EXHIBIT 10.26
CONTRACT BETWEEN
THE OFFICE OF MEDICAID POLICY AND PLANNING,
THE OFFICE OF THE CHILDREN'S HEALTH INSURANCE PROGRAM
AND
COORDINATED CARE CORPORATION INDIANA, INC
This Contract is made and entered into by and between the State of
Indiana (hereinafter "State" or "State of Indiana"), through the Office of
Medicaid Policy and Planning and the Office of Children's Health Insurance
Program (hereinafter "the Offices"), of the Indiana Family and Social Services
Administration, 402 West Washington Street, W382, Indianapolis, Indiana, and
Coordinated Care Corporation Indiana, Inc., doing business as Managed Health
Services, 1099 North Meridian, Suite 400, Indianapolis, Indiana 46204,
(hereinafter "Contractor").
WHEREAS, I.C. 12-15-30-1 and I.C. 12-17.6 authorize the Offices to
enter into contracts to assist in the administration of the Indiana Medicaid and
the Indiana Children's Health Insurance Program (CHIP), respectively;
WHEREAS, the State of Indiana desires to contract for services to
arrange for and to administer a risk-based managed care program (RBMC) for
certain Hoosier Healthwise enrollees in Packages A, B and C as procured through
BAA 01-28;
WHEREAS this Contract contains the payment rates under which the
Contractor shall be paid and that these rates have been determined to be
actuarially sound for risk contracts, in accordance with applicable law;
WHEREAS, the Contractor is willing and able to perform the desired
services for Hoosier Healthwise Packages A, B and C;
WHEREAS, the Family and Social Services Administration (FSSA) is
issuing new contract documents in lieu of renewal or amendment documents so that
FSSA may move its contract data into a single contract database. The original
contract was issued for the contract term starting January 1, 2001, through
December 31, 2002, and provided for a renewal clause, exercised at the option of
the State for two additional years. The State is hereby exercising this option
and renewing the contract.
THEREFORE, the parties to this Contract agree that the terms and
conditions specified below will apply to services in connection with this
contract, and such terms and conditions are as follows:
I. TERM AND RENEWAL OPTION
This Contract is effective from January 1, 2003 through December 31,
2004. In no event shall the term exceed December 31, 2004.
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II. DEFINITIONS
For the purposes of this contract, terms not defined herein shall be
defined as they are in the documents incorporated in and attached to this
document, subject to the order of precedence spelled out in Section V of this
document.
"Contract" means this document and all documents or standards incorporated
herein, expressly including but not limited to the following documents
appended hereto and listed in chronological order and to be given precedence
as described in Section V of this document, entitled "Order of Precedence":
Attachment 1 - BAA 01-28, released July 31, 2000;
Attachment 2 - Original contract (effective January 1, 2001);
Attachment 3 - First Amendment to the original contract
(effective April 1, 2002) and its associated
attachments; and
Any other documents, standards, laws, rules or regulations incorporated
by reference in the above materials, all of which are hereby
incorporated by reference.
"Covered Services" means all services required to be arranged, administered,
managed or provided by or on behalf of the Contractor under this contract.
"Effective Date of Enrollment" means:
o The first day of the birth month of a newborn that is
determined by the Offices to be an enrolled member;
o The fifteenth day of the current month for a member who has,
between the twenty-sixth day of the previous month and the
tenth day of the current month, been determined by the Offices
to be an enrolled member; and,
o The first day of the following month for a member who has,
between the eleventh day and the twenty-fifth day of a month,
been determined by the Offices to be an enrolled member.
"Enrolled Member", or "Enrollee", means a Hoosier Healthwise-eligible member who
is listed by the Offices on the enrollment rosters to receive covered services
from the Contractor or its subcontractors, employees, agents, or providers, as
of the Effective Date of Enrollment, under this contract.
"Provider" means a physician, hospital, home health agency or any other
institution, or health or other professional person or entity, which
participates in the provision of services to an enrolled member under BAA 01-28,
whether as an independent contractor, a subcontractor, employee, or agent of the
Contractor.
"Broad Agency Announcement", or "BAA", means BAA 01-28 for providers of managed
care services, released July 31, 2000.
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III. DUTIES OF THE CONTRACTOR
A. The Contractor agrees to assume financial risk for developing and
managing a health care delivery system and for arranging or
administering all Hoosier Healthwise covered services except, as set
out in section 3.4.3 of the BAA, dental care, long-term institutional
care, services provided as part of an individualized education plan
(IEP) pursuant to the Individuals with Disabilities Education Act
(IDEA) at 20 U.S.C. 1400 et seq., behavioral health, and hospice
services, in exchange for a per-enrollee, per-month fixed fee, to
certain enrollees in Hoosier Healthwise Packages A, B and C. Wards of
the State, foster children and children receiving adoption assistance
may enroll on a voluntary basis and will not be subject to
auto-assignment into the Hoosier Healthwise program. The Contractor
must, at a minimum, furnish covered services up to the limits specified
by the Medicaid and CHIP programs. The Contractor may exceed these
limits. However, in no instance may any covered service's limitations
be more restrictive than those which exist in the Indiana Medicaid
fee-for-service program for Packages A and B, and the Children's Health
Insurance Program for Package C.
B. The Contractor agrees to perform all duties and arrange and administer
the provision of all services as set out herein and contained in the
BAA as attached and the Contractor's responses to the BAA as attached,
all of which are incorporated into this Contract by reference. In
addition, the Contractor shall comply with all policies and procedures
defined in any bulletin, manual, or handbook yet to be distributed by
the State or its agents insofar as those policies and procedures
provide further clarification and are no more restrictive than any
policies and procedures contained in the BAA and any amendments to the
BAA. The Contractor agrees to comply with all pertinent state and
federal statutes and regulations in effect throughout the duration of
this Contract and as they may be amended from time to time.
C. The Contractor agrees that it will not discriminate against individuals
eligible to be covered under this Contract on the basis of health
status or need for health services; and the Contractor may not
terminate an enrollee's enrollment, or act to encourage an enrollee to
terminate his/her enrollment, because of an adverse change in the
enrollee's health. The disenrollment function will be carried out by a
State contractor who is independent of the Contractor; therefore, any
request to terminate an enrollee's enrollment must be approved by the
Offices.
D. The Contractor agrees that no services or duties owed by the Contractor
under this Contract will be performed or provided by any person or
entity other than the Contractor, except as contained in written
subcontracts or other legally binding agreements. Prior to entering
into any such subcontract or other legally binding agreement, the
Contractor shall, in each case, submit the proposed subcontract or
other legally binding agreement to the Offices for prior review and
approval. Prior review and approval of a subcontract or legally binding
agreement shall not be unreasonably delayed by the Offices. The Offices
shall, in appropriate cases and as requested by the Contractor,
expedite the review and approval process. Under no circumstances shall
MCO Renewel Contract Page 3 of 27 Managed Health Services
the Contractor be deemed to have breached its obligations under this
Contract if such breach was a result of the Offices' failure to review
and approve timely any proposed subcontract or other legally binding
agreement. If the Offices disapprove any proposed subcontract or other
legally binding agreement, the Offices shall state with reasonable
particularity the basis for such disapproval. No subcontract into which
the Contractor enters with respect to performance under this Contract
shall in any way relieve the Contractor of any responsibility for the
performance of duties under this Contract. All subcontracts and
amendments thereto executed by the Contractor under this Contract must
meet the following requirements; any existing subcontracts or legally
binding agreements which fail to meet the following requirements shall
be revised to include the requirements within ninety (90) days from the
effective date of this Contract:
1. Be in writing and specify the functions of the subcontractor.
2. Be legally binding agreements.
3. Specify the amount, duration and scope of services to be
provided by the subcontractor.
