "best practices" and
use of encounter data-driven performance measures
(MEDDIC-MS).
Annually, for the priority areas specified by the
Department and listed below, the HMO must monitor and
evaluate the quality of care and services through
performance improvement projects for at least two of
the listed areas in Article III, W. 13 (c) or (d)
below, or an HMO may propose alternative performance
improvement topics to be addressed by making a request
in writing to the Department. In addition, the HMO may
be required to conduct up to two additional performance
improvement initiatives and submit reports as required
to achieve performance goals specified in the MEDDIC-MS
technical specifications in addition to two performance
improvement projects required under Article III
W.13.c.d. The final or on-going status report for each
project must be submitted by October 1, 2003, and
October 1, 2004, or as may be specified in the
MEDDIC-MS technical specifications. The performance
improvement topic must take into account: the
prevalence of a condition among, or need for a specific
service by, the HMO enrollees served under this
agreement, enrollee demographic characteristics and
health risks; and the interest of consumers or
purchasers in the aspect of care or services to be
addressed. Each project report must include all of the
information in the Performance Improvement Project
Outline in Addendum XV.
b. Performance reporting will utilize standardized
indicators appropriate to the performance improvement
area or as specified in the MEDDIC-MS technical
specifications. Minimum performance levels must be
specified for each performance improvement area, using
normative standards derived from regional, national
norms, or from norms established by an appropriate
practice organization. Goals for improvement for the
"Priority Areas" listed in c. of this section, may be
set by the organization itself.
The organization must assure that improvements are
sustained through periodic audits of relevant data and
maintenance of the
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interventions that resulted in the improvement. The HMO
agrees to open at least one new performance improvement
project in 2002 with the report on that project to be
submitted to the Department by October 1, 2003. In all
cases, not less than two performance improvement
projects must be reported to the Department in any year
and not less than three different projects must be
reported to the Department between 2002 and 2004. These
projects are in addition to any that may be required as
the result of sub-goal performance on any MEDDIC-MS
Targeted Performance Improvement Measures. However, if
the HMO chooses to initiate or continue a project on a
topic that coincides with a required MEDDIC-MS project,
the Department will accept the report as fulfilling
both requirements during the next contract year.
The organization must implement a performance
improvement project in the area if a quality
improvement opportunity is identified. The HMO must
report to the Department on each study, including those
areas where the HMO will not pursue a performance
improvement project.
c. Clinical Priority Areas: 1) prenatal services; 2)
identification of adequate treatment for high-risk
pregnancies, including those involving substance abuse;
3) evaluating the need for specialty services; 4)
availability of comprehensive, ongoing nutrition
education, counseling, and assessments; 5) Family
Health Improvement Initiative: Smoking Cessation; 6)
children with special health care needs; 7) outpatient
management of asthma; 8) the provision of family
planning services; 9) early postpartum discharge of
mothers and infants; 10) STD screening and treatment;
11) high volume/high risk services selected by the HMO;
12) prevention and care of acute and chronic
conditions; and 13) coordination and continuity of
care.
Non-Clinical Priority Areas: 1) grievances, appeals and
complaints; 2) access to and availability of services;
3) enrollee satisfaction with HMO customer service; and
4) satisfaction with services for enrollees with
special health care needs or cultural competency of the
HMO and its providers.
In addition, the HMO may be required to conduct
performance improvement projects specific to the HMO
and to participate in one annual statewide project that
may be specified by the Department.
d. Performance Measurement and Improvement - MEDDIC-MS
Medicaid Encounter Data-Driven Improvement
Core--Measure Set:
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The Department will evaluate HMO performance using the
MEDDIC-MS technical specifications, based on
HMO-supplied encounter data and other data (for
selected measures). Evaluation of HMO performance on
each measure will be conducted on timetables determined
by the Department. The technical specifications for
each measure are established by the Department with HMO
input and are described in "MEDDIC-MS Proposed Measures
and Technical Specifications," as revised.
The Department will inform the HMO of its performance
on each measure, whether the HMO's performance
satisfied the goal requirements set by the Department
and whether a performance improvement initiative by the
HMO is required. The HMO will have 60 business days to
review and respond to the Departments performance
report. When a performance improvement initiative is
required due to sub-goal performance on the measure,
the HMO may request recalculation of the performance
level based on new or additional data the HMO may
supply, or if the HMO can demonstrate material error in
the calculation of the performance level. The
Department will provide a tentative schedule of measure
calculation dates to the HMO within 90 days of the
beginning of each calendar year in the contract period.
MEDDIC-MS consists of targeted performance improvement
measure (TPIMS) and monitoring measures. The
specifications for each TPIM includes denominator and
numerator specifications, performance goals and
requirements for actions to be taken when sub-goal
performance occurs.
Unless otherwise noted within a specific targeted
performance improvement measure, the Department may
specify minimum performance levels and require that the
HMOs develop plans to respond to levels below the
minimum performance levels. Additions, deletions or
modifications to the Targeted Performance Improvement
Measures and Monitoring Measures in the MEDDIC-MS
Technical Specifications and goals must be mutually
agreed upon by the parties. The Department will give 90
days notice to the HMO of its intent to change any of
measures, technical specifications or goals. The HMO
shall have the opportunity to comment on the measure
specifications, goals and implementation plan within
the 90 day notice period. The Department reserves the
right to require the HMO to report such performance
measure data as may be deemed necessary to monitor and
improve HMO-specific or program-wide quality
performance.
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X. Access to Premises
Allow duly authorized agents or representatives of the State or
Federal government, during normal business hours, access to HMO's
premises or HMO subcontractor's premises to inspect, audit,
monitor or otherwise evaluate the performance of the HMO's or
subcontractor's contractual activities and shall within a
reasonable time, but not more than 10 working days, produce all
records requested as part of such review or audit. In the event
right of access is requested under this Section, the HMO or
subcontractor shall, upon request, provide and make available
staff to assist in the audit or inspection effort, and provide
adequate space on the premises to reasonably accommodate the
State or Federal personnel conducting the audit or inspection
effort. All inspections or audits shall be conducted in a manner
as will not unduly interfere with the performance of HMO's or
subcontractor's activities. The HMO will be given 30 business
days to respond to any findings of an audit before the Department
shall finalize its findings. All information so obtained will be
accorded confidential treatment as provided under applicable
laws, rules or regulations.
Y. Subcontracts
Assure that all subcontracts shall be in writing, shall comply
with the provisions of Addendum I, shall include any general
requirements of this Contract that are appropriate to the service
or activity identified in Addendum I, and assure that all
subcontracts shall not terminate legal liability of the HMO under
this Contract. The HMO may subcontract for any function covered
by this Contract, subject to the requirements of this Contract.
Z. Compliance with Applicable Laws, Rules or Regulations
Observe and comply with all Federal and State laws, rules or
regulations in effect when the Contract is signed or which may
come into effect during the term of the Contract, which in any
manner affects HMO's performance under this Contract, except as
specified in Article III, Section B.
AA. Use of Providers Certified By Medicaid Program
Except in emergency situations, use only providers who have been
certified by the Medicaid program for services or items covered
by Wisconsin Medicaid. The Department reserves the right to
withhold retrospectively from the capitation payments the monies
related to services provided by non-Medicaid-certified providers,
at the Medicaid FFS rate for those services. (See Wisconsin
Administrative Code, Chapter HFS 105, for provider certification
requirements.) Every Medicaid HMO will require each physician
providing services to enrollees to
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have a unique physician identifier, as specified in Section
1173(b) of the Social Security Act.
BB. Reproduction and Distribution of Materials
Reproduce and distribute at HMO expense, according to a
reasonable Department timetable, information or documents sent to
HMO from Department that contain information the HMO-affiliated
providers must have in order to fully implement this Contract.
CC. Provision of Interpreters
Provide interpreter services for enrollees as necessary to ensure
availability of effective communication regarding treatment,
medical history or health education and/or any other component of
this contract. Furthermore, the HMO must provide for 24-hour a
day, 7-day a week access to interpreter services in languages
spoken by those individuals otherwise eligible to receive the
services provided by the HMO or its provider. Also, upon a
recipient or provider request for interpreter services in a
specific situation where care is needed, the HMO shall provide an
interpreter in time to assist adequately with all necessary care,
including urgent and emergency care. The HMO must clearly
document all such actions and results. This documentation must be
available to the Department at the Department's request.
1. Professional interpreters shall be used, when needed, where
technical, medical, or treatment information or other
matters, where impartiality is critical, are to be discussed
or where use of a family member or friend, as interpreter is
otherwise inappropriate. Family members, especially
children, should not be used as interpreters in assessments,
therapy and other situations where impartiality is critical.
2. The HMO will maintain a current list of interpreters who are
on "on call" status to provide interpreter services.
Provision of interpreter services must be in compliance with
Title VI of the Civil Rights Act.
3. The HMO must designate a person responsible for the
administration of interpreter/translation services.
4. The HMO must receive Department approval of written policies
and procedures for the provision of interpreter services.
The policies and procedures for interpreters must be
submitted as part of the certification application as well
as a list of interpreters the HMO uses and the language
spoken by each interpreter.
DD. Coordination and Continuation of Care
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Have systems in place to ensure well-managed patient care,
including at a minimum:
1. Management and integration of health care through primary
provider/gatekeeper/other means.
2. Systems to assure referrals for medically necessary,
specialty, secondary and tertiary care.
3. Systems to assure provision of care in emergency situations,
including an education process to help assure that enrollees
know where and how to obtain medically necessary care in
emergency situations.
4. Specific referral requirements. HMO shall clearly specify
referral requirements to providers and subcontractors and
keep copies of referrals (approved and denied) in a central
file or the patient's medical records.
5. Systems to assure provision of a clinical determination,
within 10 working days, at the request of the enrollee, of
the medical necessity and appropriateness of an enrollee to
continue with MH or Substance Abuse providers who are not
subcontracted by the HMO. If the HMO determines that the
enrollee does not need to continue with the non-contracted
provider, it must ensure an orderly transition of care.
EE. HMO ID Cards
The HMO may issue their own HMO ID cards. The HMO may not deny
services to an enrollee solely for failure to present an HMO
issued ID card. The Forward ID card will always determine HMO
enrollment, even where an HMO issues HMO ID cards.
FF. Federally Qualified Health Centers and Rural Health Centers
(FQHCs and RHCs)
If an HMO contracts with a facility or program, which has been
certified as an FQHC or RHC by the Medicaid program, for the
provision of services to its enrollees, the HMO must negotiate
payment rates for that FQHC or RHC on the same basis as it
negotiates with other clinics and primary providers and the HMO
must increase the FQHC's or RHC's payment in direct proportion to
the annual increase for physicians' services in the capitation
rate paid to the HMO. In other words, if an HMO receives a 10
percent increase from the Department for physicians' services,
the contracted rates paid to the FQHC or RHC either through
capitation or FFS, must be increased by at least 10 percent over
those that were in effect on the date this Contract is signed.
The Department will notify the HMOs of the percentage increase
for physician services made in the capitation rates by the
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Department when such changes occur. An HMO which contracts with
an FQHC or RHC must report to the Department within 45 days of
the end of each quarter (for example, January 1 - March 31 is due
May 15) the total amount paid to each FQHC or RHC, per month and
as reported on the 1099 forms prepared by the HMO for each FQHC
or RHC. FQHC or RHC payments include direct payments to a medical
provider who is employed by the FQHC or RHC. The report should be
for the entire HMO, aggregating all service areas if the HMO has
more than one service area.
GG. Coordination with Prenatal Care Services, School-Based Services,
Targeted Case Management Services, a Child Welfare Agencies, and
Dental Managed Care Organizations
1. Prenatal Care Services-- The HMO must sign an MOU (Addendum
IX) with all agencies in the HMO service area that are
Medicaid-certified prenatal care coordination agencies. The
MOU will be effective on the effective date of the agency's
PNCC certification or when both HMO and PNCC agency have
signed it, whichever is later. In addition, if the PNCC
wants to negotiate additional provisions into the MOU, the
HMO must negotiate in good faith and document those
negotiations. Such documentation must be available to the
Department for review on request. In addition, the HMO must
assign an HMO medical representative to interface with the
care coordinator from the prenatal care coordination agency.
This HMO representative shall work with the care coordinator
to identify what Medicaid covered services, in conjunction
with other identified social services, are to be provided to
the enrollee. The HMO is not liable for medical services
directed outside of their provider network by the care
coordinator unless prior authorized by the HMO. In addition,
the HMO is not required to pay for services provided
directly by the Prenatal Care Coordinating provider: such
services are paid on a FFS basis by the Department. The main
purpose of the MOU is to assure coordination of care between
the HMO, that provides medical services, and the Prenatal
Care Coordinating Agency, that provides outreach, risk
assessment, care planning, care coordination, and follow-up.
2. School-Based Services-- The HMO must sign an MOU (Addendum
XIII) with all School-Based Services (SBS) providers in the
HMO service area who are Medicaid-certified (a School-Based
Services provider is a school district or Cooperative
Educational Service Agency (CESA) and not the individual
schools within the school district). The MOU will be
effective on the date when both the HMO and the SBS provider
have signed it or the date the SBS provider is
Medicaid-certified, whichever is later. As described in
Addendum XIII, the purpose of the MOU is to develop policies
and procedures to avoid duplication of services and to
promote continuity of care between the HMO and SBS provider.
There are many
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situations where schools cannot provide services: after
school hours, during school vacations, and during the
summer, and these situations may interrupt the course of
treatment or otherwise affect the continuity of care. In
addition, the fact that HMOs and SBS providers may provide
the same services could lead to the duplication of services.
Therefore, an MOU is essential for the avoidance of
duplication of services and the assurance of continuity of
care. School-based services are paid FFS by Medicaid. SBS
providers, as a requirement of Medicaid/BadgerCare
certification, will be directed to negotiate MOUs with HMOs.
3. Targeted Case Management-- The HMO must assign an HMO
medical representative to interface with the case manager
from the Targeted Case Management (TCM) agency. This HMO
representative shall work with the case manager to identify
what Medicaid covered services, in conjunction with other
identified social services, are to be provided to the
enrollee. The HMO is not required to pay for medical
services directed outside of their provider network by the
case manager unless prior authorized by the HMO. The
Department will distribute a statewide list of
Medicaid-certified TCM agencies to the HMOs and periodically
update the list. Addendum XIV contains guidelines for how
HMOs and TCM agencies should coordinate care.
4. Child Welfare Agencies-- Milwaukee County HMOs must
designate at least one individual to serve as a contact
person for the Bureau of Milwaukee Child Welfare (BMCW)
agency. If the HMO chooses to designate more than one
contact person, the HMO should identify the service area for
which each contact person is responsible. The HMO must
provide all Medicaid covered mental health and substance
abuse services to individuals identified as clients of the
BMCW agency. Disputes regarding the medical necessity of
services identified in the Family Treatment Plan will be
adjudicated using the dispute process outlined in Addendum
X, except that HMOs will provide court ordered services in
accordance with Addendum II. Addendum X contains guidelines
for how Milwaukee County HMOs and the Bureau of Milwaukee
Child Welfare agency will work together to provide mental
health and substance abuse services.
HH. Physician Incentive Plans
A physician incentive plan is any compensation arrangement
between the HMO and a physician or physician group that may
directly or indirectly have the effect of reducing or limiting
services provided with respect to individuals enrolled with the
HMO.
1. The HMO shall fully comply with the physician incentive plan
requirements specified in 42 CFR s. 417.479(d) through (g)
and the requirements
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relating to subcontracts set forth in 42 CFR s. 417.479(i),
as those provisions may be amended from time to time, and
shall submit to the Department its physician incentive plans
as required under 42 CFR s. 434.470 and as requested by the
Department.
II. Advance Directives
Maintain written policies and procedures related to advance
directives. An advance directive is a written instruction, such
as a living will or durable power of attorney for health care,
recognized under Wisconsin law (whether statutory or recognized
by the courts of Wisconsin) and relating to the provision of such
care when the individual is incapacitated. HMO shall:
1. Provide written information at time of HMO enrollment to all
adults receiving medical care through the HMO regarding: (a)
the individual's rights under Wisconsin law (whether
statutory or recognized by the courts of Wisconsin) to make
decisions concerning such medical care, including the right
to accept or refuse medical or surgical treatment and the
right to formulate advance directives; and (b) the HMO's
written policies respecting the implementation of such
rights.
2. Document in the individual's medical record whether or not
the individual has executed an advance directive.
3. Shall not discriminate in the provision of care or otherwise
discriminate against an individual based on whether or not
the individual has executed an advance directive. This
provision shall not be construed as requiring the provision
of care which conflicts with an advance directive.
4. Ensure compliance with requirements of Wisconsin law
(whether statutory or recognized by the courts of Wisconsin)
respecting advance directives.
5. Provide education for staff and the community on issues
concerning advance directives.
The above provisions shall not be construed to prohibit the
application of any Wisconsin law which allows for an objection on
the basis of conscience for any health care provider or any agent
of such provider which as a matter of conscience cannot implement
an advance directive.
JJ. Ineligible Organizations
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Upon obtaining information or receiving information from the
Department or from another verifiable source, exclude from
participation in the HMO all organizations which could be included in
any of the following categories (references to the Act in this section
refer to the Social Security Act):
1. Entities Which Could Be Excluded Under Section 1128(b)(8) of the
Social Security Act.--These are entities in which a person who is
an officer, director, agent or managing employee of the entity,
or a person who has direct or indirect ownership or control
interest of 5 percent or more in the entity has:
a. Been convicted of the following crimes:
1) Program related crimes, i.e., any criminal offense
related to the delivery of an item or service under
Medicare or Medicaid (see Section 1128(a)(1) of the
Act);
2) Patient abuse, i.e., criminal offense relating to abuse
or neglect of patients in connection with the delivery
of health care (see Section 1128(a)(2) of the Act);
3) Fraud, i.e., a State or Federal crime involving fraud,
theft, embezzlement, breach of fiduciary
responsibility, or other financial misconduct in
connection with the delivery of health care or
involving an act or omission in a program operated by
or financed in whole or part by Federal, State or local
government (see Section 1128(b)(1) of the Act);
4) Obstruction of an investigation, i.e., conviction under
State or Federal law of interference or obstruction of
any investigation into any criminal offense described
in subsections a, b, or c (see Section 1128(b)(2) of
the Act); or
5) Offenses relating to controlled substances, i.e.,
conviction of a State or Federal crime relating to the
manufacture, distribution, prescription or dispensing
of a controlled substance (see Section 1128(b)(3) of
the Act).
b. Been Excluded, Debarred, Suspended, Otherwise Excluded, or
is an affiliate (as defined in such Act) of a person
described in JJ. above from participating in procurement
activities under the Federal Acquisition Regulation or from
participating in non procurement activities under
regulations issued pursuant to Executive Order No. 12549 or
under guideline implementing such order.
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c. Been Assessed a Civil Monetary Penalty under Section 1128A
of the Act.--Civil monetary penalties can be imposed on
individual providers, as well as on provider organizations,
agencies, or other entities by the DHHS Office of Inspector
General. Section 1128A authorizes their use in case of false
or fraudulent submittal of claims for payment, and certain
other violations of payment practice standards. (See Section
1128(b)(8)(B)(ii) of the Act.)
2. Entities Which Have a Direct or Indirect Substantial Contractual
Relationship with an Individual or Entity Listed in subsection
A.--A substantial contractual relationship is defined as any
contractual relationship which provides for one or more of the
following services:
a. The administration, management, or provision of medical
services;
b. The establishment of policies pertaining to the
administration, management, or provision of medical
services; or
c. The provision of operational support for the administration,
management, or provision of medical services.
3. Entities Which Employ, Contract With, or Contract Through Any
Individual or Entity That is Excluded From Participation in
Medicaid under Section 1128 or 1128A, for the Provision (Directly
or Indirectly) of Health Care, Utilization Review, Medical Social
Work or Administrative Services.--For the services listed, HMO
must exclude from contracting any entity which employs, contracts
with, or contracts through an entity which has been excluded from
participation in Medicaid by the Secretary under the authority of
Section 1128 or 1128A of the Act.
HMO attests by signing this Contract that it excludes from
participation in the HMO all organizations which could be included in
any of the above categories.
KK. Clinical Laboratory Improvement Amendments
Use only certain laboratories. All laboratory testing sites providing
services under this Contract must have a valid Clinical Laboratory
Improvement Amendments (CLIA) certificate along with a CLIA
identification number, and comply with CLIA regulations as specified
by 42 CFR Part 493, "Laboratory Requirements." Those laboratories with
certificates will provide only the types of tests permitted under the
terms of their certification.
LL. Limitation on Fertility Enhancing Drugs
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The HMO must get prior authorization from the Chief Medical Officer in
the Division of Health Care Financing before an HMO provider treats an
enrollee with any of the following drug products: Chorionic
Gonadotropin, Clomiphene, Gonadorelin, Menotropins, Urofollitropin and
any other new fertility enhancing drugs.
MM. Reporting of Communicable Diseases
As required by Wis. Stats. 252.05, 252.15(5)(a)6 and 252.17(7)(9b),
Physicians, Physician Assistants, Podiatrists, Nurses, Nurse Midwives,
Physical Therapists, and Dietitians affiliated with a Medicaid HMO
shall report the appearance, suspicion or diagnosis of a communicable
disease or death resulting from a communicable disease to the Local
Health Department for any enrollee treated or visited by the provider.
Reports of human immunodeficiency virus (HIV) infection shall be made
directly to the State Epidemiologist. Such reports shall include the
name, sex, age, residence, communicable disease, and any other facts
required by the Local Health Department and Wisconsin Division of
Public Health. Such reporting shall be made within 24 hours of
learning about the communicable disease or death or as specified in
Wis. Admin. Code HFS 145.04, Appendix A. Charts and reporting forms on
communicable diseases are available from the Local Health Department.
Each laboratory subcontracted or otherwise affiliated with the HMO
shall report the identification or suspected identification of any
communicable disease listed in Wis. Admin. Rules 145, Appendix A to
the local health department; reports of HIV infections shall be made
directly to the State Epidemiologist.
NN. Medicaid/BadgerCare HMO Advocate Requirements
Each HMO must employ a Medicaid/BadgerCare HMO Advocate during the
entire contract term. The HMO Advocate is to work with both enrollees
and providers to facilitate the provision of Medicaid benefits to
enrollees; is responsible for making recommendations to management on
any changes needed to improve either the care provided or the way care
is delivered; and must be in an organizational location within the HMO
which provides the authority needed to carry out these tasks. The
detailed requirements of the HMO Advocate are listed below:
1. Functions of the Medicaid/BadgerCare HMO Advocate(s)
a. Investigation and resolution of access and cultural
sensitivity issues identified by HMO staff, State staff,
providers, advocate organizations, and enrollees.
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b. Monitoring formal and informal grievances with the grievance
personnel for purposes of identification of trends or
specific problem areas of access and care delivery. An
aspect of the monitoring function is the ongoing
participation in the HMO grievance committee.
c. Recommendation of policy and procedural changes to HMO
management including those needed to ensure and/or improve
enrollee access to care and enrollee quality of care.
Changes can be recommended for both internal administrative
policies and for subcontracted providers.
d. Act as the primary contact for enrollee advocacy groups.
Work with enrollee advocacy groups on an ongoing basis to
identify and correct enrollee access barriers.
e. Act as the primary contact for local community based
organizations (local governmental units, non-profit
agencies, etc.). Work with the local community based
organizations on an ongoing basis to acquire knowledge and
insight regarding the special health care needs of
enrollees.
f. Participate in the Advocacy Program for Managed Care that is
organized by the Department. Such participation includes the
following: attendance, on an as needed basis, at the
Regional Forums chaired by a Department staff person, and at
the semiannual Statewide Forum; work with Division of Health
Care Financing Managed Care staff person assigned to the HMO
on issues of access to medical care and quality of medical
care; work with the Enrollment Contractor staff persons on
issues of access to medical care, quality of medical care,
and enrollment/ disenrollment; attendance, on an as needed
basis, at bi-monthly Advocacy Team meetings, which will be
attended by the Division of Health Care Financing Managed
Care Staff, enrollment contractor staff, community based
organizations, recipient service representatives from the
Fiscal Agent, and EDS ombudsman.
g. Ongoing analysis of internal HMO system functions, with HMO
staff, as these functions affect enrollee access to medical
care and enrollee quality of medical care.
h. Organization and provision of ongoing training and
educational materials for HMO staff and providers to enhance
their understanding of the values and practices of all
cultures with which the HMO interacts.
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i. Provision of ongoing input to HMO management on how changes
in the HMO provider network will affect enrollee access to
medical care and enrollee quality and continuity of care.
Participation in the development and coordination of plans
to minimize any potential problems that could be caused by
provider network changes.
j. Review and approve all HMO informing material to be
distributed to enrollees for the purpose of assessing
clarity and accuracy.
k. Provision of assistance to enrollees and their authorized
representatives for the purpose of obtaining medical
records.
l. The lead advocate position will be responsible for overall
evaluation of the HMO's internal advocacy plan and will be
required to monitor any contracts the HMO may enter into for
external advocacy with culturally diverse associations or
agencies. The lead advocate will be responsible for training
the associations or agencies and assuring their input into
the HMO's advocacy plan.
2. Staff Requirements and Authority of the Medicaid/BadgerCare HMO
Advocate
a. At a minimum one HMO Advocate must be located in the
organizational structure so that the Advocate has the
authority to perform the functions and duties listed in
(1)(a-l).
The HMO Certification Application requires HMOs to state the
staffing levels to perform the functions and duties listed
in (1)(a-l) in terms of number of full and part time staff
and total Full Time Equivalents (FTEs) assigned to these
tasks. The Department assumes that an HMO acting as an
Administrative Service Organization (ASO) for another HMO
will have one Advocate or FTE position for each ASO contract
as well as maintaining their own internal advocate. An HMO
may employ less than a Full Time Equivalent (FTE) advocate
position, but must justify to the satisfaction of the
Department why less than one FTE position will suffice the
HMO's enrollee population. The HMO must also regularly
evaluate the advocate position, workplan, and job duties and
allocate an FTE advocate position to meet the duties listed
in (1)(a-l) if there is significant increase in the HMO's
enrollee population or in the HMO service area. The
Department reserves the right to require an HMO to employ an
FTE advocate position if the HMO does not demonstrate
adequacy of a part-time advocate position.
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In order to meet the requirement for the Advocate position
statewide, the DHFS encourages HMOs to contract or have a
formal memorandum of understanding for advocacy and/or
translation services with associations or organizations who
have culturally diverse populations within the HMO service
area. However, the overall or lead responsibility for the
advocate position will be within each HMO. HMOs must monitor
the effectiveness of the associations and agencies under
contract and may alter the contract(s) with written
notification to the Department.
b. The HMO Advocate shall have authority for facilitating and
assuring access to all medically necessary services as
stipulated in this Contract for each enrollee.
c. The HMO Advocate staffing levels submitted in the HMO
Certification Application shall be maintained, and solely
devoted to the functions and duties listed in (1)(a-l)
throughout the contract term. Changes in the HMO Advocate
staffing levels must be approved by the Department thirty
days prior to the effective date of the change.
d. The HMO Advocate shall develop prior to contract signing,
and shall maintain and modify as necessary, throughout the
Contract term, a Medicaid/BadgerCare HMO Advocacy workplan,
with time lines and activities specified.
OO. HMO Designation of Staff Person as Contract Representative
The HMO is required to designate a staff person to act as liaison
to the Department on all issues that relate to the contract
between the Department and the HMO. The contract representative
will be authorized to represent the HMO regarding inquiries
pertaining to the Contract, will be available during normal
business hours, and will have decision making authority in regard
to urgent situations that arise. The Contract representative will
be responsible for follow-up on contract inquiries initiated by
the Department.
PP. Subcontracts with Local Health Departments
The Department encourages the HMO to contract with local health
departments for the provision of care to Medicaid/BadgerCare
enrollees in order to assure continuity and culturally
appropriate care and services. Local health departments can
provide HealthCheck outreach and screening, immunizations, blood
lead screening services, and services to targeted populations
within the community for
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the prevention, investigation, and control of communicable
diseases (e.g., tuberculosis, HIV/AIDS, sexually transmitted
diseases, hepatitis and others). WIC projects provide nutrition
services and supplemental foods, breastfeeding promotion and
support; and immunization screening. Many projects screen for
blood lead poisoning during the WIC appointment.
The Department encourages HMOs to work closely with local health
departments as noted in Addendum XXIV - Recommendations for
Coordination between HMOs and Local Health Departments and
Community-Based Health Organizations.
Local health departments have a wide variety of resources that
could be coordinated with HMOs to produce more efficient and cost
effective care for HMO enrollees. Examples of such resources are
ongoing programs of medical services, materials on health
education, prevention, and disease states, expertise on
outreaching specific subpopulations, communication networks with
varieties of medical providers, advocates, community-based health
organizations, and social service agencies, and access to ongoing
studies of and information about health status and disease trends
and patterns.
QQ. Subcontracts with Community-Based Health Organizations
The Department encourages the HMO to contract with
community-based health organizations for the provision of care to
Medicaid/BadgerCare enrollees in order to assure continuity and
culturally appropriate care and services. Community-based
organizations can provide HealthCheck outreach and screening,
immunizations, family-planning services, and other types of
services.
The Department encourages HMOs to work closely with
community-based health organizations as noted in Addendum XXIV -
Recommendations for Coordination between HMOs and Local Health
Departments and Community-Based Health Organizations.
Community-based health organizations may also provide services,
such as WIC services, that HMOs are required by Federal law to
coordinate with and refer to, as appropriate.
RR. Prescription Drugs
1. If an HMO elects not to cover dental services, the HMO is
liable for the cost of all medically necessary prescription
drugs when ordered by a certified Medicaid dental provider.
2. When an enrollee elects to use a family planning provider
that is non-HMO affiliated, the HMO is liable for the cost
of all medically necessary drugs when ordered by a certified
Medicaid family planning provider.
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SS. HMO Attestation
The Chief Executive Officer (CEO), the Chief Financial Officer
(CFO) or designee must attest to the best of their knowledge to
the truthfulness, accuracy, and completeness of all data
submitted to the Department at the time of submission. This
includes encounter data, NICU, AIDS/Vent, Sterilization Reports
or any other data in which the HMO paid claims.
TT. Fraud and Abuse Investigations
HMO agrees to cooperate with the Department on fraud and abuse
investigations. In addition, the HMO agrees to report allegations
of fraud and abuse (both provider and enrollee) to the Department
within fifteen days of the suspected fraud or abuse coming to the
attention of the HMO. Failure on the part of HMOs to cooperate or
report fraud and or abuse may result in any applicable sanctions
under Article IX.
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ARTICLE IV
IV. FUNCTIONS AND DUTIES OF THE DEPARTMENT
In consideration of the functions and duties of the HMO contained in this
Contract, the Department shall:
A. Eligibility Determination
Identify Medicaid/BadgerCare recipients who are eligible for
enrollment in HMOs as a result of eligibility under the following
eligibility status:
<Table>
<Caption>
MED STAT CAP RATE* DESCRIPTION
- -------- --------- -----------
31, WN A AFDC-Regular
32 A AFDC-Unemployed
38, 39 A AFDC-Related, No Cash Payment
CC, CM, GC, PC A Healthy Start Children
E2 A AFDC-Related, No Cash Payment
GE A Healthy Start Children Ages 15-18
N1, N2 A Medicaid Newborn
UA, WU A AFDC-Related, Unemployed
WH A AFDC Employed over 100 Hours a Month
X1, X2, X3, X4 A AFDC-Related, No Cash Payment
B1 A BadgerCare - Income equal or
greater than 100% of FPL, and
less than or equal to 150% of
FPL, Kids, No premium.
B4 A BadgerCare - Income equal or
greater than 100% of FPL, and
less than or equal to 150% of
FPL, Adults, No premium.
B2 A BadgerCare - Income greater than
150% of FPL, and less than
185% of FPL, Kids, Premium.
B5 A Income greater than 150% of FPL,
and less than 185% of FPL,
Adults, Premium.
B3 A Income equal or greater than
185% of the FPL, and less than
200% of the FPL, Kids, Premium.
B6 A Income equal or greater than
185% of the FPL, and less than
200% of the FPL, Adults,
Premium.
GP A Income less than 100% of FPL,
Adults Parents of OBRA kids
(AFDC), No premium.
95 B Pregnant Women in Intact Families
A6, A7, A8, A9 B Pregnant Woman, IRCA Alien
E3, E4 B Extension for Pregnant Woman
PW, P1 B Healthy Start Pregnant Women
</Table>
*A = AFDC/Healthy Start Children/BadgerCare capitation rate.
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*B = Pregnant Women Healthy Start capitation rate.
B. Enrollment
Promptly notify the HMO of all Medicaid/BadgerCare recipients enrolled
in the HMO under this Contract. Notification shall be effected through
the HMO Enrollment Reports. All recipients listed as an ADD or
CONTINUE on either the Initial or Final HMO Enrollment Report are
members of the HMO during the enrollment month. The reports shall be
generated in the sequence specified under HMO ENROLLMENT REPORTS.
These reports shall be in both tape and hard copy formats or available
through electronic file transfer capability and shall include Medical
Status Codes. The Department will make all reasonable efforts to
enroll pregnancy cases as soon as possible.
C. Disenrollment
Promptly notify the HMO of all Medicaid/BadgerCare recipients no
longer eligible to receive services through the HMO under this
Contract. Notification shall be effected through the HMO Enrollment
Reports which the Department will transmit to the HMO for each month
of coverage throughout the term of the Contract. The reports shall be
generated in the sequence under HMO ENROLLMENT REPORTS. Any recipient
who was enrolled in the HMO in the previous enrollment month, but does
not appear as an ADD or CONTINUE on either the Initial or Final HMO
Enrollment Report for the current enrollment month, is disenrolled
from the HMO effective the last day of the previous enrollment month.
D. HMO Enrollment Reports
For each month of coverage throughout the term of the Contract, the
Department shall transmit "HMO Enrollment Reports" to the HMO. These
reports will provide the HMO with ongoing information about its
Medicaid/ BadgerCare enrollees and disenrollees and will be used as
the basis for the monthly capitation claims described in Article
V--PAYMENT TO THE HMO. The HMO Enrollment Reports will be generated in
the following sequence:
1. The Initial HMO Enrollment Report will list all of the HMO's
enrollees and disenrollees for the enrollment month that are
known on the date of report generation. The Initial HMO
Enrollment Report will be available to the HMO on or about the
twenty-first of each month. A capitation claim shall be generated
for each enrollee listed as an ADD or CONTINUE on this report.
Enrollees who appear as PENDING on the Initial Report and are
reinstated into the HMO prior to the end of the month will appear
as a CONTINUE on the Final Report and a capitation claim shall be
generated at that time.
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2. The final HMO Enrollment Report will list all of the HMO's
enrollees for the enrollment month, that were not included in the
Initial HMO Enrollment Report. The Final HMO Enrollment Report
will be available to the HMO by the first day of the capitation
month. A capitation claim shall be generated for each enrollee
listed as an ADD or CONTINUE on this report. Enrollees in PENDING
status will not be included on the final report.
3. The Department shall provide HMOs with effective dates for
medical status code changes, county changes and other address
changes in each enrollment report to the extent that the county
reports these to the Department.
E. Utilization Review and Control
Waive, to the extent allowed by law, any present Department
requirements for prior authorization, second opinions, co-payment, or
other Medicaid restrictions for the provision of contract services
provided by the HMO to enrollees, except as may be provided in
Addendum II.
F. HMO Review
Submit to HMOs for prior approval materials that describe specific
HMOs and that will be distributed by the Department or County to
recipients.
G. HMO Review of Study or Audit Results
Submit to HMOs for a 30 business day review/comment period, any HMO
Medicaid/BadgerCare audits, the annual HMO Comparison Report, HMO
Consumer Satisfaction Reports, or any other HMO Medicaid studies the
Department releases to the public.
H. Vaccines
Provide certain vaccines to HMO providers for administration to
Medicaid/ BadgerCare HMO enrollees according to the policies and
procedures in the Wisconsin Medicaid and BadgerCare Physicians
Services Handbook. The Department will reimburse the HMO for the cost
of vaccines that are newly approved during the contract year and not
yet part of the Vaccine for Children program. The cost of the vaccine
shall be the same as the cost to the Department of buying the new
vaccine through the Vaccine for Children program. The HMO retains
liability for the cost of administering the vaccines.
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I. Coordination of Benefits
Maintain a report of recovered money reported by the HMO and its
subcontractor.
J. Wisconsin Medicaid Provider Reports
Provide a monthly electronic listing of all Wisconsin Medicaid
certified providers to include, at a minimum, the name, address,
Wisconsin Medicaid provider ID number, and dates of certification in
Wisconsin Medicaid.
K. Enrollee Health Status and Primary Language Report
The Department will provide the HMO with an enrollee health status and
primary language report of all enrollees who have agreed to
participate with the gathering of this data. The reports will be
provided to the HMO on a monthly basis. The purpose of this report is
to assist HMOs with continuity of care issues and to assist with the
identification of Non-English speaking enrollees and to facilitate
appointments for enrollees who have urgent health care needs.
L. Fraud and Abuse Training
The Department will provide fraud and abuse detection training to the
HMOs annually.
M. Provision of Data to HMOs
Provide to each HMO the following data related to the HMO's members:
1. Lead testing performed and sent to the State Lab of Hygiene for
analysis
2. Immunization information from the Wisconsin immunization registry
to the extent available. The Department will make every effort to
get the Wisconsin Immunization Registry information to HMOs.
N. Special Procedures for Retroactive Payments Adjustments for Pregnant
BadgerCare Enrollees
The Department shall develop and implement a procedure by which HMOs
may provide documentation that a BadgerCare enrollee should be
redesignated as a Healthy Start Pregnant Women. When a HMO notifies
the Department in writing of a pregnant BadgerCare enrollee who is
eligible for Healthy Start, the Department will facilitate the
correction of the enrollee's medical status code retroactive to the
beginning of the pregnancy or the first day of enrollment, whichever
is later. Providing that correct and validated documentation is
available, the Department will assume a pregnancy duration of 38 weeks
for purposes of establishing an effective date for the Healthy Start
Pregnant Women medical status code and for providing retroactive
capitation adjustments.
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ARTICLE V
V. PAYMENT TO THE HMO
A. Capitation Rates
In full consideration of contract services rendered by the HMO, the
Department agrees to pay the HMO monthly payments based on the
capitation rate specified in Addendum VII. The capitation rate shall
be prospectively designed to be less than the cost of providing the
same services covered under this Contract to a comparable Medicaid
population on a FFS basis. The capitation rate shall not include any
amount for recoupment of losses incurred by the HMO under previous
contracts. The Department shall have the right to make separate
payments to subcontractors directly on a monthly basis when the
Department determines it is necessary to assure continued access to
quality care. Such separate payment will be made only to
subcontractors that receive more than 90 percent of the contracted
monthly capitation rate from the Department to the HMO.
B. Actuarial Basis
The capitation rate is calculated on an actuarial basis (specified in
Addendum VII) recognizing the payment limits set forth in 42 CFR
447.361.
C. Renegotiation
The monthly capitation rates set forth in this article shall not be
subject to renegotiation during the contract term or retroactively
after the contract term, unless such renegotiation is required by
changes in Federal or State laws, rules or regulations.
D. Reinsurance
The HMO may obtain a risk-sharing arrangement from an insurer other
than the Department for coverage of enrollees under this Contract,
provided that the HMO remains substantially at risk for providing
services under this Contract.
E. Neonatal Intensive Care Unit Risk-Sharing
The Department agrees to reimburse each HMO for a portion of the
neonatal intensive care unit (NICU) costs incurred by the HMO if the
HMO's average number of NICU days per thousand member year exceeds 75
days per thousand member year during the contract period. This
reimbursement shall be provided in the following manner:
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1. The Department shall reimburse the HMO for the average number of
NICU days per thousand member years that the HMO exceeds 75 NICU
days per thousand member years per county during the contract
period. (Please see addendum XIX for reporting requirements.) For
each day that the HMO's average number of NICU days per thousand
member years exceeds 75 NICU days per thousand member years, the
Department will reimburse the HMO for ninety percent (90%) of the
HMO's NICU cost per day, not to exceed $1,443 per day.