4. Provide that the Offices may evaluate, through inspection or
other means, the quality, appropriateness, and timeliness of
services performed.
5. Provide for inspections of any records pertinent to the
contract by the Offices.
6. Require an adequate record system to be maintained for
recording services, charges, dates and all other commonly
accepted information elements for services rendered to
recipients under the contract.
7. Provide for the participation of the Contractor and
subcontractor in any internal and external quality assurance,
utilization review, peer review, and grievance procedures
established by the Contractor, in conjunction with the
Offices.
8. Provide that the subcontractor indemnify and hold harmless the
State of Indiana, its officers, and employees from all claims
and suits, including court costs, attorney's fees, and other
expenses, brought because of injuries or damage received or
sustained by any person, persons, or property that is caused
by any act or omission of the Contractor and/or the
subcontractors. The State shall not provide such
indemnification to the subcontractor.
9. Identify and incorporate the applicable terms of this Contract
and any incorporated documents. The subcontract shall provide
that the subcontractor agrees to perform duties under the
subcontract, as those duties pertain to enrollees, in
accordance with the applicable terms and conditions set out in
this Contract, any incorporated documents, and all applicable
state and federal laws, as amended.
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E. The Contractor agrees that, during the term of this Contract, it shall
maintain, with any innetwork provider rendering health care services
under the BAA, provider service agreements which meet the following
requirements:
1. Identify and incorporate the applicable terms of this Contract
and any incorporated documents. Under the terms of the
provider services agreement, the provider shall agree that the
applicable terms and conditions set out in this Contract, any
incorporated documents, and all applicable state and federal
laws, as amended, govern the duties and responsibilities of
the provider with regard to the provision of services to
enrollees.
2. Reference a written provider claim resolution procedure as set
out in section III.Q. below.
F. The Contractor agrees that all laboratory testing sites providing
services under this Contract must have a valid Clinical Laboratory
Improvement Amendments (CLIA) certificate and comply with the CLIA
regulations at 42 C.F.R. Part 493.
G. The Contractor agrees that it shall:
1. Retain, at all times during the period of this Contract, a
valid Certificate of Authority under applicable State laws
issued by the State of Indiana Department of Insurance.
2. Ensure that, during the term of this Contract, each provider
rendering health care services under the BAA is authorized to
do so in accordance with the following:
a. The provider must maintain a current Indiana Health
Coverage Programs (IHCP) provider agreement and must
be duly licensed in accordance with the appropriate
state licensing board and shall remain in good
standing with said board.
b. If a provider is not authorized to provide such
services under a current IHCP provider agreement or
is no longer licensed by said board, the Contractor
is obligated to terminate its contractual
relationship authorizing or requiring such provider
to provide services under the BAA. The Contractor
must terminate its contractual relationship with the
provider as soon as the Contractor has knowledge of
the termination of the provider's license or the IHCP
provider agreement.
3. Comply with the specific requirements for Health Maintenance
Organizations (HMOs) eligible to receive Federal Financial
Participation (FFP) under Medicaid, as listed in the State
Organization and General Administration Chapter of the Health
Care Financing Administration (HCFA) Medicaid Manual. These
requirements include, but are not limited to the following:
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a. The Contractor shall meet the definition of HMO as
specified in the Indiana State Medicaid Plan.
b. Throughout the duration of this Contract, the
Contractor shall satisfy the Chicago Regional Office
of the Centers for Medicare and Medicaid Services
(hereinafter called CMS) that the Contractor is
compliant with the Federal requirements for
protection against insolvency pursuant to 42 CFR
434.20(c)(3) and 434.50(a), the requirement that the
Contractor shall continue to provide services to
Contractor enrollees until the end of the month in
which insolvency has occurred, and the requirement
that the Contractor shall continue to provide
inpatient services until the date of discharge for an
enrollee who is institutionalized when insolvency
occurs. The Contractor shall meet this requirement by
posting a performance bond pursuant to Section VII,
paragraph C, of this Contract, and satisfying the
statutory reserve requirements of the Indiana
Department of Insurance.
c. The Contractor shall comply with, and shall exclude
from participation as either a provider or
subcontractor of the Contractor, any entity or person
that has been excluded under the authority of
Sections 1124A, 1128 or 1128A of the Social Security
Act or does not comply with the requirements of
Section 1128(b) of the Social Security Act.
d. In the event that the CMS determines that the
Contractor has violated any of the provisions of 42
CFR 434.67(a), CMS may deny payment of FFP for new
enrollees of the HMO under 42 USC 1396b(m)(5)(B)(ii).
The Offices shall automatically deny State payment
for new enrollees whenever, and for so long as,
Federal payment for such enrollees has been denied.
H. The Contractor shall submit proof, satisfactory to the Offices, of
indemnification of the Contractor by the Contractor's parent
corporation, if applicable, and by all of its subcontractors.
I. The Contractor shall submit proof, satisfactory to the Offices, that
all subcontractors will hold the State harmless from liability under
the subcontract. This assurance in no way relieves the Contractor of
any responsibilities under the BAA or this Contract.
K. The Contractor shall establish and maintain a quality improvement
program that meets the requirements of 42 CFR 434.34, as well as other
specific requirements set forth in the BAA. The Offices and the CMS may
evaluate, through inspection or other means, including but not limited
to, the review of the quality assurance reports required under this
Contract, and the quality, appropriateness, and timeliness of services
performed under this Contract. The Contractor agrees to participate and
cooperate, as directed by the Offices, in the annual external quality
review of the services furnished by the Contractor.
Annual HEDIS rates must be submitted in a manner and timeline
established by the Office, including but not limited, to HEDIS rates
that have been audited by a HEDIS-certified audit firm within 30 days
of receiving their final audit report. The HEDIS rates which have
MCO Renewel Contract Page 6 of 27 Managed Health Services
completed the certified audit may be submitted for 2003 HEDIS rates,
but must be submitted for 2004 HEDIS rates and all other HEDIS rates in
the future.
L. In accordance with 42 CFR 434.28, the Contractor agrees that it and any
of its subcontractors shall comply with the requirements, if
applicable, of 42 CFR 489, Subpart I, relating to maintaining and
distributing written policies and procedures respecting advance
directives. The Contractor shall distribute policies and procedures to
adult individuals during the enrollee enrollment process and whenever
there are revisions to these policies and procedures. The Contractor
shall make available for inspection, upon reasonable notice and request
by the Offices, documentation concerning its written policies,
procedures and distribution of such written procedures to enrollees.
M. Pursuant to 42 C.F.R. 417.479(a), the Contractor agrees that no
specific payment can be made directly or indirectly under a physician
incentive plan to a physician or physician group as an inducement to
reduce or limit medically necessary services furnished to an individual
enrollee. The Contractor must disclose to the State the information on
provider incentive plans listed in 42 C.F.R. 417.479(h)(1) and
417.479(i) at the times indicated at 42 C.F.R. 434.70(a)(3), in order
to determine whether the incentive plan meets the requirements of 42
C.F.R. 417(d)-(g). The Contractor must provide the capitation data
required under paragraph (h)(1)(vi) for the previous calendar year to
the State by application/contract renewal of each year. The Contractor
will provide the information on its physician incentive plan(s) listed
in 42 C.F.R. 417.479(h)(3) to any enrollee upon request.
N. The Contractor must not prohibit or restrict a health care professional
from advising an enrollee about his/her health status, medical care, or
treatment, regardless of whether benefits for such care are provided
under this Contract, if the professional is acting within the lawful
scope of practice. However, this provision does not require the
Contractor to provide coverage of a counseling or referral service if
the Contractor objects to the service on moral or religious grounds and
makes available information on its policies to potential enrollees and
enrollees within ninety (90) days after the date the Contractor adopts
a change in policy regarding such counseling or referral service.
O. In accordance with 42 U.S.C.ss. 1396u-2(b)(6), the Contractor agrees
that an enrollee may not be held liable for the following:
1. Debts of the Contractor, or its subcontractors, in the event
of any organization's insolvency;
2. Services provided to the enrollee in the event the Contractor
fails to receive payment from the Offices for such services or
in the event a provider fails to receive payment from the
Contractor or Offices; or
3. Payments made to a provider in excess of the amount that would
be owed by the enrollee if the Contractor had directly
provided the services.
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P. The Offices may from time to time request and the Contractor, and all
of its subcontractors, agree that the Contractor, or its
subcontractors, shall prepare and submit additional compilations and
reports as requested by the Offices. Such requests will be limited to
situations in which the desired data is considered essential and cannot
be obtained through existing Contractor reports. The Contractor, and
all of its subcontractors, agree that a response to the request shall
be submitted within thirty (30) days from the date of the request, or
by the Offices' requested completion date, whichever is earliest. The
response shall include the additional compilations and reports as
requested, or the status of the requested information and an expected
completion date. When such requests pertain to legislative inquiries or
expedited inquiries from the Office of the Governor, the additional
compilations and reports shall be submitted by the Offices' requested
completion date. Failure by the Contractor, or its subcontractors, to
comply with response time frames shall be considered grounds for the
Offices to pursue the provisions outlined in Section 3.16.5 of the BAA.
In the event that delays in submissions are a consequence of a delay by
the Offices or the Medicaid Fiscal Agent, the time frame for submission
shall be extended by the length of time of the delay.
Q. The Contractor shall establish a written claim resolution procedure
applicable to both in-network and out-of-network providers which shall
be distributed to all in-network providers and shall be available to
out-of-network providers upon request. The Contractor shall negotiate
the terms of a written claim resolution procedure with in-network
providers individually; but if the Contractor and an in-network
provider are unable to reach agreement on the terms of such procedure,
the out-of-network provider claims resolution procedure approved by the
Offices under this section shall govern the resolution of such
in-network provider's claims with the Contractor.
1. A statement noting that providers objecting to determinations
involving their claims will be provided due process through
the Contractor's claim resolution procedure.
2. A description of both the informal and formal claim resolution
procedures that will be available to resolve a provider's
objection to a determination involving the provider's claim.
3. An informal claim resolution procedure which:
a. shall be available for the resolution of claims
submitted to the Contractor by the provider within
120 days after the date on which services were
rendered;
b. shall precede the formal claim resolution procedure;
c. shall be used to resolve a provider's objection to a
determination by the Contractor involving the
provider's claim, including a provider's objection
to:
(1) any determination by the Contractor regarding
payment for a claim submitted by the provider,
including the amount of such payment; and
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(2) the Contractor's determination that a claim
submitted by the provider lacks sufficient supporting
information, records, or other materials;
d. may, at the election of a provider, be utilized to
determine the payment due for a claim in the event
the Contractor fails, within thirty (30) days after
the provider submits the claim, to notify the
provider of:
(1) its determination regarding payment for the
provider's claim; or
(2) its determination that the provider's claim
lacked sufficient supporting information, records, or
other materials;
e. shall be commenced by a provider submitting to the
Contractor:
(1) within sixty (60) days after the provider's
receipt of written notification of the Contractor's
determination regarding the provider's claim, the
provider's written objection to the Contractor's
determination and an explanation of the objection; or
(2) within sixty (60) days after the Contractor fails
to make a determination as described in subparagraph
(d), a written notice of the provider's election to
utilize the informal claims resolution procedure
under subparagraph (d) above;
f. shall allow providers and the Contractor to make
verbal inquiries and to otherwise informally
undertake to resolve the matter submitted for
resolution by the provider.
4. In the event the matter submitted for informal resolution is
not resolved to the provider's satisfaction within thirty (30)
days after the provider commenced the informal claim
resolution procedure, the provider shall have sixty (60) days
from that point to submit to the Contractor written
notification of the provider's election to submit the matter
to the formal claim resolution procedure. The provider's
notice must specify the basis of the provider's dispute with
the Contractor. The Contractor's receipt of the provider's
written notice shall commence the formal claim resolution
procedure.
5. The formal claim resolution procedure shall be conducted by a
panel of one (1) or more individuals selected by the
Contractor. Each panel must be knowledgeable about the policy,
legal, and clinical issues involved in the matter that is the
subject of the formal claim resolution procedure. An
individual who has been involved in any previous consideration
of the matter by the Contractor may not serve on the panel.
The Contractor's medical director, or another licensed
physician designated by the medical director, shall serve as a
consultant to the panel in the event the matter involves a
question of medical necessity or medical appropriateness.
6. The panel shall consider all information and material
submitted to it by the provider that bears directly upon an
issue involved in the matter that is the subject of the formal
MCO Renewel Contract Page 9 of 27 Managed Health Services
claim resolution procedure. The panel shall allow the provider
an opportunity to appear in person before the panel, or to
communicate with the panel through appropriate other means if
the provider is unable to appear in person, and question the
panel in regard to issues involved in the matter. The provider
shall not be required to be represented by an attorney for
purposes of the formal claim review procedure.
7. Within forty-five (45) days after the commencement of the
formal claim resolution procedure, the panel shall deliver to
the provider the panel's written determination of the matter
before it. Such determination shall be the Contractor's final
position in regard to the matter. The written determination
shall include, as applicable, a detailed explanation of the
factual, legal, policy and clinical basis of the panel's
determination.
8. In the event the panel fails to deliver to the provider the
panel's written determination within forty-five (45) days
after the after the commencement of the formal claim
resolution procedure, such failure on the part of the panel
shall have the effect of a denial by the panel of the
provider's claim.
9. The panel's written determination shall include notice to the
provider of the provider's right, within sixty (60) days after
the provider's receipt of the panel's written determination,
to submit to binding arbitration the matter that was the
subject of the formal claim resolution procedure. The provider
shall also have the right to submit the matter to binding
arbitration if the panel has failed to deliver its written
determination to the provider within the required forty-five
(45) day period.
10. Any procedure involving binding arbitration must be conducted
in accordance with the rules and regulations of the American
Health Lawyers Association (AHLA), pursuant to the Uniform
Arbitration Act as adopted in the State of Indiana at I.C.
34-57-2, unless the provider and Contractor mutually agree to
some other binding resolution procedure. However, any
Contractor and provider that are subject to statutorily
imposed arbitration procedures for the resolution of these
claims shall be required to follow the statutorily imposed
arbitration procedures, but only to the extent those
procedures differ from, or are irreconcilable with, the rules
and regulations of the American Health Lawyers Association
(AHLA), pursuant to the Uniform Arbitration Act as adopted in
the State of Indiana at I.C. 34-57-2.