2. The HMO's NICU cost per day shall include the HMO's NICU
inpatient payment per day and the HMO's associated physician
payments. Associated physician payments refers to total HMO
payments made by the HMO to the physician(s) for services
provided to the infant during the NICU stay. Associated physician
payments will be divided by the number of days reported for the
NICU stay to determine the HMO's payment per day of associated
physician payments.
3. Neonatal intensive care unit days cover any newborn transferred
or directly admitted after birth, to a Level II, Level III or
Level IV SCN/NICD for treatment and/or observation under the care
of a neonatologist or pediatrician. NICU coverage will continue
until the infant is deemed medically stable to be discharged to a
newborn nursery, medical floor or home.
NICU days will also cover any newborn infant transferred or
directly admitted after birth to a Level II, Level III or Level
IV SCN/NICD who requires transfer to another institution for a
severe, compromised physical status, diagnostic testing or
surgical intervention which cannot be provided for at the
hospital of initial admission. NICU coverage will continue until
the infant is transferred back to the initial hospital and deemed
medically stable to be discharged to a newborn nursery, medical
floor or home.
Level I facilities are those which are designed primarily for the
care of neonatal patients who have no complications but which are
able to provide competent emergency services when the need
arises. Level II facilities provide a full range of services for
low birthweight neonates who are not sick, but require frequent
feeding, and neonates who require more hours of nursing than do
normal neonates. Level III facilities provide a full range of
newborn intensive care services for neonatal patients who do not
require intensive care but require 6-12 hours of nursing each
day. Level IV facilities provide a full range of services for
severely ill neonates who require constant nursing and continuous
cardiopulmonary and other support.
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NOTE: HMOs cannot claim additional reimbursement under both the
NICU risk-sharing policy and the ventilator dependent policy for
the same enrollee on the same date of service.
4. HMOs must submit all data requested by the Department for
calculating the NICU reimbursement in the format specified by the
Department before May 1 of the following calendar year. The data
and data format required is defined in Addendum XIX. The
Department will calculate the NICU reimbursement amount by
county.
5. NICU reimbursement shall be made by the Department to the HMO
after the end of the contract year, following submittal of all
needed NICU data from the HMO. The Department will reimburse the
HMO within sixty days of receipt of all necessary data from the
HMO. A final adjustment to the NICU reimbursement amount may be
made by the Department one year after the initial payment. This
adjustment will be based on updated NICU days and eligible
months.
F. Payment Schedule
Payment to the HMO shall be based on the HMO Enrollment Reports which
the Department will transmit to the HMO according to the schedule in
Article IV. D. Payment for each person listed as an ADD or CONTINUE on
the HMO Enrollment Reports shall be made by the Department within 60
days of the date the report is generated. Also, all retroactive
capitation payments for newborns shall be paid within 60 days of the
child's first appearance on an enrollment report. (See Article V. G.)
Any claim that is not paid within these time limits shall be denied by
the Department and the recipient shall be disenrolled from the HMO for
the capitation month specified on the claim. Notification of all paid
and denied claims shall be given through the weekly Remittance Status
Report, which is available on both tape and hard copy.
G. Capitation Payments For Newborns
The HMO shall authorize provision of contract services to the newborn
child of an enrolled mother for the first ten days of life. The
child's date of birth should be counted as day one. In addition, if
the child is reported within 100 days of its date of birth, the HMO
shall provide contract services to the child from its date of birth
until the child is disenrolled from the HMO. The HMO will receive a
separate capitation payment for the month of birth and for all other
months the HMO is responsible for providing contract services to the
child. If the child is not reported within 100 days of its date of
birth the child will not be retroactively enrolled into the HMO. In
this case the HMO is not responsible for payment of services provided
prior to the child's enrollment and will receive no capitation
payments for that time period and may recoup from providers for any
services that were
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authorized in that 100 day time period. The providers who gave
services in this 100 day time period may then bill the Department on a
FFS basis. More detailed information for providers on billing the
Department on a FFS basis in these situations can be found in Part A,
Section IX, of the Wisconsin Medicaid Provider Handbook.
HMOs, or their providers, must complete an HMO Newborn Report (example
and instructions in Addendum XVII) for newborns. The HMO shall report
all births to the Department's fiscal agent as soon as possible after
the date of birth, but at least monthly. Prompt HMO reporting of
newborns will facilitate retroactive enrollment and capitation
payments for newborns, since this newborn reporting will ensure the
newborn's Medicaid/BadgerCare eligibility for the first 12 months of
life contingent upon the newborn continuously residing with the
mother.
H. Coordination of Benefits (COB)
The HMO must actively pursue, collect and retain all monies from all
available resources for services to enrollees covered under this
Contract except where the amount of reimbursement the HMO can
reasonably expect to receive is less than the estimated cost of
recovery (this exception does not apply to collections for AIDS and
ventilator dependent patients), or except as provided in Addendum II.
COB recoveries will be done by post-payment billing (pay and chase)
for certain prenatal care and preventive pediatric services.
Post-payment billing will also be done in situations where the third
party liability is derived from a parent whose obligation to pay is
being enforced by the State Child Support Enforcement Agency and the
provider has not received payment within 30 days after the date of
service.
1. Cost effectiveness of recovery is determined by, but not limited
to time, effort, and capital outlay required to perform the
activity. The HMO must be able to specify the threshold amount or
other guidelines used in determining whether to seek
reimbursement from a liable third party, or describe the process
by which the HMO determines seeking reimbursement would not be
cost effective, upon request of the Department.
2. To assure compliance, records shall be maintained by the HMO of
all COB collections and reports shall be made quarterly on the
form designated by the Department in Addendum VI. HMOs must be
able to demonstrate that appropriate collection efforts and
appropriate recovery actions were pursued. The Department has the
right to review all billing histories and other data related to
COB activities for enrollees. HMOs must seek from all enrollees'
information on other available resources. HMOs must also seek to
coordinate benefits before claiming reimbursement from the
Department for the AIDS and ventilator dependent enrollees:
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a. Other available resources may include, but are not limited
to, all other State or Federal medical care programs which
are primary to Medicaid, group or individual health
insurance, ERISAs, service benefit plans, the insurance of
absent parents who may have insurance to pay medical care
for spouses or minor enrollees, and subrogation/workers
compensation collections.
b. Subrogation collections are any recoverable amounts arising
out of settlement of personal injury, medical malpractice,
product liability, or Worker's Compensation. State
subrogation rights have been extended to HMOs under s.
49.89(9), Act 31, Laws of 1989. After attorneys' fees and
expenses have been paid, the HMO shall collect the full
amount paid on behalf of the enrollee.
3. Section 1912(b) of the Social Security Act must be construed in a
beneficiary-specific manner. The purpose of the distribution
provision is to permit the beneficiary to retain TPL benefits to
which he or she is entitled to except to the extent that Medicaid
(or the HMO on behalf of Medicaid) is reimbursed for its costs.
The HMO is free, within the constraints of State law and this
contract, to make whatever case it can to recover the costs it
incurred on behalf of its enrollee. It can use the Medicaid fee
schedule, an estimate of what a capitated physician would charge
on a FFS basis, the value of the care provided in the market
place or some other acceptable proxy as the basis of recovery.
However, any excess recovery, over and above the cost of care
(however the HMO chooses to define that cost), must be returned
to the beneficiary. HMOs may not collect from amounts allotted to
the beneficiary in a judgement or court-approved settlement. The
HMO is to follow the practices outlined in the DHFS Casualty
Recovery Manual.
4. Where the HMO has entered a risk-sharing arrangement with the
Department, the COB collection and distribution shall follow the
procedures described in Addendum III of this Contract. Act 27,
Laws of 1995 extended assignment rights to HMOs under s. 632.72.
5. COB collections are the responsibility of the HMO or its
subcontractors. Subcontractors must report COB information to the
HMO. HMOs and subcontractors shall not pursue collection from the
enrollee, but directly from the third party payer. Access to
medical services will not be restricted due to COB collection.
6. The following requirement shall apply if the Contractor (or the
Contractor's parent firm and/or any subdivision or subsidiary of
either the Contractor's parent firm or of the Contractor) is a
health care insurer (including, but not limited to, a group
health insurer and/or health
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maintenance organization) licensed by the Wisconsin Office of the
Commissioner of Insurance and/or a third-party administrator for
a group or individual health insurer(s), health maintenance
organization(s), and/or employer self-insurer health plan(s):
a. Throughout the Contract term, these insurers and third-party
administrators shall comply in full with the provision of
subsection 49.475 of the Wisconsin Statutes. Such compliance
shall include the routine provision of information to the
Department in a manner and electronic format prescribed by
the Department and based on a monthly schedule established
by the Department. The type of information provided shall be
consistent with the Department's written specifications.
b. Throughout the Contract term, these insurers and third-party
administrators shall also accept and properly process
postpayment billings from the Department's fiscal agent for
health care services and items received by Wisconsin
Medicaid enrollees.
7. If, at any time during the contract term, any of the insurers or
third party administrators fail, in whole or in part, to adhere
to the requirements of (Article V. H. subsection 6. (a.) or
(6.(b.)) above, the Department may take the remedial measures
specified in Article IX. D. 1. and Article X. B. (2).
I. Recoupments
The Department will not normally recoup HMO per capita payments when
the HMO actually provided service. However, in situations where the
Medicaid enrollee cannot use HMO facilities, the Department will
recoup HMO capitation payments. Such situations are described more
fully below:
1. The Department will recoup HMO capitation payments for the
following situations where an enrollee's HMO status has changed
before the 1st day of a month for which a capitation payment has
been made:
a. enrollee moves out of the HMO's service area
b. enrollee enters a public institution
c. enrollee dies
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2. The Department will recoup HMO capitation payments for the
following situations where the Department initiates a change in
an enrollee's HMO status on a retroactive basis, reflecting the
fact that the HMO was not able to provide services. In these
situations, recoupments for multiple month's capitation payments
are more likely.
a. correction of a computer or human error, where the person
was never really enrolled in the HMO.
b. disenrollments of enrollees for reasons of pregnancy and
continuity of care, or for reasons specified in Addendum II.
3. In instances where membership is disputed between two HMOs, the
Department shall be the final arbitrator of HMO membership and
reserves the right to recoup an inappropriate capitation payment.
4. If an HMO enrollee moves out of the HMO service area, the
enrollee will be disenrolled from the HMO on the date the
enrollee moved as verified by the eligibility worker. If the
eligibility worker is unable to verify the enrollee's move, the
HMO may mail a "certified return receipt requested" letter to the
enrollee to verify the move. The enrollee must sign for the
letter. A copy of the letter and the signed return receipt must
be sent to the Department or its designee within twenty days of
the enrollees' signature date. If this criteria is met the
effective date of the disenrollment is the first of the month in
which the returned registered receipt requested letter was sent.
Documentation that fails to meet the twenty-day criteria will
result in disenrollment the first of the month in which the HMO
supplied information to the Department or its designee. This
policy does not apply to extended service area requests that have
been approved by the HMO unless the enrollee moves out of the
extended service area or HMO's service area. Any capitation
payment made for periods of time after disenrollment will be
recouped.
5. If a contract is terminated, recoupments will be handled through
a payment by the HMO within 30 business days of contract
termination.
6. If an HMO is unable to meet the HealthCheck requirements
specified in Article III. B, 10.
J. Payment for Aids, HIV-Positive, and Ventilator Dependent
The Department will pay the HMO's costs of providing Medicaid-covered
services to HMO enrollees who meet the criteria in this section, by
HMO service area. These payments will be made based on the data
submitted by the HMO to the Department on a quarterly basis. The data
submission and payment schedule is
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included as Addendum IV to this Contract. Reimbursement already
provided to the HMO in the form of capitation payments for qualified
enrollees will be deducted from 100 percent reimbursement payments.
One-hundred percent reimbursement refers to full reimbursement of HMO
costs for providing Medicaid services to the above enrollees. The
criteria for enrollees are:
1. Ventilator Assisted Patients----Costs incurred for enrollees who
need ventilator treatment services qualify for reimbursement if
the enrollee meets the following criteria:
a. For the purposes of this reimbursement, a
ventilator-assisted patient must have died while on total
respiratory support or must meet all of the criteria below:
1) The patient must require equipment that provides total
respiratory support. This equipment may be a volume
ventilator, a negative pressure ventilator, a
continuous positive airway pressure (CPAP) system, or a
Bi (inspiratory and expiratory) PAP. The patient may
need a combination of these systems. Any equipment used
only for the treatment of sleep apnea does not qualify
as total respiratory support.
2) The total respiratory support must be required for a
total of six or more hours per 24 hours.
3) The patient must have total respiratory support for at
least 30 days which need not be continuous.
4) The patient must have absolute need for the respiratory
support, as documented by appropriate blood gases.
b. The HMO will submit the following written documentation to
qualify enrollees for reimbursement at the same time as the
quarterly reports identified in Addendum IV:
1) The Department's designated form.
2) A signed statement from the doctor attesting to the
need of the patient.
3) Copies of progress notes which show the need for
continuation of total ventilatory support, any change
in the type of ventilatory support and the removal of
the ventilatory support.
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Copies of lab reports must be submitted if the progress
notes do not include blood gas levels.
c. Dates of enhanced funding are based on the following
methodology:
1) Day one is the day that the patient is placed on the
ventilator. If the patient is on the ventilator for
less than six hours on the first day, the use must
continue into the next day and be more than six total
hours.
2) Each day that the patient is on the ventilator for a
part of any day, as long as it is part of the six total
hours per 24 hours, counts as a day for enhanced
funding.
3) The period of enhanced funding starts on the first day
of the month that the patient was placed on ventilator
support. It ends on the last day of the month after
which the patient is removed from the ventilatory
support, or at the end of the hospital stay, whichever
is later.
2. HMOs cannot claim additional reimbursement under both the
NICU risk-sharing policy and the ventilator dependent policy
for the same enrollee on the same date of service.
3. AIDS or HIV-Positive with Anti Retroviral Drug
Treatment--Costs for services provided to enrollees with a
confirmed diagnosis of AIDS, as indicated by an ICD-9-CM
diagnosis code or HIV-Positive who are on anti retroviral
drug treatment approved by the Food and Drug Administration,
qualify for reimbursement. Written requests to qualify
enrollees for reimbursement must be submitted by the HMO to
the Contract Monitor. These requests should be batched and
submitted with the reports identified in Addendum IV. A
signed statement from a physician that indicates a diagnosis
of AIDS or HIV-Positive and that the patient is on an Anti
Retroviral Drug treatment must accompany each request. One
hundred percent reimbursement will be effective for services
provided on or after the first day of the month in which
treatment begins.
a. For AIDS and HIV -- Positive enrollees retroactively
disenrolled under Article VII of this Contract, the HMO
will have to back out the cost of the care provided
during the backdated period from the reports in
Addendum IV. Part D.
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b. Submission of Data -- As required by the Wisconsin
Administrative Code HFS 106.03, payment data or
adjustment data for AIDS and/or vent enrollees must be
received by the Department's fiscal agent within 365
days after the date of the service. If the HMO cannot
meet this requirement, the HMO must provide
documentation that substantiates the delay. The
Department will make the final determination to pay or
deny the services. The Department will exercise its
discretion reasonably in making the determination to
waive the 365-day billing requirement.
4. NICU days for which the HMO will collect 100 percent
reimbursement cannot be counted under the NICU risk-sharing
policy in this Contract. (HMOs cannot choose between the 100
percent policy and the NICU policy; if a cost qualifies
under the 100 percent policy, it must be reported under that
policy.)
The HMO will manage the care of these enrollees, produce
quarterly cost and utilization reports and meet with the
Department on a quarterly basis to discuss cost and other
issues related to care management for these.
5. The HMO must submit reports (eligibility summary, cost
summary, inpatient hospital utilization summary, and detail)
to the Department according to the schedule and in the
format specified in Addendum IV.
ARTICLE VI
VI. REPORTS, DATA, AND COMPUTER/DATA REPORTING SYSTEM
A. Disclosure
The HMO and any subcontractors shall make available to the Department,
the Department's authorized agents, and appropriate representatives of
the U.S. Department of Health and Human Services any financial records
of the HMO or subcontractors which relate to the HMO's capacity to
bear the risk of potential financial losses, or to the services
performed and amounts paid or payable under this Contract. The HMO
shall comply with applicable record keeping requirements specified in
HFS 105.02(1)-(7) Wis. Adm. Code, as amended.
B. Periodic Reports
The HMO agrees to furnish within the Department's time frame and
within the Department's stated form and format, information and/or
data from its records to
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the Department, and to the Department's authorized agents, which the
Department may require to administer this Contract, including but not
limited to the following:
1. Summaries of amounts recovered from third parties for services
rendered to enrollees under this Contract in the format specified
in Addendum VI.
2. An encounter record for each service provided to enrollees
covered under this contract. The Encounter data set will include
at least those data elements specified in Addendum IV. The
Department will work with the HMOs to develop a mechanism for
sharing HMO specific data and blinded data from other HMOs in
order for HMOs to perform their own independent analysis of the
data.
The encounter data set must be submitted monthly via electronic
media. Refer to Article I, Definitions, for the definition of an
encounter.
3. Copies of all formal grievances and documentation of actions
taken on each grievance, as specified in Article VIII. A. (11).
4. Birth Cost as specified in Addendum XXIII.
C. Access to and Audit of Contract Records
Throughout the duration of the Contract, and for a period of five (5)
years after termination of the Contract, the HMO shall provide duly
authorized representatives of the State or Federal government access
to all records and material relating to the Contractor's provision of
and reimbursement for activities contemplated under the Contract. Such
access shall include the right to inspect, audit and reproduce all
such records and material and to verify reports furnished in
compliance with the provisions of the Contract. All information so
obtained will be accorded confidential treatment as provided under
applicable laws, rules or regulations.
D. Records Retention
The HMO shall retain, preserve and make available upon request all
records relating to the performance of its obligations under the
Contract, including claim forms, paper and electronic, for a period of
not less than five (5) years from the date of termination of the
Contract. Records involving matters which are the subject of
litigation shall be retained for a period of not less than five (5)
years following the termination of litigation. Microfilm copies of the
documents contemplated herein may be substituted for the originals
with the prior written consent of the Department, provided that the
microfilming procedures are approved by the Department as reliable and
are supported by an effective retrieval system.
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Upon expiration of the five (5) year retention period, the subject
records shall, upon request, be transferred to the Department's
possession. No records shall be destroyed or otherwise disposed of
without the prior written consent of the Department.
E. Special Reporting and Compliance Requirements
The HMO shall comply with the following State and Federal reporting
and compliance requirements for the services listed below, for the
entire HMO, aggregating all service areas if the HMO has more than one
service area:
1. Abortions shall comply with the requirements of Chapter 20.927,
Wis. Stats., and with 42 CFR 441 Subpart E--Abortions.
2. Hysterectomies and sterilizations shall comply with 42 CFR 441
Subpart F--Sterilizations.
Sanctions in the amount of $10,000.00 may be imposed for
noncompliance with the above special reporting and compliance
requirements.
3. HMOs shall abide by s. 609.30 Wis. Stats.
F. Reporting of Corporate and Other Changes
If corporate restructuring or any other change affects the continuing
accuracy of certain information previously reported by the HMO to the
Department, the HMO shall report the change in information to the
Department. The HMO shall report each such change in information as
soon as possible, but not later than 30 days after the effective date
of the change. Changes in information covered under this section
include all of the following:
1. Any change in information previously provided by the HMO in
response to questions posed by the Department in the current HMO
Certification Application or any previous RFB for
Medicaid/BadgerCare HMO Contracts. This includes any change in
information originally provided by the HMO as a "new HMO," within
the meaning of the HMO Certification Application or RFB.
2. Any change in information relevant to Article III, Section JJ of
this Contract, relating to ineligible organizations.
3. Any change in information relevant to Section 4 of Addendum I of
this Contract, relating to ownership and business transactions of
the HMO.
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G. Computer/Data Reporting System
The HMO must maintain a computer/data reporting system that meets the
Department's following requirements. The HMO is responsible for
complying with all of the reporting requirements established by the
Department and with assuring the accuracy and completeness of the data
as well as the timely submission of data. The data submitted must be
supported by records available to the Department or its designee. The
Department reserves the right to conduct on-site inspections and/or
audits prior to awarding the Contract. The HMO must have a contact
person responsible for the computer/data reporting system and in a
position to answer questions from the Department and resolve problems
identified by the Department in regard to the requirements listed
below:
1. The HMO must have a claims processing system that is adequate to
meet all claims processing and retrieval requirements specified
in this Contract, specifically Article III. G.
2. The HMO must have a computer/data collection, processing, and
reporting system sufficient to monitor HMO
enrollment/disenrollment (in order to determine on any specific
day which recipients are enrolled or disenrolled from the HMO)
and to monitor service utilization for the Utilization Management
requirements of Quality Improvement that are specified in Article
III. W. (9) of the Contract.
3. The HMO must have a computer/data collection, processing, and
reporting system sufficient to support the Quality Improvement
(QI) requirements described in Article III. W. The system must be
able to support the variety of QI monitoring and evaluation
activities, including the monitoring/ evaluation of quality of
clinical care and service (III. W. (3)); periodic evaluation of
HMO providers (III. W.(6)(b)); member feedback on QI (III. W.
(7)(b) and (c)); maintenance of and use of medical records in QI
(III. W. (8)(f) and (i)); and monitoring and evaluation of
priority areas (III. W. (13)(a) - (f)).
4. The HMO must have a computer and data processing system
sufficient to accurately produce the data, reports, and encounter
data set, in the formats and time lines prescribed by the
Department in this contract, that are included in Addendum IV of
the Contract. Newly certified HMOs and HMOs who substantially
change the IS system during the contract period are required to
submit electronic test encounter data files as required by the
Department in the format specified in the HMO encounter data user
manual and timelines specified in Addendum IV of the Contract and
as may be further specified by the Department. The electronic
test encounter data files are subject to Department review and
approval before production data is accepted by the Department.
Production claims or other documented encounter data must be used
for the test data files.
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5. The HMO must capture and maintain a claim record of each service
or item provided to enrollees, using HCFA 1500, UB-92, NCPDP, or
other claim, or claim formats that are adequate to meet all
reporting requirements of this contact. The computerized database
must be a complete and accurate representation of all services
covered by the HMO for the contract period. The HMO is
responsible for monitoring the integrity of the data base, and
facilitating its appropriate use for such required reports as
encounter data, and targeted performance improvement studies.
6. The HMO must have a computer processing and reporting system that
is capable of following or tracing an encounter within its system
using a unique encounter record identification number for each
encounter.
7. The HMO reporting system must have the ability to identify all
denied claims/encounters using national ANSI EOB codes.
8. The HMO system must be capable of reporting original and reversed
claim detail records and encounter records.
9. The HMO system must be capable of correcting an error to the
encounter record within 90 days of notification by the
Department.
10. The HMO must notify the Department of all significant changes to
the system that may impact the integrity of the data, including
such changes as new claims processing software, new claims
processing vendors and significant changes in personnel.
ARTICLE VII
VII. ENROLLMENT AND DISENROLLMENTS
A. Enrollment
The HMO shall accept as enrolled all persons who appear as enrollees
on the HMO Enrollment Reports and newborns as defined in Article I.
Enrollment in the HMO shall be voluntary by the recipient except where
limited by Departmental implementation of a State Plan Amendment or a
Section 1115(a) waiver. The current State Plan Amendment and 1115(a)
waiver requires mandatory enrollment into an HMO for those service
areas in which there are two or more HMOs with sufficient slots for
the HMO eligible population. The Department reserves the right to
assign a Medicaid/ BadgerCare recipient to a specific HMO when the
recipient fails to choose an HMO during a required enrollment period.
The HMO shall designate, in Article XV, and Addendum XX, of this
Contract, their maximum enrollment level for the different service
areas of the HMO throughout the State. The Department may take up to
60 days, from the date of
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written notification, to implement maximum enrollment level changes.
The HMO shall accept as enrolled all persons who appear as enrollees
on the HMO Enrollment Reports and newborns up to the HMO specified
enrollment level for a particular service area. The number of
enrollees may exceed the maximum enrollment level by 5 percent on a
temporary basis. The Department does not guarantee any minimum
enrollment level. The maximum enrollment level for a service area may
be increased or decreased during the course of the contract period
based on mutual acceptance of a different maximum enrollment level.
B. Third Trimester Pregnancy Disenrollment
Enrollees who are in their third trimester of pregnancy when they are
expected to enter an HMO may be eligible for disenrollment. In order
for disenrollment to occur, the enrollee must have been automatically
assigned or reassigned. In addition, they must be seeking care from a
provider (physician and/or hospital) who is either not affiliated with
the HMO to which they were assigned or is affiliated but the HMO is
closed to new enrollment. Disenrollment requests can only be made by
the enrollee and/or casehead. Disenrollment requests must be made
before the end of the second month in the HMO or before the birth,
whichever occurs first. Disenrollment requests should be directed to
the Enrollment Contractor or the Department's assigned HMO Contract
Monitor.
C. Ninth Month Pregnancy Disenrollment
Enrollees who deliver or are expected to deliver the first month they
are assigned to a HMO may be eligible for disenrollment. In order for
disenrollment to occur, the enrollee must have been automatically
assigned or reassigned and must not have been in the HMO to which they
were assigned or reassigned within the last seven months. In addition,
they must be seeking care from a provider (physician and/or hospital)
not affiliated with the HMO to which they were assigned. Disenrollment
requests can be made by the HMO, a provider, or the recipient.
Requests for ninth month pregnancy disenrollments should be directed
to the Department's assigned HMO Contract Monitor.
D. Exemptions from Enrollment in any HMO and Disenrollment for Patients
of Certified Nurse Midwives or Nurse Practitioners
1. Enrollees may be eligible for an exemption from enrollment if:
a. the enrollee resides in a service area of a certified nurse
midwife or nurse practitioner; and
b. the enrollee chooses to receive their care from a certified
nurse midwife or nurse practitioner; and
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c. the certified nurse midwife or nurse practitioner is not
affiliated with any HMO in the service area; or
d. the certified nurse midwife or nurse practitioner is not
independently certified as a provider of any HMO within the
service area.
2. Exemptions and disenrollment requests may be made by the enrollee
and should be directed to the Department's Enrollment Contractor.
Exemptions will be processed as soon as possible and will be
effective as of the first of the month of request.
E. Exemption from Enrollment in any HMO and Disenrollment For AIDS or
HIV-Positive with Anti Retroviral Drug Treatment
Enrollees with a confirmed diagnosis of AIDS, as indicated by an
ICD-9-CM diagnosis code, or HIV-Positive who are on anti retroviral
drug treatment approved by the Federal Food and Drug Administration,
are eligible for an exemption. The casehead may apply for the
exemption. The HMO shall not counsel or otherwise influence an
enrollee or potential enrollee in such a way as to encourage exemption
from enrollment or continued enrollment. Exemptions will be processed
as soon as possible. Disenrollment will be effective with the first
day of the month in which anti retroviral treatment begins or in which
the enrollee was diagnosed with AIDS except that disenrollment will
not be backdated more than nine (9) months from the date the request
is received.
F. Exemptions from Enrollment in any HMO and Disenrollment for Patients
of Federally Qualified Health Centers
1. Enrollees may be eligible for an exemption from enrollment if:
a. the enrollee resides in the service area of an FQHC;
b. the enrollee chooses to receive their primary care from the
FQHC; and
c. the FQHC is not affiliated with any HMO within the service
area.
2. Exemption and Disenrollment requests may be made by the casehead
and should be directed to the Department's assigned HMO Contract
Monitor. Exemptions will be processed as soon as possible and
will be effective as of the first of the month of the request.
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G. Native American Disenrollment
Enrollees who are Native American and members of a federally
recognized tribe are eligible for disenrollment. Only the enrollee can
make disenrollment requests.
H. Special Disenrollments
The HMO may request and the Department may approve disenrollment for
specific cases or persons where there is just cause. Just cause is
defined as a situation where enrollment would be harmful to the
interests of the recipient or in which the HMO cannot provide the
recipient with appropriate medically necessary contract services for
reasons beyond its control. Disruptive behavior resulting from
diminished mental capacity from a special needs enrollee will not
qualify as a just cause disenrollment.
I. Exemptions from Enrollment in any HMO and Disenrollment for Recipients
With Commercial HMO Insurance or Commercial Insurance With a
Restricted Provider Network
Enrollees who have commercial HMO insurance may be eligible for
exemption from enrollment in any HMO or disenrollment, if the
commercial HMO does not participate in Medicaid. In addition,
enrollees who have commercial insurance which limits enrollees to a
restricted provider network (e.g., PPOs, PHOs, etc.) may be eligible
for an exemption from enrollment in any HMO or disenrollment. Requests
for exemption and disenrollment should be directed to the Department's
Enrollment Contractor. Exemptions will be processed as soon as
possible and will be effective as of the first of the month of the
request.
J. Exemption from Enrollment in any HMO and Disenrollment for Families
Where One or More Members are receiving SSI benefits
1. Families may be eligible for exemption from enrollment if:
a. there are one or more members in the family who are
receiving SSI benefits, and
b. the SSI member receives primary care from a provider who
does not accept any Medicaid HMO, and
c. other family members receive their primary care from the
same provider as the SSI member.
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2. Exemption and Disenrollment requests may be made by the SSI
member, parent or guardian and should be directed to the
Department's Enrollment Contractor. Exemptions will be processed
as soon as possible and will be effective as of the first of the
month of request.
K. Voluntary Disenrollment
All enrollees shall have the right to disenroll from the HMO pursuant
to 42 CFR 434.27(b)(1) unless otherwise limited by a State Plan
Amendment or a Section 1115(a) waiver of federal laws, or pursuant to
Addendum II. A voluntary disenrollment shall be effective no later
than the first day of the second month after the month in which the
enrollee requests termination. The HMO will promptly forward to the
Department or its designee all requests from enrollees for
disenrollment. Wisconsin currently has a State Plan Amendment and an
1115(a) waiver which allows the Department to "lock-in" enrollees to
an HMO for a period of 12 months in mandatory HMO service areas,
except that disenrollment is allowed for good cause as described in
Sections B. through J. above. The lock-in policy is described more
completely in Section O below. Addendum II allows voluntary exemptions
and disenrollment from HMOs for a variety of reasons. Because of these
two Department policies, voluntary disenrollment is limited to the
situations described in Sections B. through K. of Article VII. and
Addendum II.
L. Section 1115(A) Waiver and State Plan Amendment
Should the Department, at any time during the Contract, obtain a State
Plan Amendment, a waiver or revised waiver authority under the Social
Security Act (as amended), the conditions of enrollment described in
the Contract, including but not limited to voluntary enrollment and
the right to voluntary disenrollment, shall be amended by the terms of
said waiver and State Plan Amendment.
M. Additional Services
The HMO shall not obtain enrollment through the offer of any
compensation, reward, or benefit to the enrollee except for additional
health-related services that have been approved by the Department.
N. Enrollment/Disenrollment Practices
The HMO shall permit the Department to monitor enrollment and
disenrollment practices of the HMO under this Contract. The HMO will
not discriminate in enrollment/disenrollment activities between
individuals on the basis of health status or requirement for health
care services, including those individuals who have AIDS or are
HIV-Positive. This includes an enrollee with a diminished mental
capacity, who is uncooperative and displays disruptive behavior and
the behavior results from the enrollees' special needs. This section
shall not prevent the HMO from
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assisting in the disenrollment process for individuals who can be in a
different medical status code.
O. Enrollee Lock-In Period
Under the Department's State Plan Amendment and waiver authority of
Section 1115(a) of the Social Security Act (as amended), in mandatory
HMO service areas, enrollees will be locked in to an HMO for twelve
months. The first 90 days of the 12-month lock-in period will be an
open enrollment period in which the enrollee may change their HMO. The
conditions of disenrollment as specified in VII. B - K still apply
during this lock-in period.
ARTICLE VIII
VIII. GRIEVANCE PROCEDURES
Medicaid/BadgerCare enrollees may grieve regarding any aspect of service
delivery provided or arranged by the HMO.
A. Procedures:
The HMO shall:
1. Have written policies and procedures that detail what the
grievance system is and how it operates.
2. Identify a contact person in the HMO to receive grievances and be
responsible for routing/processing.
3. Operate an informal grievance process which enrollees can use to
get problems resolved without going through the formal, written
grievance process.
4. Operate a formal grievance process which enrollees can use to
grieve in writing.
5. Inform enrollees about the existence of the formal and informal
grievance processes and how to use the formal and informal
grievance process.
6. Attempt to resolve grievances informally.
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7. Respond to written grievances (i.e., formal grievances) in
writing within 10 business days of receipt of grievance, except
that in cases of emergency or urgent (expedited grievances)
situations, HMOs must resolve the grievance within 2 business
days of receiving the complaint or sooner if possible. This
represents the first response. More complete procedures are
described in Section B. of this Article.
8. Operate a grievance process within the HMO which enrollees can
use to appeal any negative response to their grievance to the
Board of Directors of the HMO. The HMO Board of Directors may
delegate this authority to review appeals to an HMO grievance
appeal committee, but the delegation must be in writing. If a
grievance appeal committee is established, the Medicaid HMO
Advocate must be a member of the committee.
9. Grant the enrollee the right to appear in person before the
grievance committee, to present written and oral information. The
enrollee may bring a representative to this meeting. The HMO must
inform the enrollee in writing of the time and place of the
meeting at least 7 calendar days before the meeting.
10. Maintain a record keeping system for informal grievances in the
form of a "log" that includes a short, dated summary of each of
the problems, the response, and the resolution. This log shall
distinguish Medicaid/ BadgerCare from commercial enrollees, if
the HMO does not have a separate log for Medicaid. The HMO must
submit quarterly reports to the Department of all informal
grievances/complaints. The analysis of the log will include the
number of informal grievances/complaints divided into two
categories, program administration and benefits denials.
11. Maintain a record keeping system for formal grievances that
includes a copy of the original grievance, the response, and the
resolution. This system shall distinguish Medicaid/BadgerCare
from commercial enrollees.
12. Notify the enrollee who grieves, at the time of the initial HMO
grievance decision denying the grievance, that the enrollee may
appeal to the Division of Hearings and Appeals (DHA) or the
Department.
13. Assure that individuals with the authority to require corrective
action are involved in the grievance process.
14. Distribute to their gatekeepers* and IPAs the informational flyer
on enrollee's grievance rights `(the ombudsman brochure). When a
new brochure is available, the HMO shall distribute copies to
their gatekeepers and IPAs within three weeks of receipt of the
new brochure.
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15. Assure that their gatekeepers* and IPAs have written procedures
for describing how enrollees are informed of denied services. The
HMO will make copies of the gatekeeper's and IPA's grievance
procedures available for review upon request by the Department.
16. HMOs must inform enrollees about the availability of interpreter
services during the grievance process. In addition, HMOs must
provide interpreter services for non-English speaking and hearing
impaired enrollees throughout the grievance process except during
the Department's fair hearing process. The Department will
arrange for interpreters during the state fair hearing process.
*The word "gatekeeper" in this context refers to any entity that
performs a management services contract, a behavioral health
science IPA, or a dental IPA, and not to individual physicians
acting as a gatekeeper to primary care services.
B. Recipient Appeals of HMO Formal Grievance Decisions/Formal Grievance
Process.
The enrollee may choose to use the HMO's formal grievance process or
may appeal to the Department instead of using the HMO's formal
grievance process. If the enrollee chooses to use the HMO's process,
the HMO must provide an initial response within ten business days and
a final response within thirty calendar days of receiving the
grievance. If the HMO is unable to resolve the grievance within thirty
calendar days, the time period may be extended another fourteen
calendar days from receipt of the grievance if the HMO notifies the
enrollee in writing that the HMO has not resolved the grievance, when
the resolution may be expected, and why the additional time is needed.
The total timeline for HMOs to finalize a formal grievance may not
exceed 45 calendar days from the date of the receipt of the grievance.
Any formal grievance decision by the HMO may be appealed by the
enrollee to the Department. The Department shall review such appeals
and may affirm, modify, or reject any formal grievance decision of the
HMO at any time after the enrollee files the formal appeal. The
Department will give a final response within 30 days from the date the
Department has all information needed for a decision. Also, an
enrollee can submit a formal, written grievance directly to the
Department at any time during the grievance process. Any formal
decision made by the Department under this section is subject to
enrollee appeal rights to the extent provided by State and Federal
Laws and rules. The Department will receive input from the recipient
and the HMO in considering appeals.
For an expedited grievance, the HMO must resolve all issues within two
business days of receiving the written request for an expedited
grievance.
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C. Notifications of Denial, Termination, Suspension, or Reduction of
Benefits to Enrollees
1. When an HMO, its gatekeepers,* or its IPAs discontinues,
terminates, suspends, limits, or reduces a service (including
services authorized by an HMO the enrollee was previously
enrolled in or services received by the enrollee on a Medicaid
FFS basis), the HMO shall notify the affected enrollee(s) in
writing of:
a. The nature of the intended action.
b. The reasons for the intended action.
c. The circumstance under which a benefit will continue during
the grievance process. The fact that if the enrollee
continues to receive the disputed service, the enrollee may
be liable for the care if the decision is adverse to the
enrollee.
d. The fact that the enrollee if appealing the action must do
so within forty-five (45) days.
e. The enrollee has the right to examine the documentation used
when the HMO made its determination.
f. The fact that interpreter services are available free of
charge during the grievance process and how the enrollee can
access those services.
g. The enrollee may bring a representative with him/her to the
hearing.
h. The enrollee may present "new" information during the
grievance process
i. The process for requesting an expedited grievance.
j. An explanation of the enrollee's right to appeal the HMO's
decision to the Department.
k. The fact that the enrollee, if appealing the HMO action, may
file a request for a hearing with the Division of Hearings
and Appeals (DHA) and the address of the DHA.
l. The fact that the enrollee can receive help in filing a
grievance by calling either the Enrollment contractor or the
Ombudsman.
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m. The telephone number of both the Enrollment contractor and
the Ombudsman.
* The word "gatekeeper" in this context refers to any entity that
performs a management services contract, a behavioral health
science IPA, or a dental IPA, and not to individual physicians
acting as a gatekeeper to primary care services.
This notice requirement does not apply when an HMO, its
gatekeeper or its IPA triages an enrollee to proper health care
provider or when an individual health care provider determines
that a service is medically unnecessary.
The Department must review and approve all notice language prior
to its use by the HMO. Department review and approval will occur
during the Medicaid certification process of the HMO and prior to
any change of the notice language by the HMO.
2. If the recipient files a request for a hearing with the Division
of Hearings and Appeals by the effective date of the decision to
reduce, limit, terminate or suspend benefits, upon notification
by the Division of Hearings and Appeals:
a. The Department will notify the enrollee they are eligible to
continue receiving care but may be liable for care if DHA
overturns the decision; and
b. The Department will put the enrollee on FFS status effective
the first of the month in which the enrollee received the
termination, reduction, or suspension notice from the HMO;
and:
1) If the Division of Hearings and Appeals reverses the
HMO's decision, the Department will recoup from the HMO
the amount paid for any benefits provided to the
enrollee during the period of the enrollee's FFS status
while the decision was pending. The enrollee will be
reenrolled into the HMO following the resolution of the
medical condition, the completion of medical,
psychological or dental services or the end of medical
necessity of the service(s) unless the HMO has reversed
its original decisions and agrees to reimburse the
provider(s) for services provided to the enrollee
during the administrative hearing process.
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2) If the Division of Hearings and Appeals upholds the
HMO's decision, the Department may pursue reimbursement
from the enrollee for all services provided to the
enrollee during their FFS period. The enrollee will be
reenrolled into the HMO no later than the end of the
second month following notification from the DHA.