11. A provider may, within the requisite sixty (60) day time
period, include in a single arbitration proceeding matters
from multiple formal claim resolution procedures involving the
Contractor and the provider.
12. For claims disputed under Paragraph 3. c. (2) above:
a. a claim that is finally determined through the
Contractor's claim resolution procedure (including
arbitration) not to lack sufficient supporting
documentation shall be processed by the Contractor
within thirty (30) days after such final
MCO Renewel Contract Page 10 of 27 Managed Health Services
determination. The processing of the claim and the
Contractor's determination involving the claim shall
be subject to Paragraph 3. c. and Paragraph 3. d. and
the Contractor's formal claim resolution procedure
and binding arbitration.
b. a claim that is finally determined through the
Contractor's claim resolution procedure (including
arbitration) to lack sufficient supporting
documentation shall be processed by the Contractor
within thirty (30) days after the provider submits to
the Contractor the requisite supporting
documentation. The provider shall have thirty (30)
days after written notice of the final determination
establishing that the claim lacked sufficient
supporting documentation is received by the provider
to submit the requisite supporting documentation. The
processing of the claim and the Contractor's
determination involving the claim shall be subject to
Paragraph 3. c. and Paragraph 3. d. and the
Contractor's formal claim resolution procedure and
binding arbitration.
13. A Contractor may not include in its claim resolution
procedures elements that restrict or diminish the claim review
procedures, time periods or subject matter provided for in
paragraphs 1 through l2 above.
14. A Contractor shall maintain a log of all informally and
formally filed provider objections to determinations involving
claims. The logged information shall include the provider's
name, date of objection, nature of the objection, and
disposition. The Contractor shall submit quarterly reports to
the Offices regarding the number and type of provider
objections.
R. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Section 3.6.1.3 of the BAA is amended
to require the Contractor to submit the "Mandatory RBMC Transition
Report" (Attachment A) according the schedule set out in the "2002
Hoosier Healthwise MCO Reporting Calendar for Mandatory RBMC Transition
Report" (Attachment B), unless the MCO has received written
notification from OMPP that the report, or certain data elements in the
report, is/are no longer required or may be reported less frequently.
Pursuant to the reporting calendar (Attachment B), the final submission
shall be due on January 6, 2003.
S. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Section 3.6.3 of the BAA is amended to
require the Contractor to obtain written approval of the State prior to
closing its provider networks, which shall not be unreasonably withheld
or delayed.
T. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Sections 3.6.6 and 3.6.7.3 of the BAA
are amended to require the Contractor to maintain a monthly telephone
abandonment rate equal to or less than five percent of calls received
each by the member helpline and provider helpline. The parties agree
that BAA Section 3.16 is amended to add a new section 3.16.8 to read as
follows:
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Section 3.16.8 The MCO will comply with the call abandonment
requirements for the member and provider helplines described in
Sections 3.6.6. and 3.6.7.3 of this BAA. Because actual damages caused
by non-compliance are not subject to exact determination, the State
will assess the MCO, as liquidated damages and not as a penalty, (a)
two hundred dollars ($200.00) for each business day the MCO fails to
submit required documentation to provide evidence of compliance with
this requirement, or (b) two thousand dollars ($2000.00) for each month
the MCO fails to meet the requirement after 2 consecutive months of
non-compliance on the member helpline or (c) two thousand dollars
($2000.00) for each month the MCO fails to meet the requirement after 2
consecutive months of non-compliance on the provider helpline.
U. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Section 3.5.3 of the BAA is amended to
allow OMPP to change, at OMPP's discretion, the frequency of the MCO
Enrollment Rosters generated by OMPP's fiscal agent to once per month,
upon reasonable and adequate prior written notice to the Contractor.
V. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, Section 3.6.3 of the BAA is amended to
require the Contractor to develop and adhere to a plan for identifying
and serving people with special needs. The plan must satisfy any
applicable federal requirements.
W. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the Contractor agrees to provide OMPP
with prior written notice at least ninety (90) days in advance of their
inability to maintain a sufficient Primary Medical Provider (PMP)
network in any of the counties where mandatory RBMC has been or will be
implemented, including Marion, Allen, Elkhart, St. Joseph, Lake,
Hamilton, and Vanderburgh Counties, such that the program would not be
able to maintain the appropriate member choice of two (2) MCOs,
pursuant to federal requirements.
X. In accordance with the First Amendment to the original contract between
the parties dated April 1, 2002, the Contractor agrees that agreements
with PMPs in mandatory counties shall comply with the following
requirements:
1. Any PMP agreements entered into on or after April 1, 2002,
shall include a provision allowing the PMP to terminate the
agreement for any reason upon written notice to the
Contractor. The Contractor may require that the physician
provide said notice to the Contractor up to ninety (90) days
prior to termination.
2. Any PMP agreements entered into before April 1, 2002, in which
the initial term, as defined in the agreement, will expire on
or after June 30, 2002, will be amended by July 1, 2002, to
allow the PMP to terminate the agreement for any reason upon
written notice to the Contractor. The Contractor may require
that the physician provide said notice to the Contractor up to
ninety (90) days prior to termination. The Contractor agrees
to notify these PMPs, by April 30, 2002, that their agreements
will be amended and that they may terminate the agreement upon
ninety (90) days written notice.
MCO Renewel Contract Page 12 of 27 Managed Health Services
3. Existing PMP agreements in which the initial term expired
before July 1, 2002, may be terminated by the PMP for any
reason upon one hundred twenty (120) days written notice to
the Contractor. The Contractor agrees to notify the PMPs whose
initial agreement term has expired that they may terminate the
agreement upon one hundred twenty (120) days written notice.
If an agreement described in this paragraph is amended for any
reason, the agreement shall include a provision allowing the
PMP to terminate the agreement for any reason upon written
notice to the Contractor. The Contractor may require that the
physician provide said notice to the Contractor up to ninety
(90) days prior to termination.
//The remainder of this page is intentionally left blank.//
MCO Renewel Contract Page 13 of 27 Managed Health Services
IV. PAYMENT
A. In consideration of the services to be performed by the Contractor, the
Offices agree to pay the Contractor the following amounts per month per
enrolled member as contained in the Offices' capitation payment listing
based upon the capitation rates by category and benefit package as
listed below:
--------------------------------------------------------------------------------------
2003 CAPITATION RATES
------------------------ -------------------------------- ----------------------------
CATEGORY PACKAGES A/B PACKAGE C
======================== ================================ ============================
NORTH REGION
======================== ================================ ============================
Newborns $345.03 $120.80
------------------------ -------------------------------- ----------------------------
Preschool $73.77 $77.43
------------------------ -------------------------------- ----------------------------
Children $60.75 $65.44
------------------------ -------------------------------- ----------------------------
Adolescents $92.44 $94.60
------------------------ -------------------------------- ----------------------------
Adult Males $255.16
------------------------ -------------------------------- ----------------------------
Adult Females $199.62
------------------------ -------------------------------- ----------------------------
Deliveries $3,380.41/delivery $3,393.54/delivery
======================== ================================ ============================
CENTRAL REGION
======================== ================================ ============================
Newborns $362.15 $119.28
------------------------ -------------------------------- ----------------------------
Preschool $77.43 $76.45
------------------------ -------------------------------- ----------------------------
Children $63.73 $64.62
------------------------ -------------------------------- ----------------------------
Adolescents $97.03 $93.42
------------------------ -------------------------------- ----------------------------
Adult Males $267.82
------------------------ -------------------------------- ----------------------------
Adult Females $209.53
------------------------ -------------------------------- ----------------------------
Deliveries $3,481.35/delivery $3,491.61/delivery
======================== ================================ ============================
SOUTH REGION
======================== ================================ ============================
Newborns $348.38 $116.83
------------------------ -------------------------------- ----------------------------
Preschool $74.48 $74.88
------------------------ -------------------------------- ----------------------------
Children $61.31 $63.29
------------------------ -------------------------------- ----------------------------
Adolescents $93.34 $91.49
------------------------ -------------------------------- ----------------------------
Adult Males $257.64
------------------------ -------------------------------- ----------------------------
Adult Females $201.56
------------------------ -------------------------------- ----------------------------
Deliveries $3,544.51/delivery $3,544.51/delivery
------------------------ -------------------------------- ----------------------------
B. The actuarial basis for computing the rates set forth above is as
follows: The capitation rates have been determined from historical
Hoosier Healthwise claim experience for the PCCM enrollees. The
historical experience has been adjusted to reflect anticipated trend in
the Hoosier Healthwise program, cost containment initiatives, morbidity
variations between the PCCM and RBMC enrollees, and anticipated managed
care utilization adjustments. The Offices may rely on self-report RBMC
experience to determine appropriate managed care utilization
adjustments and other morbidity variation adjustments.
C. The parties agree that the Offices have the option to adjust the
capitation rates annually. In the event that the Offices adjust the
fee-for-service (FFS) rates, the Offices may, in its sole discretion,
further adjust the capitation rates in accordance with the FFS
MCO Renewel Contract Page 14 of 27 Managed Health Services
adjustment. If the Offices made such an adjustment, it shall apply only
to the specific service component of the capitation rate that
corresponds to the FFS adjustment. Any capitation rates adjusted due to
a change in the FFS program may be further adjusted to ensure actuarial
soundness. All adjustments are subject to federal regulations for risk
contracts. Rates revised under this provision shall be implemented only
after a contract amendment is executed and approved.
D. All payment obligations of the Offices are subject to the encumbrance
of monies and shall be paid to the Contractor on the first Wednesday
after the fifteenth of the month.
E. The capitation payment will be prospective, based upon the number of
enrollees assigned to the Contractor as of the first of the month. The
Offices will establish an administrative procedure to allow retroactive
or other payment adjustments as necessary to implement this contract.
F. The Contractor will be provided a capitation payment listing which
includes a detailed listing of all enrollees for which the Contractor
is receiving a capitation payment.
G. It is understood and agreed upon by the parties that all obligations of
the State of Indiana are contingent upon the availability and continued
appropriation of State and Federal funds, and in no event shall the
State of Indiana be liable for any payments in excess of available
appropriated funds.
H. When the Director of the State Budget Agency makes a written
determination that funds are not appropriated or otherwise available to
support continuation of performance of this Contract, the Contract
shall be cancelled. A determination by the State Budget Director that
funds are not appropriated or otherwise available to support
continuation of performance shall be final and conclusive.
V. ORDER OF PRECEDENCE
Any inconsistency or ambiguity in this Contract shall be resolved by giving
precedence in the following order:
1) The express terms of this contract;
2) Attachment 1 - BAA 01-28, released July 31, 2000, and
Attachment 3 - First Amendment to the original contract,
effective April 1, 2002;
3) Attachment 2 - Contractor's response to the BAA;
4) Any other documents, standards, laws, rules or regulations
incorporated by reference in the above materials, all of which
are hereby incorporated by reference.
MCO Renewel Contract Page 15 of 27 Managed Health Services
VI. NOTICE
A. Whenever notice is required to be given to the other party, it shall be
made in writing and delivered to that party. Delivery shall be deemed
to have occurred if a signed receipt is obtained when delivered by hand
or according to the date on the return receipt if sent by certified
mail, return receipt requested. Notices shall be addressed as follows:
In case of notice to the Contractor: In case of notice to the Offices:
Rita Johnson-Mills, President John Barth, Managed Care Director
Managed Health Services Office of Medicaid Policy and Planning
1099 North Meridian, Suite 400 Family and Social Services Administration
Indianapolis, IN 46204 402 W. Washington St., IGCS W382, MS07
Indianapolis, Indiana 46204
B. Said notices shall become effective on the date of delivery or the date
specified within the notice, whichever comes later. Either party may
change its address for notification purposes by mailing a notice
stating the change and setting forth the new address.
VII. MISCELLANEOUS PROVISIONS
A. Entire Agreement. This Contract constitutes the entire agreement
between the parties with respect to the subject matter; all prior
agreements, representations, statements, negotiations, and undertakings
are superseded hereby.
B. Changes. Any changes to this Contract shall be by formal amendment of
this Contract signed by all parties required by Indiana law.
C. Termination. The Office may, without cause, cancel and terminate this
Contract in whole or in part upon sixty (60) days' prior written
notice. The Contractor will be reimbursed for services performed prior
to the date of termination consistent with the terms of the Contract.
The Office will not be liable for services performed after notice of
termination, but before the date of termination, without written
authorization from the Office. In no event will the Office be liable
for services performed after the termination date.
In the event that the Office requests that the Contractor perform any
additional services associated with the transition or turnover of the
contract, the Office agrees to pay reasonable costs for those
additional services specifically requested by the Office. Any
additional services and costs must receive prior approval in writing by
the Office.
D. Disputes. Should any disputes arise with respect to this Contract, the
Contractor and the State of Indiana agree to act immediately to resolve
any such disputes. Time is of the essence in the resolution of
disputes.
MCO Renewel Contract Page 16 of 27 Managed Health Services
The Contractor agrees that, the existence of a dispute notwithstanding,
it will continue without delay to carry out all of its responsibilities
under this Contract which are not affected by the dispute. Should the
Contractor fail to continue without delay to perform its
responsibilities under this Contract in the accomplishment of all
non-disputed work, any additional costs incurred by the Contractor or
the State of Indiana as a result of such failure to proceed shall be
borne by the Contractor, and the Contractor shall make no claim against
the State of Indiana for such costs. If the Contractor and the State of
Indiana cannot resolve a dispute within ten (10) working days following
notification in writing by either party of the existence of said
dispute, then the following procedure shall apply:
1. The parties agree to resolve such matters through submission
of their dispute to the Commissioner of the Indiana Department
of Administration who shall reduce a decision to writing and
mail or otherwise furnish a copy thereof to the Contractor and
the State of Indiana within ten (10) working days after
presentation of such dispute for decision. The Commissioner's
decision shall be final and conclusive unless either party
mails or otherwise furnishes to the Commissioner, within ten
(10) working days after receipt of the Commissioner's
decision, a written appeal. Within ten (10) working days of
receipt by the Commissioner of a written request for appeal,
the decision may be reconsidered. If no reconsideration is
provided within ten (10) working days the Contractor may
submit the dispute to an Indiana court of competent
jurisdiction.
2. The State of Indiana may withhold payments on disputed items
pending resolution of the dispute. The non-payment by the
State of Indiana to the Contractor of one or more invoices not
in dispute shall not constitute default, however, the
Contractor may bring suit to collect such monies without
following the disputes procedure contained herein.