D. Notifications of Denial of New Benefits to Enrollees
When an HMO, its gatekeeper, or IPA denies a new service, the HMO
shall notify the affected enrollee (s) in writing of:
1. The nature of the intended action.
2. The reasons for the intended action.
3. The fact that the enrollee if appealing the action must do so
within forty-five (45) days.
4. An explanation of how the enrollee may request an expedited
grievance.
5. The enrollee may bring a representative with him/her to the
hearing.
6. The enrollee may present "new" information during the grievance
process.
7. The enrollee may review the documents used to make the decision.
8. An explanation of the enrollee's right to appeal the HMO's
decision to the Department.
9. The fact that interpreter services are available free of charge
during the grievance process and how the enrollee can access
those services.
10. The fact that the enrollee can receive help in filing a grievance
by calling either the Enrollment contractor or the Ombudsman.
11. The telephone number of both the Enrollment contractor and the
Ombudsman.
If the enrollee was not receiving the service prior to the denial, the
HMO is not required to provide the benefit while the decision is being
appealed.
HMO grievance procedures must be reviewed and approved by the
Department prior to signing the HMO Contract. All changes to HMO
grievance procedures require prior review and approval by the
Department.
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E. Reporting of Grievances to the Department
1. HMOs shall forward both the formal and informal grievances
reports to the Department within thirty days of the end of a
quarter in the format specified in Addendum XXI. Failure on the
part of an HMO to submit the quarterly grievance reports in the
required format within five days of the due date may result in
any or all sanctions available under Article IX.
ARTICLE IX
IX. REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT
A. Suspension of New Enrollment
Whenever the Department determines that the HMO is out of compliance
with this Contract, the Department may suspend the HMO's right to
receive new enrollment under this Contract. The Department, when
exercising this option, must notify the HMO in writing of its intent
to suspend new enrollment at least 30 days prior to the beginning of
the suspension period. The suspension will take effect if the
noncompliance remains uncorrected at the end of this period. The
Department may suspend new enrollment sooner than the time period
specified in this paragraph if the Department finds that enrollee
health or welfare is jeopardized. The suspension period may be for any
length of time specified by the Department, or may be indefinite. The
suspension period may extend up to the expiration of the Contract as
provided under Article XV.
The Department may also notify enrollees of HMO non-compliance and
provide an opportunity to enroll in another HMO.
B. Department-Initiated Enrollment Reductions
The Department may reduce the maximum enrollment level and/or number
of current enrollees whenever it determines that the HMO has failed to
provide one or more of the contract services required under Article
III or that the HMO has failed to maintain or make available any
records or reports required under this Contract which the Department
needs to determine whether the HMO is providing contract services as
required under Article III. The HMO shall be given at least 30 days to
correct the non-compliance prior to the Department taking any action
set forth in this paragraph. The Department may reduce enrollment
sooner than the time period specified in this paragraph if the
Department finds that enrollee health or welfare is jeopardized.
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C. Other Enrollment Reductions
The Department may also suspend new enrollment or disenroll enrollees
in anticipation of the HMO not being able to comply with federal or
state law at its current enrollment level. Such suspension shall not
be subject to the 30 day notification requirement.
D. Withholding of Capitation Payments and Orders to Provide Services
Notwithstanding the provisions of Article V, the Department may
withhold portions of capitation payments as liquidated damages or
otherwise recover damages from the HMO on the following grounds:
1. Whenever the Department determines that the HMO has failed to
provide one or more of the medically necessary Medicaid covered
contract services required under Article III, the Department may
either order the HMO to provide such service, or withhold a
portion of the HMO's capitation payments for the following month
or subsequent months, such portion withheld to be equal to the
amount of money the Department must pay to provide such services.
If the Department orders the HMO to provide services under this
section and the HMO fails to provide the services within the
timeline specified by the Department, the Department may withhold
an amount up to 150 percent of the FFS amount for such services
from the HMO's capitation payments.
When it withholds payments under this section, the Department
must submit to the HMO a list of the participants for whom
payments are being withheld, the nature of the service(s) denied,
and payments the Department must make to provide medically
necessary services.
If the Department acts under this section and subsequently
determines that the services in question were not covered
services:
a. In the event the Department withheld payments it shall
restore to the HMO the full capitation payment, or
b. In the event the Department ordered the HMO to provide
services under this section, it shall pay the HMO the actual
documented cost of providing the services.
2. If the HMO fails to submit required data and/or information to
the Department or the Department's authorized agents, or fails to
submit such data or information in the required form or format,
by the deadline
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specified by the Department, the Department may immediately
impose liquidated damages in the amount of $1,500 per day for
each day beyond the deadline that the HMO fails to submit the
data or fails to submit the data in the required form or format,
such liquidated damages to be deducted from the HMO's capitation
payments.
3. If the HMO fails to submit State and Federal reporting and
compliance requirements for abortions, hysterectomies and
sterilizations, the Department may impose liquidated damages in
the amount of $10,000 per reporting period.
4. If the HMO fails to correct an error to the encounter record
within the timeframe specified, the Department may assess
liquidated damages of $5 per erred encounter record per month
until the error has been corrected. The liquidated damage amount
will be deducted from the HMO's capitation payment. When applied,
these liquidated damages will be calculated and assessed on a
monthly basis.
If upon audit or review, the Department finds that the HMO has,
without Department approval, removed an erred encounter record,
the Department may assess liquidated damages for each day from
the date of original error notification until the date of
correction.
The term "erred encounter record" means an encounter record that
has failed an edit when a correction is expected by the
Department.
The following criteria will be used prior to assessing liquidated
damages:
o The Department will calculate a percentage rate by dividing
the number of erred records not corrected within 90 days
(numerator), by the total number of records in error
(denominator) and multiply the result by 100.
o Records failing non-critical edits, as defined in the
Wisconsin Medicaid/BadgerCare HMO Encounter Data User
Manual, will not be included in the numerator.
o If this rate is 2 percent or less, liquidated damages will
not be assessed.
o The Department will calculate this rate each month.
5. Whenever the Department determines that the HMO has failed to
perform an administrative function required under this Contract,
the Department may withhold a portion of future capitation
payments. For the purposes of this section, "administrative
function" is defined as any contract obligation
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other than the actual provision of contract services. The amount
withheld by the Department under this section will be an amount
that the Department determines in the reasonable exercise of its
discretion to approximate the cost to the Department to perform
the function. The Department may increase these amounts by 50
percent for each subsequent non-compliance.
Whenever the Department determines that the HMO has failed to
perform the administrative functions defined in Article V. H. (1)
and (2), the Department may withhold a portion of future
capitation payments sufficient to directly compensate the
Department for the Medicaid/BadgerCare program's costs of
providing health care services and items to individuals insured
by said insurers and/or the insurers/ employers represented by
said third party administrators.
6. In any case under this Contract where the Department has the
authority to withhold capitation payments, the Department also
has the authority to use all other legal processes for the
recovery of damages.
7. Notwithstanding the provisions of this subsection, in any case
where the Department deducts a portion of capitation payments
under subsection (2) above, the following procedures shall be
used:
a. The Department will notify the HMO's contract administrator
no later than the second business day after Department's
deadline that the HMO has failed to submit the required data
or the required data cannot be processed.
b. The HMO will be subject to liquidated damages without
further notification per submission, per data file or
report, beginning on the second business day after the
Department's deadline.
c. If the late submission of data is for encounter data, and
the HMO responds with a submission of the data within five
(5) business days from the deadline, the Department will
rescind liquidated damages if the data can be processed
according to the criteria published in the Wisconsin
Medicaid/BadgerCare HMO Encounter Data User Manual. The
Department will not edit the data until the process period
in the subsequent month.
d. If the late submission is for any other required data or
report, and the HMO responds with a submission of the data
in the required format within five (5) business days from
the deadline, the Department will rescind liquidated damages
and immediately process the data or report.
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e. If the HMO repeatedly fails to submit required data or
reports, or data that cannot be processed, the Department
will require the HMO to develop an action plan to comply
with the contract requirements that must meet Department
approval.
f. If the HMO, after a corrective action plan has been
implemented, continues to submit data beyond the deadline,
or continues to submit data that cannot be processed, the
Department will invoke the remedies under Article IX,
section A (SUSPENSION OF NEW ENROLLMENT), from section B
(DEPARTMENT-INITIATED ENROLLMENT REDUCTIONS), or both, in
addition to liquidated damages that may have been imposed
for a current violation.
g. If an HMO notifies the Department it is discontinuing
contracting with the Department at the end of a contract
period, but reports or data are due for a contract period,
the Department retains the right to withhold up to two
months of capitation payments otherwise due the HMO which
will not be released to the HMO until all required reports
or data are submitted and accepted after expiration of the
contract. Upon determination by the Department that the
reports and data are accepted, the Department will release
the monies withheld.
E. Inappropriate Payment Denials
HMOs that inappropriately fail to provide or deny payments for
services may be subject to suspension of new enrollments, withholding,
in full or in part, of capitation payments, contract termination, or
refusal to contract in a future time period, as determined by the
Department. The Department will select among these sanctions based
upon the nature of the services in question, whether the failure or
denial was an isolated instance or a repeated pattern or practice, and
whether the health of an enrollee was injured, threatened or
jeopardized by the failure or denial. This applies not only to cases
where the Department has ordered payment after appeal, but also to
cases where no appeal has been made (i.e., the Department is
knowledgeable about the documented abuse from other sources).
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F. Sanctions
Section 1903(m)(5)(B)(ii) of the Social Security Act vests the
Secretary of the Department of Health and Human Services with the
authority to deny Medicaid payments to an HMO for enrollees who enroll
after the date on which the HMO has been found to have committed one
of the violations identified in the federal law. State payments for
enrollees of the contracting organization are automatically denied
whenever, and for so long as, Federal payment for such enrollees has
been denied as a result of the commission of such violations.
G. Sanctions and Remedial Actions
The Department may pursue all sanctions and remedial actions with HMOs
that are taken with Medicaid FFS providers, including any civil
penalties not to exceed the amounts specified in the Balanced Budget
Amendment of 1997 P.L. 105-33 Sec. 4707(a) [42 U.S.C. 1396v(d)(2)].
ARTICLE X
X. TERMINATION AND MODIFICATION OF CONTRACT
A. Mutual Consent
This Contract may be terminated at any time by mutual written
agreement of both the HMO and the Department.
B. Unilateral Termination
This Contract between the parties may be terminated only as follows:
1. This Contract may be terminated at any time, by either party, due
to modifications mandated by changes in Federal or State laws,
rules or regulations, that materially affect either party's
rights or responsibilities under this Contract. In such case, the
party initiating such termination procedures must notify the
other party, at least 90 days prior to the proposed date of
termination, of its intent to terminate this Contract.
Termination by the Department under these circumstances shall
impose an obligation upon the Department to pay the Contractor's
reasonable and necessarily incurred termination expenses.
2. This Contract may be terminated by either party at any time if it
determines that the other party has substantially failed to
perform any of its functions or duties under this Contract. In
such event, the party exercising this option must notify the
other party, in writing, of this intent to terminate this
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Contract and give the other party 30 days to correct the
identified violation, breach or non-performance of Contract. If
such violation, breach or non-performance of Contract is not
satisfactorily addressed within this time period, the exercising
party may terminate this Contract. The termination date shall
always be the last day of a month. The Contract may be terminated
by the Department sooner than the time period specified in this
paragraph if the Department finds that enrollee health or welfare
is jeopardized by continued enrollment in the HMO. A "substantial
failure to perform" for purposes of this paragraph includes any
violation of any requirement of this Contract that is repeated or
ongoing, that goes to the essentials or purpose of the Contract,
or that injures, jeopardizes or threatens the health, safety,
welfare, rights or other interests of enrollees.
3. By either party, in the event Federal or State funding of
contractual services rendered by the Contractor become or will
become permanently unavailable. In the event it becomes evident
State or Federal funding of claims payments or contractual
services rendered by the Contractor will be temporarily suspended
or unavailable, the Department shall immediately notify the
Contractor, in writing, identifying the basis for the anticipated
unavailability or suspension of funding. Upon such notice, the
Department or the Contractor may suspend performance of any or
all of the Contractor's obligations under this Contract if the
suspension or unavailability of funding will preclude
reimbursement for performance of those obligations. The
Department or Contractor shall attempt to give notice of
suspension of performance of any or all of the Contractor's
obligations by 60 calendar days prior to said suspension, if this
is possible; otherwise, such notice of suspension should be made
as soon as possible. In the event funding temporarily suspended
or unavailable is reinstated, the Contractor may remove
suspension hereunder by written notice to the Department, to be
made within 30 calendar days from the date the funds are
reinstated. In the event the Contractor elects not to reinstate
services, the Contractor shall give the Department written notice
of its reasons for such decision, to be made within 30 calendar
days from the date the funds are reinstated. The Contractor shall
make such decision in good faith and will provide to the
Department documentation supporting its decision. In the event of
termination under this Section, this Contract shall terminate
without termination costs to either party.
C. Obligations of Contracting Parties
When termination of the Contract occurs, the following obligations
shall be met by the parties:
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1. Where this Contract is terminated unilaterally by the Department,
due to non-performance by the HMO or by mutual consent with
termination initiated by the HMO:
a. The Department shall be responsible for notifying all
enrollees of the date of termination and process by which
the enrollees will continue to receive contract services;
and
b. The HMO shall be responsible for all expenses related to
said notification.
c. The Department shall grant the HMO a hearing before
termination occurs. The Department shall notify the
enrollees of the hearing and allow them to disenroll from
the HMO without cause.
2. Where this Contract is terminated on any basis not given in (1)
above:
a. The Department shall be responsible for notifying all
enrollees of the date of termination and process by which
the enrollees will continue to receive contract services;
and
b. The Department shall be responsible for all expenses
relating to said notification.
D. Where this Contract is terminated for any reason:
1. Any payments advanced to the HMO for coverage of enrollees for
periods after the date of termination shall be returned to the
Department within the period of time specified by the Department;
and
2. The HMO shall supply all information necessary for the
reimbursement of any outstanding Medicaid/BadgerCare claims
within the period of time specified by the Department.
3. If a contract is terminated, recoupments will be handled through
a payment by the HMO within 90 days of contract termination.
E. Where this Contract is terminated on any basis not given including
non-renewal of the contract for a given contract period:
1. The Department shall be responsible for notifying all enrollees
of the date of the termination and the process by which the
enrollees will continue to receive contract services.
2. The HMO shall be responsible for all expenses related to said
notification.
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3. Any payments advanced to the HMO for coverage of enrollees for
periods after the date of termination shall be returned to the
Department within the period of time specified by the Department.
4. Recoupments will be handled through a payment by the HMO within
90 days of the termination of the contract.
F. Modification
This Contract may be modified at any time by written mutual consent of
the HMO and the Department or when modifications are mandated by
changes in Federal or State laws, rules or regulations. In the event
that changes in State or Federal law, rule or regulation require the
Department to modify its contract with the HMO, notice shall be made
to the HMO in writing. However, the capitation rate to the HMO can be
modified only as provided in Article V relating to RENEGOTIATION.
If the Department exercises its right to renew this Contract, as
allowed by Article XV, the Department will recalculate the capitation
rate for succeeding calendar years. The HMO will have 30 days to
accept the new capitation rate in writing or to initiate termination
of the Contract. If the Department changes the reporting requirements
during the contract period, the HMO shall have 180 days to comply with
such changes or to initiate termination of the Contract.
ARTICLE XI
XI. INTERPRETATION OF CONTRACT LANGUAGE
A. Interpretations
The Department has the right to final interpretation of the contract
language when disputes arise. The HMO has the right to appeal to the
Department or invoke the procedures outlined in Chapter 788, Wis.
Stats. if it disagrees with the Department's decision. Until a
decision is reached, the HMO shall abide by the interpretation of the
Department.
ARTICLE XII
XII. CONFIDENTIALITY OF RECORDS
A. The parties agree that all information, records, and data collected in
connection with this Contract shall be protected from unauthorized
disclosure as provided in Chapter 19, Subchapter II, Wis. Stats., HFS
108.01, Wis. Admin. Code, and 42 CFR 431 Subpart F. Except as
otherwise required by law, rule or regulation,
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access to such information shall be limited by the HMO and the
Department to persons who, or agencies which, require the information
in order to perform their duties related to this Contract, including
the U.S. Department of Health and Human Services and such others as
may be required by the Department.
With respect to the services provided under this contract, the HMO
will comply with all applicable health data and information privacy
and security policies, standards and regulations as may be adopted or
promulgated under the Health Insurance Portability and Accountability
Act (HIPAA)of 1996 in final form, and as amended or revised from time
to time. This includes cooperating with the Department in amending
this contract, or developing a new agreement, if the Department deems
it necessary to meet the Department's obligations under HIPAA.
B. The HMO agrees to forward to the Department all media contacts
regarding Medicaid/BadgerCare enrollees or the Medicaid/BadgerCare
program.
ARTICLE XIII
XIII. DOCUMENTS CONSTITUTING CONTRACT
A. Current Documents
The contract between the parties to this Contract shall include, in
addition to this document, existing Medicaid Provider Publications
addressed to HMOs, the terms of the most recent HMO Certification
Application issued by this Department for Medicaid/BadgerCare HMO
Contracts, any Questions and Answers released pursuant to said HMO
Certification Application by this Department, and an HMO's signed
application. The terms of the HMO Certification Application are also
part of this Contract even if the HMO had a Medicaid/BadgerCare HMO
Contract in the prior contract period and consequently did not have to
answer all the questions in the HMO Certification Application. In the
event of any conflict in provisions among these documents, the terms
of this Contract shall prevail. The provisions in any Question and
Answer Document shall prevail over the HMO Certification Application.
And the HMO Certification Application terms shall prevail over any
conflict with an HMO's actual signed application. In addition, the
Contract shall incorporate the following Addenda:
I. Subcontracts and Memoranda of Understanding
II. Policy Guidelines for Mental Health/Substance Abuse and
Community Human Service Programs
III. Risk-Sharing for Inpatient Hospital Services (if the HMO
has elected to risk-share with the Department)
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IV. Contract Specified Reporting Requirements
V. Standard Enrollee Handbook Language
VI. COB Report Format
VII. Actuarial Basis
VIII. Compliance Agreement: Affirmative Action/Civil Rights
IX. Model MOU for Prenatal Care Coordination
X. Bureau of Milwaukee Child Welfare MOU
XI. HealthCheck Worksheet
XII. Common Carrier Transportation MOU for Milwaukee County
XIII. Model MOU for School Districts or CESAs
XIV. Guidelines for Coordination of Services between HMOs,
Targeted Case Management Agencies, and Child Welfare
Agencies
XV. Performance Improvement Project Outline
XVI. Targeted Performance Improvement Measures Data Set
XVII. Medicaid/BC HMO Newborn Report
XVIII. Recommended Childhood Immunization Schedule
XIX. Reporting Requirements for NICU Risk-Sharing
XX. Specific Terms of the Medicaid/BC HMO Contract
XXI. Formal Grievance Experience Summary Report
XXII. Guidelines for the Coordination of Services Between
Medicaid HMOs and County Birth to Three (B-3) Agencies
XXIII. Wisconsin Medicaid HMO Report on Average Birth Cost by
County
XXIV. Local Health Departments and Community-Based Health
Organizations - A Resource for HMOs
XXV. General Information About the WIC Program, Sample
HMO-to-WIC Referral Form, and Statewide List of WIC
Agencies
B. Future Documents
The HMO is required, by this Contract, to comply with all future
Medicaid Provider Publications addressed to the HMOs and Contract
Interpretation Bulletins issued pursuant to this Contract.
The documents listed above constitute the entire Contract between the
parties and no other expression, whether oral or written, constitutes any
part of this Contract.
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ARTICLE XIV
XIV. MISCELLANEOUS
A. Indemnification
The HMO agrees to defend, indemnify and hold the Department harmless,
with respect to any and all claims, costs, damages and expenses,
including reasonable attorney's fees, which are related to or arise
out of:
1. Any failure, inability, or refusal of the HMO or any of its
subcontractors to provide contract services;
2. The negligent provision of contract services by the HMO or any of
its subcontractors; or
3. Any failure, inability or refusal of the HMO to pay any of its
subcontractors for contract services.
B. Independent Capacity of Contractor
Department and HMO agree that HMO and any agents or employees of HMO,
in the performance of this Contract, shall act in an independent
capacity, and not as officers or employees of Department.
C. Omissions
In the event that either party hereto discovers any material omission
in the provisions of this Contract which such party believes is
essential to the successful performance of this Contract, said party
may so inform the other party in writing, and the parties hereto shall
thereafter promptly negotiate in good faith with respect to such
matters for the purpose of making such reasonable adjustments as may
be necessary to perform the objectives of this Contract.
D. Choice of Law
This Contract shall be governed by and construed in accordance with
the laws of the State of Wisconsin. HMO shall be required to bring all
legal proceedings against Department in Wisconsin State courts.
E. Waiver
No delay or failure by either party hereto to exercise any right or
power accruing upon noncompliance or default by the other party with
respect to any of the terms
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of this Contract shall impair such right or power or be construed to
be a waiver thereof. A waiver by either of the parties hereto of a
breach of any of the covenants, conditions, or agreements to be
performed by the other shall not be construed to be a waiver of any
succeeding breach thereof or of any other covenant, condition, or
agreement herein contained.
F. Severability
If any provision of this Contract is declared or found to be illegal,
unenforceable, invalid or void, then both parties shall be relieved of
all obligations arising under such provision; but if such provision
does not relate to payments or services to Medicaid/BadgerCare
enrollees and if the remainder of this Contract shall not be affected
by such declaration or finding, then each provision not so affected
shall be enforced to the fullest extent permitted by law.
G. Force Majeure
Both parties shall be excused from performance hereunder for any
period that they are prevented from meeting the terms of this Contract
as a result of a catastrophic occurrence or natural disaster including
but not limited to an act of war, and excluding labor disputes.
H. Headings
The article and section headings used herein are for reference and
convenience only and shall not enter into the interpretation hereof.
I. Assignability
Except as allowed under subcontracting, the Contract is not assignable
by the HMO either in whole or in part, without the prior written
consent of the Department.
J. Right to Publish
The Department agrees to allow the HMO to write and have such writing
published provided the HMO receives prior written approval from the
Department before publishing writings on subjects associated with the
work under this Contract.
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EXHIBIT 10.1
ARTICLE XV
XV. HMO SPECIFIC CONTRACT TERMS
A. Initial Contract Period
The respective rights and obligations of the parties as set forth in
this Contract shall commence on January 1, 2002, and, unless earlier
terminated under Article X, shall remain in full force and effect
through December 31, 2003. The specific terms for enrollment, rates,
risk-sharing, dental coverage, and chiropractic coverage are as
specified in C.
B. Renewals
By mutual written agreement of the parties, there may be one (1)
one-year renewal of the term of the Contract. An agreement to renew
must be effected at least forty-five (45) calendar days prior to the
expiration date of any contract term. The terms and conditions of the
Contract shall remain in full force and effect throughout any renewal
period, unless modified under the provision of Article X, Section D.
C. Specific Terms of the Contract
The specific terms of the Medicaid/BadgerCare HMO Contract that the
HMO is agreeing to are indicated by the Department in a completed
Addendum VII -Actuarial Basis of the Medicaid/BadgerCare HMO Contract.
These specific terms include the following items: the service area to
be covered; and, whether dental services and chiropractic services
will be provided by the HMO and the HMO's maximum enrollment level for
each area; finally, whether the HMO, on a Statewide basis. The
Department has completed Addendum VII based on the information
supplied the Department by the HMO in the HMO Certification
Application.
In WITNESS WHEREOF, the State of Wisconsin has executed this agreement:
<Table>
<Caption>
- -------------------------------------- --------------------------------------
(Name of HMO) State of Wisconsin
- -------------------------------------- --------------------------------------
Official Signature Official Signature
/s/ Kathleen R. Crampton /s/ Peggy Bartells
- -------------------------------------- --------------------------------------
Title Title
President and Chief Executive Officer Deputy Administrator
- -------------------------------------- --------------------------------------
Date
- -------------------------------------- --------------------------------------
</Table>
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NOTE: The following subcontract with the Department for Chiropractic
Services is not effective unless signed below.
SUBCONTRACT FOR CHIROPRACTIC SERVICES
A. THIS AGREEMENT is made and entered into by and between the HMO and the
Department of Health and Family Services.
The parties agree as follows:
1. The Department agrees to be at risk for and pay claims for
chiropractic services covered under this Contract.
2. The HMO agrees to a deduction from the capitation rate of an
amount of money based on the cost of chiropractic services. This
deduction is reflected in the Contract that is being signed on
the same date.
B. This is the only subcontract for services that the Department is
entering into with the HMO.
C. The provisions of the Contract regarding subcontracts, in Addendum I,
do not apply to this subcontract.
D. The term of this subcontract is for the same period as the Contract
between HMO and Department for medical services.
Signed:
<Table>
FOR FOR
HMO: /s/ Kathleen R. Crampton STATE: /s/ Peggy Bartells
-------------------------------- --------------------------------
TITLE: President and CEO TITLE: Deputy Administrator
------------------------------ --------------------------------
DATE: DATE:
------------------------------- ---------------------------------
</Table>
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ADDENDUM I
SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING
NOTE: This Addendum does not apply to subcontracts between the Department
and the HMO. The Department shall have sole authority to determine
the conditions and terms of such subcontracts.
1. Original Review and Approval for HMOs that did not have a
Medicaid/BadgerCare HMO Contract in the Prior Contract Period, or
that are going to accept enrollment of recipients in a new county.
a. The Department may approve, approve with modification, or deny
subcontracts under this Contract at its sole discretion. The
Department may, at its sole discretion and without the need to
demonstrate cause, impose such conditions or limitations on its
approval of a subcontract as it deems appropriate. The Department
may consider such factors as it deems appropriate to protect the
interests of the State and recipients, including but not limited
to the proposed subcontractor's past performance. DHFS will give
the HMO (1) 120 days to implement a change that requires the HMO
to find a new subcontractor, and (2) 60 days to implement any
other change required by DHFS. DHFS will acknowledge the approval
or disapproval of a subcontract within 14 days after its receipt
from the HMO.
b. The Department will review and approve or disapprove each
subcontract before contract signing. Any disapproval of
subcontracts may result in the application by the Department of
remedies pursuant to Article IX of this Contract. The
Department's subcontract review will assure that the HMO has
inserted the following standard language in subcontracts (except
for specific provisions that are inapplicable in a specific HMO
management subcontract):
c. Subcontractor (hereafter identified as subcontractor) agrees to
abide by all applicable provisions of the (HMO's NAME)'s contract
with the Department of Health and Family Services, hereafter
referred to as the Medicaid/BadgerCare HMO Contract.
Subcontractor compliance with the Medicaid/HMO Contract
specifically includes but is not limited to the following
requirements:
1) Subcontractor uses only Medicaid-certified providers in
accordance with Article III. AA. of the Medicaid/BadgerCare
HMO Contract.
2) No terms of this subcontract are valid which terminate legal
liability of HMO in accordance with Article III.Y. of the
Medicaid/BadgerCare HMO Contract.
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3) Subcontractor agrees to participate in and contribute
required data to HMO Quality Assessment/Performance
Improvement programs as required in Article III. W. of the
Medicaid/BadgerCare HMO Contract.
4) Subcontractor agrees to abide by the terms of the
Medicaid/BadgerCare HMO Contract (Article III. D.) for the
timely provision of emergency and urgent care. Where
applicable, subcontractor agrees to follow those procedures
for handling urgent and emergency care cases stipulated in
any required hospital/emergency room MOUs signed by HMO in
accordance with Article III. J. of the Medicaid/BadgerCare
HMO Contract.
5) Subcontractor agrees to submit HMO encounter data in the
format specified by the HMO, so the HMO can meet the
Department specifications required by Article VI and
Addendum IV of the Medicaid/ BadgerCare HMO Contract. HMOs
will evaluate the credibility of data obtained from
subcontracted vendors' external databases to ensure that any
patient-reported information has been adequately verified.
6) Subcontractor agrees to comply with all non-discrimination
requirements in Article III. O. of the Medicaid/BadgerCare
HMO Contract.
7) Subcontractor agrees to comply with all record retention
requirements and, where applicable, the special reporting
requirements on abortions, sterilizations, hysterectomies,
and HealthCheck requirements.
8) Subcontractor agrees to provide representatives of the HMO,
as well as duly authorized agents or representatives of DHFS
and the Federal Department of Health and Human Services,
access to its premises and its contract and/or medical
records in accordance with Article III and Article IX of the
Medicaid/BadgerCare HMO Contract. Subcontractor agrees
otherwise to preserve the full confidentiality of medical
records in accordance with Article XII of the
Medicaid/BadgerCare HMO Contract.
9) Subcontractor agrees to the requirements for maintenance and
transfer of medical records stipulated in Article III. W. of
the Medicaid/BadgerCare HMO Contract.
10) Subcontractor agrees to ensure confidentiality of family
planning services in accordance with Article III. B. of the
Medicaid/BadgerCare HMO Contract.
11) Subcontractor agrees not to create barriers to access to
care by imposing requirements on recipients that are
inconsistent with the provision of medically necessary and
covered Medicaid benefits (e.g., COB recovery procedures
that delay or prevent care).
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12) Subcontractor agrees to clearly specify referral approval
requirements to its providers and in any sub-subcontracts.
13) Subcontractor agrees not to bill a Medicaid/BadgerCare
enrollee for medically necessary services covered under the
Medicaid/BadgerCare HMO Contract and provided during the
enrollee's period of HMO enrollment. Subcontractor also
agrees not to bill enrollees for any missed appointments
while an enrollee is eligible under the Medicaid/BadgerCare
Program. This provision shall continue to be in effect even
if the HMO becomes insolvent. However, if an enrollee agrees
in writing to pay for a non-Medicaid covered service, then
the HMO, HMO provider, or HMO subcontractor can bill.
The standard release form signed by the enrollee at the time
of services does not relieve the HMO and its providers and
subcontractors from the prohibition against billing a
Medicaid enrollee in the absence of a knowing assumption of
liability for a non-Medicaid covered service. The form or
other type of acknowledgment relevant to Medicaid/
BadgerCare enrollee liability must specifically state the
admissions, services, or procedures that are not covered by
Medicaid.
14) Subcontractors must forward to the HMO medical records
pursuant to grievances, within 15 working days of the HMO's
request. If the subcontractor does not meet the 15 day
requirement, the subcontractor must explain why and indicate
when the medical records will be provided.
15) Subcontractor agrees to abide by the terms of Article III.
H. regarding appeals to the HMO and to the Department for
HMO non-payment of service providers.
16) Subcontractor agrees to abide by the HMO marketing/informing
requirements. Subcontractor will forward to the HMO for
prior approval all flyers, brochures, letters, and pamphlets
the subcontractor intends to distribute to its
Medicaid/BadgerCare enrollees concerning its HMO
affiliation(s), changes in affiliation, or relates directly
to the Medicaid/BadgerCare population. Subcontractor will
not distribute any "marketing" or recipient informing
materials without the consent of the HMO and the Department.
2. The Department will also review HMO management subcontracts to assure
that rates are reasonable.
a. Subcontracts for HMO management must clearly describe the
services to be provided and the compensation to be paid.
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b. Any potential bonus, profit-sharing, or other compensation not
directly related to costs of providing goods and services to the
HMO, shall be identified and clearly defined in terms of
potential magnitude and expected magnitude during the
Medicaid/BadgerCare HMO Contract period.
c. Any such bonus or profit-sharing shall be reasonable compared to
services performed. The HMO shall document reasonableness.
d. A maximum dollar amount for such bonus or profit-sharing shall be
specified for the contract period.
e. Requirements A through D do not have to relate to
non-Medicaid/BadgerCare enrollees if the HMO wishes to have
separate arrangements for these Medicaid enrollees.
3. Subcontract Review for HMOs that have had a Medicaid/BadgerCare HMO
Contract in the Previous Contract Period and are Not Expanding into
New Service Areas during the Current Contract Period.
a. The HMO shall submit, and the Department shall review, before
signing this Contract, an affidavit that the contract language
required above in all Medicaid/ BadgerCare HMO subcontracts is
included in all the HMO's subcontracts for medical services (and
dental care, if covered). The affidavit shall specify the
expiration date of all subcontracts.
b. These HMOs shall submit the HMO management subcontract for review
as specified for new contractors above.
4. Review and Approval of New Subcontracts and Changes in Approved
Subcontracts During the Contract Period.
a. New subcontracts and changes in approved subcontracts shall be
reviewed and approved by the Department before taking effect.
This requirement will be considered met if the Department has not
responded within 15 consecutive days of the date of Departmental
receipt of request.
b. This review requirement applies to changes which affect the
amount, duration, scope, location, or quality of services. In
other words, technical changes do not have to be approved.
c. Changes in rates paid do not have to be approved, with the
exception of changes in the amounts paid to HMO management
services subcontractors.
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d. The HMO shall submit notice within 10 days to the Department of
addition or deletion of subcontracts involving: (i) a clinic or
group of physicians, (ii) an individual physician (iii) a mental
health provider and/or clinic.
e. The HMO shall notify the Department's enrollment broker within 10
days of additions to, and deletions from, the provider network.
f. The HMO shall submit to the enrollment broker an electronic
listing of all network Medicaid providers, facilities and
pharmacies within the first 10 days of each calendar quarter in a
mutually agreed upon format approved by the Department. This
listing will include, but is not limited to, provider name,
provider number, address, phone number, and specialty as well as
indicators designating whether a provider can be selected as a
PCP, and whether the PCP is accepting new patients. The listing
shall include only Medicaid certified providers who are
contracted with the HMO to provide contract services to
Medicaid/BadgerCare enrollees.
g. The HMO must send timely written notification to enrollees whose
PCP, mental health provider, gatekeeper or dental clinic
terminates a contract with the HMO. The Department must approve
notifications before they are sent to enrollees.
h. The HMO shall be required to submit transition plans when a
primary care provider(s), mental health provider(s), gatekeeper
or dental clinic terminates their contractual relationship with
the HMO. The transition plan will address continuity of care
issues, enrollee notification and any other information required
by the Department to assure adequate enrollee access. The
Department will either approve, deny, or modify the transition
plan prior to the effective date of the subcontract change.
5. Disclosure Statements
Ownership
The HMO agrees to submit to the Department within 30 days of contract
signing full and complete information as to the identity of each
person or corporation with an ownership or controlling interest in the
HMO, or any subcontractor in which the HMO has a 5 percent or more
ownership interest.
a. Definition of "Person with an Ownership or Controlling
Interest."--A "person with an ownership or controlling interest"
means a person or corporation that:
1) Owns, directly or indirectly, 5 percent or more of the HMO's
capital or stock or receives 5 percent or more of its
profits (see subsection B);
2) Has an interest in any mortgage, deed of trust, note, or
other obligation secured in whole or in part by the HMO or
by its property or assets, and
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that interest is equal to or exceeds 5 percent of the total
property and assets of the HMO; or
3) Is an officer or director of the HMO (if it is organized as
a corporation) or is a partner in the HMO (if it is
organized as a partnership).
b. Calculation of 5 percent Ownership or Receipt of Profits.--The
percentage of direct ownership or control is calculated by
multiplying the percent of interest, which a person owns, by the
percent of the HMO's assets used to secure the obligation. Thus,
if a person owns 10 percent of a note secured by 60 percent of
the HMO's assets, the person owns 6 percent of the HMO.
The percentage of indirect ownership or control is calculated by
multiplying the percentages of ownership in each organization.
Thus, if a person owns 10 percent of the stock in a corporation
which owns 80 percent of the stock of the HMO, the person owns 8
percent of the HMO.
c. Information to be Disclosed -- The following information must be
disclosed:
1) The name and address of each person with an ownership or
controlling interest of 5 percent or more in the HMO or in
any subcontractor in which the HMO has direct or indirect
ownership of 5 percent or more;
2) A statement as to whether any of the persons with ownership
or controlling interest is related to any other of the
persons with ownership or controlling interest as spouse,
parent, child, or sibling; and
3) The name of any other organization in which the person also
has ownership or controlling interest. This is required to
the extent that the HMO can obtain this information by
requesting it in writing. The HMO must keep copies of all of
these requests and responses to them, make them available
upon request, and advise the Department when there is no
response to a request.
d. Potential Sources of Disclosure Information -- This information
may already have been reported on Form HCFA-1513, "Disclosure of
Ownership and Controlling Interest Statement." Form HCFA-1513 is
likely to have been completed in two different cases. First, if
an HMO is Federally qualified and has a Medicare contract, it is
required to file Form HCFA-1513 with HCFA within 120 days of the
HMO's fiscal year end. Secondly, if the HMO is owned by or has
subcontracts with Medicaid providers which are reviewed by the
State survey agency, these providers may have completed Form
HCFA-1513 as part of the survey process. If Form HCFA-1513 has
not been completed, the HMO may supply the ownership and
controlling information on a separate report or submit reports
filed with the
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State's insurance or health regulators as long as these reports
provide the necessary information for the prior 12 month period.
e. As directed by the Center for Medicaid/Medicare Services (CMS)
Regional Office (RO), this Department must provide documentation
of this disclosure information as part of the prior approval
process for contracts. This documentation must be submitted to
the Department and the RO prior to each contract period. If an
HMO has not supplied the information that must be disclosed, a
contract with the HMO is not considered approval for this period
of time and no FFP is available for the period of time preceding
the disclosure.
f. A managed care entity may not knowingly have a person who is
debarred, suspended, or otherwise excluded from participating in
procurement activities under the Federal Acquisition Regulation
or from participating in non-procurement activities as a
director, officer, partner, or person with beneficial ownership
of more than 5 percent of the entity's equity, or have an
employment, consulting, or other agreement for the provision of
items and services that are significant and material to the
entity's obligations under its contract with the State.
g. Business Transactions
All HMOs which are not Federally qualified must disclose to the
Department information on certain types of transactions they have
with a "party in interest" as defined in the Public Health
Service Act. (See Sections 1903(m)(2)(A)(viii) and 1903(m)(4) of
the Act.):
1) Definition of a Party in Interest -- As defined in Section
1318(b) of the Public Health Service Act, a party in
interest is:
a) Any director, officer, partner, or employee responsible
for Management or administration of an HMO and HIO; any
person who is directly or indirectly the beneficial
owner of more than 5 percent of the equity of the HMO;
any person who is the beneficial owner of more than 5
percent of the HMO; or, in the case of an HMO organized
as a nonprofit corporation, an incorporator or member
of such corporation under applicable State corporation
law;
b) Any organization in which a person described in
subsection 1 is director, officer or partner; has
directly or indirectly a beneficial interest of more
than 5 percent of the equity of the HMO; or has a
mortgage, deed of trust, note, or other interest
valuing more than 5 percent of the assets of the HMO;
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c) Any person directly or indirectly controlling,
controlled by, or under common control with an HMO; or
d) Any spouse, child, or parent of an individual described
in subsections 1, 2, or 3.
2) Types of Transactions Which Must Be Disclosed. Business
transactions which must be disclosed include:
a) Any sale, exchange or lease of any property between the
HMO and a party in interest;
b) Any lending of money or other extension of credit
between the HMO and a party in interest; and
c) Any furnishing for consideration of goods, services
(including management services) or facilities between
the HMO and the party in interest. This does not
include salaries paid to employees for services
provided in the normal course of their employment.
3) The information which must be disclosed in the transactions
listed in subsection b. between an HMO and a party in
interest includes:
a) The name of the party in interest for each transaction;
b) A description of each transaction and the quantity or
units involved;
c) The accrued dollar value of each transaction during the
fiscal year; and
d) Justification of the reasonableness of each
transaction.
4) If this Medicaid/BadgerCare HMO Contract is being renewed or
extended, the HMO must disclose information on these
business transactions which occurred during the prior
contract period. If the Contract is an initial contract with
Medicaid, but the HMO has operated previously in the
commercial or Medicare markets, information on business
transactions for the entire year preceding the initial
contract period must be disclosed. The business transactions
which must be reported are not limited to transactions
related to serving the Medicaid enrollment. All of these HMO
business transactions must be reported.