E. Debarment and Suspension. Contractor certifies, by entering into this
agreement, that neither it nor its principals are presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from entering into this agreement by any federal agency or
department, agency or political subdivision of the State of Indiana.
The term "principal" for the purposes of this agreement is defined as
an officer, director, owner, partner, key employee, or other person
with primary management or supervisory responsibilities or a person who
has a critical influence on or substantive control over the operations
of the Contractor.
F. Compliance with Laws. The Contractor agrees to comply with all
applicable Federal, State, and local laws, rules, regulations, or
ordinances, and all provisions required thereby to be included herein
are hereby incorporated by reference. The enactment of any state or
federal statute or the promulgation of regulations thereunder after
execution of this Contract shall be reviewed by the State and the
Contractor to determine whether the provisions of the Contract require
formal modification.
MCO Renewel Contract Page 17 of 27 Managed Health Services
G. Indemnification. Contractor agrees to indemnify, defend, and hold
harmless the State of Indiana and its agents, officers, and employees
from all claims and suits including court costs, attorney's fees, and
other expenses caused by any act or omission of the Contractor and/or
its subcontractors, if any. The State shall not provide such
indemnification to the Contractor.
H. Nondiscrimination. Pursuant to IC 22-9-1-10 and the Civil Rights Act of
1964, Contractor and its subcontractors shall not discriminate against
any employee or applicant for employment in the performance of this
contract. The Contractor shall not discriminate with respect to the
hire, tenure, terms, conditions or privileges of employment or any
matter directly or indirectly related to employment, because of race,
color, religion, sex, disability, national origin or ancestry. Breach
of this covenant may be regarded as a material breach of contract.
Acceptance of this Contract also signifies compliance with applicable
federal laws, regulations, and executive orders prohibiting
discrimination in the provision of services based on race, color,
national origin, age, sex, disability, or status as a veteran. The
Contractor understands that the State is a recipient of federal funds.
Pursuant to that understanding, the Contractor and its subcontractor,
if any, agree that if the Contractor employs fifty (50) or more
employees and does at least fifty-thousand dollars ($50,000.00) worth
of business with the State and is not exempt, the Contractor will
comply with the affirmative action reporting requirements of 41
C.F.R.ss.60-1.7, if applicable. The Contractor shall comply with
Section 202 of Executive Order 11246, as amended, 41 C.F.R.ss.60-250,
and 41 C.F.R.ss.60-741, as amended, which are incorporated herein by
specific reference. Breach of this covenant may be regarded as a
material breach of contract.
I. Confidentiality of State of Indiana Information. The Contractor
understands and agrees that data, materials and information disclosed
to the Contractor may contain confidential and protected data;
therefore, the Contractor promises and assures that data, material, and
information gathered, based upon or disclosed to the Contractor for the
purpose of this Contract will not be disclosed to others or discussed
with other parties without the prior written consent of the State of
Indiana.
J. Confidentiality of Data, Property Rights in Products, and Copyright
Prohibition. The Contractor further agrees that all information, data,
findings, recommendations, proposals, etc., by whatever name described
and by whatever form therein, secured, developed, written, or produced
by the Contractor in furtherance of this Contract shall be the property
of the State of Indiana. The Contractor shall take such action as is
necessary under law to preserve such property rights in and of the
State of Indiana while such property is within the control and/or
custody of the Contractor. By this Contract the Contractor specifically
waives and/or releases to the State of Indiana any cognizable property
right in the Contractor to copyright or patent such information, data,
findings, recommendations, proposals, etc.
K. Ownership of Documents and Materials. All documents, records, programs,
data, film, tape, articles, memoranda, and other materials developed
under this Contract shall be considered "work for hire" and the
Contractor transfers any ownership claim to the State of Indiana and
MCO Renewel Contract Page 18 of 27 Managed Health Services
all such matters will be the property of the State of Indiana. Use of
these materials, other than related to contract performance by the
Contractor, without the prior written consent of the State of Indiana
is prohibited. During the performance of the services specified herein,
the Contractor shall be responsible for any loss or damage to these
materials developed for or supplied by the State of Indiana and used to
develop or assist in the services provided herein, while they are in
the possession of the Contractor, and any loss or damage thereto shall
be restored at the Contractor's expense. Full, immediate and
unrestricted access to the work product of the Contractor during the
term of this Contract shall be available to the State of Indiana. The
Contractor will give to the State of Indiana, or the State of Indiana's
designee, all records of other materials described in this section,
after termination of the Contract and upon five (5) days notice of a
request from the State of Indiana.
L. Conveyance of Documents And Continuation of Existing Activity: Should
the Contract for whatever reason, (i.e. completion of a contract with
no renewal, or termination of service by either party), be discontinued
and the activities as provided for in the Contract for services cease,
the Contractor and any subcontractors employed by the terminating
Contractor in the performance of the duties of the Contract shall
promptly convey to the State of Indiana, copies of all vendor working
papers, data collection forms, reports, charts, programs, cost records
and all other material related to work performed on this Contract.
The Contractor and the Office shall convene immediately upon
notification of termination or non-renewal of the Contract to determine
what work shall be suspended, what work shall be completed, and the
time frame for completion and conveyance. The Office will then provide
the Contractor with a written schedule of the completion and conveyance
activities associated with termination. Documents/materials associated
with suspended activities shall be conveyed by the Contractor to the
State of Indiana upon five days' notice from the State of Indiana. Upon
completion of those remaining activities noted on the written schedule,
the Contractor shall also convey all documents and materials to the
State of Indiana upon five days' notice from the State of Indiana.
M. Independent Contractor. The Office and the Contractor acknowledge and
agree that in the performance of this contract, the Contractor is an
independent contractor and both parties will be acting in an individual
capacity and not an as agents, employees, partners, joint venturers,
officers, or associates of one another. The employees or agents of one
party shall not be deemed or construed to be the employees or agents of
the other party for any purposes whatsoever. Neither party will assume
any liability for any injury (including death) to any persons, or
damage to any property arising out of the acts or omissions of the
agents, employees or subcontractors of the other party.
The Contractor shall be responsible for providing all necessary
unemployment and worker compensation insurance for the Contractor's
employees.
N. Work Standards. The Contractor agrees to execute its respective
responsibilities by following and applying at all times the highest
professional and technical guidelines and standards. If the State
MCO Renewel Contract Page 19 of 27 Managed Health Services
becomes dissatisfied with the work product or the working relationship
with those individuals assigned to work on this Contract, the State may
request in writing the replacement of any or all such individuals and
the Contractor shall grant such a request.
O. Governing Laws. This Contract shall be construed in accordance with and
governed by the laws of the State of Indiana and suit, if any, must be
brought in the State of Indiana.
P. Severability. The invalidity in whole or in part of any provision of
this Contract shall not void or affect the validity of any other
provision.
Q. Waiver of Rights. No right conferred on either party under this
Contract shall be deemed waived and no breach of this Contract deemed
excused, unless such waiver or excuse shall be in writing and signed by
the party claimed to have waived such right.
Failure of the Office to enforce at any time any provision of this
Contract shall not be construed as a waiver thereof. The remedies
herein reserved shall be cumulative and additional to any other
remedies in law or equity.
R. Taxes. The State of Indiana is exempt from all State, Federal and local
taxes. The State will not be responsible for any taxes levied on the
Contractor as a result of this Contract.
S. Force Majeure, Suspension and Termination. In the event either party is
unable to perform any of its obligations under this Contract or to
enjoy any of its benefits because of (or if failure to perform the
service is caused by) natural disaster, actions or decrees of
governmental bodies, or communication line failure not the fault of the
affected party (hereinafter referred to as a "Force Majeure Event"),
the party who has been so affected shall immediately give notice to the
other party and shall take reasonable measures to resume performance.
Upon receipt of such notice, all obligations under this Contract shall
be immediately suspended. If the period of non-performance exceeds
thirty (30) days from the receipt of notice of the Force Majeure Event,
the party whose ability to perform has not been so affected may, by
giving written notice, terminate this Contract.
T. Assignment. The Contractor shall not assign or subcontract the whole or
any part of this Contract without the State's prior written consent.
The Contractor may assign its right to receive payments to such third
parties as the Contractor may desire without the prior written consent
of the State, provided that the Contractor gives written notice
(including evidence of such assignment) to the State thirty (30) days
in advance of any payment so assigned. The assignment shall cover all
unpaid amounts under this Contract and shall not be made to more than
one party.
U. Successors and Assignees. The Contractor binds its successors,
executors, assignees, and administrators, to all covenants of this
Contract. Except as set forth above, the Contractor shall not assign,
sublet, or transfer the Contractor's interest in this Contract without
the prior written consent of the Office.
MCO Renewel Contract Page 20 of 27 Managed Health Services
V. Drug-Free Workplace Certification
The Contractor hereby covenants and agrees to make a good faith effort
to provide and maintain a drug-free workplace. Contractor will give
written notice to the State within ten (10) days after receiving actual
notice that the Contractor or an employee of the Contractor has been
convicted of a criminal drug violation occurring in the contractor's
workplace.
False certification or violation of the certification may result in
sanctions including, but not limited to, suspension of contract
payments, termination of the contract or agreement and/or debarment of
contracting opportunities with the State of Indiana for up to three (3)
years.
In addition to the provisions of the above paragraphs, if the total
contract amount set forth in this agreement is in excess of $25,000.00,
Contractor hereby further agrees that this agreement is expressly
subject to the terms, conditions, and representations of the following
certification:
This certification is required by Executive Order No. 90-5, April 12,
1990, issued by the Governor of Indiana. Pursuant to its delegated
authority, the Indiana Department of Administration is requiring the
inclusion of this certification in all contracts with and grants from
the State of Indiana in excess of $25,000.00. No award of a contract
shall be made, and no contract, purchase order or agreement, the total
amount of which exceeds $25,000.00, shall be valid, unless and until
this certification has been fully executed by the Contractor and made a
part of the contract or agreement as part of the contract documents.
The Contractor certifies and agrees that it will provide a drug-free
workplace by:
1. Publishing and providing to all of its employees a statement
notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled
substance is prohibited in the Contractor's workplace and
specifying the actions that will be taken against employees
for violations of such prohibition;
2. Establishing a drug-free awareness program to inform employees
of (1) the dangers of drug abuse in the workplace; (2) the
Contractor's policy of maintaining a drug-free workplace; (3)
any available drug counseling, rehabilitation, and employee
assistance programs; and (4) the penalties that may be imposed
upon an employee for drug abuse violations occurring in the
workplace;
3. Notifying all employees in the statement required by
subparagraph (1) above that as a condition of continued
employment the employee will (A) abide by the terms of the
statement; and (B) notify the Contractor of any criminal drug
statute conviction for a violation occurring in the workplace
no later than five (5) days after such conviction;
MCO Renewel Contract Page 21 of 27 Managed Health Services
4. Notifying in writing the State within ten (10) days after
receiving notice from an employee under subdivision (3)(B)
above, or otherwise receiving actual notice of such
conviction;
5. Within thirty (30) days after receiving notice under
subdivision (3)(B) above of a conviction, imposing the
following sanctions or remedial measures on any employee who
is convicted of drug abuse violations occurring in the
workplace: (1) take appropriate personnel action against the
employee, up to and including termination; or (2) require such
employee to satisfactorily participate in a drug abuse
assistance or rehabilitation program approved for such
purposes by a Federal, State or local health, law enforcement,
or other appropriate agency; and
Making a good faith effort to maintain a drug-free workplace through
the implementation of subparagraphs (1) through (5) above.
W. Lobbying Activities. Pursuant to 31 U.S.C.ss.1352, and any regulations
promulgated thereunder, the Contractor hereby assures and certifies
that no federally appropriated funds have been paid, or will be paid,
by or on behalf of the Contractor, to any person for influencing or
attempting to influence an officer or employee of any agency, a member
of Congress, an officer or employee of Congress, or an employee of a
member of Congress, in connection with the awarding of any federal
contract, the making of any federal grant, the making of any federal
loan, the entering into of any cooperative contract, and the extension,
continuation, renewal, amendment, or modification of any federal
contract, grant, loan or cooperative contract. If any funds other than
federally appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or
employee of any agency, a member of Congress, an officer or employee of
Congress, or an employee of a member of Congress in connection with
this Contract, the Contractor shall complete and submit Standard
Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its
instructions.
X. Access to Records. The Contractor and any subcontractor shall maintain
all books, documents, papers, accounting records, and any other
evidence pertaining to the cost incurred under this agreement.
Contractor and any subcontractors shall make such materials available
at all reasonable times during the contract period and for three (3)
years from the date of final payment under the Contract or until all
pending matters are closed, whichever date is later, for inspection by
the Office, or any other duly authorized representative of the State of
Indiana or the Federal government. Copies thereof shall be furnished at
no cost to the State if requested.
Y. Environmental Standards. If the contract amount set forth in this
Contract is in excess of $100,000, the Contractor shall comply with all
applicable standards, orders, or requirements issued under section 306
of the Clean Air Act (42 U.S.C. ss. 7606), section 508 of the Clean
Water Act (33 U.S.C. ss. 1368), Executive Order 11738, and
Environmental Protection Agency regulations (40 C.F.R. Part 32), which
prohibit the use under non-exempt Federal contracts of facilities
MCO Renewel Contract Page 22 of 27 Managed Health Services
included on the EPA List of Violating Facilities. The Contractor shall
report any violations of this paragraph to the State of Indiana and to
the United States Environmental Protection Agency Assistant
Administrator for Enforcement.
Z. Conflict of Interest
1. As used in this section:
"Immediate family" means the spouse and the unemancipated
children of an individual.
"Interested party" means:
a. The individual executing this Contract;
b. An individual who has an interest of three percent
(3%) or more of the Contractor if the Contractor is
not an individual; or
c. Any member of the immediate family of an individual
specified under subdivision a or b.
"Department" means the Indiana Department of Administration.
"Commission" means the State Ethics Commission.
2. The Department may cancel this Contract without recourse by
the Contractor if any interested party is an employee of the
State of Indiana.
3. The Department will not exercise its right of cancellation
under section 2 above if the Contractor gives the Department
an opinion by the Commission indicating that the existence of
this Contract and the employment by the State of Indiana of
the interested party does not violate any statute or code
relating to ethical conduct of state employees. The Department
may take action, including cancellation of this Contract
consistent with an opinion of the Commission obtained under
this section.
4. The Contractor has an affirmative obligation under this
Contract to disclose to the Department when an interested
party is or becomes an employee of the State of Indiana. The
obligation under this section extends only to those facts
which the Contractor knows or reasonably could know.