6. The HMO shall notify Department within seven days of any notice by the
HMO to a subcontractor, or any notice to the HMO from a subcontractor,
of a subcontract
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termination, a pending subcontract termination, or a pending
modification in subcontract terms, that could reduce
Medicaid/BadgerCare enrollee access to care.
a. If the Department determines that a pending subcontract
termination or pending modification in subcontract terms will
jeopardize enrollee access to care, then the Department may
invoke the remedies provided for in Article IX and Article X of
this Contract. These remedies include contract termination
(notice to HMO and opportunity to correct are provided for),
suspension of new enrollment, and giving enrollees an opportunity
to enroll in a different HMO.
7. The HMO shall submit MOUs referred to in this Contract to the
Department upon the Department's request and during the certification
process if required by the Department.
8. The HMO shall submit to the Department copies of new MOUs, or changes
in existing MOUs within 15 days of signing.
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ADDENDUM II
POLICY GUIDELINES FOR MENTAL HEALTH/SUBSTANCE ABUSE AND
COMMUNITY HUMAN SERVICE PROGRAMS
The HMO shall develop a working relationship with community agencies
that are involved in the provision of non-medical services to
enrollees. The HMO may under certain conditions be exempted from
taking on or continuing to provide services to Medicaid/BadgerCare HMO
enrollees who require highly specialized or extensive treatment and/or
non-medical services for mental illness, methadone treatment,
developmental disabilities, or due to child abuse and neglect or
domestic violence. The extent of HMO responsibility for working
cooperatively with other community agencies, for treating the medical
aspects of the above conditions as legitimate health care problems and
the terms under which enrollee exemption may be obtained are specified
as follows:
1. CONDITIONS ON COVERAGE OF MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT
FOR DISABLED PERSONS----On the effective date of this Contract,
unless waived by DHFS, the HMO shall, in compliance with the
provision of s. 632.89 Wis. Stats.:
a. be certified as an outpatient Mental Health and/or Substance
Abuse treatment facility; or
b. have contracted with a certified facility or other certified
providers under s. 632.89, Wis. Stats., for the treatment of
mental health/substance abuse problems.
Regardless of whether a. or b., above, is chosen, such treatment
facilities and/or providers must provide transitional treatment
arrangements in addition to other outpatient mental health and/or
substance abuse services; such transitional treatment
arrangements are defined as Adult Mental Health Day Treatment,
Child/Adolescent Mental Health Day Treatment and Substance Abuse
Day Treatment.
Decisions to waive this requirement shall be based solely on
whether there is a certified clinic that is geographically or
culturally accessible to enrollees, and whether the use of
psychiatrists or psychologists alone improves either the quality
or the cost-effectiveness of care.
In compliance with said provisions, the HMO shall further
guarantee all enrolled Medicaid/BadgerCare enrollees access to
all medically necessary outpatient mental health/substance abuse
treatment. No limit may be placed on the number of hours of
outpatient treatment which the HMO shall provide or reimburse
where it has been determined that treatment for mental disorders
and substance abuse is medically necessary.
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The HMO shall not establish any monetary limit or limit on the
number of days of inpatient hospital treatment where it has been
determined that this treatment is medically necessary.
2. MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT REQUIREMENTS----The HMO
shall further assure that authorization for mental
health/substance abuse treatment to its enrollees shall be
governed by the findings of an assessment performed promptly by
the HMO upon request of a client or referral from a primary care
provider or physician in the HMO's network. Such assessments
shall be conducted by qualified staff in a certified program, who
are experienced in mental health/substance abuse treatment. All
denials of service and the selection of particular modalities of
service shall be governed by the findings of this assessment and
the medical necessity of treatment. The lack of motivation of an
enrollee to participate in treatment shall not be considered a
factor in determining medical necessity and may not be used as a
rationale for withholding or limiting treatment of a
client/enrollee. HMOs will use Wisconsin Uniform Placement
Criteria (WI-UPC) or placement criteria developed by the American
Society of Addiction Medicine (ASAM) as mandated for AODA
providers in HFS 75. The requirement in no way obligates the HMOs
to provide care options included in the placement criteria, but
not paid for by fee-for-service Medicaid.
The HMO shall involve and engage the enrollee in the process used
to select a provider and treatment option. The purpose of the
participation is to get a good match between the enrollee's
condition, cultural preference (see Article III. Q), medical
needs and the provider who will seek to meet these needs. This
section does not require HMOs to use providers who are not
qualified to treat the individual enrollee or who are not
contracted providers.
3. MEMORANDA OF UNDERSTANDING REQUIRED AND RELATIONS WITH OTHER
HUMAN SERVICE AGENCIES DEFINED----Listed below are the minimum
standards to be addressed in an MOU with counties. HMOs and
counties may develop alternative MOU language, if both parties
agree. However, all elements of the MOU (items a. through b.)
must be addressed in the MOU. As an alternative to an MOU, HMOs
may enter into a contract with the counties. If the HMO enters
into a contract with the county, those contracts must be in
compliance with Addendum I and would supercede any MOU
requirements.
In addition, HMOs must make a "good faith" attempt to negotiate
either an MOU or a contract with the county(ies) in their service
area(s). A "good faith" attempt is defined as a minimum of one
face-to-face meeting between the HMO and the county in an attempt
to develop either an MOU or a contract. If a face-to-face meeting
is not possible, the HMO must maintain a written record of their
attempt to negotiate either an MOU or a contract with the
county(ies). The MOU(s), contract(s) or written documentation of
a good faith attempt must be available during the certification
process and when requested by the Department. Failure of the HMO
to have an MOU, contract or demonstrate a good faith effort, as
specified by the Department, may result in the application by the
Department of remedies specified under Article IX of this
Contract.
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a. Boards created under SS. 51.42, 51.437 or 46.23, Wis.
Stats., specifying, at a minimum, the conditions under which
the HMO will either reimburse the Board(s) or another
contract provider, or directly cover medical services,
including, but not limited to, examinations ordered by a
court, specified by the Board's designated assessment agency
in an enrollee's driver safety plan as provided under HFS
62. It is the responsibility of both the HMO and the Board
to assure that courts order the use of the HMO's providers.
If the court orders a non-HMO source to provide the
treatment or evaluation, the HMO is liable for the cost up
to the full Medicaid rate if the HMO could not have provided
the service through its own provider arrangements. If the
service was such that the HMO could reasonably have been
expected to provide it through its own provider
arrangements, the HMO is not liable. Reasonable
arrangements, in this situation, are certified providers
with facilities and services to safely meet the medical and
psychiatric needs of the recipient within a prompt and
reasonable time frame. The MOU shall further specify
reimbursement arrangements between the HMO and the Board's
provider for assessments performed by the Board's designated
assessment agency under HFS 62, Intoxicated Driver Program
rules. The MOU shall also specify other reporting and
referral relationships if required by the Board or the HMO.
b. The Department of Social Services (DSS) created under
S. 46.21 or 46.22, Wis. Stats., or the Human Service
Department created under S. 46.23, Wis. Stats.,
specifying, at a minimum, that the HMO will reimburse the
DSS or its provider if the HMO cannot provide the treatment,
or will directly cover medical services including
examinations and treatment which are ordered by a court. It
is the responsibility of both the HMO and the DSS to assure
that courts order the use of the HMO's providers. If the
court orders a non-HMO source to provide the treatment or
evaluation, the HMO is liable for the cost up to the full
Medicaid rate if the HMO could not have provided the service
through its own provider arrangements. If the service was
such that the HMO could reasonably have been expected to
provide it through its own provider arrangements, the HMO is
not liable. The MOU will also specify the reporting and
referral relationships for suspected cases of child abuse or
neglect pursuant to S. 48.981, Wis. Stats. The MOU
shall also specify a referral agreement for HMO enrollees
who are physically disabled and who may be in need of
Supportive Home Care or other programming provided or
purchased by the county agency. The MOU may specify that
evaluations for substitute care will be provided by a
provider acceptable to both parties; the DSS may require in
the MOU that the HMO specify expert providers acceptable to
the DSS and the HMO in dealing with court-related children's
services, victims of child abuse and neglect, and domestic
abuse.
4. ASSURANCE OF EXPERTISE FOR CHILD ABUSE AND NEGLECT AND DOMESTIC
VIOLENCE----The HMO shall arrange for the provision of
examination and treatment services by providers with expertise
and experience in dealing with the medical/psychiatric aspects of
caring for victims and perpetrators of child abuse and
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neglect and domestic violence. Such expertise shall include the
identification of possible and potential victims of child abuse
and neglect and domestic violence, statutory reporting
requirements, and local community resources for the prevention
and treatment of child abuse and neglect and domestic violence.
The HMO shall consult with human service agencies on appropriate
providers in their community.
The HMO shall notify all persons employed by or under contract to
the HMO who are required by law to report suspected child abuse
and neglect, and ensure they are knowledgeable about the law and
about the identification requirements and procedures. Services
provided shall include and are not limited to court-ordered
physical, psychological and mental or developmental examinations
and psychiatric treatment appropriate for victims and
perpetrators of child abuse and neglect.
The HMO shall further assure that providers with appropriate
expertise and experience in dealing with perpetrators and victims
of domestic abuse and incest are utilized in service provision.
5. COURT-RELATED CHILDREN'S SERVICES----The HMO shall be liable for
the cost of providing assessments under the Children's Code,
S. 48.295, Wis. Stats., and shall be responsible for
reimbursing for the provision of medically necessary treatment if
unable to itself provide for such treatment ordered by a juvenile
court. The medical necessity of court-ordered evaluation and
treatment is assumed to be established and the HMO may be allowed
to provide the care through its network, if at all possible. The
HMO may not withhold or limit services unless or until the court
has agreed.
6. COURT-RELATED SUBSTANCE ABUSE SERVICES----The HMO shall be liable
for the cost of providing medically necessary substance abuse
treatment, as long as the treatment occurs in an HMO-approved
facility or by an HMO-approved provider ordered in the subject's
Driver Safety Plan, pursuant to Chapter 343, Wis. Stats., and HFS
62 of the Wis. Administrative Code. The medical necessity of
services specified in this plan is assumed to be established, and
the HMO shall provide those services unless the assessment agency
agrees to amend the enrollee's Driver Safety Plan. This is not
meant to require HMO coverage of substance abuse educational
programs, or the initial assessment used to develop the Driver
Safety Plan. Necessary HMO referrals or treatment authorizations
by providers must be furnished promptly. It is expected that no
more than five days will elapse between receipt of a written
request by an HMO and the issuance of a referral or authorization
for treatment. Such referral or authorization, once determined to
be medically necessary, will be retroactive to the date of the
request. After the 5th day, an assumption will exist that an
authorization has been made until such time as the HMO responds
in writing.
7. EMERGENCY CARE COVERAGE----The HMO shall be liable for the cost
of all mental health/substance abuse treatment, including
involuntary commitment or stipulated voluntary commitment
provided by non-HMO providers to HMO enrollees where the time
required to obtain such treatment at the HMO's facilities, or the
facilities of a provider
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with which the HMO has arrangements, would have risked permanent
damage to the enrollee's health or safety, or the health or
safety of others. The extent of the HMO's liability for
appropriate emergency treatment shall be the current Medicaid
fee-for-service rate for such treatment. Where appropriate
emergency treatment is provided by a non-HMO provider to an HMO
enrollee, the non-HMO provider must notify the HMO within three
business days of the initiation of service excluding weekends and
holidays. The HMO is liable for the cost of the first 72 hours of
care. Upon notification within 72 hours the HMO shall be
responsible for payment of the first three business days, plus
any intervening weekend days and/or holidays. The HMO is
responsible for payment of additional care only if given the
opportunity to provide such care. Such referral or authorization,
is medically necessary, and will be retroactive to the date of
the request. After the 5th day following the date of request, an
assumption will exist that an authorization has been made until
such time as the HMO responds in writing.
In addition, the HMO shall be liable for the provision of crisis
intervention benefit. To the extent that counties provide the
crisis intervention service, the HMO will be liable to the extent
that FFS would pay except where contractual arrangements include
the crisis intervention service. The crisis intervention provider
must inform the HMO within twenty-four hours of initiation of
treatment care if the enrollee is stabilized. The HMO has the
option to transfer care in-plan or authorize the county's crisis
intervention provider to continue to provide the care. Other
provisions proposed by county human service agencies relating to
emergency care may be covered in the MOU and required if both
parties agree.
8. COURT-RELATED COMMITMENT COVERAGE----If services are provided in
an HMO facility, or approved by the HMO for provision in a
non-contracted facility, the HMO shall be financially liable for
the enrollee's court ordered assessment and/or treatment where an
HMO enrollee is defending him/herself or a member of his/her
Medicaid/BadgerCare case against a mental disability or substance
abuse commitment.
9. INSTITUTIONALIZED CHILDREN, COVERAGE REQUIRED----If inpatient or
institutional services are provided in an HMO facility, or
approved by the HMO for provision in a non-contracted facility,
the HMO shall be financially liable for all children enrolled
under this Contract for the entire period for which capitation is
paid. The HMO remains financially liable for the entire period a
capitation is paid even if the child's medical status code
changes , or the child's relationship to the original AFDC case
changes.
10. EXEMPTION PRIVILEGE DEFINED----For Medicaid/BadgerCare enrollees
who are eligible for HMO enrollment under the terms of Article IV
of this Contract, and who are thought to meet one or more of the
criteria in 11 a-d of this addendum, the AFDC/BadgerCare case
head shall be given the option of enrolling the enrollee who
meets one or more criteria in an HMO or applying to have the
affected person remain in the Medicaid FFS system. The same
privilege applies to HMO enrollees who are identified after
enrollment as meeting one or more of the criteria described in 11
a-d of this
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addendum. The AFDC/BadgerCare case head shall be given the option
of having the affected person remain in the HMO or applying to be
exempted at any point during the terms of this Contract. Where
the conditions in requirement 11 a-d of this addendum might
apply, the HMO, upon confirmation of this, shall promptly inform
the AFDC/BadgerCare case heads of their options as described
above. Beyond the obligation to inform, the HMO shall not counsel
or otherwise influence an enrollee or potential enrollee in such
a way as to encourage exemption from enrollment or continued
enrollment. The Department, the local boards, and the county
social service departments may notify enrollees or potential
enrollees of their options independently where such notification
is deemed appropriate. County Birth to Three programs may apply,
on behalf of enrollees, for exemption for children who are
thought to meet the criteria in 11 (d) of this addendum.
11. CRITERIA FOR EXEMPTION----The HMO shall not be liable, at the
point in time commencing with the month for which the `
enrollee's voluntary exemption becomes effective, except as
provided in 9 above, for providing contract services to
Medicaid/BadgerCare cases in which there is an HMO enrollee who
meets one or more of the following criteria as provided in
requirement 11 of this addendum:
a. a person with recurrent or persistent psychosis and/or a
major disruption in mood, cognition or perception;
b. a child from birth through two years of age (i.e., including
2 year olds), who is severely developmentally disabled or
suspected of a severe developmental delay, or who is
admitted to a 0-3 program;
c. a person participating in a methadone treatment program, or
who has been determined to need methadone treatment unless
the person declines to receive such treatment;
d. a person who has extensive non-medical programming needs
which the 51.42, 51.437, and social/human services system
are typically best equipped to provide or coordinate.
12. DISPUTE RESOLUTION----The Department shall be the sole arbitrator
of disputes concerning the criteria described in 11 a - d of this
addendum and all other requirements of this addendum and of
disputes arising out of MOUs negotiated. A local board, county
social or human service department, recipient, or advocate for an
enrollee, may request a review of complaints regarding denial of
access to medically necessary Medicaid-covered services after
they have utilized the HMO dispute resolution process. The
Department shall review the complaint and make a final
determination. The Department will accept written comments from
all parties to the dispute prior to making a decision. Failure to
pay providers promptly within 30 days for properly referred care
will be considered as a denial of access to such care. Where a
Departmental ruling is invoked in any dispute relating to the
terms of this addendum, the Department's decision shall be
communicated to the
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HMO, and when appropriate, to the 51.42, 51.437, or 46.23 Board
and/or to the county social service or human service department,
in writing and within 30 days of receipt of the request. The HMO
shall abide by all decisions of the Department.
13. LIVING IN A PUBLIC INSTITUTION----The HMO shall be liable for the
cost of providing all medically necessary services to enrollees
who are living in a public institution as defined in Article I,
during the month in which they first enter the public
institution. Enrollees who remain in a public institution after
the last day of the month are no longer eligible for Medical
Assistance/BadgerCare and HMOs are not liable for providing care
after the end of the first month.
14. TRANSFER FROM A PUBLIC INSTITUTION TO A MEDICAL
FACILITY----Enrollees who are living in a public institution and
go directly from the public institution to a medical facility,
court ordered or voluntarily, are no longer living in a public
institution and remain eligible for Medicaid/BadgerCare. The HMO
shall be responsible for reimbursing for the provision of
medically necessary treatment if treatment is at the HMO's
facilities, or if unable to itself provide for such treatment.
15. TRANSPORTATION FOLLOWING EMERGENCY DETENTION----The HMO shall be
liable for the provision of medical transportation to an
HMO-affiliated provider when the enrollee is under emergency
detention or commitment and the HMO requires the enrollee to be
moved to a participating provider, provided the transfer can be
made safely. If a transfer requires a secured environment by
local law enforcement officials, i.e., Sheriff Department, Police
Department, etc., the HMO shall not be liable for the cost of
transfer. Nothing precludes the HMO from entering into an MOU or
agreement with local law enforcement agencies or with county
agencies for such transfer.
HMO Contract for January 1, 2002 - December 31, 2003
-124-
ADDENDUM III
(DELETED)
RISK-SHARING FOR INPATIENT HOSPITAL SERVICES
HMO Contract for January 1, 2002 - December 31, 2003
-125-
ADDENDUM IV
CONTRACT SPECIFIED REPORTING REQUIREMENTS
PART A. REPORTS AND DUE DATES
<Table>
<Caption>
DUE REPORTING
DATE* TYPE OF REPORT PERIOD DUE TO REPORT FORMAT REPORTING UNIT
----- -------------- --------- ------ ------------- --------------
Within 15 Affirmative Action Plan Contract period Managed Care
days of
contract
signing
Within 30 Disclosure Statements As of present Managed Care
days of time
contract
signing
YEAR 2002
Jan 1 Encounter Data File (AFDC/HS & Dec., 2001 EDS-MEDS Electronic Media Encounter
BC)
Jan 15 Dental Utilization Data ** Oct - Dec, 2001 Managed Care Hardcopy Dental
Preventive
Encounter
Feb 1 Encounter Data File (AFDC/HS & BC) Jan., 2002 EDS-MEDS Electronic Media Encounter
Feb 1 AIDS/Ventilator Dependent Oct - Dec, 2001 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Feb 7 Abortions/Sterilization/Hysterectomi Oct - Dec, 2001 EDS Hardcopy Entire HMO
es (AFDC/HS & BC)
Feb 15 Federally Qualified Health Centers Oct - Dec, 2001 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Feb 15 Formal/Informal Grievance Oct - Dec, 2001 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Feb 15 Coordination of Benefits Report Oct - Dec, 2001 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Mar 1 Encounter Data File AFDC/HS and Feb., 2002 EDS-MEDS Electronic Media Encounter
BC)
Mar 1 ***Physician Incentive Plan - Jan - Dec, 2001 Managed Care Hardcopy Entire HMO
Disclosure Form (AFDC/HS & BC)
Apr 1 Encounter Data File (AFDC/HS & March 2002 EDS -MEDS Electronic Media Encounter
BC)
Apr 15 Dental Utilization Data ** Jan - Mar 2002 Managed Care Hardcopy Dental
Preventive
Encounter
Apr 30 Formal/Informal Grievance Jan - Mar, 2002 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
May 1 Neonatal ICU Patient Care Data Jan - Dec, 2001 EDS Hardcopy HMO By
(AFDC/HS & BC) County
May 1 Encounter Data File (AFDC/HS & BC) Jan - Apr, 2002 EDS-MEDS Electronic Media Encounter
May 1 AIDS/Ventilator Dependent Jan - Mar, 2002 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
May 7 Abortion/Sterilization/Hysterectomies Jan - Mar, 2002 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
<Caption>
DUE CONTRACT
DATE* REFERENCE
----- ---------
Within 15 Art. III, P
days of
contract
signing
Within 30 Add. I, V
days of
contract
signing
YEAR 2002
Jan 1 Art. VI, B;
Add. IV, B
Jan 15 Art. III, B, 8 d
Feb 1 Art. VI, B;
Add. IV, B
Feb 1 Art. V, K;
Add. IV, D
Feb 7 Art. VI, E
Feb 15 Art. III, FF
Feb 15 Art VIII, A. 10-11;
Add. XXI
Feb 15 Art. VI, B.1;
Art V, H; Add. VI
Mar 1 Art. VI, B;
Add IV, B
Mar 1 Art. III, HH
Apr 1 Art. VI, B;
Add IV, B
Apr 15 Art. III, B, 8 d
Apr 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
May 1 Art. V, E
Add. XIX
May 1 Art. VI, B;
Add. IV, B
May 1 Art. V, J
dd. IV, D
May 7 Art. VI, E
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-126-
<Table>
<Caption>
DUE REPORTING
DATE* TYPE OF REPORT PERIOD DUE TO REPORT FORMAT REPORTING UNIT
- ----- -------------- --------- ------ ------------- --------------
May 15 Federally Qualified Health Centers Jan - Mar, 2002 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
May 15 Coordination of Benefits Report Jan - Mar, 2002 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Jun 1 Encounter File (AFDC/HS & BC) May, 2002 EDS-MEDS Electronic Media Encounter
Jul 1 Encounter File (AFDC/HS & BC) Jun, 2002 EDS-MEDS Electronic Media Encounter
Jul 15 Dental Utilization Data Mar - Jun 2002 Managed Care Hardcopy Dental
Preventive
Encounter
Jul 30 Formal/Informal Grievance Apr - Jun, 2002 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Aug 1 AIDS/Ventilator Dependent Apr - Jun, 2002 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Aug 1 Encounter File (AFDC/HS & BC) Jul, 2002 EDS-MEDS Electronic Media Encounter
Aug 7 Abortions/Sterilization/ Apr - Jun, 2002 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
Aug 15 Federally Qualified Health Centers Apr - Jun, 2002 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Aug 15 Coordination of Benefits Report Apr - Jun, 2002 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Sept 1 Encounter File (AFDC/HS & BC) Aug, 2002 EDS-MEDS Electronic Media Encounter
Sept 1 Birth Cost Reporting (AFDC/HS & Jan - Dec, 2001 Managed Care Hardcopy Entire HMO
BC)
Oct 1 Targeted Performance Improvement Jan - Dec, 2001 Managed Care Electronic Media Per
Measures (AFDC/HS & BC) Project
Oct 1 Performance Improvement Projects Jan - Dec, 2001 Managed Care Hardcopy Per Improvement
(AFDC/HS & BC) Project
Oct 1 Encounter File (AFDC/HS & BC) Sep, 2002 EDS-MEDS Electronic Media Encounter
Oct 15 Dental Utilization Data Jul - Sep 2002 Managed Care Hardcopy Dental
Preventive
Encounter
Oct 30 Formal/Informal Grievance Jul - Sep, 2002 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Nov 1 AIDS/Ventilator Dependent Jul - Sep, 2002 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Nov 1 ***Physician Incentive Plan Jan - Dec 2001 Managed Care Hardcopy Entire HMO
Provider Risk Survey Report
Nov 1 Encounter File (AFDC/HS & BC) Oct, 2002 EDS-MEDS Electronic Media Encounter
Nov 7 Abortions/Sterilization/ Jul - Sep, 2002 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
Nov 15 Federally Qualified Health Centers Jul - Sep, 2002 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Nov 15 Coordination of Benefits Report Jul - Sep, 2002 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
<Caption>
DUE CONTRACT
DATE* REFERENCE
- ----- ---------
May 15 Art. III, FF
May 15 Art. V, H;
Add. VI
Jun 1 Art. VI, B;
Add. IV, B
Jul 1 Art. VI, B;
Add. IV, B
Jul 15 Art. III, B, 8 d
Jul 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
Aug 1 Art. V, J;
Add. IV, D
Aug 1 Art. VI, B;
Add. IV, B
Aug 7 Art. VI, E
Aug 15 Art. III, FF
Aug 15 Art. V, H;
Add. VI
Sept 1 Art. VI, B;
Add. IV, B
Sept 1 Art. VI, B. 4;
Add. XXIII
Oct 1 Art. III, W 13;
Add. XVI
Oct 1 Art. III, W 13;
Add. XV, XVI
Oct 1 Art. VI, B;
Add. IV, B
Oct 15 Art. III, B, 8 d.
Oct 30 Art. VIII, A. 10-11;
Art.VIII, E;
Add. XXI
Nov 1 Art. V, J;
Add. IV, D
Nov 1 Art. III, HH
Nov 1 Art. VI, B;
Add. IV, B
Nov 7 Art. VI, E
Nov 15 Art. III, FF
Nov 15 Art. V, H;
Add. VI
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-127-
<Table>
<Caption>
DUE REPORTING
DATE* TYPE OF REPORT PERIOD DUE TO REPORT FORMAT REPORTING UNIT
- ----- -------------- --------- ------ ------------- --------------
Dec 1 Encounter File (AFDC/HS & BC) Nov, 2002 EDS-MEDS Electronic Media Encounter
YEAR 2003
Jan 1 Encounter File (AFDC/HS & BC) Dec, 2002 EDS-MEDS Electronic Media Encounter
Jan 15 Dental Utilization Data Oct - Dec 2002 Managed Care Hardcopy Dental
Preventive
Encounter
Jan 30 Formal/Informal Grievance Oct - Dec, 2002 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Jan 31 Provider List on Tape Dec. 31, 2002 Managed Care Disc HMO Service
Area
Feb 1 AIDS/Ventilator Dependent Oct - Dec, 2002 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Feb 1 Encounter File (AFDC/HS & BC) Jan, 2003 EDS-MEDS Electronic Media Encounter
Feb 7 Abortions/Sterilization/ Oct - Dec, 2002 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
Feb 15 Federally Qualified Health Centers Oct - Dec, 2002 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Feb 15 Coordination of Benefits Report Oct - Dec, 2002 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Mar 1 ***Physician Incentive Disclosure Jan - Dec, 2002 Managed Care Hardcopy Entire HMO
Form (AFDC/HS & BC)
Mar 1 Encounter File (AFDC/HS & BC) Feb, 2003 EDS-MEDS Electronic File Encounter
Apr 1 Encounter File (AFDC/HS & BC) Mar, 2003 EDS-MEDS Electronic File Encounter
Apr 15 Dental Utilization Data Jan - Mar 2003 Managed Care Hardcopy Dental
Preventive
Encounter
Apr 30 Formal/Informal Grievance Jan - Mar, 2003 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
May 1 Neonatal ICU Patient Care Data Jan - Dec, 2002 EDS Hardcopy HMO By
(AFDC/HS & BC) County
May 1 Encounter File (AFDC/HS & BC) Apr, 2003 EDS-MEDS Electronic File Encounter
May 1 AIDS/Ventilator Dependent Jan - Mar, 2003 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
May 7 Abortions/Sterilization/ Jan - Mar, 2003 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
May 15 Federally Qualified Health Centers Jan - Mar, 2003 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
May 15 Coordination of Benefits Report Jan - Mar, 2003 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Jun 1 Encounter File (AFDC/HS & BC) May, 2003 EDS-MEDS Electronic File Encounter
Jul 1 ***Physician Incentive Plan Jan - Dec 2002 Managed Care Hardcopy Entire HMO
Provider Risk (AFDC/HS and BC)
Jul 1 Encounter File (AFDC/HS & BC) Aug, 2003 EDS-MEDS Electronic File Encounter
<Caption>
DUE CONTRACT
DATE* REFERENCE
- ----- ---------
Dec 1 Art. VI, B;
Add. IV, B
YEAR 2003
Jan 1 Art. VI, B;
Add. IV, B
Jan 15 Art. III, B, 8 d.
Jan 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
Jan 31 Add. IV, C
Feb 1 Art. V, J;
Add. IV, D
Feb 1 Art. VI, B;
Add. IV, B
Feb 7 Art. VI, E
Feb 15 Art. III, FF
Feb 15 Art. V, H;
Add. VI
Mar 1 Art. III, HH
Mar 1 Art. VI, B;
Add. IV, B
Apr 1 Art. VI, B;
Add. IV, B
Apr 15 Art. III, B, 8 d.
Apr 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
May 1 Art. V, E;
Add. XIX
May 1 Art. VI, B;
Add. IV, B
May 1 Art. V, J;
Add. IV, D
May 7 Art. VI, E
May 15 Art. III, FF
May 15 Art. V, H;
Add. VI
Jun 1 Art. VI, B;
Add. IV, B
Jul 1 Art. III, HH
Jul 1 Art. VI, B;
Add. IV, B
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-128-
<Table>
<Caption>
DUE REPORTING
DATE* TYPE OF REPORT PERIOD DUE TO REPORT FORMAT REPORTING UNIT
- ----- -------------- --------- ------ ------------- --------------
Jul 15 Dental Utilization Data Apr - Jun 2003 Managed Care Hardcopy Dental
Preventive
Encounter
Jul 30 Formal/Informal Grievance Apr - Jun, 2003 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Aug 1 AIDS/Ventilator Dependent Apr - Jun, 2003 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Aug 1 Encounter File (AFDC/HS & BC) Jul, 2003 EDS-MEDS Electronic File Encounter
Aug 7 Abortions/Sterilization/ Apr - Jun, 2003 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
Aug 15 Federally Qualified Health Centers Apr - Jun, 2003 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Aug 15 Coordination of Benefits Report Apr - Jun, 2003 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Sep 1 Birth Cost Reporting (AFDC/HS & Jan - Dec, 2002 Managed Care Hardcopy Entire HMO
BC)
Sep 1 Encounter File (AFDC/HS & BC) Aug, 2003 EDS-MEDS Electronic File Encounter
Oct 1 Performance Improvement Projects Jan - Dec, 2002 Managed Care Hardcopy Per Improvement
(AFDC/HS & BC) Project
Oct 1 Encounter File (AFDC/HS & BC) Sep, 2003 EDS-MEDS Electronic File Encounter
Oct 15 Dental Encounter Data Jul - Sep, 2003 Managed Care Hardcopy Dental
Preventive
Encounter
Oct 30 Formal/Informal Grievance Jul - Sep, 2003 Managed Care Hardcopy Entire HMO
Experience Summary report
(AFDC/HS & BC)
Nov 1 AIDS/Ventilator Dependent Jul - Sep, 2003 EDS Hardcopy & Disc HMO Service
(AFDC/HS & BC) Area
Nov 1 Encounter File (AFDC/HS & BC) Oct, 2003 EDS-MEDS Electronic File Entire HMO
Nov 7 Abortions/Sterilization/ Jul - Sep, 2003 EDS Hardcopy Entire HMO
Hysterectomies (AFDC/HS & BC)
Nov 15 Federally Qualified Health Centers Jul - Sep, 2003 Managed Care Hardcopy - no By FQHC/RHC
& Rural Health Centers (AFDC/HS & form
BC)
Nov 15 Coordination of Benefits Report Jul - Sep, 2003 EDS Hardcopy Entire HMO
(AFDC/HS & BC)
Dec 1 Encounter File (AFDC/HS & BC) Nov, 2003 EDS-MEDS Electronic File Encounter
<Caption>
DUE CONTRACT
DATE* REFERENCE
- ----- ---------
Jul 15 Art. III, B, 8 d
Jul 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
Aug 1 Art. V, J;
Add. IV, D
Aug 1 Art. VI, B;
Add. IV, B
Aug 7 Art. VI, E
Aug 15 Art. III, FF
Aug 15 Art. V, H;
Add. VI
Sep 1 Art. VI, B 4;
Add. XXIII
Sep 1 Art. VI, B;
Add. IV, B
Oct 1 Art. III, W 13;
Add. XV, XVI
Oct 1 Art. VI, B;
Add. IV, B
Oct 15 Art III, B, 8 d.
Oct 30 Art. VIII, A. 10-11;
Art. VIII, E;
Add. XXI
Nov 1 Art. V, J;
Add. IV, D
Nov 1 Art. VI, B;
Add. IV
Nov 7 Art. VI, E
Nov 15 Art. III, FF
Nov 15 Art. V, H;
Add. VI
Dec 1 Art. VI, B;
Add. IV, B
</Table>
Any reports that are due on a weekend or holiday are due the following workday.
** Only HMOs who are certified to provide dental are required to submit
preventive dental encounter data for the service areas in which the HMO is
certified to provide dental.
<Table>
REPORT MAILING EDS-MEDS Bureau of Managed Care Programs EDS
ADDRESS: 10 E. Doty Street, Suite 200 P.O. Box 309 6406 Bridge Road
Madison, WI 53703 Madison, WI 53701-0309 Madison WI 53713
</Table>
*** This report is due only for HMOs with substantial financial risk as shown in
the PIP Disclosure Form for the reporting period. Surveys must include enrollees
and disenrollees.
HMO Contract for January 1, 2002 - December 31, 2003
-129-
PART B. WISCONSIN MEDICAID/BADGERCARE HMO SUMMARY AND
ENCOUNTER DATA SET
Encounter Data Reporting
1. All HMOs that contract with the Wisconsin Department of Health
and Family Services (DHFS) to provide Medicaid services must
submit monthly encounter data files according to the
specifications and submission protocols published in the
Wisconsin Medicaid HMO Encounter Data User Manual.
2. Encounter data should be reported using the following
specifications:
a. The rules governing the level of detail when reporting
encounters should be those rules established by the
following classification schemes: ICD-9-CM (or ICD-10-CM)
diagnosis codes and procedure codes CPT procedure codes
(HCPCS level I codes), level II HCPCS codes, level III HCPCS
codes, National Drug Codes (NDC), CDT-2 codes, Hospital
revenue codes for inpatient and outpatient hospital
services, and hospital inpatient Diagnostic Related Group
(DRG) codes.
Multiple encounters can occur between a single provider and
a single recipient on a day. For example, if a physician
provides a limited office visit, administers an
immunization, and takes a chest x-ray, and the provider
submits a claim or report specifically identifying all three
services, then there are three encounters, and the HMO will
report three encounters to the Wisconsin Medicaid Program.
Testing Encounter Data
1. New HMOs must test the encounter data set until the Department is
satisfied that the HMO is capable of submitting valid, accurate,
and timely encounter data according to the schedule and timetable
in this addendum.
2. Each HMO must specify to the DHFS the name of the primary contact
person assigned responsibility for submitting and correcting HMO
encounter and utilization data, and a secondary contact person
that should be contacted in the event the primary contact person
is not available.
HMO Encounter Technical Workgroup
1. All HMOs must assign staff to participate in HMO encounter
technical workgroup meetings periodically scheduled by the
Department. This workgroup's purpose is to enhance the HMO and
Medicaid data submission protocols and improve the accuracy and
completeness of the data. The HMO encounter technical workgroup
is also responsible for planning the implementation of the
electronic transaction
HMO Contract for January 1, 2002 - December 31, 2003
-130-
formats mandated by the Health Insurance Portability and
Accountability Act (HIPAA).
Encounter Data Completeness and Accuracy
1. The Department has established a goal for the encounter data set
of 98 percent completeness and accuracy. The HMO encounter
technical workgroup will develop the mechanism to achieve this
goal by the end of the contract period.
2. The Department will conduct data validity and completeness audits
during the contract period. At least one of these audits will
include a review of the HMO's encounter data system and system
logic.
Analysis of Encounter Data
1. The Department retains the right to analyze encounter data and
use it for any purpose it deems necessary. However, the
Department will make every effort to ensure that the analysis
does not violate the integrity of the reported data submitted by
the HMO.
PART C. PROVIDER LIST ON TAPE
All HMOs that contract with the Department to provide Medicaid
services must submit the provider data requested on the HMO Provider
List once per contract period, based on the HMO files as of December
31, 2002. The tape should be submitted by January 31, 2003, according
to the schedule in Part A of Addendum IV. This data must be submitted
in computer readable format. Data must be included for physicians,
dentists, pharmacies, optometrists, transportation providers,
hospitals, Substance Abuse and/or mental health providers, and
freestanding urgent care centers.
PROVIDER DATA RECORD LAYOUT
<Table>
<Caption>
FIELD NAME TYPE WIDTH POSITION NOTES
---------- ---- ----- -------- -----
a. HMO_ID Num 8 1-8 Right justified. This field represents the base
HMO Medicaid provider number with the two-digit
suffix that indicates an HMO's service area.
b. CTY Num 2 9-10 County Code (1-72)
c. PROV_LAST Char 13 11-23 Provider's last name
d. PROV_FIRST Char 10 24-33 Provider's first name
e. ADDRESS Char 26 34-59 Practice address
f. CITY Char 18 60-77
g. ZIPCODE Char 10 78-87 Left justified
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-131-
PROVIDER DATA RECORD LAYOUT
<Table>
<Caption>
FIELD NAME TYPE WIDTH POSITION NOTES
---------- ---- ----- -------- -----
h. PROV_ID Num 8 88-95 Provider's Medicaid ID number
i. PROV_TYPE Char 2 96-97 Provider type
j. SPEC Char 3 98-100 Provider's specialty
k. CLINIC_AFFIL Char 26 101-126 Clinic affiliation
l. IPA_AFFIL Char 26 127-152 IPA affiliation
m. #MAX_PAT Num 4 153-156 If you assign Medicaid patients to this provider,
what number is currently assigned?
n. MAX Char 1 157 Is this provider taking more Medicaid patients?
(Y = Yes, N = No)
</Table>
To help provide this information, HMOs are encouraged to refer to the monthly
file of Medicaid-certified providers that they receive.
HMOs must enter data in field m. #MAX_PAT for primary care physicians, dentists,
Substance Abuse and mental health providers. If HMOs do not assign enrollees to
other provider types (for example, pharmacies), they do not make entries here.
For providers who practice in more than one location, the HMOs must list all of
the information for each location.
The HMO must provide the address where the provider practices, not a billing
address or a post office address.
In a memo that accompanies the provider list, the HMO must identify the name and
phone number of a contact person for this tape.
HMO Contract for January 1, 2002 - December 31, 2003
-132-
PART D: AIDS AND VENTILATOR DEPENDENT ENROLLEE QUARTERLY
REPORTS
AIDS COST SUMMARY
HMO NAME:
----------------------------------
REPORT PERIOD:
-----------------------------
NUMBER OF CASES REPORTED:
------------------
<Table>
<Caption>
CATEGORY OF SERVICE AMOUNT BILLED AMOUNT PAID
------------------- ------------- -----------
Inpatient
Outpatient
Physician
Pharmacy
All Other
TOTAL
</Table>
VENTILATOR COST SUMMARY
HMO NAME:
----------------------------------
REPORT PERIOD:
-----------------------------
NUMBER OF CASES REPORTED:
------------------
<Table>
<Caption>
CATEGORY OF SERVICE AMOUNT BILLED AMOUNT PAID
------------------- ------------- -----------
Inpatient
Outpatient
Physician
Pharmacy
All Other
TOTAL
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-133-
AIDS AND VENTILATOR DEPENDENT DETAIL REPORT
The detail report must be provided on disk and must be in the following layout:
<Table>
<Caption>
FIELD NAME TYPE WIDTH DEC POSITION EXPLANATION
---------- ---- ----- --- -------- -----------
1 HMO_ID Num 8 0 1-8 Right justified (HMO Service
Area Provider Number)
2 MA_ID Num 10 0 9-18 Recipient Medicaid ID
3 LNAME Char 13 19-31 Recipient Last Name - Left
justified
4 FNAME Char 10 32-41 Recipient First Name - Left
justified
5 ELIG_CODE Char 1 42 A = AIDS;
N = NICU vent dependent;
V = Vent dependent, non-NICU
6 DOB Date 8 43-50 mmddyyyy
7 SEX Char 1 51 F or M
8 PROV_ID Num 8 0 52-59 Medicaid Provider Number
9 FROM_DATE Date 8 60-67 mmddyyyy
10 TO_DATE Date 8 68-75 mmddyyyy
11 DIAG_1 Char 5 76-80 Left justified, ICD-9, implied
decimal
12 DIAG_2 Char 5 81-85 Left justified, ICD-9, implied
decimal
13 QTY Num 4 0 86-89 Right justified (do not zero fill)
14 PROC_CODE Char 5 90-94 Left justified, CPT-4, UB92
15 PROC_DESC Char 10 95-104
16 DRUG_CODE Num 11 0 105-115 National drug code
17 AMT_BILL Num 9 2 116-124 Include decimal (do not zero fill)
18 AMT-PAID Num 9 2 125-133 Include decimal (do not zero fill)
19 ADMIT_DATE Date 8 134-141 Hospital admission date:
mmddyyyy
20 DIS_DATE Date 8 142-149 Hospital discharge date:
mmddyyyy
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-134-
ADDENDUM V
STANDARD ENROLLEE HANDBOOK LANGUAGE
INTERPRETER SERVICES
English - For help to translate or understand this, please call [1-800-xxx-xxxx]
(TTY).
Spanish - Si necesita ayuda para traducir o entender este texto, por favor llame
al telefono [1-800-xxx-xxxx] (TTY).
Russian - ? ??? ??? ?? ??? ??????? ? ???? ????? ????, ?? ??????? ?? ?????
??? [1-800-xxx-xxx] (?? Y).
Hmong - Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau
[1-800-xxx-xxxx] (TTY).
Laotian - GRNJV-J;P.ODKOCX S]NG0QK.9GONVSK.OOUF DTI5OK3MITLA[SK
[1-800-xxx-xxxx] (TTY).
Interpreter services are provided free of charge to you.
IMPORTANT [HMO NAME] PHONE NUMBERS
<Table>
Customer Service [1-800-xxx-xxxx] [Hours/Days Available]
Emergency Number [1-800-xxx-xxxx] Call 24 hours a day, 7 days a week
TDD/TTY [1-800-xxx-xxxx]
</Table>
WELCOME
Welcome to [HMO NAME]. As a member of [HMO NAME], you will receive all your
health care from [HMO NAME] doctors, hospitals, and pharmacies. See [HMO NAME]
Provider Directory for a list of these providers. You may also call our Customer
Service Department at [1-800-xxx-xxxx]. Providers not accepting new patients are
marked in the Provider Directory.
YOUR FORWARD ID CARD
Always carry your Forward ID card with you, and show it every time you get care.
You may have problems getting care or prescriptions if you do not have your card
with you. Also bring any other health insurance cards you may have.
HMO Contract for January 1, 2002 - December 31, 2003
-135-
PRIMARY CARE PHYSICIAN (PCP)
It is important to call your primary care physician (PCP) first when you need
care. This doctor will manage all your health care. If you think you need to see
another doctor, or a specialist, ask your PCP. Your PCP will help you decide if
you need to see another doctor, and give you a referral. Remember, you must get
approval from your PCP before you see another doctor.
You can choose your primary care physician (PCP) from those available (NOTE: For
women you may also see a women's health specialist (for example a OB/GYN doctor
or a nurse midwife) without a referral, in addition to choosing your PCP).There
are HMO doctors who are sensitive to the needs of many cultures. To choose a
PCP, or to change to a different PCP, call our Customer Service Department at
[1-800-xxx-xxxx].
EMERGENCY CARE
Emergency care is care needed right away. This may be caused by an injury or a
sudden illness. Some examples are:
Choking Severe or unusual bleeding
Trouble breathing Suspected poisoning
Serious broken bones Suspected heart attack
Unconsciousness Suspected stroke
Severe burns Convulsions
Severe pain Prolonged or repeated seizures
If you need emergency care, go to a [HMO NAME] provider for help if you can.
BUT, if the emergency is severe, go to the nearest provider (hospital, doctor or
clinic). You may want to call 911 or your local police or fire department
emergency services if the emergency is severe.
If you must go to a [non-HMO NAME] hospital or provider , call [HMO NAME] at
[1-800-xxx-xxxx] as soon as you can and tell us what happened. This is important
so we can help you get follow up care.
Remember, hospital emergency rooms are for true emergencies only. Call your
doctor or our 24-hour emergency number at [1-800-xxx-xxxx] before you go to the
emergency room, unless your emergency is severe.
URGENT CARE
Urgent Care is care you need sooner than a routine doctor's visit. Urgent care
is not emergency care. Do not go to a hospital emergency room for urgent care
unless your doctor tells you to go there. Some examples of urgent care are:
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Most broken bones Minor cuts
Sprains Bruises
Non-severe bleeding Most drug reactions
Minor burns
If you need urgent care, call [insert instructions here--call clinic, doctor,
24-hour number, nurse line, etc.] We will tell you where you can get care. You
must get urgent care from [HMO NAME] doctors unless you get our approval to see
a [non-HMO NAME] doctor. Remember, do not go to a hospital emergency room for
urgent care unless you get approval from [HMO NAME] first.
OUT-OF-AREA MEDICAL CARE
Out-of-area means more than 50 miles away from our service area. Our service
area is:
HMOs MAY USE A MAP TO EXPLAIN WHAT THE HMO SERVICE AREA IS, MAY LIST MAJOR
CITIES, MAJOR CLINICS, OR A COMBINATION THEREOF TO EXPLAIN SERVICE NETWORK.
For help with out-of-area services, call HMO NAME customer service line at
1-800-xxx-xxxx or the enrollment specialist at 1-800-291-2002.
HOW TO GET MEDICAL CARE WHEN YOU ARE AWAY FROM HOME
Follow these rules if you need medical care but are too far away from home to go
to your assigned primary care physician (PCP) or clinic.
For severe emergencies, go to the nearest hospital, clinic, or doctor.
For urgent or routine care away from home, you must get approval from us to go
to a different doctor, clinic or hospital. This includes children who are
spending time away from home with a parent or relative. Call us at
[1-800-xxx-xxxx] for approval to go to a different doctor, clinic, or hospital.
PREGNANT WOMEN AND DELIVERIES
You must go to a [HMO NAME] hospital to have your baby. Talk to your [HMO NAME]
doctor to make sure you understand which hospital you are to go to when it's
time to have your baby.
Also, talk to your doctor if you plan to travel in your last month of pregnancy.
Because we want you to have a healthy birth and a good birthing experience, it
may not be a good time for you and your unborn child to be traveling. We want
you to have a healthy birth and your [HMO Name] doctor knows your history and is
the best doctor to help you have a healthy birth. Do not go out of area to have
your baby unless you have [HMO NAME] approval.
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You may also wish to pick a doctor for your child before you give birth. We will
be able to help you pick a doctor for your unborn child.
WHEN YOU MAY BE BILLED FOR SERVICES
It is very important to follow the rules when you get medical care so you are
not billed for services. You must receive your care from [HMO NAME] providers,
hospitals, and pharmacies unless you have our approval. The only exception is
for severe emergencies.
IF YOU ARE BILLED
If you receive a bill for services, call our Customer Service Department at
[1-800-xxx-xxxx]. You do not have to pay for services that [HMO NAME] is
required to provide you.
OTHER INSURANCE
If you have other insurance in addition to [HMO NAME], you must tell your doctor
or other provider. Your health care provider must bill your other insurance
before billing [HMO NAME]. If your [HMO NAME] doctor does not accept your other
insurance, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment
Specialist can tell you how to match your HMO enrollment with your other
insurance so you can use both insurance plans.
SERVICES COVERED BY [HMO NAME]
[HMO NAME] provides all medically necessary covered services. Some services may
require a doctor's order or a prior authorization. Covered services include:
o Prescription drugs and certain over-the-counter drugs when ordered by a
doctor
o Services by doctors and nurses, including nurse practitioners and nurse
midwives
o Inpatient and outpatient hospital services
o Laboratory and X-ray services
o HealthCheck for members under 21 years of age, including referral for other
medically necessary services
o Certain podiatrists' (foot doctors) services
o Inpatient care at institutions for mental disease (care for persons 22-64
years of age is not included)
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o Optometrists' (eye doctors) or opticians' services, including eyeglasses
o Mental health treatment
o Substance abuse (drug and alcohol) services
o Family planning services and supplies
o The following services when a doctor gives a written order:
>> Prostheses and other corrective support devices
>> Hearing aids and other hearing services
>> Home health care
>> Personal care
>> Independent nursing services
>> Medical supplies and equipment
>> Occupational therapy
>> Physical therapy
>> Speech therapy
>> Respiratory therapy
>> Nursing home services
>> Medical Nutrition Counseling
>> Hospice care
>> Appropriate transportation to obtain medical care by ambulance or
specialized medical vehicles
o Certain dental services (not all dental services are covered) [Eliminate if
HMO does not provide dental]
o Certain chiropractic services [Eliminate if HMO does not provide
chiropractic]
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES
[HMO NAME] provides mental health and substance abuse (drug and alcohol)
services to all enrollees. If you need these services, call [PCP, gatekeeper,
Customer Service, as appropriate].
FAMILY PLANNING SERVICES
We provide confidential family planning services to all enrollees. This includes
minors. If you don't want to talk to your primary care doctor about family
planning, call our Customer Service Department at [1-800-xxx-xxx]. We will help
you choose a [HMO NAME] family planning doctor who is different from your
primary care doctor.
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You can also go to any family planning clinic that will accept your Forward ID
card even if the clinic is not part of [HMO NAME]. But we encourage you to
receive family planning services from a [HMO NAME] doctor. That way we can
better coordinate all your health care.
DENTAL SERVICES
[Note to HMO: Use statement 1. if you provide dental services. Use statement 2.
if you do not provide dental services. If you provide dental services in only
part of your service area, use both statements and list the appropriate counties
with each statement.]
1. [HMO NAME] provides all covered dental services. But you must go to a [HMO
NAME] dentist. See the Provider Directory or call the Customer Service
Department at [1-800-xxx-xxxx] for the names of our dentists.
2. You may get dental services from any dentist who will accept your Forward
ID card. Your dental services are provided by the State, not [HMO NAME]. If
you are enrolled in the State dental managed care program, you must get
your dental services from that program.
DENTAL EMERGENCY:
A dental emergency is an immediate dental service needed to treat dental pain,
swelling, fever, infection, or injury to the teeth.
WHAT TO DO IF YOU OR YOUR CHILD HAS A DENTAL EMERGENCY
1. If you already have a dentist who is with HMO name:
>> Call the dentist's office.
>> Identify yourself or your child as having a dental emergency.
>> Tell the dentist's office what the exact dental problem is. This may
be something like a toothache or swollen face. Make sure the office
understands that you or your child is having a "dental emergency."
>> Call us if you need help with transportation to your dental
appointment.
2. If you do not currently have a dentist who is with HMO Name
>> Call {HMO specific dental gatekeeper or HMO}. Tell us that you/your
child is having a dental emergency. We can help you get dental
services.
>> Tell us if you need a ride to the dentist's office.
>> Alternative language for HMO's whose dental gatekeeper handles
appointment for emergencies. Call HMO NAME if you need help with
transportation to the dentist's office. We can help with
transportation.
For help with a dental emergency call xxx-xxx-xxxx.
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CHIROPRACTIC SERVICES
[Note to HMO: Use statement 1. if you provide chiropractic services. Use
statement 2. if you do not provide chiropractic services.]
1. [HMO NAME] provides covered chiropractic services. But you must go to a
[HMO NAME] chiropractor. See the Provider Directory or call the Customer
Service Department at [1-800-xxx-xxxx] for the names of our chiropractors.
2. You may get chiropractic services from any chiropractor who will accept
your Forward ID card. Your chiropractic services are provided by the State,
not [HMO NAME].
HEALTHCHECK
HealthCheck is a preventive health checkup program for members under the age of
21. The HealthCheck program covers complete health checkups. These checkups are
very important for children's health. Your child may look and feel well, yet may
have a health problem. Your doctor wants to see your children for regular
checkups, not just when they are sick.
The HealthCheck health program has three purposes:
1. To find and treat children's health problems early,
2. To let you know about the special child health services you can receive,
and
3. To make your children eligible for some health care not otherwise covered.
The HealthCheck program covers the care for any health problems found during the
checkup including medical care, eye care and dental care.
The HealthCheck checkup includes:
>> a health history
>> physical exam
>> developmental assessment
>> hearing and vision test
>> blood and urine lab tests
>> complete immunizations (shots)
Children age three and older will be referred to a dentist. You will receive
help in choosing and getting to a dentist.
[HMO NAME] will help arrange for transportation for HealthCheck visits. Call our
Customer Service Department a [1-800-xxx-xxxx].
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Ask your child's primary care doctor (PCP) when your child should have his/her
next HealthCheck exam or call our Customer Service Department at
[1-800-xxx-xxxx] for more information.
TRANSPORTATION
(Note to HMO: Use statement 1. if you arrange transportation for your enrollees.
Use statement 2. if you do not arrange transportation for your enrollees. Use
statement 3. if you arrange transportation in only part of your service area.)
1. Bus or taxi rides to receive care are arranged by [HMO NAME]. Call our
Customer Service Department at [1-800-xxx-xxxx] if you need a ride.
2. Bus or taxi rides to receive care are arranged by your county Department of
Social or Human Services Call them for information.
3. Bus or taxi rides to receive care are arranged by [HMO NAME] if you live in
[INSERT COUNTIES]. Call our Customer Service Department at [1-800-xxx-xxxx]
if you need a ride. If you live in a county that is not listed, please call
your county Department of Social or Human Services for information about
arranging a ride.
AMBULANCE
[HMO NAME] covers ambulance service for Emergency Care. We may also cover this
service at other times, but you must have approval for all non-emergency
ambulance trips. Call our Customer Service Department at [1-800-xxx-xxxx] for
approval.
SPECIAL MEDICAL VEHICLE (SMV)
[HMO NAME] covers transportation by special vehicle for those in wheelchairs. We
may also cover this service for others if your doctor asks for it. Call our
Customer Service Department at [1-800-xxx-xxxx] if you need this service.
IF YOU MOVE
If you are planning to move, contact your county Department of Social or Human
Services. If you move to a different county, you must also contact the
Department of Social or Human Services in your new county to update your
eligibility.
If you move out of [HMO NAME'S] service area, call the HMO Enrollment Specialist
at 1-800 291-2002. [HMO NAME] will only provide emergency care if you move out
of our service area. The Enrollment Specialist will help you choose an HMO that
serves your area.
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HEALTH INSURANCE AFTER YOUR ELIGIBILITY ENDS
You have the right to purchase a private health insurance policy from [HMO NAME]
when your eligibility ends. Call our Customer Service Department at
[1-800-xxx-xxxx]. If you decide to purchase a policy from us, you have 30 days
after the date your eligibility ends to apply.
SECOND MEDICAL OPINION
A second medical opinion on recommended surgeries may be appropriate in some
cases. Contact your doctor or our Customer Service Department for information.
HMO EXEMPTIONS
An HMO exemption means you are not required to join an HMO to receive your
health care benefits. Most exemptions are granted for only a short period of
time so you can complete a course of treatment before you are enrolled in an
HMO. If you think you need an exemption from HMO enrollment, call the HMO
Enrollment Specialist at 1-800-291-2002 for more information.
LIVING WILL OR POWER OF ATTORNEY FOR HEALTH CARE
You have a right to make decisions about your medical care. You have a right to
accept or refuse medical or surgical treatment. You also have the right to plan
and direct the types of health care you may receive in the future if you become
unable to express your wishes. You can let your doctor know about your feelings
by completing a living will or power of attorney for health care form. Contact
your doctor for more information.
RIGHT TO MEDICAL RECORDS
You have the right to ask for copies of your medical record from your
provider(s). We can help you get copies of these records. Please call
[1-800-xxx-xxxx] for help. Please note: You may have to pay to copy your medical
record. You also may correct wrong information in your medical records if your
doctor agrees to the correction.
[HMO NAME'S] MEMBER ADVOCATE
[HMO NAME] has a Member Advocate to help you get the care you need. The Advocate
can answer your questions about getting health care from [HMO NAME]. The
Advocate can also help you solve any problems you may have getting health care
from [HMO NAME]. You can reach the Advocate at [1-800-xxx-xxxx].
STATE OF WISCONSIN HMO OMBUD PROGRAM
The State has Ombuds who can help you with any questions or problems you have as
an HMO member. The Ombuds can tell you how to get the care you need from your
HMO. The Ombuds
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can also help you solve problems or complaints you may have about the HMO
Program or your HMO. Call 1-800-760-0001 and ask to speak to an Ombud.
COMPLAINTS
We would like to know if you have a complaint about your care at [HMO NAME].
Please call [HMO NAME'S] Member Advocate at [1-800-xxx-xxxx] if you have a
complaint. Or you can write to us at:
[HMO name and mailing address]
If you want to talk to someone outside of [HMO NAME] about the problem, call the
HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist may be
able to help you solve the problem, or can help you write a formal complaint to
[HMO NAME] or to the State HMO Program. The address to complain to the State HMO
Program is:
EDS
HMO Ombuds
P. O. Box 6470
Madison, WI 53716
We cannot treat you differently than other members because you file a complaint.
Your health care benefits will not be affected.
WHEN BENEFITS ARE DENIED (FAIR HEARINGS)
You may appeal to the State if you believe your benefits are unfairly denied,
limited, reduced, delayed or stopped by [HMO NAME]. An appeal must be made not
later than 45 days after the date of the action being appealed.
To appeal to the State, call the HMO Ombuds at 1-800-760-0001. Or you can write
to the HMO Ombuds at:
EDS
HMO Ombuds
P. O. Box 6470
Madison, WI 53716
You have the right to appeal to the State of Wisconsin Division of Hearings and
Appeals (DHA) for a Fair Hearing if you believe your benefits are unfairly
denied, limited, reduced, delayed or stopped by [HMO NAME]. An appeal must be
made no later than 45 days after the date of the action being appealed. If you
appeal this action to DHA before the effective date, the service may continue.
You may need to pay for the cost of services if the hearing decision is not in
your favor.
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If you want a Fair Hearing, send a written request to:
Department of Administration
Division of Hearings and Appeals
P. O. Box 7875
Madison, WI 53707-7875
The hearing will be held in the county where you live. You have the right to
bring a friend or be represented at the hearing. If you need a special
arrangement for a disability, or for English language translation, please call
(608) 266-3096 (voice) or (608) 264-9853 (hearing impaired).
We cannot treat you differently than other members because you request a Fair
Hearing. Your health care benefits will not be affected.
If you need help writing a request for a Fair Hearing, please call:
EDS Ombuds 1-800-760-0001
or
HMO Enrollment Specialist 1-800-291-2002
PHYSICIAN INCENTIVE PLAN
You are entitled to ask if we have special financial arrangements with our
physicians that can affect the use of referrals and other services you might
need. To get this information, call our Customer Service Department at
[1-800-xxx-xxxx] and request information about our physician payment
arrangements.
PROVIDER CREDENTIALS
You have the right to information about our providers that includes the
provider's education, Board certification and recertification. To get this
information, call our Customer Service Department at [1-800-xxx-xxxx].
MEMBER RIGHTS
You have the right to ask for an interpreter and have one provided to you during
any Medicaid/BadgerCare covered service.
You have the right to receive the information provided in this member handbook
in another language or another format.
You have the right to receive health care services as provided for in Federal
and State law. All covered services must be available and accessible to you.
When medically appropriate, services must be available 24 hours a day, 7 days a
week.
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You have the right to receive information about treatment options including the
right to request a second opinion.
You have the right to make decisions about your health care.
You have the right to be treated with dignity and respect.
You have the right to be free from any form of restraint or seclusion used as a
means of force, control, ease or reprisal.
YOUR CIVIL RIGHTS
[HMO NAME] provides covered services to all eligible members regardless of:
o Age
o Race
o Religion
o Color
o Disability
o Sex
o Sexual Orientation
o National Origin
o Marital Status
o Arrest or Conviction Record
o Military Participation
All medically necessary covered services are available to all members.
All services are provided in the same manner to all members.
All persons or organizations connected with [HMO Name] who refer or recommend
members for services shall do so in the same manner for all members.
Translating or interpreting services are available for those members who need
them. This service is free.
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ADDENDUM VI
STATE OF WISCONSIN
MEDICAID/BADGERCARE
HMO REPORT ON COORDINATION OF BENEFITS
Name of HMO Mailing Address
----------------------------- -------------------
Office Telephone
------------------------ -------------------
Provider Number
------------------------- -------------------
Please designate below the quarter period for which information is given in this
report.
____________________________, 20____ through _________________________, 20______
INSTRUCTIONS
For the purposes of this report, an enrollee is any Medicaid recipient listed on
the monthly enrollment reports coming from the fiscal agent, and who is an ADD
or CONTINUE.
Subrogation may include collections from auto, homeowners, or malpractice
insurance, as well as restitution payments from the Division of Corrections. In
addition, subrogation should include collections from Workers' Compensation.
Birth costs or delivery costs (e.g., routine delivery and associated hospital
charges) are not to be included in this report. Recovery of birth costs are
collected through the county agencies.
Coordination of Benefits Reports are to be completed on a calendar quarterly
basis.
The report is to be for the entire HMO, aggregating all separate service areas
if the HMO has more than one service area.
Please complete and return this report within 45 days of the end of the quarter
being reported to:
DHFS - Managed Care Section
P.O. Box 309
Madison, WI 53701-0309
Attn: COB Report from ____________________HMO
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COB REPORT
The following information is REQUIRED in order to comply with CMS (formerly
HCFA) reporting requirements:
Cost Avoidance
Indicate the dollar amount of the claims you denied as a result of your
knowledge of other insurance being available for the enrollee. The provider did
not indicate at the time of the claim submission (with an EOB, etc.) that the
other insurance was billed prior to submitting the claim to you. Therefore, you
denied the claim. Please indicate the dollar amount of these denials.
Amount Cost Avoided:
-----------------------------------------------------------
Including claims denied for third party liability.
RECOVERIES (POST-PAY BILLING/PAY AND CHASE)
Indicate the dollar amount you recovered as a result of billing an enrollee's
other insurance:
---------------------------------------------------------------
Subrogation/Worker's
Compensation:
------------------------------------------------------------------
Amount of other recoveries (Dollars) This Quarter:
-----------------------------
I HEREBY CERTIFY that to the best of my knowledge and belief, the
information contained in this report is a correct and complete statement
prepared from the records of the HMO, except as noted on the report.
Signed:
------------------------------------------------------------------------
Original Signature of Director or Administrator
Title:
-------------------------------------------------------------------------
Date Signed:
-------------------------------------------------------------------
HMO Contract for January 1, 2002 - December 31, 2003
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ADDENDUM VII
ACTUARIAL BASIS
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ADDENDUM VIII
COMPLIANCE AGREEMENT AFFIRMATIVE ACTION/CIVIL RIGHTS
THE HMO HEREBY AGREES THAT it will comply with the following.
1. The HMO agrees to comply with Public Law 103-227, also known as the
Pro-Children Act of 1994, which prohibits tobacco-smoke in any portion of a
facility owned or leased or contracted for by an entity which receives
federal funds, either directly or through the State, for the purpose of
providing services to children under the age of 18.
2. The HMOs shall implement and adhere to rules and regulations prescribed by
the United States, Department of Labor and in accordance with 41 Code of
Federal Regulations, Chapter 60.
3. The HMO shall comply with regulations of the United States Department of
Labor recited in 20 Code of Federal Regulations, Part 741 and the Federal
Rehabilitation Act of 1973. The HMO shall ensure compliance by any and all
subcontractors engaged by Contractor under the Contract with said
regulations.
Affirmative Action Plan/Civil Rights
1. The HMO assures that they have submitted to the Department Affirmative
Action/Civil Rights Compliance Office a current copy of an Affirmative
Action Plan and Civil Rights Compliance Action Plan for Meeting Equal
Opportunity Requirements under Title VI of the Civil Rights Act of 1964,
Section 504 of the Rehabilitation Act of 1973, Title VI and XVI of the
Public Service Health Act, the Age Discrimination Act of 1975, the Omnibus
Budget Reconciliation Act of 1981 and the Americans with Disabilities Act
(ADA) of 1990, the Wisconsin Fair Employment Act, and any or all applicable
Federal and State nondiscrimination statutes as may be in effect during the
term of this Contract. If an approved plan has been reviewed during the
previous calendar year, a plan update must be submitted during this
contract period. The plan may cover a two-year period.
a. No otherwise qualified person shall be excluded from participation in,
be denied the benefits of, or otherwise subject to discrimination in
any manner on the basis of race, color, national origin, sexual
orientation, religion, sex, disability or age. This policy covers
eligibility for and access to service delivery, and treatment in all
programs and activities.
b. No otherwise qualified person shall be excluded from employment, be
denied the benefits of employment or otherwise be subject to
discrimination in employment in any manner or term of employment on
the basis of age, race, religion, color, sex, national origin, or
ancestry, handicap [as defined in Section 504 and the American
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With Disabilities Act (ADA)], physical condition, developmental
disability [as defined in s. 51.05(5) Wis. Stats.], arrest or
conviction record [in keeping with s.111.32 Wis. Stats.], sexual
orientation, marital status, or military participation. All employees
are expected to support goals and programmatic activities relating to
nondiscrimination in employment.
2. The HMO shall post the Equal Opportunity Policy, the name of the Equal
Opportunity Coordinator and the discrimination complaint process in
conspicuous places available to applicants and clients of services, and
applicants for employment and employees. The complaint process will be
according to Department standards and made available in languages and
formats understandable to applicants, clients and employees. The HMO will
continue to provide appropriate translated State procedures, mandated
brochures and forms for local distribution.
3. The HMO agrees to comply with guidelines in the Civil Rights Compliance
Standards and a Resource Manual for Equal Opportunity in Service Delivery
and Employment for the Wisconsin Department of Health and Family Services,
its Service Providers and their Subcontractors (September 1997 Edition).
4. Requirements herein stated apply to any subcontracts. The HMO has primary
responsibility to take constructive steps, as per the CRC Standards and
Resource Manual, to ensure compliance of subcontractors. However, where the
Department has a direct contract with another community agency or vendor,
the HMO need not obtain a Subcontractor Affirmative Action Plan and Civil
Rights Compliance Action Plan or monitor that agency or vendor.
5. The Department will monitor the Civil Rights Compliance of the HMO and will
conduct reviews to ensure that the HMO is ensuring compliance of its
subcontractors in compliance with guidelines in the CRC Standards and
Resource Manual. The HMO agrees to comply with Civil Rights monitoring
reviews, including the examination of records and relevant files maintained
by the HMO, as well as interviews with staff, clients, applicants for
services, subcontractors and referral agencies.
6. The HMO agrees to cooperate with the Department in developing, implementing
and monitoring corrective action plans that result from complaint
investigations or other monitoring efforts.
Access to Agency
1. The HMO agrees to hire staff, contract with, or identify community
individuals with special translation or sign language skills and/or provide
staff with special translation or sign language skills training or find
persons who are available within reasonable time and who can communicate
with non-English speaking or hearing impaired clients; train staff in human
relations techniques, sensitivity to persons with disabilities and
sensitivity to cultural characteristics; and make programs and facilities
accessible, as appropriate,
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through outstations, authorized representatives, adjusted work hours,
ramps, doorways, elevators or ground floor rooms, and Braille, large print
or taped information for the visually impaired. Informational materials
will be posted and/or available in languages and formats appropriate to the
needs of the client population.
2. The HMO shall ensure the establishment of safeguards to prevent employees,
consultants or members of governing bodies from using their positions for
purposes that are, or give the appearance of being, motivated by a desire
for private gain for themselves or others, such as those with whom they
have family, business, or other ties as specified in Wisconsin Statutes
946.10 and 946.13.
3. The applicant gives assurance that he/she will immediately take any
measures necessary to effectuate this agreement.
4. The applicant shall comply with Conflict of Interest (Section 946.10 and
946.13 Wis. Stats. and DHFS Employee Guidelines DMB-Pers. 102-7/1/71).
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ADDENDUM IX
MODEL MEMORANDUM OF UNDERSTANDING
BETWEEN
HEALTH MAINTENANCE ORGANIZATION
AND
PRENATAL CARE COORDINATION AGENCY
Prenatal care coordination services are paid FFS by the Wisconsin Medical
Assistance Program (Wisconsin Medicaid) for all recipients, including those
enrolled in HMOs. The prenatal care coordination agencies (PNCC) are responsible
for services which include outreach, risk assessment, care planning, care
coordination and follow-up to support high-risk pregnant women. The HMOs are
responsible for providing and managing medically necessary services. Successful
provision of the services to individual enrollees requires cooperation,
coordination and communication between the HMO and the PNCC.
The HMO and the PNCC agree to facilitate effective communication between
agencies, work to resolve inter-agency coordination and communication problems,
and inform staff from both the HMO and the PNCC about the policies and
procedures for this cooperation, coordination and communication.
Recognizing that these "clients-in-common" are at high risk for poor birth
outcomes, the HMO and the PNCC agree to cooperate in removing access barriers,
coordinating care and providing culturally competent services.
This agreement becomes effective on the date the PNCC is certified by WISCONSIN
MEDICAID or on the date when both HMO and PNCC have signed, whichever is later.
It may be terminated in writing with two weeks notice by either signer.
<Table>
<Caption>
- ------------------------------------ ------------------------------------
HMO PNCC
- ------------------------------------ ------------------------------------
Authorizing Signature Authorizing Signature
- ------------------------------------ ------------------------------------
Title Title
- ------------------------------------ ------------------------------------
Date Date
- ------------------------------------ ------------------------------------
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-153-
ADDENDUM X
MEMORANDUM OF UNDERSTANDING BETWEEN
MILWAUKEE COUNTY HMOS
AND
BUREAU OF MILWAUKEE CHILD WELFARE
HMO RIGHTS AND RESPONSIBILITIES:
o The HMO must designate at least one individual to serve as a contact person
for the Bureau of Milwaukee Child Welfare (BMCW) agency(ies). If the HMO
chooses to designate more than one contact person, the HMO should identify
the service area for which each contact person is responsible.
o The HMO must provide all Medicaid covered mental health and substance abuse
services to individuals identified as clients of the BMCW agency. Disputes
in the medical necessity of services identified in the Family Treatment
Plan will be adjudicated using the dispute process outlined in this MOU,
except that HMOs will provide court ordered services in accordance with
Addendum II.
o The HMO liaison, or other appropriate staff as designated by the HMO, will
participate in case conference with BMCW upon the request of the BMCW
agency. The planning session may be done through telephone contact or other
means of communication when attending a formal case conference is not
feasible.
o The HMO liaison and the BMCW agency will discuss who will be responsible
for ensuring that the recipient receives the services authorized and
provided through the HMO. The HMO must have a mechanism in place for
notifying the BMCW agency of missed appointments or family crisis
situations that could potentially lead to an out-of-home placement by the
BMCW agency. The notification will be within three business days of
occurrence or sooner if possible.
o The HMO agrees to participate in dispute resolution using the following
process:
o The BMCW and the HMO designated personnel will meet or teleconference to
discuss the case and attempt to resolve issues of dispute.
If the BMCW designees and the HMO designees (known as the team) are unable to
resolve the issues, the BMCW and the HMO will schedule a meeting or a
teleconference of representatives with expertise in the area of dispute to look
at outstanding issues within 2 days of the teleconference or sooner if
indicated.
HMO Contract for January 1, 2002 - December 31, 2003
-154-
If the team is unable to resolve the issues to both party's satisfaction, either
party may appeal to the Department. It will be the disputing party's
responsibility to supply the necessary documentation for the Department to
adjudicate the dispute.
o The HMO will work with the BMCW in developing lists of providers and
fostering a provider network which has expertise in:
>> Working with adults and children effectively.
>> Working with dual diagnosed clients effectively.
>> Understanding adult functioning problems in the context of parenting,
child safety and child well-being.
>> Recognizing the interrelationship of the problems BMCW families
experience and, therefore, the value of close collaboration among the
various service providers working with the family.
o The HMO will share with the BMCW agency(ies) the procedure and process for
prior authorization and out-of-plan referrals.
MILWAUKEE CHILD CARE COORDINATION AGENCY'S RIGHTS AND RESPONSIBILITIES:
o It is the Bureau of Milwaukee Child Welfare Agencies' responsibility to
initiate contact with the HMO regarding child welfare families and/or
individuals in need of service. BMCW will provide (through court order
and/or signed release of information) completed assessment information
which supports the request for HMO services.
o The BMCW will complete and involve the HMO in the development of a
comprehensive case plan, which identifies the outcomes to be achieved, the
services to be provided and the measures to be used for evaluation.
o The BMCW will utilize the HMO's provider network for routine services
whenever possible and will attempt to utilize the HMO provider network for
emergency services. BMCW will obtain criteria from the HMO concerning
BMCW's ability to utilize non-participating providers and the mechanism for
authorizing non-participating providers.
o The BMCW will evaluate the progress of the case plan at 90-day intervals,
including the effectiveness of services and will forward those results to
the HMO within ten days of completion.
o The BMCW will be responsible for informing the HMO of the status of the
case, including court-ordered revisions within two business days of the
revisions.
o The BMCW agrees to participate in dispute resolution using the following
process:
HMO Contract for January 1, 2002 - December 31, 2003
-155-
The BMCW and the HMO designated personnel will meet or teleconference to discuss
the case and attempt to resolve issues of dispute.
If the BMCW designees and the HMO designees (known as the team) are unable to
resolve the issues the BMCW and the HMO will schedule a meeting of
representatives to look at outstanding issues within two (2) days of the meeting
or teleconference or sooner if indicated.
If the team is unable to resolve the issues to both parties' satisfaction,
either party may appeal to the Department. It will be the disputing party's
responsibility to supply the necessary documentation for the Department to
adjudicate the dispute.
HMO Contract for January 1, 2002 - December 31, 2003
-156-
ADDENDUM XI
HEALTHCHECK WORKSHEET
HMO: HMO Provider Number:
---------------------- --------------------------
<Table>
<Caption>
Age Groups
------------------------------
Calculation < 1 1-5 6-14 15-20 Total
----------- --- --- ---- ----- -----
1 Number of eligible months Entered
for enrollees under age 21 (Total is sum of age groups.)
2 Number of unduplicated Entered
enrollees under age 21
3 Ratio of recommended Given 5.00 1.4 0.56 0.50
screens per age group
member
4 Average period of eligibility Line 1 / line 2 / 12
(in years) (Total is calculated by formula.)
5 Adjusted ratio of Line 3 x line 4
recommended screens per
age group member
6 Expected number of screens Line 2 x line 5
(100% of required screens (Total is sum of age groups.)
for ages and months of
eligibility)
7 Number of screens in goal Line 6 x 0.80
(80%) (Total is calculated by formula.)
8 Actual number of screens Entered
completed (Total is sum of age groups.)
9 Difference between goal and Line 8 - line 7
actual (Positive result means goal is
met; negative result means goal is
not met.)
10 Percent of the HMO
discount or premium if
applicable except for
Milwaukee, Dane, Eau
Claire, Kenosha and
Waukesha Counties.
11 Amount per screen to be FFS maximum allowable fee
recouped *(Article III. B. 10) x line 10
12 Total recoupment Line 11 x line 9
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-157-
HMO RATE REGIONS AND ESTABLISHED COUNTIES
<Table>
<Caption>
REGION 1: DULUTH/SUPERIOR REGION 2: WAUSAU/RHINELANDER
02 Ashland 85 Red Cliff RNIP 21 Forest 60 Taylor
04 Bayfield 89 Bad River 34 Langlade 63 Vilas
07 Burnett 94 Lac Courte RNIP 35 Lincoln 86 Stockbridge RNIP
16 Douglas 95 St Croix RNIP 37 Marathon 87 Potawatomi RNIP
26 Iron 43 Oneida 88 Lac du Flambeau RNIP
57 Sawyer 50 Price 91 Sokaogon RNIP
65 Washburn 58 Shawano
</Table>
<Table>
<Caption>
REGION 3: GREEN BAY REGION 4: TWIN CITIES
05 Brown 38 Marinette 03 Barron 47 Pierce
15 Door 42 Oconto 09 Chippewa 48 Polk
19 Florence 72 Menominee 17 Dunn 54 Rusk
31 Kewaunee 84 Menominee RNIP 46 Pepin 55 St Croix
36 Manitowoc
</Table>
<Table>
<Caption>
REGION 5: MARSHFIELD/STEVENS POINT REGION 6: APPLETON/OSHKOSH
01 Adams 39 Marquette 08 Calumet 92 Oneida RNIP
10 Clark 49 Portage 20 Fond Du Lac
24 Green Lake 69 Waushara 44 Outagamie
27 Jackson 71 Wood 68 Waupaca
29 Juneau 70 Winnebago
</Table>
<Table>
<Caption>
REGION 7: LACROSSE REGION 8: MADISON/SOUTH CENTRAL
06 Buffalo 61 Trempealeau 11 Columbia 28 Jefferson
12 Crawford 62 Vernon 14 Dodge 33 Lafayette
32 LaCrosse 22 Grant 53 Rock
41 Monroe 23 Green 56 Sauk
52 Richland 25 Iowa
</Table>
<Table>
<Caption>
REGION 9: SOUTHEAST WISCONSIN ESTABLISHED COUNTIES
45 Ozaukee 13 Dane
51 Racine 18 Eau Claire
59 Sheboygan 30 Kenosha
64 Walworth 40 Milwaukee
66 Washington 67 Waukesha
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-158-
ADDENDUM XII
COMMON CARRIER TRANSPORTATION
MEMORANDUM OF UNDERSTANDING
BETWEEN
MILWAUKEE COUNTY MEDICAID/BADGERCARE HMOS
AND
MILWAUKEE COUNTY DEPARTMENT OF HUMAN SERVICES
All Milwaukee County Medicaid Health Maintenance Organizations (HMOs) will
provide common carrier transportation for their Medicaid/BadgerCare enrollees.
Transportation services will be limited to:
o Transportation of Medicaid/BadgerCare HMO members only.
o Transportation of Medicaid/BadgerCare HMO members to and from Medicaid
covered services only.
The HMO is responsible for arranging for the common carrier transportation and
providing monthly costs to Milwaukee County Department of Human Services (DHS),
of common carrier transportation provided. Monthly costs will include
information specified in the attachment. The DHS is responsible for reimbursing
the HMO for mileage and an administration fee.
The HMO and DHS agree to facilitate effective communication between agencies,
work together to resolve inter-agency coordination and communication problems,
and inform staff from both the HMO and DHS about the policies and procedures for
this cooperation, coordination and communication.
This agreement becomes effective when both the HMO and DHS have signed.
<Table>
<Caption>
Milwaukee County Department of Milwaukee County
Human Services Health Maintenance Organization
------------------------------------- -------------------------------------
Signature Signature
------------------------------------- -------------------------------------
Title Title
------------------------------------- -------------------------------------
Date Date
------------------------------------- -------------------------------------
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-159-
Milwaukee County Medicaid/HMO Common Carrier Transportation
Monthly Invoice from HMO to County
(DATE)
Milwaukee County DHS
Financial Assistance Division Administrator
1220 West Vliet Street
Milwaukee, WI 53205
Dear Sir:
(HMO NAME)'s total transportation costs for the month of (MONTH, YEAR) was
($_____________). This amount includes transportation and administration fees.
Please remit the above dollar amount to:
(HMO NAME)
(AUTHORIZED INDIVIDUAL)
(ADDRESS)
Thank you.
Sincerely,
(NAME/HMO)
HMO Contract for January 1, 2002 - December 31, 2003
-160-
ADDENDUM XIII
MODEL MEMORANDUM OF UNDERSTANDING
BETWEEN
HEALTH MAINTENANCE ORGANIZATION
AND
SCHOOL DISTRICT OR CESA MEDICAID-CERTIFIED FOR THE SCHOOL BASED
SERVICES BENEFIT
School based services is a benefit paid FFS by the Wisconsin Medicaid Program
for all school enrolled recipients, including those enrolled in HMOs. The School
Based Service (SBS) provider is responsible for services which include
occupational/physical/speech therapies, private duty or home care individualized
nursing services, mental health services, testing services, school Individual
Education Plan (IEP) services, and Individualized Family Service Program (IFSP)
services, when provided in the school. The HMOs are responsible for providing
and managing medically necessary services outside of school settings. However,
there are some situations where schools cannot provide services, such as after
school hours, during school vacations, and during the summer. Therefore,
avoidance of duplication of services and promotion of continuity of care for
Medicaid/BadgerCare HMO enrollees requires cooperation, coordination and
communication between the HMO and the SBS provider.
The HMO and the SBS provider agree to facilitate effective communication between
agencies, work to resolve inter-agency coordination and communication problems,
and inform staff from both the HMO and the SBS provider about the policies and
procedures for this cooperation, coordination and communication. Recognizing
that these "clients-in-common" could receive duplicate services and could suffer
with problems in continuity of care (e.g., when the school year ends in the
middle of a series of treatments), the HMO and the SBS provider agree to
cooperate in communicating information about the provision of services and in
coordinating care.
This agreement becomes effective on the date the SBS provider is certified by
the Wisconsin Medicaid Program or on the date when both the HMO and the SBS
provider have signed, whichever is later. It may be terminated in writing with
two weeks notice by either signer. The SBS provider is the School District or
the CESA.
<Table>
<Caption>
- ------------------------------------ ------------------------------------
HMO SBS Provider
- ------------------------------------ ------------------------------------
Authorizing Signature Authorizing Signature
- ------------------------------------ ------------------------------------
Title Title
- ------------------------------------ ------------------------------------
Date Date
- ------------------------------------ ------------------------------------
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-161-
ADDENDUM XIV
GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS, TARGETED
CASE MANAGEMENT (TCM) AGENCIES, AND CHILD WELFARE AGENCIES
(The same language will be incorporated as an Appendix in the case management
provider handbook, ensuring that both HMOs and case management providers have
the same language available to them.)
HMO RIGHTS AND RESPONSIBILITIES
1. The HMO must designate at least one individual to serve as a contact person
for case Management providers. If the HMO chooses to designate more than
one contact person, the HMO should identify the target populations for
which each contact person is responsible.
2. The HMO may make referrals to case management agencies when they identify
an enrollee from an eligible target population who they believe could
benefit from case management services.
3. If the enrollee or case manager requests the HMO to conduct an assessment,
the HMO will determine whether there are signs and symptoms indicating the
need for an assessment. If the HMO finds that assessment is needed, the HMO
will determine the most appropriate level for an assessment to be conducted
(e.g., primary care physician, specialist, etc.). If the HMO determines
that no assessment is needed, the HMO will document the rationale for this
decision.
4. The HMO must determine the need for medical treatment of those services
covered under the HMO Contract based on the results of the assessment and
the medical necessity of the treatment recommended.
5. The HMO case management liaison, or other appropriate staff as designated
by the HMO, must participate in case planning with the case management
agency, unless no services provided through the HMO are required.
o The case planning may be done through telephone contact or means of
communication other than attending a formal case planning meeting.
o The HMO must informally discuss differences in opinion regarding the
HMO's determination of treatment needs if requested by the recipient
or case manager.
o The HMO case management liaison and the case manager must discuss who
will be responsible for ensuring that the enrollee receives the
services authorized by and provided through the HMO.
HMO Contract for January 1, 2002 - December 31, 2003
-162-
o The HMO's role in the case planning may be limited to a confirmation
of the services the HMO will authorize if the enrollee and case
manager find these acceptable.
CASE MANAGEMENT AGENCY RIGHTS AND RESPONSIBILITIES
1. The case management agency is responsible for initiating contact with the
HMO to coordinate services to recipient(s) they have in common and provide
the HMO with the name and phone number of the case Manager(s).
2. If the HMO refers an enrollee to the case management agency, the case
management agency must conduct an initial screening based on their usual
procedures and policies. The case management agency must determine whether
or not they will provide case management services and notify the HMO of
this decision.
3. The case management agency must complete a comprehensive assessment of the
enrollee's needs in accordance with the requirements in the Part U provider
handbook. This includes a review of the enrollee's physical and dental
health needs.
4. If the case management agency requires copies of the enrollee's medical
records, the case Management agency must obtain the records directly from
the service provider, not from the HMO.
5. The case manager must identify whether the enrollee has additional service
or treatment needs. As a part of this process, the case manager and the
enrollee may seek additional assessment of conditions which the HMO may be
expected to treat under the terms of its contract, if the HMO determines
there are specific signs and symptoms indicating the need for an
assessment.
6. The case management agency may not determine the need for specific medical
care covered under the HMO Contract, nor may the case management agency
make referrals directly to specific providers of medical care covered
through the HMO.
7. The case manager must complete a comprehensive case plan in accordance with
the requirements of the Part U provider handbook. The plan must include the
medical services the enrollee requires as determined by the HMO.
8. If the case management agency specifically requests the HMO liaison to
attend a planning meeting in person, the case management agency must
reimburse the HMO for the costs associated with attending the planning
meeting. These are allowable costs for case management reimbursement
through Wisconsin Medicaid.
Nothing in these guidelines precludes the HMO and the case management
agency from entering into a formal contract or Memorandum of Understanding
to address issues not outlined here.
HMO Contract for January 1, 2002 - December 31, 2003
-163-
ADDENDUM XV
PERFORMANCE IMPROVEMENT PROJECT OUTLINE
The report for each performance improvement project must address each of the
following points in order for the Department to evaluate the reliability and
validity of the data and the conclusions described in the study:
1. Topic
a. Is the topic important to the enrolled population?
b. Can it be affected by the actions of the HMO?
c. Was the process of the topic selection described?
2. Method
a. Was the method and procedure used to study the topic clear?
b. Study question:
o Was the study question clearly stated and consistent throughout
the study?
o Is the study question specific?
3. Data Collection
a. Was the data fully described in detail?
b. Was the data appropriate to answer the study question?
c. Was the data collection process fully described?
d. Was the data collection appropriate to answer the study question?
e. Were the data collectors appropriate to collect the data?
f. Was interrater reliability adequate?
g. Did the loss of data or subjects affect validity?
h. Was the study time clear?
4. Intervention (not applicable if the project is to establish a baseline
only)
a. Was the intervention fully described?
b. Was the intervention practical (can it be widely implemented?)
c. Was the implementation of the intervention monitored and reported to
ensure that it was done properly?
5. Results and interpretation
a. Was the data collected fully reported?
b. Did the study include comparisons to give meaning to the results?
c. Is the norm or standard expressed in a specific numerical manner?
d. Is the goal, norm or standard appropriate to this population and
study?
e. Was the comparison group (if applicable) as close as possible to the
population under study and were any differences acknowledged?
f. If pre-and-post measures were used, was an explanation for the
differences between the measures considered?
HMO Contract for January 1, 2002 - December 31, 2003
-164-
g. Was assignment to groups random?
h. Did the study appropriately use statistical testing? (x2 t-test,
regression analysis, etc.)?
i. Were the conclusions consistent with the results?
j. Were data tables, figures and graphs consistent with the text?
k. Did the study consider its limitations?
l. Did the study conclude or imply causality when the supporting data is
only correlational?
m. Did the study include how to improve the study?
n. Did the study present recommendations on the results?
o. Did the report clearly state whether performance improvement goals
were met (if an intervention was carried out), and if the goals were
not met, was there an analysis of why not and a plan for future
action?
6. Miscellaneous
a. Was enrollee confidentiality protected?
b. Did consumers participate in the study (other than as the subjects)?
c. Did the study include cost/benefit analysis or some other
consideration of financial impact?
d. Were next steps described in detail? (Dates and timelines).
e. Were the results and conclusions distributed throughout the HMO?
f. Did table, figures and graphs convey their information clearly without
reference to the report text?
g. Did the study report include an accurate summary?
h. Was the study clearly written?
HMO Contract for January 1, 2002 - December 31, 2003
-165-
ADDENDUM XVI
TARGETED PERFORMANCE IMPROVEMENT MEASURES DATA SET
The Quality Assessment/Performance Improvement section of the Contract requires
each Medicaid/BadgerCare contracted HMO to report their activity in targeted
care areas. The data reporting guidelines and specifications to be used for
reporting 2001 data are defined in "1999 Preventive Care Objectives and 2000
Targeted Performance Improvement Measures Reporting Documentation Reporting
Periods 1999 and 2000." The HMOs must use these guidelines and specifications
unless the HMO has worked with the Department in developing alternative
reporting arrangements. The Targeted Performance Improvement Measures for
calendar year 2001 must be reported to the Department by October 1, 2002.
Starting in calendar year 2002, the Department will use the MEDDIC-MS system.
(See Article III W 13 for a description of the MEDDIC-MS system.)
HMO Contract for January 1, 2002 - December 31, 2003
-166-
ADDENDUM XVII
MEDICAID/BADGERCARE HMO NEWBORN REPORT
PLEASE PRINT, TYPE, OR COMPLETE IN A LEGIBLE MANNER.
1. HMO NAME
-----------------------------------------------------------------
HMO PROVIDER NUMBER
-------------------------------------------------------
TELEPHONE NUMBER
----------------------------------------------------------
2. NEWBORN NAME
--------------------------------------------------------------
(First) (M.I.) (Last)
DATE OF BIRTH SEX
-------------------------------- --------------------
TWIN: NO YES IF YES, COMPLETE TWO FORMS
------ ------
DATE OF DEATH
-------------------------------------------------------------
3. MOTHER'S NAME
-------------------------------------------------------------
(First) (M.I.) (Last)
ADDRESS
------------------------------------------------------------------
(Street Address)
-----------------------------------------------------------------------
(City) (State) (Zip Code)
4. MOTHER'S MEDICAID/BADGERCARE ID NUMBER
-----------------------------------
THIS INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
- --------------------------------- ----------------------------------
SIGNATURE DATE
MAIL TO: FAX TO:
EDS EDS
ATTN: HMO UNIT ATTN: HMO UNIT
6406 BRIDGE ROAD (608) 221-8815
MADISON, WI 53784
HMO Contract for January 1, 2002 - December 31, 2003
-167-
INSTRUCTIONS FOR COMPLETING THE MEDICAID/BADGERCARE HMO NEWBORN REPORT
This report should be completed for infants born to mothers who are
Medicaid/BadgerCare eligible and enrolled in the HMO at the time of birth of the
infant.
<Table>
1. HMO Name: In this field enter the name of the HMO reporting.
HMO Provider Number: In this field enter the 8 digit Medicaid provider number of the
HMO reporting.
Telephone Number: In this field enter the telephone number of the HMO that fiscal
agent can call with questions about submitted Newborn reports.
2. Newborn Name: In this field enter the name of the newborn infant. It is a fairly
frequent occurrence that the mother has not given a first and
middle name to the baby at the time the report is completed. In
these situations, you should still enter the last name of the
newborn as the mother's last name; the first name/middle initial
can be entered as "baby male" or "baby female."
Date of Birth: In this field enter the date of birth of the newborn infant, in
MM/DD/YY format.
Sex: In this field enter the sex of the newborn infant, M=Male,
F=Female.
Twin: In this field check no if the newborn infant is not a twin, check
yes if the newborn infant is a twin. If the newborn infant is a
twin, complete one Newborn Report for each twin.
Date of Death: In this field enter the date of death of the newborn infant, if it has
occurred, in MM/DD/YY format.
3. Mother's Name: In this field enter the first name, middle initial, and last name of
the mother of the newborn infant.
Address: In this field enter the address of the mother of the newborn
infant - street address, city, state, and zip code.
Mother's Medicaid ID In this field enter the 10 digit Medicaid/BC ID number of the
Number: mother of the newborn infant.
</Table>
The HMO staff person completing the report should sign and date the form and
send it to the address listed at the bottom of the report.
The particular format of the form shown in Addendum XVII does not have to be
used by the HMO if a more efficient format has been designed by the HMO.
However, whatever format is used, the information described above is the
necessary information that must be sent to EDS.
HMO Contract for January 1, 2002 - December 31, 2003
-168-
ADDENDUM XVIII
(DELETED)
RECOMMENDED CHILDHOOD IMMUNIZATION SCHEDULE
HMO Contract for January 1, 2002 - December 31, 2003
-169-
ADDENDUM XIX
REPORTING REQUIREMENTS FOR NEONATAL INTENSIVE CARE UNIT
RISK-SHARING
HMO reporting of NICU costs should follow the requirements listed below, and are
due at the Department before May 1 of the year following the previous calendar
year. Department risk-sharing for NICU is based on Level II, Level III, and
Level IV neonatal intensive care unit facilities and services only. HMO
reporting shall be by HMO service area.
HMO: Reporting Period:
--------------------------- January 1, 200___ - December 31, 200___
Medicaid Provider (Payee) Number:
A. HMO SUMMARY DATA BY COUNTY
1. Hospital Inpatient Costs for Level II, III, and IV NICU Services*
<Table>
<Caption>
NUMBER NUMBER OF AMOUNT AMOUNT
OF DAYS ADMISSIONS BILLED PAID
------- ---------- ------ ------
</Table>
* NICU Level II, III, and IV facilities and services are described in
Article V.E.(3) of the Contract.
2. Physician Services Associated with Level II, III, and IV NICU Services
<Table>
<Caption>
AMOUNT BILLED: AMOUNT PAID
-------------- -----------
</Table>
B. HMO DETAILED DATA (for costs summarized in Part A) Data must be reported by
month, by county, and by year (i.e., if an enrollee is in NICU for two or
more months the dollar amounts and other data must be separated by the
month in which it occurred). Amounts paid should include payments made the
following year, as long as the service was provided during the reporting
period.
<Table>
<Caption>
ENROLLEE
MEDICAID/B NICU NICU NUMBER AMOUNT AMOUNT AMOUNT AMOUNT
ENROLLEE C ID ADMIT DISCHARGE OF DAYS BILLED-HOSP PAID-HOSP BILLED- PAID-
NAME NUMBER MONTH DATE DATE BILLED (UB-92) (UB-92) PHYSICIAN PHYSICIAN
- -------- ---------- ----- ----- --------- ------- ----------- --------- --------- ---------
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-170-
Neonatal Intensive Care Unit Risk-Sharing Worksheet
<Table>
<Caption>
CALCULATION
1. HMO enrollee months:
-------------------
2. Enrollee years: (line 1/12)
-------------------
3. Threshold: 75 days per 1000 enrollee years (75 x line 2/1000)
-------------------
4. NICU days reported by HMO:
-------------------
5. NICU days over threshold to be reimbursed: (line 4 - line 3)
-------------------
6. Inpatient paid:
-------------------
7. Physician paid:
-------------------
8. Total cost: (line 6 + line 7)
-------------------
9. Average cost per day: (line 8 /line 4)
-------------------
10. 90% of cost/day: (Not to exceed $1,443) (0.9 x line 9)
-------------------
11. Reimbursement amount: Days x 90% cost (line 5 x line 10)
-------------------
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-171-
ADDENDUM XX
(DELETED)
SPECIFIC TERMS OF THE MEDICAID/BADGERCARE HMO CONTRACT
HMO Contract for January 1, 2002 - December 31, 2003
-172-
ADDENDUM XXI-A
FORMAL GRIEVANCE EXPERIENCE SUMMARY REPORT
SUMMARIZE EACH MEDICAID/BADGERCARE GRIEVANCE REVIEWED IN THE PAST QUARTER.
I. GRIEVANCES RELATED TO PROGRAM ADMINISTRATION
<Table>
<Caption>
Administrative
Member Date Summary of Changes as a
Identification Grievance Nature of Date Grievance Result of
Number Filed Grievance Resolved Resolution Grievance Review
-------------- --------- --------- -------- ---------- ----------------
</Table>
II. GRIEVANCES RELATED TO BENEFITS DENIALS/REDUCTION
<Table>
<Caption>
Administrative
Member Date Summary of Changes as a
Identification Grievance Nature of Date Grievance Result of
Number Filed Grievance Resolved Resolution Grievance Review
-------------- --------- --------- -------- ---------- ----------------
</Table>
III. SUMMARY
SUBTOTAL: PROGRAM ADMINISTRATION _________
SUBTOTAL: BENEFITS DENIALS _________
TOTAL NUMBER OF GRIEVANCES: _________
RETURN THE COMPLETED FORM TO:
BUREAU OF MANAGED HEALTH CARE PROGRAMS
P.O. BOX 309
MADISON, WI 53701-0309
FAX: (608) 266-7729
HMO Contract for January 1, 2002 - December 31, 2003
-173-
ADDENDUM XXI-B
HMO REPORTING FORM FOR INFORMAL GRIEVANCES
- --------------------------------------------------------------------------------
HMO NAME
[ ] First Quarter
[ ] Second Quarter
[ ] Third Quarter
[ ] Fourth Quarter
[ ] Calendar Year 2002
[ ] Calendar Year 2003
<Table>
<Caption>
TYPE OF INFORMAL GRIEVANCE TOTAL NUMBER OF GRIEVANCES
- -------------------------- --------------------------
ACCESS PROBLEMS
BILLING ISSUES
QUALITY OF CARE
DENIAL OF SERVICE
OTHER SPECIFY:
</Table>
General Definitions
Access problems include any problem identified by the HMO that causes an
enrollee to have difficulties getting an appointment, receiving care or
receiving culturally appropriate care including the provision of interpreter
services in a timely manner.
Billing issues include the denial of a claim or a recipient receiving a bill for
a Medicaid covered service in which the HMO is responsible for providing or
arranging for the provision of that service.
Qualify of care includes long waiting time in the reception area of providers'
offices, rude providers or provider staff or any other complaint related
directly to patient care.
Others as identified by each HMO.
HMO Contract for January 1, 2002 - December 31, 2003
-174-
ADDENDUM XXII
GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN MEDICAID HMOS
AND COUNTY BIRTH TO THREE (B-3) AGENCIES
I. The Birth to Three (B-3) Program is an entitlement program established by
the Federal Individual with Disabilities Education Act (IDEA). The goal of
the program is to provide Early Intervention (EI) services to children from
birth up to the age of three who have developmental disabilities or delays.
The intended outcome of the program is to ensure maximum amelioration of
the impact of developmental disabilities or delays on infants and toddlers
by early and ongoing provision of rehabilitation services.
A. The B-3 program is a program funded by Federal, state, and local
funds. Early Intervention services under Part C (previously Part H) of
the Individuals with Disabilities Education Act (IDEA) are
administered in Wisconsin under Administrative Code HSF 90 by county
Health and Human Services Departments' Birth to Three programs. B-3
agencies arrange for provision of rehabilitative services (including
needed physical therapy, occupational therapy, speech-language
pathology, special instruction, audiology, certain nursing,
psychological and other services), service coordination, and related
parent education. Regulations require that B-3 services are delivered
in a "natural" environment, frequently the child's home. Federal rules
designate that IDEA, Part C funds are a payer of last resort after all
other private and public funds, including Medicaid funds.
B. There are HMO enrollees that either are or will be in the B-3 program.
C. For the purpose of summarizing the B-3 program process for ease of HMO
understanding, we can consider that the B-3 program has 4 stages.
These "stages" are only a conceptual tool.
1. Stage 1 is the identification of a child as potentially eligible
and in need of evaluation of whether the child is developmentally
delayed. This can be done simply by a parent who believes the
child is not developing normally, or more formally though a
medical evaluation by the HMO provider. The child is then
referred to the HMO for evaluation of eligibility and assessment
of medically necessary services for the Individual Family Service
Plan (IFSP). If the HMO originated the referral to the B-3
agency, then any evaluations already completed by the HMO can be
used as part of the eligibility decision process.
2. Stage 2 is the evaluation for eligibility by the B-3 program
according to State and Federal rules and the assessment of needed
medical and developmental services for the IFSP.
HMO Contract for January 1, 2002 - December 31, 2003
-175-
3. Stage 3 is the coordinated development of an IFSP that describes
the integrated set of services that the child and family should
receive. The HMO, the family, the B-3 agency, and other relevant
agencies are involved in the development of the IFSP.
4. Stage 4 is the provision of services based on the IFSP.
D. The HMO is involved with the B-3 program throughout all of the above
stages. The HMO can identify and refer a child to the B-3 program
based on the physician's determination that the child is not
developing normally. The HMO will receive referrals from the B-3
program. The HMO will be involved in performing evaluation/assessment
for eligibility determination and needed IFSP services. The HMO will
be involved in planning a course of rehabilitative treatment and other
services for the IFSP in conjunction with the family members, B-3
program staff, and other agencies. Finally, the HMO will be providing
the services in the IFSP that meet medical necessity per Medicaid
guidelines.
E. Federal and state regulations require an evaluation for eligibility,
an assessment of needs and the development of an IFSP within 45 days
of an EI referral to the B-3 agency. A child eligible for B-3 receives
services according to the IFSP document.
F. Regulations require that Medicaid pay for covered IFSP services that
meet Medicaid's definition of medical necessity. Services meeting
Medicaid's coverage requirement are to be paid by Medicaid funds
before county, state or federal IDEA funds are used to pay for the
services. Wisconsin Medicaid requires HMOs to seek payment from a
recipient's health insurance first. However, in the B-3 program,
parents do not have to allow their Medicaid HMO to bill their health
insurance for B-3 services. In this situation, where the enrollee has
other insurance but the parents do not allow billing of their health
insurance for B-3 services, the HMO should bill the B-3 agency. The
B-3 agencies have established an "average insurance liability amount"
per month for IFSP therapy services for these situations and will
reimburse the HMO this amount. HMOs would be responsible for the cost
of services after the county pays the average insurance liability. The
B-3 agency will inform the HMOs of those recipients participating in
the B-3 program for whom the parents/ guardians do not allow billing
of their health insurance. The B-3 agency will inform the HMOs of the
alternative billing procedures for these recipients.
G. The following guidelines have been developed to establish the
complementary roles of the HMO and the B-3 agency for clients they
have in common and to identify the mutual activities of each party
that will promote effective communication and coordination between the
two parties. This language will also be incorporated as an Appendix in
the county B-3 provider materials ensuring that both HMOs and county
B-3 providers have the same information available to
HMO Contract for January 1, 2002 - December 31, 2003
-176-
them. All actions by B-3 are governed by HSF 90, and HMOs are required
to make a reasonable attempt to assure:
That HSF 90 standards are met (e.g., two-day referral).
II. HMO Rights and Responsibilities
A. The HMO must designate at least one individual to serve as a contact
person for county B-3 agencies. If the HMO chooses to designate more
than one contact person, the HMO should identify the counties which
each contact person is responsible for. The contact person will work
toward achieving a close, cooperative relationship between the HMO and
the B-3 agency. The contact person will work with the B-3 agency to
establish a mechanism to identify and refer eligible recipients for
services and for the distribution of appropriate paperwork.
B. The HMO will make referrals to county B-3 agencies when they identify
a recipient who may meet the eligibility guidelines of the Wisconsin
Administrative Code, Chapter 90 HFS for B-3 services, within 2 days. A
child under the age of three can be identified and referred to the B-3
agency based on the judgment of the HMO provider that the child is not
developing normally.
C. If the parent of a child requests the HMO to conduct an
evaluation/assessment, the HMO will determine the need for such
evaluation/assessment in accordance with the Medicaid and Chapter 90
HFS definition of medical necessity. If the evaluation/assessment
warrants eligibility for B-3 services, a referral should be made to
the B-3 agency as soon as possible. The HMO evaluation/assessment may
be used by the B-3 agency for eligibility determination. If additional
information is needed, the HMO and B-3 program will coordinate a B-3
evaluation of eligibility and an assessment of IFSP services needed.
The evaluation and assessment results should be completed within 35
days from the date of the parent request. Results should be sent to
the B-3 agency with the parent/guardian consent at the time of
referral. This provides the B-3 agency sufficient time to complete the
IFSP within the 45-day time limit mandated by HSF Chapter 90.
D. If the county B-3 agency requests a B-3 eligibility determination
evaluation and assessment of IFSP service needs, the agency will
provide a copy of the recipient screening tool to assist the HMO in
determining the need for a full evaluation/assessment. If the HMO
agrees with the agency request, the HMO will conduct a complete
evaluation/assessment of the recipient's rehabilitative needs. Federal
regulations under Chapter 90 HFS require the HMO to forward a copy of
the findings to the county B-3 agency within 35 days from the date of
the parent/guardian request. This allows the B-3 agency sufficient
time to complete the IFSP within the 45-day deadline required by
federal regulations under Chapter 90 HFS. If the HMO determines that
no medically necessary
HMO Contract for January 1, 2002 - December 31, 2003
-177-
evaluation/assessment is needed, the HMO will document the rationale
for this decision.
E. If the HMO requires copies of the recipient's early intervention
records held by the county B-3 agency, the HMO may request the records
directly from the B-3 agency with the parents'/guardians' consent.
1. The HMO case management liaison and the county B-3 case manager
must establish feasible administrative procedures for obtaining
parents'/guardians' consent for release of such records.
2. If the parents'/guardians' consent is not obtained, then any
further actions on the part of the HMO requiring such records may
cease.
F. The HMO must determine the need for medical treatment related to B-3
services covered under the HMO contract based on the results of the
evaluation/assessment and the HMO determination of medical necessity.
The HMO will not have final say on the entire IFSP, but only on
whether the EI services indicated in the IFSP are the HMO's
responsibility.
G. The HMO shall work cooperatively with the B-3 agency so that the
provision of medically necessary services identified in the IFSP plan
do not suffer interruption due to delays caused by HMO prior
authorization and/or utilization management procedures.
H. The HMO B-3 liaison, or other appropriate staff as designed by the
HMO, must participate in case planning for the development of the IFSP
with the county B-3 agency, unless no services are provided through
the HMO:
1. The case planning may be done through telephone contact or
written communication rather than attending a formal case
planning meeting.
2. The HMO is encouraged to recommend the type, frequency, and
amount of services that might be on the IFSP.
3. The HMO must informally discuss differences in opinion regarding
the HMO's determination of medically necessary treatment needs if
requested by the recipient or case manager.
4. The HMO case management liaison and the county B-3 manager must
discuss the follow-up to be undertaken so that IFSP services
authorized by the HMO according to the criteria of medical
necessity are made available and accessible to the recipient, and
work with B-3 agencies to assist in scheduling recipient
appointments.
HMO Contract for January 1, 2002 - December 31, 2003
-178-
5. The HMO's role in the case planning may be limited to a
confirmation of the services the HMO will authorize if the
recipient and county B-3 case manager find these acceptable.
I. The parent/guardian of a B-3 recipient may chose to receive B-3
services from the recipient's HMO or may elect to disenroll the child
from the HMO as allowed by Medicaid. However, HMOs may not restrict in
any way the right of the recipient to remain enrolled in the HMO and
to receive medically necessary services through the HMO.
J. HMOs must arrange for providers with expertise appropriate to treat
the infant and toddler population to meet the medically necessary
needs of B-3 recipients enrolled in the HMO.
III. County B-3 Agency Rights and Responsibilities
A. The county B-3 agency is responsible for the initial contact with the
HMO to coordinate services to recipient(s) they have in common, and
will provide the HMO with the name and phone number of the county B-3
agency.
B. If the HMO refers a recipient to the county B-3 agency, the county B-3
agency must conduct an eligibility evaluation/assessment based on
their usual procedures and policies in collaboration with the HMO.
C. If the county B-3 agency requires copies of the recipient's medical
records, the B-3 agency may request the records directly from the HMO
with the consent of the parent/guardian.
D. The B-3 case manager (service coordinator) may also identify whether
the recipient has service or treatment needs over and above what is
included in the child's IFSP. As a part of this process, the county
B-3 agency and the recipient may seek additional assessment for
treatment of medical conditions not included in the IFSP which the HMO
may be expected to assess and treat under the terms of its contract.
In these cases, the HMO will determine if there are specific signs and
symptoms indicating the medical necessity for the assessment and
treatment. The B-3 agency must refer and coordinate
evaluation/assessment with the HMO within 2 days of identifying a
potentially eligible child.
E. The county B-3 agency may not determine the need for specific medical
care covered under the HMO contract, nor may the county B-3 agency
make referrals directly to specific providers of medical care covered
through the HMO.
F. The county B-3 agency must complete an IFSP in accordance with the
requirements of HSF 90.
HMO Contract for January 1, 2002 - December 31, 2003
-179-
G. If the county B-3 agency specifically requests the HMO liaison to
attend a planning meeting in person, the county B-3 agency may
coordinate with the HMO for the costs associated with attending the
planning meeting. These are not separately allowable costs for
reimbursement through Wisconsin Medicaid.
H. The county B-3 agency is responsible for making timely referrals to
School Based Services (SBS) providers for recipients participating in
B-3 programs, who turn the age of 3 and are therefore losing
eligibility for B-3 services, and are likely to be eligible for the
SBS program.
I. Nothing in these guidelines precludes the HMO and the county B-3
agency from entering into a formal contract or Memorandum of
Understanding to address issues not outlined here.
HMO Contract for January 1, 2002 - December 31, 2003
-180-
ADDENDUM XXIII
WISCONSIN MEDICAID
HMO REPORT ON AVERAGE BIRTH COSTS BY COUNTY
County Child Support Agencies (CSA) obtain court orders requiring fathers to
repay birth costs that have been paid by Medicaid FFS as well as Medicaid Health
Maintenance Organizations (HMO). The purpose of this report is to provide CSAs
with appropriate HMO birth cost payment information.
1. Data must be reported annually. The submission schedule can be found in
Addendum IV, Part A, of the HMO contract.
2. Data must be reported for one full year beginning January 1, of the prior
year through December 31, of that year (i.e., for contract year 2002, data
would accumulated and reported for the period January 1, 2001, through
December 31, 2001).
3. Data must reflect claims/encounters with dates of service January 1 through
December 31 and not claims paid through the reporting deadline.
4. Data must be reported individually for each county the HMO has been
certified by the Department to serve. Do not leave any column of the HMO
birth cost chart blank. Use NA if the data is not available.
5. Average dollar amounts paid must include professional and hospital (UB-92)
services for the categories defined in the HMO birth cost chart. Do not
include high risk delivery costs in the average payments (i.e., NICU
related charges).
6. HMO birth cost chart:
MEDICAID HEALTH MAINTENANCE ORGANIZATION AVERAGE BIRTH COSTS
January 1, ____, through December 31, ____
<Table>
<Caption>
Average Paid Average Paid Average Paid Average Paid Average Paid
Hospital Hospital Newborn Vaginal Delivery Cesarean Section
HMO County (UB-92) - Mother (UB-92) - Newborn (Physician) (Physician) (Physician)
- --- ------ ---------------- ----------------- ------------ ---------------- ----------------
XXX Dane $ NA $ $ $
XXX Door $ $ $ $ $
</Table>
7. In some counties, judges will not assign birth costs to the father based
upon average figures. Upon request of the EDS Contract Monitor, the HMO
must provide actual charges less any payments made by a third party payer
for the use by the court in setting actual birth and related costs to be
paid by the father. Birth cost information must be submitted to the EDS
Contract Monitor within fourteen (14) days from the date the request was
received by the HMO. Refer to the next page for the reporting requirements.
HMO Contract for January 1, 2002 - December 31, 2003
-181-
MEDICAID/BADGERCARE HMO BIRTH COST REQUEST
PART I: LOCAL CHILD SUPPORT AGENCY PORTION
PART I IS TO BE COMPLETED BY THE LOCAL CHILD SUPPORT AGENCY. PLEASE PRINT, TYPE
OR COMPLETE IN A LEGIBLE MANNER.
1. HMO NAME
-----------------------------------------------------------------
2. NEWBORN NAME
--------------------------------------------------------------
(First) (M.I.) (Last)
*(If multiple births, please list all names)
DATE OF BIRTH SEX
-------------------------------- --------------------
3. MOTHER'S NAME
-------------------------------------------------------------
(First) (M.I.) (Last)
MEDICAID/BADGERCARE ID NUMBER
--------------------------------------------
ADDRESS
------------------------------------------------------------------
(Street Address)
-----------------------------------------------------------------------
(City) (State) (Zip Code)
4. I certify this information is accurate to the best of my knowledge:
Name of Local Child Support Agency
Name (Please Print)
Signature
Title
Date
Phone Number: FAX Number:
MAIL THE FORM TO: FAX THE FORM TO:
EDS EDS
ATTN: HMO UNIT ATTN: HMO UNIT
6406 BRIDGE ROAD (608) 221-8815
MADISON, WI 53784
HMO Contract for January 1, 2002 - December 31, 2003
-182-
PART II: HMO PORTION
PART II IS TO BE COMPLETED BY THE HMO. PLEASE PRINT, TYPE OR COMPLETE IN A
LEGIBLE MANNER.
1. The actual payment for birthing costs for the mother and her baby.
MOTHER'S NAME ID#
-------------------------------- -------------------
HOSPITAL/BIRTHING CENTER PAYMENT (MOTHER) $
------------
HOSPITAL/BIRTHING CENTER PAYMENT (NEWBORN) $
------------
PHYSICIAN PAYMENT (MOTHER) $
------------
PHYSICIAN PAYMENT (NEWBORN) $
------------
AMOUNT PAID BY OTHER INSURANCE $
------------
2. COMMENTS: (i.e., retroactively disenrolled from [HMO NAME]) effective
[DATE], services denied
[STATE DENIAL REASON]:
-------------------------------------------------
-----------------------------------------------------------------------
3. I certify this information is accurate to the best of my knowledge.
Name of HMO
Name (Please Print)
Signature
Title
Date
4. MAIL OR FAX PART I AND PART II WITHIN 14 OF RECEIPT TO:
MAIL THE FORM TO: FAX THE FORM TO:
EDS EDS
ATTN: HMO UNIT ATTN: HMO UNIT
6406 BRIDGE ROAD (608) 221-8815
MADISON, WI 53784
HMO Contract for January 1, 2002 - December 31, 2003
-183-
ADDENDUM XXIV
LOCAL HEALTH DEPARTMENTS AND
COMMUNITY-BASED HEALTH ORGANIZATIONS
A RESOURCE FOR HMOs
LOCAL HEALTH DEPARTMENTS
Local Health Departments (LHDs) throughout the state have an essential role in
promoting the health of citizens of Wisconsin. They have general and specific
statutory authority to prevent disease, promote health and protect the health of
the citizens. They work in collaboration with community-based organizations,
medical care facilities, and local community agencies to develop and coordinate
systems of care so that the public's health can be protected. Specific statutory
authority includes the three public health core functions of assessment, policy
development and assurance:
ASSESSMENT: means the regular, systematic collection, assembly, analysis and
dissemination of information on the health of the community. This includes
incidence and prevalence data, and morbidity, mortality and environmental data
in areas that include: communicable disease, chronic disease and environmental
health.
POLICY DEVELOPMENT: means the exercise of responsibility to serve the public's
interest by fostering shared ownership with the community in the development of
comprehensive public health plans, programs, services and guidelines.
ASSURANCE: means to take reasonable and necessary action to assure citizens that
services necessary to achieve public health goals are available. This is done by
encouraging the actions of others in the private, public and/or voluntary
sectors, and by requiring action through enforcement or by directly providing
services.
DESCRIPTION OF PUBLIC HEALTH SERVICES: LHDs' capacities may vary, however, LHDs
are required to provide or assure five basic public health services. These
include: communicable disease surveillance, prevention and control; health
promotion; disease prevention; human health hazard control; and generalized
public health nursing programs. Although LHDs serve the population as a whole,
they have established traditions of working with population groups at increased
risk of illness, disability and premature death. The following specific services
have been delineated with the hope of linking Medicaid Managed Care Plans with
Local Health Departments. Linking primary care and public health is an essential
strategy to strengthen the health of local communities and thus benefit the
population of the state as a whole.
o LHDs have access to population data that may be very useful to managed care
organizations in determining their services and quality studies.
HMO Contract for January 1, 2002 - December 31, 2003
-184-
o LHDs closely collaborate their programs with key community agencies that
serve the Medicaid population. These include: WIC, Prenatal Care
Coordination, School Health Services, Birth to Three Programs, Family
Planning, and Developmental Disabilities.
o LHDs promote and provide health education programs on topics that include:
Domestic Abuse/Violence Prevention, Smoking Cessation, Breast Feeding,
Cardiovascular Risk Reduction, Prenatal/Postpartum Education, Nutrition,
and Self-Care Skills.
o LHDs provide health-related home/community inspections in areas that
include Lead Poisoning, Asbestos, Indoor Air Quality, Home Safety, and
Drinking Water Safety.
o LHDs monitor communicable disease incidence/prevalence, provide information
to the public on prevention, and conduct epidemiological investigations of
outbreaks/unusual conditions.
ACCESS TO SPECIAL POPULATIONS
Wisconsin's LHDs perform many public health services, including the provision of
direct services to Medicaid recipients. Some local health departments provide
Medicaid reimbursable services for which HMOs may contract, such as:
o HealthCheck screening, outreach and follow-up;
o Immunizations;
o Blood lead screening;
o Extended case management of medical conditions such as asthma, diabetes,
hypertension and children with special health care needs; and
o Home health and personal care services.
Some important considerations to remember are that LHDs provide:
o Clinics serving high-risk populations;
o Culturally competent staff experienced in dealing with diverse, high risk
populations;
o Direct access to outreach and follow up at-risk population groups in home
and community settings;
o Environmental inspection and case management for children with elevated
blood lead levels;
o Ability to reach hard-to-reach people to assist HMOs in achieving required
rates, such as the HealthCheck screening rate;
HMO Contract for January 1, 2002 - December 31, 2003
-185-
o Experience in family-centered care;
o Linkages with other community based providers and advocacy groups; and
o Highly skilled staff who emphasize prevention and public health.
COMMUNITY BASED HEALTH ORGANIZATIONS
Throughout the state, the health care network includes many nonprofit community
based health organizations including: private HealthCheck providers, family
planning clinics, and WIC clinics. These organizations may provide some of the
same Medicaid reimbursable services as LHDs and are an essential element to
advance the health of community. They may also have the same access to special
populations as LHDs. (ADDENDUM XXIV.)
COLLABORATION WITH PUBLIC AND COMMUNITY BASED HEALTH ORGANIZATIONS
HMOs should consider how to utilize the LHDs and community based health
organizations through:
o IDENTIFYING AND UTILIZING THE RESOURCES THEY PROVIDE; AND
o WHERE APPROPRIATE, CONTRACTING WITH LHDS AND OTHER COMMUNITY
HEALTH AGENCIES FOR MEDICAID REIMBURSABLE SERVICES.
The complementary roles of managed care and public health are significant and
evolving. Communities will be healthier and health care costs will be reduced if
health care providers work together. To find out the names of key contacts at
LHDs and community based health organizations in your area, contact your LHD.
HMO Contract for January 1, 2002 - December 31, 2003
-186-
ADDENDUM XXV
GENERAL INFORMATION ABOUT THE WIC PROGRAM,
SAMPLE HMO-TO-WIC REFERRAL FORM, AND
STATEWIDE LIST OF WIC AGENCIES
GENERAL INFORMATION ABOUT THE WIC PROGRAM AND ITS RELATIONSHIP TO MEDICAID HMOS
The Special Supplemental Nutrition Program for Women, Infants, and Children
(WIC) program is a program enacted as an amendment to the Child Nutrition Act of
1996, and is funded by USDA. WIC provides supplemental nutritious foods,
nutrition education, and referrals to pregnant and breastfeeding women, infants
and children up to age five, who are determined to be at nutritional risk.
Income eligibility is determined by family size and gross income (185 percent of
the poverty level). WIC uses "adjunctive" eligibility which means that any
recipient of Medicaid (including Healthy Start and BadgerCare) is eligible for
WIC.
The State Division of Public Health contracts with 68 local agencies to provide
WIC benefits. In Wisconsin, most WIC agencies are local health departments, but
other community-based organizations are contracted with WIC to provide WIC
benefits, including community action programs and other private non-profit
health agencies.
WIC serves approximately 106,000 women, infants and children each month.
Approximately thirty-five (35) percent of all Wisconsin births are on WIC.
Approximately half of all WIC participants were enrolled in a Medicaid HMO.
Sixty-eight (68) percent of all participants have incomes below the poverty
level; thirty-five (35) percent have less than a high school education.
Section 1902(a)(11)(C) of the Social Security Act requires coordination between
Medicaid HMOs and WIC. This coordination includes the referral of potentially
eligible women, infants, and children to the WIC program and the provision of
medical information by providers working within Medicaid managed care plans to
the WIC program if requested by WIC agencies. Typical types of medical
information requested by WIC agencies include information on nutrition related
metabolic disease, diabetes, low birth weight, failure to thrive, prematurity,
infants of alcoholic, mentally retarded, or drug addicted mothers, AIDS, allergy
or intolerance that affects nutritional status, and anemia.
For more information, refer to the WIC Referral Forms, WIC Project Directory and
the partnership pamphlet that are part of this addendum. Multiple copies of the
WIC Referral Form may be obtained from local WIC agencies.
HMO Contract for January 1, 2002 - December 31, 2003
-187-
<Table>
DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN
Division of Public Health Bureau of Family & Community Health
DOH 4024 (Rev. 02/99) WIC Program, Federal Reg. 246
</Table>
WIC MEDICAL REFERRAL FORM
FOR
PREGNANT AND BREASTFEEDING AND NONBREASTFEEDING POSTPARTUM WOMEN
Completion of this form is voluntary. Information gathered on this form is used
for WIC certification and for food package issuance.
Patient's First and Last Name: Birthdate:
-------------------- ----------------
Address: Telephone:
------------------------------------------ ----------------
<Table>
<Caption>
ALL WOMEN: PREGNANT: POSTPARTUM:
Present weight: Hct: % E.D.D.: Del. date:
----------------- ----------------- ---------------- ------------------
And/or
Present height: Hgb: gm Wks gest: Prepreg. wt.:
----------------- ----------------- -------------- ---------------
Date taken: Date taken: Prepreg. wt: Wt. gained:
--------------------- ---------- ----------- -----------------
Vit/Min Rx:
---------------------
ALL WOMEN.
Current nutrition-related health problems:
food allergy or intolerance (specify):
- --- ----------------------------
recent major surgery, trauma, or burns:
- --- ----------------------------
infectious disease in last 6 months:
- --- -------------------------------
pneumonia HIV or AIDS parasitic infection
--- --- ---
bronchiolitis (# episodes in last 6 mos: ) meningitis tuberculosis
--- --- ---
nutrition-related chronic disease, genetic or central nervous system
- --- disorder, or other medical condition (specify):
-------------------------
Obstetrical history in any previous pregnancy (if currently pregnant) or most
recent pregnancy (if currently postpartum):
gestational diabetes large for gestational age infant
- --- ---
low birth weight or preterm infant fetal or neonatal death
- --- ---
infant with nutrition-related birth defect (specify):
- --- --------------------------------
PREGNANT WOMEN:
Current nutrition-related health problems:
gestational diabetes hyperemesis gravidarum
- --- ---
pregnancy-induced hypertension fetal growth restriction
- --- ---
MEDICAL NUTRITIONAL PRESCRIBED:
Ensure(R) Ensure w/Fiber(R) Ensure Plus(R) Sustacal(R) Sustacal w/Fiber(R) Boost Plus(R)
- --- --- --- --- --- ---
Additional Diagnoses/Health Concerns/Diet Orders: Physician or Health Professional's Name:
-----------------------------------
Medical Office/Clinic:
--------------------------------------------------------------------------------------------------------
Address: Telephone:
------------------------------------------------ -----------------------------------------------------
Signature: Date:
---------------------------------------------- ----------------------------------------------------------
LOCAL WIC PROJECT:
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-188-
WIC MEDICAL REFERRAL FORM
FOR
INFANTS AND CHILDREN (THROUGH 4 YEARS OF AGE)
Completion of this form is voluntary. Information gathered on this
form is used for WIC certification and for food package issuance.
Patient's First and Last Name: Birthdate:
-------------------- ----------------
Address: Telephone:
------------------------------------------ ----------------
Parent/Caregiver's First and Last Name:
---------------------------------------
<Table>
<Caption>
ALL INFANTS AND CHILDREN: INFANTS ONLY:
Present Wt: Length/height: ( recumbent or standing) Birth weight:
------- --------- --- --- -------------------
Date measurements taken:
---------------------------------
Birth length:
-------------------
Hct: % and/or Hgb: gm Date taken:
------- ------- -----------------------
Blood lead: Date taken: Gestational age:
--------------------------- ------------------------- ----------------
Vitamin/Mineral Rx:
-----------------------------
INFANTS. Medical conditions the mother had prenatally:
anemia high blood lead
- ---- ----
pregnancy-induced hypertension gestational diabetes
- ---- ----
food allergy or intolerance (specify):
- ---- -----------------------------------
nutrition-related infectious disease, chronic disease, genetic or
- ---- central nervous system disorder, or other medical condition (specify):
--------------------------------------------------------------------------
INFANTS AND CHILDREN. Current nutrition-related health problems:
Infants: pyloric stenosis GI reflux LGA at birth currently LGA head circumference <5th percentile
--- --- --- --- ---
Infants and Children:
SGA at birth food allergy or intolerance (specify):
- --- ---
currently SGA recent surgery, trauma, or burns (specify):
- --- ---
failure to thrive
- ---
infectious disease in last 6 months:
- ---
pneumonia HIV or AIDS tuberculosis
--- --- ---
bronchiolitis (# episodes in last 6 mos: ) meningitis parasitic infection
--- --- --- ---
nutrition-related chronic disease, genetic or central nervous system
- --- disorder, or other medical condition (specify):
-------------------------
FORMULA PRESCRIBED. Special formula for infants and children:
Similac NeoSure(R) Enfamil AR(R) Kindercal(R) Neocate One+(R)
- --- --- --- ---
Enfamil 22(R) Neocate(R) PediaSure(R) EleCare(R)
- --- --- --- ---
Nutramigen(R) Similac PM 60/40(R) PediaSurew/Fiber(R) Portagen(R)
- --- --- --- ---
Alimentum(R) Pregestimil(R)
- --- ---
Standard formula for children: Similac with Iron(R) Isomil(R) Similac Lactose Free(R)
--- --- ---
Intended length of use:
---------------------------------------------------------------------------------------------------
Additional Diagnoses/Health Concerns/Diet Orders:
Physician or Health Professional's Name:
---------------------------------------------------------------------------------------
Medical Office/Clinic:
--------------------------------------------------------------------------------------------------------
Address: Telephone:
------------------------------------------------ -----------------------------------------------------
Signature: Date:
---------------------------------------------- ----------------------------------------------------------
LOCAL WIC PROJECT:
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-189-
Partnerships
for
Healthy
Kids
[GRAPHIC]
Wisconsin
Division of Public Health
Immunization Program
Childhood Lead Poisoning Prevention Program
WIC Program
HMO Contract for January 1, 2002 - December 31, 2003
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Table of Contents
<Table>
A. INTRODUCTION ................................................................................ 192
B. EXPANDING THE PARTNERSHIP ................................................................... 193
C. WHY THE THREE PROGRAMS WORK TOGETHER ........................................................ 193
APPENDIX
PROGRAM DESCRIPTIONS:
IMMUNIZATION PROGRAM ............................................................................. 195
1. What is the Immunization Program? ........................................................... 195
2. Does the Immunization Program have educational materials? ................................... 196
3. Does Wisconsin have a statewide Immunization Registry? ...................................... 196
4. Are children in Wisconsin well immunized? ................................................... 197
5. Who are the contact people for the Immunization Program? .................................... 198
CHILDHOOD LEAD POISONING PREVENTION PROGRAM ...................................................... 198
1. What is the Wisconsin Childhood Lead Poisoning Prevention Program? .......................... 198
2. What is lead poisoning? ..................................................................... 198
3. Is childhood lead poisoning a problem in Wisconsin? ......................................... 199
4. How is screening for lead poisoning done? ................................................... 199
5. Are Wisconsin children being screened adequately? ........................................... 200
6. Why are children enrolled in or eligible for Medicaid at higher risk for lead poisoning? .... 200
7. What can be done for children with lead poisoning? .......................................... 200
WIC (WOMEN, INFANTS, AND CHILDREN) PROGRAM ....................................................... 201
1. What is WIC? ................................................................................ 201
2. Who is eligible and what is provided? ....................................................... 201
3. Who are WIC participants? ................................................................... 202
4. How are services provided? .................................................................. 204
5. Is WIC effective? ........................................................................... 204
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
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A. INTRODUCTION
The state and federally funded Women's, Infant, and Children Nutrition
Program (WIC), the Immunization Program (IP), and the Wisconsin Childhood
Lead Poisoning Prevention Program (WCLPPP) all carry the mandate to assure
that the children of Wisconsin are well nourished, and are protected from
vaccine-preventable diseases and lead poisoning.
These public health functions are to assure the health of all the citizens
of the community. Historically, public health, physicians, and other health
care providers work together, often as silent partners, to accomplish this.
Within the partnership, it often fell to public health to assess and
provide these services to children who may be most vulnerable to a number
of health and environmental threats: those who are poor, and/or whose
access to "traditional" insurers and providers was limited.
Today, care for many of these children has been assumed by a new partner:
the managed care and health maintenance organizations. In collaboration
with the Wisconsin Medicaid Program, these insurers/provider groups have
renewed their commitment to providing health care services to children
enrolled in Medicaid in a more organized and structured way. The model of
all children having a "medical home," a setting in which consistent care
over time is given by one, or selected health care providers, has been
adopted. This model increases the opportunities for providing education,
assessments, and interventions that can prevent illness and injury or treat
it in the earliest stages.
Our programs, within the Wisconsin Division of Public Health, believe that
strong collaboration between the public and private sectors will strengthen
our will and abilities to meet the nutrition, immunization and lead
poisoning prevention goals for Wisconsin children.
WHY ARE WE HERE?
There are many effective collaborative efforts already in place around the
state and we hope to build on these successes and help facilitate working
on problem areas. We don't assume to know how each agency or county or HMO
works; all are so different and there are varying levels of collaboration
taking place. We also don't assume to know how each county, program, agency
should or could work together. Our goal in being here is to start (or in
many cases, expand) the discussion between the programs and the HMO's at
the local levels. This is obviously the best place to work out the many
details associated with collaborative efforts. Perhaps there is a good
working relationship with one program, but the community could benefit from
further collaborations. Perhaps this will simply affirm and celebrate the
collaborative efforts, which we can then share with others. In either case,
we look forward to joining you on this venture.
HMO Contract for January 1, 2002 - December 31, 2003
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B. EXPANDING THE PARTNERSHIP
WIC, WCLPPP, and IP would like to build and expand on the public/private
partnerships that already exist to provide health care for Wisconsin
children, especially those for whom access to consistent health care
resources may be inadequate or underutilized. We believe that WIC clinics
can provide a pathway that can facilitate not only entrance into the
healthcare system, but also the assurance that needed and/or required
services (nutrition counseling/support, immunizations, and lead testing)
are obtained by all families.
As new partnerships are defined, and old ones revised, our public health
programs are looking to private providers and managed care organizations to
begin to discuss how some of the following concerns may be addressed:
1. Increase understanding of the need, requirements for, and services
available to meet children's nutritional needs, recommended
immunizations and blood lead screening schedules.
2. To facilitate billing and information sharing practices between public
health, providers, and managed care organizations so that services can
be provided at all points of contact with children and are not
duplicated.
3. To assure that reimbursement for services provided by local health
departments and programs is obtainable in a timely and cost-effective
manner.
4. To strengthen and coordinate outreach and referral for WIC services
when appropriate, and to establish and support a medical home for all
clients.
5. To clarify the roles of managed care and public health in assuring
(providing and documenting service) the delivery of nutrition,
immunization and blood lead screening to Wisconsin children.
By addressing these topics, our programs can be of assistance in providing
needed services for children, while complementing the work of private
health care providers.
C. WHY THE THREE PROGRAMS COLLABORATE
The Immunization, Lead Poisoning Prevention, and WIC Programs all have a
common goal: healthy kids in Wisconsin. Even though the programs focus on
specific objectives, e.g. improve nutritional status, improve immunization
rates, decrease lead poisoning, they are often positioned in the community
to best serve this high-risk population.
Many public health agencies administer all three programs and often share
space, information, staff and other resources. It is logical for the three
programs to collaborate because all are seeing a similar target group:
HMO Contract for January 1, 2002 - December 31, 2003
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o children age five and under,
o families that are either at risk or high risk,
o low-moderate income,
o uninsured or underinsured and often receiving sporadic health care.
Enhancing collaboration between the programs only serves to enhance
accessibility to these health services, and provides them in a convenient
and familiar setting.
WIC IS A LOGICAL PARTNER
WIC provides a comfortable and convenient setting for receiving benefits.
WIC has early and late hours, and many projects have Saturday hours to
better serve working families and students.
The Wisconsin Immunization, Lead and WIC Programs have been working
together these past years to enhance services to children and advance the
objectives of each program. Memorandums of Understanding (MOU) for sharing
information are in place, as well as policies and procedures for local WIC
projects to follow. For example, it is a requirement of the WIC Program to
screen the immunization records of all children, and refer children to
their provider for immunizations as needed. Immunization dates are entered
onto either the WIC data system or immunization data system. Another
example is blood lead screening. During each certification appointment,
children will have a hemoglobin or hematocrit taken. With a minor
adjustment of that procedure, the child can also be tested for lead.
As described in the Appendix, WIC Program, WIC sees many at-high risk
families in Wisconsin. They return to WIC frequently for recertification
and food voucher pick-up. Enhancing WIC services with immunization and lead
screening fits well into certification process, as well as the follow-up
visits. WIC also provides frequent opportunities to reinforce health
messages through education sessions and materials. WIC has an elaborate
data collection system, which collects immunization and lead data, and has
the capacity to provide informative outcome reports.
Children at risk for lead poisoning require screening and referral for
lead, and nutrition information to decrease the toxic effects of lead. WIC
can do both.
Children at risk for under-immunization require screening and referral to
their immunization provider. WIC can and is doing this.
HMO Contract for January 1, 2002 - December 31, 2003
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THE PARTNERSHIP IS WORKING
Studies show that WIC improves immunization status and screening rates for
lead poisoning.
In the current 1998-99 grant cycle, 89 percent of local health departments
receiving state funding for childhood lead poisoning prevention programs
identified WIC as a screening location. In 1996-97, 21 percent of children
with severe lead poisoning (blood lead levels >20(MU)g/dL) were screened in
WIC clinic settings.
APPENDIX
The following provides a Question and Answer description of each program, along
with data that reflects the health needs of the children we serve. We trust that
you will recognize similarities between some of your clients.
IMMUNIZATION PROGRAM
(608)267-9959
1. WHAT IS THE IMMUNIZATION PROGRAM?
The purpose of the immunization program is to eliminate vaccine preventable
diseases by maintaining high immunization levels among infants, preschool
and school age children. This includes vaccines against the following
diseases: diphtheria, tetanus, pertussis, polio, haemophilus influenza b
(Hib), measles, mumps, rubella, hepatitis B and varicella (chicken pox).
The Immunization Program distributes vaccine to local health departments
(LHDs), federally qualified community health centers (FQHCs), tribal health
clinics and private providers throughout the state. The use of state
supplied vaccine by private providers is limited to children who are
uninsured, on medical assistance or Native American or Alaskan natives. The
Program distributes federal Immunization Action Plan (IAP) funds to LHDs to
support efforts to improve vaccine delivery such as outreach and education
programs, tracking and recall systems to keep children on the recommended
immunization schedule and immunization clinic expansion when current
efforts do not meet identified need.
Collaborative efforts with other infant and child oriented programs are
also funded through IAP funds. The State WIC and Immunization Programs have
received national attention for the cooperative efforts taking place
between the two programs. Program staff, assigned to the Regional Offices,
monitors the IAP Grants and offer consultation and technical assistance to
all providers regarding safe and effective methods to immunize children.
HMO Contract for January 1, 2002 - December 31, 2003
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The Immunization Program coordinates the investigation of all reported
cases of vaccine preventable diseases. Cases are followed up to determine
source and appropriate control measures are initiated to limit spread.
The Wisconsin Immunization Law mandates that children attending day care
and schools in the state meet minimum immunization requirements. The
Immunization Program works with day care centers, schools, local health
departments and physicians to ensure these requirements are met.
Hepatitis B vaccine is the only vaccine that is recommended at birth. In a
collaborative effort with LHDs, the state chapters of the AAP and the AAFP,
the State Medical Society, the Wisconsin Hospital Association and the
Association of Wisconsin HMO Directors, the Immunization Program was
successful in promoting infant hepatitis B immunization at hospital
birthing centers prior to discharge. Recent chart reviews indicate that 75
percent of infants born in 1996 received their initial hepatitis B vaccine
at birth.
Hospital labor and delivery personnel play a critical role in preventing
perinatal hepatitis B virus transmission from an infected mother to her
infant at birth. Without preventive treatment, the infant has a 40 percent
chance of becoming infected. In 1996, 95 percent of infants born to
infected mothers were correctly treated.
2. DOES THE IMMUNIZATION PROGRAM HAVE EDUCATIONAL MATERIALS?
Educational materials promoting on schedule immunization are produced by
the immunization program and available upon request. These materials are
used by public and private providers, community based organizations and
others interested in promoting immunization. One pamphlet titled "The Bear
Necessity - Immunization" (enclosed) is designed for new mothers and is
distributed by birthing centers in hospitals throughout the state.
3. DOES WISCONSIN HAVE A STATEWIDE IMMUNIZATION REGISTRY?
The Wisconsin Immunization Registry (WIR) is being developed as a tool to
assist providers in their efforts to properly immunize children. Many
parents seek immunizations for their children from more than one provider.
Coupled with the fact that parents may not keep their child's immunization
record up-to-date makes it very difficult for the new provider to determine
which immunizations are needed. The WIR will be a repository for all
immunizations given by any public or private provider in the state. This
system will enable the provider to determine what was previously given and
immunize accordingly. The WIR will also be capable of tracking children to
remind parents when children are due for immunizations or to recall them if
the child falls behind schedule.
HMO Contract for January 1, 2002 - December 31, 2003
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4. ARE CHILDREN IN WISCONSIN WELL IMMUNIZED?
The state's school aged children are well immunized. School immunization
law reports indicate that over 90 percent of Wisconsin's school children
meet the "minimum requirements" of the immunization law. The minimum
requirements reflect the dose specific requirements for the individual
vaccines that are covered under the law. Parents may opt for a waiver to
the vaccine requirements for medical, religious or personal conviction
reasons. Less than 2 percent (2%) of the total Wisconsin school enrollment
have opted for the three waivers combined.
WISCONSIN IMMUNIZATION LAW COMPLIANCE
<Table>
<Caption>
SCHOOL YEAR 94-95 95-96 96-97 97-98*
----------- ----- ----- ----- ------
MEET MIN. REQ. 94.7% 94.7% 96.3% 90.4%
IN PROCESS 1.6% 1.7% 0.8% 3.5%
BEHIND SCHEDULE 1.5% 1.4% 0.8% 3.5%
NO RECORD 0.6% 0.6% 0.6% 0.9%
MED. WAIVER 0.2% 0.3% 0.3% 0.2%
RELIGIOUS WAIVER 0.1% 0.1% 0.1% 0.1%
PER. CONV. WAIVER 0.9% 1.0% 1.0% 1.0%
</Table>
* Effective for the 1997-98 school year, the Administrative Rules for the
immunization law were changed to include a requirement for hepatitis B
vaccine.
The pre-school population has been found to be at greatest risk for not
receiving their immunizations according to the recommended schedule. The
state and national goals for childhood immunization are that 90 percent of
all children complete their primary series of immunizations by their second
birthday. The 1997 National Immunization Survey indicates that only 79
percent of Wisconsin's children have attained this goal. It is through
collaboration and partnering efforts, such as those described here, that
may best help us realize these goals.
WISCONSIN IMMUNIZATION LEVELS *
CHILDREN 2 YEARS OF AGE
<Table>
<Caption>
YEAR 1995 1996 1997
---- ---- ---- ----
Wisconsin 74% 76% 79%
Milw. Co. 68% 70% 70%
WI minus Milw. 76% 78% 81%
U.S. 77% 77% 76%
</Table>
* Proportion of 2 year olds that have completed 4 DTP/3 Polio/1 MMR/3
Hib by 24 months of age
HMO Contract for January 1, 2002 - December 31, 2003
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5. WHO ARE THE CONTACT PEOPLE FOR THE IMMUNIZATION PROGRAM?
Dan Hopfensperger, Immunization Program Director: (608)266-1339
Jim Zanto, Western/Eau Claire Region: (715)836-2499
Jean Zastro, Northeastern/Green Bay Region: (920)448-5231
Jerry Gabor, Southern/Madison Region: (608)243-2366
Jackie Kowalski, Southeastern/Milwaukee Region: (414)227-4876
Bill Sheeley, Southeastern/Milwaukee Region: (414)227-3995
Jane Dunbar, Northern/Rhinelander Region: (715)365-2709
WISCONSIN CHILDHOOD LEAD POISONING PREVENTION PROGRAM (WCLPPP)
(608) 266-5817
1. WHAT IS WISCONSIN CHILDHOOD LEAD POISONING PREVENTION PROGRAM (WCLPPP)?
The WCLPPP, in the Wisconsin Department of Health and Family Services,
Division of Public Health, works collaboratively with local health
departments, private, public, and voluntary sectors to reduce childhood
lead morbidity and assure lead safe environments for children, their
families, and communities. Lead poisoning prevention activities are
supported by federal agency grants (HUD, EPA, CDC) and Wisconsin general
purpose revenue funds.
2. WHAT IS LEAD POISONING?
Lead poisoning is a blood lead level in a child of more then 10(MU)g/dL.
The primary sources of lead poisoning for children are lead-based paint
chips and dust found in pre-1950 homes, or in homes built before 1978
undergoing renovation, remodeling, or paint removal.
Research has found that even at the most common low levels of lead exposure
(blood lead levels between 10-19 (MU)g/dL) lead poisoning can impair a
child's ability to learn, alter behavior, and can have long lasting
effects. At higher levels, effects of lead poisoning can include decreases
in growth, hearing, Vitamin D metabolism, anemia, gastrointestinal
complaints, coma and death.
Most children with lead poisoning show no symptoms. The only way to know a
blood lead level is elevated is to draw a blood sample on the child.
HMO Contract for January 1, 2002 - December 31, 2003
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3. IS CHILDHOOD LEAD POISONING A PROBLEM IN WISCONSIN?
Yes. Wisconsin rates of lead poisoning exceed the national average. The
following table indicates Lead Poisoning In Wisconsin* and the Nation**
<Table>
<Caption>
Wisconsin United States
--------- -------------
BLL > or = to 10 (MU)g/dL 10.1% 4.4%
BLL > or = to 15 (MU)g/dL 2.2 1.3
BLL > or = to 20 (MU)g/dL 1.8 0.4
</Table>
*Source: Fiscal Year 96/97 Annual Report of Childhood Lead Poisoning in
Wisconsin
*Source: Third National Health and Nutrition Examination Survey-Phase 2
(1991-1994), MMWR, Vol. 46, No. 7, February 21, 1997.
Factors in Wisconsin that place children at risk for lead poisoning include
the number of young children in poverty and the age of the housing stock.
In a 1996 report from the Center for Health Statistics, 36 percent of
Wisconsin children age 0-4 years live below 185 percent of poverty.
According to the 1990 census 37 percent of Wisconsin housing was built
prior to 1950.
4. HOW IS SCREENING FOR LEAD POISONING DONE?
Blood lead screening is an important element of a comprehensive program to
eliminate childhood lead poisoning. The goal of such screening is to
identify children who need individual interventions to reduce their blood
lead levels.
Testing children for lead poisoning should occur at ages 1 and 2 years,
when their behavior is most likely to expose them to sources of lead, and
brain development is most vulnerable to lead toxicity. In the cities of
Milwaukee and Racine, where risk factors for lead poisoning and current
prevalence rates are high, all children are tested around 12 and 24 months
of age, and older children if assessment indicates a risk of exposure. For
the rest of Wisconsin, an assessment of the child's risk for lead exposure
is done and a test performed if indicated (call WCLPPP @ (608) 266-5817 for
more information on Wisconsin Screening Recommendations).
Testing for lead should be available at any contact point where children
receive health related services. In Wisconsin, testing for lead poisoning
is done by physicians in private clinics, at health department clinics and
at WIC sites. In FY 1996/97, of children with blood lead levels
> or = to 20(MU)g/dL, 57 percent were diagnosed in private clinics, 14
percent in health department clinics, and 21 percent at public or private
WIC clinics.
HMO Contract for January 1, 2002 - December 31, 2003
-199-
5. ARE WISCONSIN CHILDREN BEING SCREENED ADEQUATELY?
No. For a variety of reasons, Wisconsin children are not being screened for
lead poisoning in adequate numbers. It is feared that children are not
routinely having their risk for lead exposure assessed.
PERCENT OF WISCONSIN CHILDREN TESTED FOR LEAD POISONING BY AGE
FISCAL YEAR 1996-97
<Table>
<Caption>
Wisconsin Population* Number Tested (% Pop)
--------------------- ---------------------
Age 1 71,276 19,029 (27%)
Age 2 71,947 9,922 (14%)
Ages 3-5 224,311 16,178 (7%)
Total 367,534 45,129 (12%)
</Table>
* 1990 United State Census, Modified Age, Race, Sex (MARS) File,
U. S. Bureau of the Census,
6. WHY ARE CHILDREN ENROLLED IN OR ELIGIBLE FOR MEDICAID AT HIGHER RISK FOR
LEAD POISONING?
National and Wisconsin data show that children who are enrolled in federal
assistance programs (Medical Assistance, WIC, Head Start) have higher rates
of lead poisoning. For this reason, the federal and state Medical
Assistance programs require that blood lead tests be done at around 12 and
24 months of age. The reasons for increased lead poisoning among children
on MA is unclear, but is most likely attributed to the accessibility of
affordable, well maintained housing.
7. WHAT CAN BE DONE FOR CHILDREN WITH LEAD POISONING?
The detection and treatment of lead poisoning involves the entire family,
and collaboration between physicians and public health for effective
interventions. The following lead poisoning prevention and treatment
services are needed for families screened and those with lead poisoning:
o Assessment of lead exposure, and screening of children at risk at ages
1 and 2 years, and for children ages 3-5 if never done.
o For families of children receiving a blood lead test, education about
nutrition that can decrease lead absorption, hand-washing, and
cleaning techniques to decrease lead exposure.
o For all children with blood lead levels over 10 (MU)g/dL, an
assessment of what the source of lead may be, and information about
how to decrease the exposure.
HMO Contract for January 1, 2002 - December 31, 2003
-200-
o Referral to local health departments for all children with blood lead
levels over 20(MU)g/dL for a risk assessment of their home and case
management and follow-up. Many health departments become involved at
lower blood lead levels; consult your local health department to find
out at what level they intervene.
o Chelation therapy for children with blood lead levels over 45(MU)g/dL.
o Ongoing assessment of learning delays and behavioral problems, with
referral for early intervention or other educational support or
behavioral modification programs as needed.
WIC (WOMEN, INFANTS AND CHILDREN) PROGRAM
(608) 266-9824
1. WHAT IS WIC?
WIC is the Special Supplemental Nutrition Program for Women, Infants and
Children. WIC was enacted in 1972 as an amendment to the Child Nutrition
Act of 1966. It is administered in Wisconsin by the Department of Health
and Family Services, Division of Public Health. It is administered at the
local level by sixty eight (68) public and private non-profit agencies.
Fifty-one (51) of the sixty eight (68) are in local health departments.
It is funded primarily by the US Department of Agriculture - Food and
Nutrition Service, and some State General Purpose Revenue (GPR). The annual
budget is approximately $74 million, to provide food benefits, nutrition
services and administration funds.
2. WHO IS ELIGIBLE AND WHAT IS PROVIDED?
WIC provides supplemental nutritious foods, nutrition education, and
referrals to health care to low-income pregnant and breastfeeding women,
mothers with children under 6 months, and infants and children up to age
five, who are determined by a nutritionist or nurse to be at nutritional
risk.
Income eligibility is determined by family size (or economic unit) and the
gross income. Family income must be less than 185 percent of the poverty
level (for example, a family of four may make up to $30,432 to be income
eligible for WIC). Income levels are adjusted each July.
WIC also uses "adjunctive" income eligibility, which means if a participant
receives or is eligible for Food Stamps, Medical Assistance or W-2, they
are automatically income eligible for WIC.
HMO Contract for January 1, 2002 - December 31, 2003
-201-
WIC benefits include:
o Basic nutrition information and counseling at certifications and draft
pick-up, in groups or individually.
o Health and nutrition screening for WIC eligibility determinations
(health history questions, height/length, weight,
hematocrit/hemoglobin, diet screening). Projects also screen
immunization status.
o Through collaboration with other programs, many WIC projects also
offer blood lead testing, Prenatal Care Coordination, HealthCheck and
immunizations.
o Supplemental nutritious foods, which include milk, cheese, fruit
juices, high iron cereals, peanut butter, dried beans/peas, eggs,
iron-fortified infant formula, tuna and carrots for breastfeeding
women.
o Referral to other health and family services. This includes prenatal
care, immunizations, blood lead testing, well-baby checks, and
HealthCheck for ongoing health care and additional nutrition services
(e.g., medical nutrition therapy, special formulas).
3. WHO ARE WIC PARTICIPANTS?
WIC currently serves approximately 106,000 women, infants and children each
month with a food package. The following chart describes the statewide
total by race and category. (June 1998)
<Table>
<Caption>
% Pregnant Brstfdng Post-partum Infants Children
----- -------- -------- ----------- ------- --------
Black 23.5 2,322 568 2,084 5,814 14,027
Hispanic 11.3 1,242 785 688 2,860 6,429
Asian 6.2 471 170 416 1,166 4,361
Native Am 2.4 239 109 175 574 1,423
White 56.5 6,629 2,929 5,009 14,424 30,801
TOTAL 10,917 4,562 8,356 24,849 57,054
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-202-
Using the 1996 total births in Wisconsin, this chart shows that approximately
35% of the mothers were on the WIC Program during their pregnancy.
WIC also serves a very high percentage of the births to Black, Hispanic,
American Indian, or Asian mothers.
PERCENT OF 1996 BIRTHS BY
RACE/ETHNIC IN WISCONSIN
[GRAPH]
<Table>
<Caption>
PERCENT OF BIRTHS
1996 Birth Records on WIC Prenatal on WIC Postpartum
------------------ --------------- -----------------
State 100% 35% 9%
White 82% 25%
Black 10% 81%
Hispanic 5% 71%
Am. Indian 1% 60%
Asian/other 3% 69%
</Table>
WIC also serves a large number of high risk individuals. The following
chart provides some statistics regarding income levels, age and education
levels.
<Table>
<Caption>
Income by % Poverty Age at Certification Education Level
- ----------------------------- --------------------------- ----------------------------
<100% 79,704 68.0% <1 29,786 25.4% 0-7 yrs 10,747 9.2%
101-124 13,272 11.3% 1 yr 19,694 16.8 8-11 29,883 25.5
125-149 11,603 9.9% 2 yr 15,977 13.6 12 yrs 54,017 46.0
150-174 8,504 7.3% 3 yr 15,018 12.8 13-15 16,701 14.2
175-185 2,375 2.0% 4 yr 11,639 9.9 16+ 4,074 3.5
>185% 1,683 1.4% 11-14 132 .1 unk 1,961 1.7
15-18 3,890 3.3
19-35 20,017 17.0
36+ 1,178 1.0
</Table>
1996 WI BIRTHS
WOMEN <20 YEARS
[GRAPH]
<Table>
<Caption>
Women <20
on WIC
Total Births Women <20 Prenatal & PP
------------ --------- -------------
100% 11% 10%
67,150 7,106 6,592
</Table>
1996 WI BIRTHS
WOMEN <HIGH SCHOOL EDUCATION
[GRAPH]
<Table>
<Caption>
Educ<HS on WIC
Total Births Educ<HS Prenatal & PP
------------ --------- --------------
100% 16% 14%
67,150 10,795 9,693
</Table>
WIC screens each applicant to determine where they are receiving their health
services. The following indicates that over half of the participants are
receiving Medical Assistance.
HMO Contract for January 1, 2002 - December 31, 2003
-203-
<Table>
<Caption>
Health Care Source
--------------------------------------------------
MA/HS, non-HMO 21,835 19.1%
MA/HS, HMO 50,267 43.9
Indian/Migrant Hlth Service 1,725 1.5
Health Insurance, Full cov 6,748 5.9
Health Insurance, co-pay/ded 29,533 25.8
No Insurance 9,889 8.6
Unknown 2,317 2.0
</Table>
4. HOW ARE SERVICES PROVIDED?
Each participant must be certified as eligible to receive WIC benefits. At
this certification appointment, WIC staff checks income and collects the
necessary data, including immunization records for all children. A health
screener or aide then weighs and measures the woman or child and plots the
result on a growth grid. A hemoglobin or hematocrit is also taken to assess
blood iron levels. Many WIC projects are also drawing samples for blood
lead at the same time.
A registered dietitian or other nutrition professional reviews the health
and nutrition questionnaires and medical data and determines the risk
factors and whether the applicant is eligible to participate. Nutrition
information is provided which is specific to each participant's risk,
follow-up visits are planned, and referrals are made.
Participants pick up food drafts every 1,2, or 3 months and purchase the
nutritious foods at WIC authorized stores. The participants are recertified
every six months to determine whether they are still eligible to
participate.
The food draft pick-up appointment is a very important point of contact for
WIC participants. This is when they receive additional nutrition
information, follow up on high risk factors, and can have access to other
available services within the agency, for example, immunizations and lead
screening follow-up.
5. IS WIC EFFECTIVE?
There are numerous local, state and federal evaluations of the WIC Program
which document the benefits of the program. These studies found that WIC
participation was associated with an improved outcome of pregnancy,
including reduction in late fetal death rates, increased head size of
infants, longer pregnancies and fewer premature births, and increases in
the number of women seeking prenatal care early in pregnancy. With respect
to children, the report shows that:
o WIC participation leads to better cognitive performance of four and
five year olds.
HMO Contract for January 1, 2002 - December 31, 2003
-204-
o Children participating in WIC are better immunized and more likely to
have a regular source of medical care.
o WIC has a major impact on reducing anemia among children.
Other research shows WIC to be cost-effective. In May 1992, a General
Accounting Office (GAO) study was released showing that the provision of
WIC benefits to pregnant women has a cost-benefit ratio of approximately
3:1. According to GAO, providing WIC benefits to pregnant women has
resulted in a 25 percent reduction in the incidence of low birthweight
babies and a reduction of 44 percent in "very low birthweight" babies (<3.3
pounds). Nine previous studies that examined Medicaid payments to WIC
families showed cost-benefit ratios of $1.92 to $4.21 for every dollar
spent.
Wisconsin data also indicates that WIC benefits provided to pregnant women
has a positive impact on the outcome of pregnancy. The incidence of low
birthweight (<5.5 pounds) decreases the longer the pregnant mother is
enrolled in WIC.
<Table>
<Caption>
10/97, WIC 814 0 months 1-3 mo 4-6 mo 7-8 mo
-------------- -------- ------ ------ ------
Birthweight
< 5.5 lbs 10.1% 8.9 8.3 4.4
> 5.5 lbs 89.9 91.1 91.7 95.6
</Table>
Enclosures:
o WIC Outreach Brochure (also available in Spanish and Hmong)
o Health Care Providers and Wisconsin WIC brochure
HMO Contract for January 1, 2002 - December 31, 2003
-205-
ADDENDUM XXVII
STATEWIDE LIST OF LOCAL WIC AGENCIES
HMO Contract for January 1, 2002 - December 31, 2003
-206-
WISCONSIN WIC PROGRAM
PROJECT DIRECTORY
WISCONSIN WIC & FMNP PROGRAMS
CENTRAL OFFICE
(608) 266-9824
FAX: (608) 266-3125
1414 East Washington Avenue, Room 167
Madison, WI 53703-3043
WIC VENDOR MANAGEMENT SECTION
(608) 266-6912
FAX: (608) 266-1514
1 West Wilson Street
PO Box 309
Madison, WI 53701 MCH/WIC Hotline: 800-722-2295
PDA: 800-488-8799
<Table>
STATE WIC STAFF
PATTI H. HERRICK, RD, MPA, Director ................................................. 266-3821
CONNIE WELCH, MPH, RD, Nutrition Coordinator ........................................ 267-7320
VACANT, MCH Nutritionist/Breastfeeding Coordinator ..................................
DEBORAH GRENIER, RD, MPA, Program Operations Coordinator ............................ 266-2148
NANCY BROWN-JOYCE, Fiscal Manager ................................................... 261-6383
GLENN THOMPSON, DAISy Systems Manager ............................................... 267-2201
JUDY HOENISCH, Program Assistant .................................................... 261-6381
VI SCHOMBERG, Program Assistant ..................................................... 266-9824
JUDY ALLEN, Local Contracts/Farmers' Market Coordinator ............................. 261-8867
VENDOR MANAGEMENT SECTION
CHRIS MADSEN, RD, WIC Vendor Section Supervisor ..................................... 261-6382
DONNA DUSSO, Vendor Relations Manager ............................................... 261-9431
GREG MCNEELY, Compliance Manager .................................................... 266-3748
JANA STEINMETZ, JD, Monitoring & Food Center Coordinator ............................ 267-9002
SANDRA GAGLIANO, Program Assistant .................................................. 266-6912
VACANT, Milwaukee Vendor Coordinator ................................................
</Table>
-207-
FY `99 WISCONSIN WIC PROJECTS
[MAP]
-208-
DIVISION OF PUBLIC HEALTH
BUREAU OF FAMILY & COMMUNITY HEALTH
REGIONAL OFFICE STAFF
NORTHERN REGIONAL OFFICE
Public Health Nutrition Consultant
Paula Lickteig, RD (715) 365-2715
Projects-01,10,13,17,46,51
e-mail: lickpj@dhfs.state.wi.us
Barbara Pevytoe, RD (715) 365-2719
Projects-01,25,30,41,47,49
e-mail: pevytba@dhfs.state.wi.us
1853 North Stevens Street
Rhinelander, WI 54501
FAX: (715) 365-2705
SOUTHERN REGIONAL OFFICE
Public Health Nutrition Consultant
Dan Cash, RD MBA(608) 243-2353
Projects-07,21,32,38,53,54,57,67,71
e-mail: cashd@dhfs.state.wi.us
Terrell Brock, MPH, RD (608) 243-2368
e-mail: brockta@dhfs.state.wi.us 3518
Memorial Drive, Building 4
Madison, WI 53704
FAX: (608) 243-2365
SOUTHEASTERN REGIONAL OFFICE
Public Health Nutrition Consultant
Marilyn Bolton, RD (414) 227-5042
Projects-04,06,33,34,35,36,52,62,63
e-mail: boltoml@dhfs.state.wi.us
Sandra Poehlman, RD, MPH (414) 227-4795
Projects-05,15,29,37,40,64
e-mail: poehlse@dhfs.state.wi.us
819 North Sixth Street, Room
860 Milwaukee, WI 53203-1697
FAX: (414) 227-2010
WESTERN REGIONAL OFFICE
Public Health Nutrition Consultant
Linda Petersen, RD, MPH (715) 836-3826
Projects-16,18,22,24,26,56,60,69
e-mail: peterlj@dhfs.state.wi.us
JoAnn Wegenke, RD (715) 836-6689
Projects-09,20,23,28,31,39,48,58,59,68
e-mail: wegenjr@dhfs.state.wi.us
312 South Barstow Street, Suite 2
Eau Claire, WI 54701-3679
FAX: (715) 836-6686
NORTHEASTERN REGIONAL OFFICE
Public Health Nutrition Consultant
Diane Moreau-Stodola, MS, RD (920) 448-5228
Projects-11,12,14,19,42,45,50,65
e-mail: moreadm@dhfs.state.wi.us
Mary Silha, RD (920) 448-0113
Projects-02,03,08,27,43,44,61,66
e-mail: silhamj@dhfs.state.wi.us
Nutrition Surveillance
Linda Spaans-Esten (920) 448-5346
e-mail: spaanln@dhfs.state.wi.us
200 North Jefferson Street, Room 126
Green Bay, WI 54301
FAX: (920) 448-5265
HMO Contract for January 1, 2000 - December 31, 2001
-209-
State WIC Staff
Areas of Responsibility
WHO SHOULD I CALL?
ADMINISTRATION AND NUTRITION
FIRST POINT OF CONTACT:
REGIONAL NUTRITION CONSULTANTS/CONTRACT ADMINISTRATORS
WIC and other MCH nutrition (Gladys Kubitz is
the back-up for non-WIC nutrition)
Program operations
Training and consultation
Performance review
Budget revisions
Fiscal management
Equipment requests
Workplans
Caseload Management, Deviations in caseload counts
Contract Administration
Site Description Chart revisions
Clinic Activities/Responsibilities
Chart revisions
Back-up: State WIC Office Staff
ADMINISTRATION / OPERATIONS
PATTI HERRICK: DIRECTOR
Phone 608/266-3821
e-mail: herriph@dhfs.state.wi.us
Funding
National issues
Service area issues
Other miscellaneous issues and concerns
Immunization coordination
Back-up: Nancy Brown-Joyce, Deb Grenier
DEB GRENIER: PROGRAM OPERATIONS COORDINATOR
Phone: 608/266-2148
e-mail: grenidm@dhfs.state.wi.us
Program operations, policies and procedures
Staffing patterns, Time Studies
Caseload, Caseload mgmt, participation counts
Outreach
Draft issuance policies
Accessibility
ADP reports
Questionable Issuance
Dual Participation
Enrollment and Participation (801)
Other management reports
Infant Formula Samples
Back-up: Patti Herrick
NANCY BROWN JOYCE: FISCAL MANAGER
Phone: 608/261-6383
e-mail: brownnj@dhfs.state.wi.us
Fiscal management
Allowable expenditures
Local Salary information
ADP/Rebate Contracts
Back-up: Patti Herrick
JUDY ALLEN: ADMINISTRATIVE ASSISTANT/FARMERS' MARKET COORDINATOR
Phone: 608/261-8867
e-mail: allenjl@dhfs.state.wi.us
Contract amendments and budget revisions
Farmers' Market Nutrition Program
HMO Contract for January 1, 2000 - December 31, 2001
-210-
NUTRITION SERVICES
CONNIE WELCH: NUTRITION COORDINATOR
Phone: 608/267-7320
e-mail: welchcl@dhfs.state.wi.us
Nutrition Services:
Certification; eligibility determination
Secondary nutrition education,
scheduling, evaluation
Model Nutrition Services
Care Guidelines
Risk Factors/Flow Sheets
Risk Factor Rationale
Screening and assessment; tools
High risk
Confidentiality
Supplemental Foods
Authorized food list
Food packages
Draft messages
Infant formula questions and problems
Coordination with Other Programs
Birth to 3
HealthCheck
Nutrition Surveillance
ADP reports
Nutrition (excluding Breastfeeding)
Birthweight by Trimester
Secondary education
Food Package
Back-up: Regional Nutrition Consultant
HMO Contract for January 1, 2000 - December 31, 2001
-211-
VACANT: MCH & WIC BREASTFEEDING COORDINATOR
Phone: 608/267-3694
e-mail:
Breastfeeding promotion and support activities
MCH Nutrition and breastfeeding education materials, tools
ADP reports
Breastfeeding
Smoking and Drinking Behavior
Alcohol, Tobacco and Other Drug Abuse information and referral
Back-up: Gladys Kubitz, MCH Nutritionist
Phone: 608/266-2003, FAX: 608/267-3824
e-mail: kubitgk@dhfs.state.wi.us
LINDA SPAANS-ESTEN: NUTRITION SURVEILLANCE
Phone: 920/448-5346
e-mail: spaanln@dhfs.state.wi.us
MCH Data system
PNSS
Gladys Kubitz: MCH Nutrition Consultant
Phone: 608/266-2003
e-mail: kubitgk@dhfs.state.wi.us
MCH Nutrition
5-A-Day
FMNP Nutrition
DAISy
HMO Contract for January 1, 2000 - December 31, 2001
-212-
GLENN THOMPSON: WIC SYSTEM MANAGER
Phone: 608/267-2201
e-mail: thompge@dhfs.state.wi.us
PDA and the ADP system
DAISy support
DAISy enhancements
Mass changes
Creating and running special reports
WordPerfect, Word
QuattroPro, Excel
Computer purchase information
Back up: PDA
PDA HELPDESK:
Phone: 800/488-8799 X3922
DAISy support
Hardware problems; maintenance
JUDY HOENISCH: PROGRAM ASSISTANT
Phone: 608/261-6381
e-mail: hoenija@dhfs.state.wi.us
VI SCHOMBERG: PROGRAM ASSISTANT
Phone: 608/266-9824
e-mail: schomva@dhfs.state.wi.us
Forms and Publications (ordering and availability)
Project Directory (update and distribution)
Monthly Updates and other mailings
Equipment Inventory and stickers
Receptionist and phone messages for WIC staff
Caseload Status Reports
MAILING
Central WIC Office
Questionable Issuance Report - Deb
Dual Participation Report - Deb
Forms and Publications (DMS-25) - Vi, Judy
Equipment Inventory - Vi
Caseload Status Report - Vi
Computer purchase requests - Glenn
Vendor Management Section
Complaints regarding vendors - Greg
Vendor Monitoring Reports - Jana
Vendor site visit materials - Sandra
Proof of Training Affidavit - Sandra
Vendor supply orders - Sandra
Regional Offices - Regional Nutrition Consultants
Budget revisions
Equipment requests
Site Description Chart revisions
Clinic Activities/Responsibilities Chart revisions
HMO Contract for January 1, 2000 - December 31, 2001
-213-
VENDOR RELATIONS
CHRIS MADSEN: WIC VENDOR SECTION CHIEF
Phone: 608/261-6382
e-mail: madseca@dhfs.state.wi.us
Vendor Section Supervision
Administrative Rules
Miscellaneous Issues & Concerns
Back-up: Donna Dusso
DONNA DUSSO: VENDOR RELATIONS MANAGER
Phone: 608/261-9431
e-mail: dussodm@dhfs.state.wi.us
Vendor management, policies and procedures
Vendor authorization and reauthorization process
Vendor training
Replacements for drafts rejected to vendors
Vendor reports Draft status or look-up
Back-up: Chris Madsen
GREG MCNEELY: COMPLIANCE MANAGER
Phone: 608/266-3748
e-mail: mcneegt@dhfs.state.wi.us
Vendor fraud and abuse, policies and procedures
Vendor complaints
Vendor Training
Back-up: Chris Madsen
JANA STEINMETZ: MONITORING COORDINATOR
Phone: 608/267-9002
e-mail: steinjd@dhfs.state.wi.us
Participant fraud and abuse
Lost/Stolen Drafts
Food package/draft redemption amount for repayment purposes
Vendor monitoring
Back-up: Chris Madsen
SANDRA GAGLIANO: VENDOR PROGRAM ASSISTANT
Phone: 608/266-6912
e-mail: gaglisl@dhfs.state.wi.us
Vendor applications (request, information,
status)
Vendor supplies
Vendor status
Back-up: Donna Dusso
VACANT: MILWAUKEE VENDOR COORDINATOR
Phone:
Site visits & Vendor monitoring, Milwaukee County vendors
Vendor questions, Milwaukee County vendors
Vendor Training
Back-up: Greg McNeely (compliance issues)
Donna Dusso (vendor issues)
HMO Contract for January 1, 2000 - December 31, 2001
-214-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
01 1130 Great Lakes Inter-Tribal Council, Inc. Bad River A. Elaine Valliere
WIC Project Lac du Flambeau B. Paula Havisto
2932 Hwy 47 North Lac Courte Oreilles C. Michael Allen
P.O. Box 9 Mole Lake D. Paula Havisto
Lac du Flambeau, WI 54538 Potawatomi-Forest County E. Elaine Valliere
Red Cliff F. Elaine Valliere
(715) 588-3324 FAX: (715) 588-7900 St. Croix G. Paula Lickteig/Barbara Pevytoe
Stockbridge-Munsee
Ho Chunk
02 4260 Northeastern Wisconsin Community Clinic, LTD Brown County A. Judy Brose
East WIC Project B. Judy Brose
622 Bodart Way C. Bonnie Kuhr (920) 437-9773
Green Bay, WI 54301 F. Bonnie Kuhr
G. Mary Silha
(920) 437-8368 FAX: (920) 437-0984
D. Carol Evans
N.E.W. Community Clinic West E. Jamie North
610 South Broadway
Green Bay, WI 54303
(920) 431-0243 FAX: (920) 431-0248
e-mail: newcomm@netnet.net
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-215-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
03 520 Menominee Indian Tribe of WI Menominee County A. Scott Krueger
WIC Project B. Scott Krueger
P.O. Box 970 D. Deb Prijic
Keshena, WI 54135-0970 E. Scott Krueger
F. Karen Page
(715) 799-5444 FAX: (715) 799-3099 G. Mary Silha
C. Betty Jo Wozniak
Menominee Indian Tribe of WI
PO Box 910
Keshena, WI 54135
(715) 799-5154
e-mail: skruege2@mail.wiscnet.net
04 1515 Milwaukee Health Services, Inc Milwaukee County A. Nancy Castro
MLK-Heritage Health Center WIC Project B. Nancy Castro
2555 N. Dr. Martin Luther King Drive C. Zettie D. Page (Acting)
Milwaukee, WI 53212 D. Karen Miller
E.
(414) 372-9029 FAX: (414) 372-5758 F. Nancy Castro
G. Marilyn Bolton
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-216-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
05 2120 Waukesha Co Dept of Health & Human Services Waukesha County A. Merrie Baltramonas
WIC Project B. Merrie Baltramonas
615 W Moreland Boulevard C. Nancy Healy (414) 896-8433
Waukesha, WI 53188 D. Mary Callan
E. Merrie Baltramonas
(414) 896-8440 FAX: (414) 896-8387 F. Joyce Ernst/Lonnie Strasen
G. Sandra Poehlman
06 6295 Milwaukee Indian Health Board Inc. Milwaukee County A. Beth Sadowski
Rainbow Community Health Center B. Vacant
WIC Project C. Richard Grzybowski
2733 W. Wisconsin Ave., Suite 200 D. Beth Sadowski
Milwaukee, WI 53208 E. Beth Sadowski
F. Laurie Dye
(414) 931-8606 FAX: (414) 937-3065 G. Marilyn Bolton
Milwaukee Indian Health Board C. Richard Grzybowski
PO Box 04065
Milwaukee, WI 53204
(414) 389-3880 Ext: 126
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-217-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
07 970 Southwestern Wisconsin Community Action Crawford County A. Amy Graber
Program (SWCAP) Iowa County B. Amy Graber
WIC Project Lafayette County C. Richard Strand
149 North Iowa Street Richland County D. Amy Graber
Dodgeville, WI 53533 E. Amy Graber
F. Jody Kitelinger
(608) 935-2326 G. Dan Cash
STS 7-7963 FAX: (608) 935-2876
e-mail: swcap@mhtc.net
08 1310 La Clinica de los Campesinos, Inc. Adams County A. Lois Schmedeke
Family Health WIC Project Green Lake County B. Lois Schmedeke
P.O. Box 1440 Marquette County C. Ted Kay (920) 787-5514 x7101
400 S. Townline Road Waushara County D. Lois Schmedeke
Wautoma, WI 54982 Migrant Population E. Amy Mann
F. Aurora Grimm
(920) 787-1340 ext. 7107 G. Mary Silha
(920) 787-5514 FAX: (920) 787-2746
FAX: (920) 787-4737
e-mail: fhlc@wirural.net
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-218-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
09 2290 Northwest Wisconsin Community Service Ashland County A. Grace Gee
Agency, Inc (NWCSA), Bayfield County B. Grace Gee
WIC Project Douglas County D. Mary Mahan (Superior)
2231 Catlin Avenue Iron County E. Sandy Swanson (Ashland)
Superior, WI 54880 F. Sandy Swanson (Ashland)
G. JoAnn Wegenke
(715) 394-2750 (Superior)
(715) 682-6661 (Ashland)
FAX: (715) 394-7414 (Superior)
(0475 (Ashland)
NWCSA C. Richard Monson
1118 Tower Avenue
Superior, WI 54880
(715) 392-5127
10 495 Taylor County Health Department Taylor County A. Patty Krug
WIC Project B. Brenda Herrell
Courthouse C. Patty Krug
224 S Second Street D. Michele Armbrust
Medford, WI 54451 E. Brenda Herrell
F. Jacky Peterson
(715) 748-1410 FAX: (715) 748-1415 G. Paula Lickteig
e-mail: krug101w@wonder.em.cdc.gov
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-219-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
11 2130 Outagamie County Dept of Health & Human Serv Outagamie County A. Sue Kamien
WIC Project B. Sue Kamien
410 South Walnut Street D. Cindy Brylski
Appleton, WI 54911 E. Melissa Rentmeester
F. Neu Yang
(920) 832-5109 FAX: (920) 832-5110 G. Diane Moreau-Stodola
Outagamie County Health & Human Serv Dept
401 S Elm Street C. Barb Thiel, Acting Director
Appleton, WI 54911
(920) 832-5100
12 430 Oneida Tribe of Indians of Wisconsin Oneida Reservation A. Susan Beck
Community Health Center WIC Project B. Elizabeth Schwantes
P.O. Box 365 C. Deanna Bauman (920) 869-2711
Oneida, WI 54155 x4806
D. Susan Beck
(920) 869-4829 FAX: (920) 869-1077 E.
(920) 869-2711 ext 4829 F. Kelly Skenandore
G. Diane Moreau-Stodola
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-220-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
13 2850 Family Planning Health Services, Inc. Langlade County A. Kay Perkins
WIC Project Lincoln County B. Kay Perkins
719 North Third Avenue Marathon County C. Lon Newman (715) 675-9858
Wausau, WI 54401 D. Mary Fischer
E. Kay Perkins
(715) 675-5449 FAX: (715) 675-5475 F. Kay Perkins
e-mail: perk104w@wonder.em.cdc.gov G. Paula Lickteig
14 1685 Fond du Lac County Health Dept Fond du Lac County A. Colleen Deanovich
WIC Project B. Colleen Deanovich
160 South Macy Street C. Diane Cappozzo (920) 929-3093
Fond du Lac, WI 54935 D. Kathy Behlke
E. Cheryl Callis
(920) 929-3104 FAX: (920) 929-3102 F. Barb Roloff
G. Diane Moreau-Stodola
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-221-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
15 2915 Racine/Kenosha Community Action Agency Inc. Kenosha County A. Michael Lill
WIC Project B. Pamela Halbach
2000 63rd Street D. Pamela Halbach
Kenosha, WI 53143 E. Michael Lill
F. Michael Lill
(414) 657-0840 FAX: (414) 657-1631 G. Sandra Poehlman
e-mail: maxchaos@execpc.com
R/K Community Action Agency C. Thomas White
72 Seventh Street
Racine, WI 53403
(414) 637-8377
16 2255 La Crosse County Health Department La Crosse County A. Linda Lee
WIC Project B. Cheryl Levendoski
300 Fourth Street North C. Doug Mormann (608) 785-9807
La Crosse, WI 54601 D. Cheryl Levendoski
E. Linda Lee
(608) 785-9865 FAX: (608) 785-9846 F. Judy deBack
G. Linda Petersen
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-222-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
17 1030 Portage County Health & Human Services Dept Portage County A. Suzanne Oehlke
WIC Project B. Suzanne Oehlke
817 Whiting Avenue C. Judy Bablitch (715) 345-5700
Stevens Point, WI 54481 D. Rosemary Dobbe
E. Suzanne Oehlke
(715) 345-5775 FAX: (715) 345-5966 F. Cathy McCorkell
G. Paula Lickteig
18 510 Jackson County Dept of Health & Human Serv Jackson County A. Heidi Nighbor
WIC Project B. Amy Modjeski
420 Hwy 54 West C. Kevin Mannell
P.O. Box 457 D. Heidi Nighbor
Black River Falls, WI 54615 E. Heidi Nighbor
F. Diane Milnthorpe
(715) 284-4301 FAX: (715) 284-7713 G. Linda Petersen
e-mail: byrn100w@wonder.em.cdc.gov
19 460 Door County Public Health Dept Door County A. Teresa Pasewald
WIC Project B. Teresa Pasewald
421 Nebraska Street C. Rhonda Kolberg (920) 746-2234
P.O. Box 670 D. Teresa Pasewald
Sturgeon Bay, WI 54235 E. Patricia Gosser
F. Teresa Pasewald
(920) 746-2237 FAX: (920) 746-2320 G. Diane Moreau-Stodola
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-223-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
20 1030 Pepin County Health Dept Pepin County A. Anne Bauch
Pepin-Dunn WIC Project Dunn County B. Anne Bauch
740 7th Avenue West C. Sharon Prissel
P.O. Box 39 D. Anne Bauch
Durand, WI 54736 E. Anne Bauch
F. Cindy Holmstadt
(715) 672-5984 FAX: (715) 672-5920 G. JoAnn Wegenke
(888) 332-5768
e-mail: bies100w@wonder.em.cdc.gov
21 720 Juneau County Health Dept Juneau County A. Kris Willey
WIC Project B. Amy Podmolik
Courthouse Annex C. Barbara Theis (608) 847-9373
220 LaCrosse Street D. Teresa Field
Mauston, WI 53948-1395 E. Kris Willey
F. Jennifer Frosh
(608) 847-9375 FAX: (608) 847-9407 G. Dan Cash
e-mail: jccecii@mwt.net
22 1995 Eau Claire City-County Health Department Eau Claire County A. Cheryl Yarrington
WIC Project B. Cheryl Yarrington
720 Second Avenue C. James Ryder (715) 839-4718
Eau Claire, WI 54703 D. Cheryl Yarrington
E. Jackie Hawkenson
(715) 839-5051 FAX: (715) 839-1674 F. Sandy Nordlund
e-mail: yarr0415@wonder.em.cdc.gov G. Linda Petersen
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-224-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
23 1190 Chippewa County Department of Public Health Chippewa County A. Judy Fedie
WIC Project B. Judy Fedie
711 North Bridge Street, Room 222 C. Jean Durch
Chippewa Falls, WI 54729 D. Judy Fedie
E. Judy Culver
(715) 726-7903 FAX: (715) 726-7910 F. Deb Blum
e-mail: fedi100w@wonder.em.cdc.gov G. JoAnn Wegenke
24 835 Monroe County Health Department Monroe County A. Theresa Kleinertz
WIC Project B. Theresa Kleinertz
Community Service Bldg A C. Sharon Nelson (608) 269-8666
14301 Cty Hwy B Box 18 D. Rebecca Campbell
Sparta, WI 54656 E. Theresa Kleinertz
F. Theresa Kleinertz
(608) 269-8671 FAX: (608) 269-8872 G. Linda Petersen
25 515 Price County Health Dept Price County A. Vickie Petrashek
WIC Project B. Vickie Petrashek
104 South Eyder Avenue C. Mary Hahn
Phillips, WI 54555 D. Vickie Petrashek
E Laurie McKuen
(715) 339-3054 FAX: (715) 339-3057 F. Laurie McKuen
G. Barbara Pevytoe
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-225-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
26 750 Trempealeau County Health Dept Trempealeau County A. Joan Smedberg
WIC Project B. Ellen Blumer
36245 Main Street C. Eileen Gutknecht (ext 231)
P.O. Box 67 D. Ellen Blumer
Whitehall, WI 54773 E. Joan Smedberg
F. Tammie Coburn
(715) 538-2311, Ext. 233 G. Linda Petersen
FAX: (715) 538-4861
e-mail: nepe100w@wonder.em.cdc.gov
27 2005 Winnebago County Health Department Winnebago County A. Barbara Sheldon
WIC Project B. Barbara Sheldon
220 Washington Ave., P.O. Box 2808 D. Christine Possell
Oshkosh, WI 54901 E. Barbara Sheldon
F. Barbara Sheldon
(920) 236-4991 FAX: (920) 303-4792 G. Mary Silha
Winnebago County Health Department C. Susan Huelsbeck
725 Butler Ave., P.O. Box 68
Winnebago, WI 54985
(920) 232-3029
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-226-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
28 1140 Barron County Health Dept Barron County A. Marla Prytz
WIC Project B. Marla Prytz
1443 East Division Avenue C. Kathleen Newman (414) 741-3133
Barron, WI 54812 D. Marla Prytz
E. Shirley Glaser
(715) 537-6580 FAX: (715) 537-6274 F. Shirley Glaser
e-mail: pryt100w@wonder.em.cdc.gov G. JoAnn Wegenke
29 1175 Walworth County Public Health Nursing Serv Walworth County A. Patricia Grove
WIC Project B. Teresa Rutkowski
W3929 Highway NN C. Patricia Grove
P.O. Box 1006 D. Teresa Rutkowski
Elkhorn, WI 53121 E. Pat Grove
F. Kathleen Ludtke
(414) 741-3146 FAX: (414) 741-3757 G. Sandra Poehlman
e-mail: walcophn@elknet.net
30 285 Vilas County Health Services, Inc. Vilas County A. Phyllis Dicka
WIC Project B. Jennifer Mikulich
226 Highway 70 C. Phyllis Dicka
P.O. Box 456 D. Jennifer Mikulich
St. Germain, WI 54558 E. Phyllis Dicka
F. Nancy Minx
(715) 479-3357 FAX: None G. Barbara Pevytoe
e-mail: vicohlth@bfm.org
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-227-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
31 680 St. Croix County Dept of Health & Human Serv St. Croix County A. Melinda Hanson
WIC Project B. Ruth Lehmann
1445 North Fourth Street C. John Borup (715) 246-8223
New Richmond, WI 54017 D. Cindy Gulyash
E. Ellen Rominski
(715) 246-8359 FAX: (715) 246-8225 F. Shirley Peterson
e-mail: hans122w@wonder.em.cdc.gov G. JoAnn Wegenke
32 665 Columbia County Health Department Columbia County A. Linda Cromheecke
WIC Project B. Linda Cromheecke
711 East Cook Street C. Terry Kruse (608) 742-9250
Portage, WI 53901 D. Linda Cromheecke
E. Linda Cromheecke
(608) 742-9254 FAX: (608) 742-9759 F. Gail Benz
G. Dan Cash
33 475 Sinai Samaritan Medical Center Milwaukee County A. Jen Agnello
WIC Project B. Jen Agnello
945 N 12th Street, RE 120 C. William Jenkins (414) 219-7273
Milwaukee, WI 53233 D. Teri Kodrich
E.
(414) 219-3210 FAX: (414) 219-3123 F. Jen Agnello
G. Marilyn Bolton
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-228-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
34 790 West Allis Health Department City of West Allis A. Jennifer Vaclav
WIC Project B. Jennifer Vaclav
7120 West National Avenue C. Terry Brandenburg
West Allis, WI 53214 (414) 302-8637
D. Cheryl Davies
E. Jennifer Vaclav
(414) 302-8642 FAX: (414) 302-8628 F. Jennifer Vaclav
G. Marilyn Bolton
35 5485 Sixteenth Street Community Health Center Milwaukee County A. Sue Denman
WIC Project B. Diane Dankert
1337 South Cesar Chavez Drive C. John Bartkowski
Milwaukee, WI 53204 (414) 672-1315 x342
D. Sally Callan
E. Vacant
(414) 643-7554 FAX: (414) 643-1899 F. Lizbeth Garcia
e-mail: denman@sschc.org G. Marilyn Bolton
36 4870 Seeds of Health, Inc. Milwaukee County A. Marcia Spector
WIC Project (concentration on Hispanic B. Lisa Hanson
1445 S 32nd Street population), South Suburbs, C. Marcia Spector (414) 672-3364
Milwaukee, WI 53215 City of Wauwatosa D. Brenda Kalchbrenner/
Monica Janza
E. Lisa Hanson
(414) 672-3430 FAX: (414) 672-3845 F. Lisa Hanson
e-mail: mspector@execpc.com G. Marilyn Bolton
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-229-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
37 1200 Jefferson County Health Dept Jefferson County\ A. Ann Lynch
WIC Project All City of Watertown B. Vacant
N3995 Annex Road C. Gail Chamberlain(920) 674-7228
Jefferson, WI 53549 D. Vacant
E. Vacant
(920) 674-7275 FAX: (920) 674-7477 F. Terry Meloy
e-mail: cham100w@wonder.em.cdc.gov G. Sandra Poehlman
38 3755 Nutrition and Health Associates, Inc. Rock County A. Cathy Dean
Rock County WIC Project Green County B. Mary Pesik
32 East Racine Street C. Cathy Dean
Janesville, WI 53545 D. Mary Pesik
E. Bonnie Bohr
(608) 754-3722 FAX: (608) 754-3132 F. Mary Pesik
e-mail: nha@jvlnet.com G. Dan Cash
39 275 Buffalo County Dept of Health & Human Services Buffalo County A. Heather Repinski
WIC Project B. Claudia Cater
407 S 2nd Street C. Stuart Berg
PO Box 517 D. Claudia Cater
Alma, WI 54610 E. Heather Repinski
F. Barb Bauman
(608) 685-4412 FAX: (608) 685-3342 G. JoAnn Wegenke
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-230-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
40 2880 Health and Nutrition Service of Racine, Inc. Racine County A. Margie Carrington
WIC Project B. Kathy Bible
2316 Rapids Drive C. Margie Carrington
Racine, WI 53404 D. Tracy Steh
E. Rae Jean Vistain
(414) 637-7750 FAX: (414) 637-7926 F. Kathy Bible
G. Marilyn Bolton
41 685 Oneida County Health Department Oneida County A. Kathryne Sutliff
WIC Project B. Valerie Klave
Courthouse C. Kathryne Sutliff(715) 369-6111
P.O. Box 400 D. Debra Durchslag
Rhinelander, WI 54501 E. Valerie Klave
F. Debra Drake
(715) 369-6109 FAX: (715) 732-7646 G. Barbara Pevytoe
e-mail: sutl100w@wonder.em.cdc.gov
42 885 Marinette County Health Department Marinette County A. Mary Mursau
WIC Project B. Sherry Stender
2500 Hall Avenue, Suite C C. Robert Jarentowski
Marinette, WI 54143 (715) 732-7700
D. Sherry Stender
E. Sherry Stender
(715) 732-7670 FAX: (715) 732-7646 F. Sherry Stender
e-mail: murs101w@wonder.em.cdc.gov G. Diane Moreau-Stodola
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-231-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
43 800 Shawano County Health Department Shawano County A. Linda Waggoner
WIC Project B. Linda Waggoner
Courthouse C. Janet Lewellyn (715) 526-4805
311 North Main Street D. Linda Waggoner
Shawano, WI 54166 E. Susan Larson
F. Susan Larson
(715) 526-2822 FAX: (715) 524-5157 G. Mary Silha
(715) 526-3040
e-mail: lewe100w@wonder.em.cdc.gov
44 1520 Sheboygan County Health & Human Services Sheboygan County A. Jean Beinemann
WIC Project B. Laura Graney
1011 North Eighth Street C. Gary Johnson (920) 459-3213
Sheboygan, WI 53081 D. Marcia Beauchaine
E. Karin Gunderson
(920) 459-3417 FAX: (920) 459-4353 F. Karin Gunderson
e-mail: jmbeinem@sheboygan.wi.us G. Mary Silha
45 1210 Manitowoc County Health Department Manitowoc County A. Jeanne Gauthier
WIC Project B. Jeanne Gauthier
823 Washington Street C. James Blaha (920) 683-4453
Manitowoc, WI 54220 D. Barbara Redmer
E. Sandy Hollen
(920) 683-4526 FAX: (920) 683-4156 F. Sandy Hollen
G. Diane Moreau-Stodola
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-232-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
46 140 Florence County Health Dept Florence County A. Karen Wertanen
WIC Project B. Barbara Pevytoe
Courthouse, PO Box 17 C. Karen Wertanen
501 Lake Avenue D. Karen Wertanen
Florence, WI 54121 E. Karen Wertanen
F. Mary Jo Bomberg
(715) 528-4837 FAX: (715) 528-5269 G. Paula Lickteig
e-mail: wert101w@wonder.cdc.em.gov
47 225 Forest County Health Dept Forest County A. Linda Kortbein
WIC Project B. Vacant
Courthouse C. Linda Kortbein
200 E Madison Street D. Stephanie Mattson
Crandon, WI 54520 E. Lillie Erdmann
F. Anne Loduha
(715) 478-3371 FAX: (715) 478-5171 G. Barbara Pevytoe
48 350 Burnett County Health Department Burnett County A. Nancy Osterberg
WIC Project B. Nancy Osterberg
7410 County Road K, No. 114 C. Daniel Brown
Siren, WI 54872 D. Nancy Osterberg
E. Amy Erickson
(715) 349-2141 FAX: (715) 349-2140 F. Amy Erickson
e-mail: oste101w@wonder.em.cdc.gov G. JoAnn Wegenke
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-233-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
49 345 Sawyer County Health & Human Services Sawyer County A. Karla Arrigoni
WIC Project B. Karla Arrigoni
105 East Fourth Street C. Pat Harrington
PO Box 528 D. Karla Arrigoni
Hayward, WI 54843 E. Karla Arrigoni
F. Lois Downey
(715) 634-4874 FAX: (715) 634-3580 G. Barbara Pevytoe
50 600 Oconto County Department of Human Services WIC Oconto County A. Paulette Watermolen
Project B. Paulette Watermolen
501 Park Avenue C. Dennis Tomchek (920) 834-7000
Oconto, WI 54153 D. Paulette Watermolen
E. Paulette Watermolen
(920) 834-7072 FAX: (920) 834-6889 F. Paulette Watermolen
e-mail: konitde@co.oconto.wi.us G. Diane Moreau-Stodola
51 1210 Wood County Health Department Wood County A. Mary Arnold
WIC Project B. Connie Eisch
184 Second Street North C. Robert Newman (715) 421-8911
Wisconsin Rapids, WI 54494 D. Mary Arnold
E. Pam Killian
(715) 421-8950 FAX: (715) 421-8962 F. Pam Killian
G. Paula Lickteig
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-234-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
52 10260 City of Milwaukee Health Department City of Milwaukee C. Seth Foldy (414) 286-3521
WIC Project E. Clarice Hall Moore
841 North Broadway G. Marilyn Bolton
Milwaukee, WI 53202-3653
(414) 286-3616 FAX: (414) 286-8174
52-01 Isaac Coggs Community Health Center
WIC Project
2770 North Fifth Street
Milwaukee, WI 53212
(414) 286-8819 (Staff) FAX: (414) 286-2368
52-02 Johnston Community Health Center A. Clarice Hall Moore
WIC Project (414) 286-8804
1230 West Grant Street D. Bonnie Brower (414) 286-8820
Milwaukee, WI 53215 F. Shirley Newby (414) 286-8737
(414) 286-8805 (Staff)
52-03 Northwest Health Center B. Yvonne Greer (414) 286-3619
WIC Project
7630 West Mill Road
Milwaukee, WI 53218
(414) 286-8807 (Staff) FAX: (414) 286-5479
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-235-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
52-04 Keenan Health Center
WIC Project
3200 North 36th Street
Milwaukee, WI 53216
(414) 286-8803 (Staff) FAX: (414) 286-2112
53 2915 City of Madison/Madison Dept of Public Health City of Madison A. Janet Daniel
WIC Project B. Sue Marshall
2202 S Park Street D. Janet Daniel
Madison, WI 53713 E. Janet Daniel
F. Julann Esse/Kathy Boldt
(608) 267-1111 FAX: (608) 261-9606 G. Dan Cash
e-mail: jdaniel@ci.madison.wi.us
smarshall@ci.madison.wi.us
City of Madison/Madison Dept of Public Health C. Patricia Gadow
City-County Building Room 507
210 Martin Luther King Jr Blvd
Madison, WI 53710
(608) 266-4821
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-236-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
54 1885 Dane County Department of Human Dane County A. Laura Snyder
Services/Division of Public Health B. Carol Johnson-Hohol
WIC Project C. Gareth Johnson (608) 242-6511
1202 Northport Drive D. Laura Snyder
Madison, WI 53704 E. Laura Snyder
F. Barb Bailey
(608) 242-6525 FAX: (608) 242-6256 G. Dan Cash
56 415 Vernon County Health Department Vernon County A. Elizabeth Johnson
WIC Project B. Shyamala Ganesh
Rt 3, Hwy BB C. Elizabeth Johnson
PO Box 209 (608) 637-2233
Viroqua, WI 54665-0209 D. Janet Reed
E. Shyamala Ganesh
F. Shyamala Ganesh
(608) 637-6488 FAX: (608) 637-8750 G. Linda Petersen
e-mail: john125w@wonder.em.cdc.gov
57 1025 Sauk County Dept of Health Sauk County A. Linda Bormann
WIC Project B. Linda Bormann
505 Broadway C. Beverly Muhlenbeck
Baraboo, WI 53913 (608) 355-4300
D. Linda Bormann
E. Linda Bormann
(608) 355-4302 FAX: (608) 355-3469 F. Sonja Schyvinch
(608) 355-4320 G. Dan Cash
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-237-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
58 390 Washburn County Public Health/Home Care Washburn County A. Billie La Bumbard
WIC Project B. Sarah Fry
222 Oak Street C. Billie La Bumbard
Spooner, WI 54801 D. Sarah Fry
E. Sarah Fry
(715) 635-7616 FAX: (715) 635-6475 F. Cindy Duffy
e-mail: labu100w@wonder.em.cdc.gov G. JoAnn Wegenke
59 525 Rusk County Health Dept Rusk County A. Claudia Cater
WIC Project B. Claudia Cater
311 Miner Avenue East C. Kathleen Mai
Suite C220 D. Claudia Cater
Ladysmith, WI 54848 E. Audrey Tinder
F. Audrey Tinder
(715) 532-2177 FAX: (715) 532-2217 G. JoAnn Wegenke
60 580 Clark County Health Department Clark County A. Diane Roach
WIC Project B. Diane Roach
517 Court Street C. Cindy Woldt-Schmidt
Neillsville, WI 54456 (715) 743-5105
D. Diane Roach
E. Diane Roach
(715) 267-5001 FAX: (715) 267-5001 F. Bev Reynolds
G. Linda Petersen
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-238-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
61 295 Kewaunee County Public Health Dept Kewaunee County A. Lynn Drzewieski
WIC Project B. Lynn Drzewieski
510 Kilbourn Street C. Mary Halada (920) 388-7161
Kewaunee, WI 54216 D. Lynn Drzewieski
E. Lynn Drzewieski
(920) 388-7166 FAX: (920) 388-2122 F. Alisa Herrick
e-mail:kcpublichealth@itol.com G. Mary Silha
62 1250 Washington County Health Department Washington County A. Kimber Baars
Washington/Ozaukee WIC Project Ozaukee County B. Kimber Baars
333 East Washington Street, Suite 1100 C. Delores Harder (414) 335-4462
West Bend, WI 53095 D. Kimber Baars
E. Carol Frank
(414) 335-4466 (Washington) F. Jackie Henderleiter
(414) 284-8172 (Ozaukee) G. Marilyn Bolton
FAX: (414) 335-4705 (Washington)
e-mail: chnmichell@co.washington.wi.us
63 5650 Wee Care Day Care, Inc City of Milwaukee/ C. Nate Jefferson
WIC Project Central City North G. Marilyn Bolton
4355 N Richards St Suite 205
Milwaukee, WI 53212
(414) 964-9621 FAX: (414) 964-0683
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-239-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
63-01 Wee Care A. Ann White
3882 North Teutonia Avenue B. Jodi Klement
Milwaukee, WI 53206 D. Jodi Klement
E. Ann White
(414) 449-8460 FAX: (414) 449-8465 F. Sheila Lampley
e-mail: whiteam@aol.com
63-02 Wee Care F. Theresa Scott
5825 West Capitol Drive
Milwaukee, WI 53216
(414) 449-8470 FAX: (414) 449-8475
whiteam@aol.com
64 1430 Racine Health Department City of Racine A. Amy Brieske
WIC Project B. Amy Brieske
730 Washington Avenue C. Diane S Muri (414) 636-9495
Racine, WI 53403 D. Amy Brieske
E. Amy Brieske
(414) 636-9494 FAX: (414) 636-9504 F. Kris Nevarez
G. Sandra Poehlman
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-240-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
65 830 Waupaca County Dept of Hlth & Human Serv Waupaca County A. Gail Yest
WIC Project B. Gail Yest
Courthouse C. Barbara Black (715) 258-6385
811 Harding Street D. Gail Yest
Waupaca, WI 54981 E. Debbie Meidl
F. Debbie Meidl
(715) 258-6391 FAX: (715) 258-6409 G. Diane Moreau-Stodola
66 345 Calumet County Health Dept Calumet County A. Jennifer Colla
WIC Project B. Jennifer Colla
206 Court Street C. Rosemary Roy
Chilton, WI 53014 D. Barbara Schaefer
E. Jennifer Colla
(920) 849-1432 FAX: (920) 849-1476 F. Shari Holterman
e-mail: royl105w@wonder.em.cdc.gov G. Mary Silha
67 855 Dodge County Human Serv & Hlth Dept Dodge County A. Carol Schwab
WIC Project B. Kathy Campbell
143 East Center Street C. David Titus (920) 386-3534
Juneau, WI 53039 D. Carol Schwab
E. Kathy Campbel
(920) 386-3680 FAX: (920) 386-3533 F. Sharon Kok
e-mail: phndodge@globaldialog.com G. Dan Cash
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-241-
<Table>
<Caption>
A. PROJECT DIRECTOR
B. PROJECT NUTRITIONIST
C. AGENCY DIRECTOR
D. BREASTFEEDING COORDINATOR
E. VENDOR CONTACT
PROJ FY '99 AREA OR F. DAISY CONTACT PERSON
NO. CASELOAD PROJECT NAME POPULATION SERVED G. REGIONAL NUTRITIONIST
- ---- -------- ------------ ----------------- ----------------------------
68 610 Pierce County Public Health Pierce County A. Ann Rosenthal
WIC Project B. Diane H-Robinson
412 West Kinne Street, PO Box 238 C. Jane Bruggeman (715) 273-6755
Ellsworth, WI 54011 D. Ann Rosenthal
E. Mary Halls
(715) 273-6760 FAX: (715) 273-6854 F. Mary Halls
e-mail: rose101w@wonder.em.cdc.gov G. JoAnn Wegenke
69 835 Polk County Health Dept Polk County A. Andrea Seifert
WIC Project B. Andrea Seifert
300 Polk County Plaza, Suite 10 C. Gretchen Sampson
Balsam Lake, WI 54810 D. Andrea Seifert
E. Ardis Kelly
(715) 485-8520: (715) 485-8501 F. Ardis Kelly
e-mail: seif104w@wonder.em.cdc.gov G. Linda Petersen
71 1025 Grant County Health Dept Grant County A. Danielle Varney
WIC Project B. Danielle Varney
125 S Monroe Street C. Linda Adrian (608) 723-6416
Lancaster, WI 53813 D. Ann Jenkins
E. Charlotte Brandt
(608) 723-6758 FAX: (608) 723-6501 F. Kelly Stadele
e-mail: adrilw@wonder.em.cdc.gov G. Dan Cash
</Table>
HMO Contract for January 1, 2002 - December 31, 2003
-242-