AA. Assurance of Compliance with Civil Rights Act of 1964, Section 504 of
the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975,
the Americans with Disabilities Act of 1990 and Title IX of the
Education Amendments of 1972: The Contractor agrees that it, and all of
its subcontractors and providers, will comply with the following:
MCO Renewel Contract Page 23 of 27 Managed Health Services
1. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45
C.F.R. Part 80), to the end that, in accordance with Title VI
of that Act and the Regulation, no person in the United States
shall on the ground of race, color, or national origin, be
excluded from participation in, be denied the benefits of, or
be otherwise subjected to discrimination under any program or
activity for which the Contractor receives Federal financial
assistance under this Contract.
2. Section 504 of the Rehabilitation Act of 1973 (Pub. L.
93-112), as amended, and all requirements imposed by or
pursuant to the Regulation of the Department of Health and
Human Services (45 C.F.R. Part 84), to the end that, in
accordance with Section 504 of that Act and the Regulation, no
otherwise qualified handicapped individual in the United
States shall, solely by reason of his/her handicap, be
excluded from participation in, be denied the benefits of, or
be subjected to discrimination under any program or activity
for which the Contractor receives Federal financial assistance
under this Contract.
3. The Age Discrimination Act of 1975 (Pub. L. 94-135), as
amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Health and Human Services (45
C.F.R. Part 91), to the end that, in accordance with the Act
and the Regulation, no person in the United States shall, on
the basis of age, be denied the benefits of, be excluded from
participation in, or be subjected to discrimination under any
program or activity for which the Contractor receives Federal
financial assistance under this Contract.
4. The Americans with Disabilities Act of 1990 (Pub. L. 101-336),
as amended, and all requirements imposed by or pursuant to the
Regulation of the Department of Justice (28 C.F.R. 35.101 et
seq.), to the end that in accordance with the Act and
Regulation, no person in the United States with a disability
shall, on the basis of the disability, be excluded from
participation in, be denied the benefits of, or otherwise be
subjected to discrimination under any program or activity for
which the Contractor receives Federal financial assistance
under this Contract.
5. Title IX of the Education Amendments of 1972, as amended (20
U.S.C. ss.ss. 1681-1683, and 1685-1686), and all requirements
imposed by or pursuant to regulation, to the end that, in
accordance with the Amendments, no person in the United States
shall, on the basis of sex, be excluded from participation in,
be denied the benefits of, or otherwise be subjected to
discrimination under any program or activity for which the
Contractor receives Federal financial assistance under this
Contract.
The Contractor agrees that compliance with this assurance constitutes a
condition of continued receipt of Federal financial assistance, and
that it is binding upon the Contractor, its successors, transferees and
assignees for the period during which such assistance is provided. The
Contractor further recognizes that the United States shall have the
right to seek judicial enforcement of this assurance.
MCO Renewel Contract Page 24 of 27 Managed Health Services
BB. Security and Privacy of Health Information. The Contractor agrees to
comply with all requirements of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA in all activities related to this
contract, to maintain compliance throughout the life of the contract,
to operate any systems used to fulfill the requirements of this
contract in full compliance with HIPAA and to take no action which
adversely affects the State's HIPAA compliance.
The parties acknowledge that the Department of Health and Human
Services has issued the Final Rule, as amended from time to time on the
Standards for Privacy of Individually Identifiable Health Information,
as required by the Administrative Simplification Section of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). To the
extent required by the provisions of HIPAA and regulations promulgated
thereunder, the Contractor assures that it will appropriately safeguard
Protected Health Information (PHI), as defined by the regulations,
which is made available to or obtained by the Contractor in the course
of its work under the contract. The Contractor agrees to comply with
applicable requirements of law relating to PHI with respect to any task
or other activity it performs for the Office including, as required by
the final regulations:
1. Not using or further disclosing PHI other than as permitted or
required by this Contract or by applicable law;
2. Using appropriate safeguards to prevent use or disclosure of
PHI other than as provided by this Contract or by applicable
law;
3. Reporting to the Office any use or disclosure by the
Contractor, its agent, employees, subcontractors or third
parties, of PHI obtained under this Contract in a manner not
provided for by this Contract or by applicable law of which
the Contractor becomes aware;
4. Ensuring that any subcontractors or agents to whom the
Contractor provides PHI received from, or created or received
by the Contractor on behalf of the Office agrees to the same
restrictions, conditions and obligations applicable to such
party regarding PHI;
5. Making the Contractor's internal practices, books and records
related to the use of disclosure of PHI received from, or
created or received by the Contractor on behalf of the Office
available to the Secretary of the United States Department of
Health and Human Services for purposes of determining the
Office's compliance with applicable law. The Contractor shall
immediately notify the Office upon receipt by the Contractor
of any such request, and shall provide the Office with copies
of any materials made available in response to such a request;
6. Making available the information required to provide an
accounting of disclosures pursuant to applicable law; and
7. At the termination of this Contract, returning or destroying
all PHI obtained under this Contract.
MCO Renewel Contract Page 25 of 27 Managed Health Services
CC. Substantial Performance. This Contract shall be deemed to be
substantially performed only when fully performed according to its
terms and conditions and any modification thereof.
DD. Penalties/Interest/Attorney's Fees. The State will in good faith
perform its required obligations hereunder and does not agree to pay
any penalties, liquidated damages, interest, or attorney's fees, except
as required by Indiana law, in part, IC 5-17-5, IC 34-54-8, and IC
34-13-1.
EE. Authority to Bind Contractor. Notwithstanding anything in the Contract
to the contrary, the signatory for the Contractor represents that
he/she has been duly authorized to execute contracts on behalf of the
Contractor designated herein and has obtained all necessary or
applicable approval from the home office of the Contractor, if
applicable, to make this, the contract, fully binding upon the
Contractor when his/her signature is affixed and is not subject to home
office acceptance hereto when accepted by the State of Indiana.
FF. Performance Bond. The Contractor agrees that a performance bond in the
amount of five hundred thousand dollars ($500,000.00) will be
maintained by the Indiana Department of Administration (IDOA). Said
bond will be in the form of a cashier's check, a certified check, or a
surety bond executed by a surety company authorized to do business in
the State of Indiana as approved by the Insurance Department of State
of Indiana. No other check or surety will be accepted. The performance
bond shall be made payable to the IDOA and shall be effective for the
duration of the contract and any extensions thereof. The State reserves
the right to increase the performance bond amount if enrollment levels
indicate the need for higher liquidated damages.
GG. Non-Collusion and Acceptance. The undersigned attests, subject to the
penalties for perjury, that he/she is the contracting party, or that
he/she is the representative, agent, member or officer of the
contracting party, that he/she has not, nor has any other member,
employee, representative, agent, or officer of the firm, company,
corporation, or partnership represented by him/her, directly or
indirectly, to the best of his/her knowledge, entered into or offered
to enter into any combination, collusion, or agreement to receive or
pay, and that he/she has not received or paid, any sum of money or
other consideration for the execution of this agreement other than that
which appears upon the face of the agreement.
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MCO Renewel Contract Page 26 of 27 Managed Health Services
IN WITNESS WHEREOF, Coordinated Care Corporation Indiana, Inc., and the State of
Indiana have, through duly authorized representatives, entered into this
agreement. The parties having read and understand the foregoing terms of the
Contract do by their respective signatures dated below hereby agree to the terms
thereof.
For the Contractor: For the State of Indiana:
/s/ Rita Johnson-Mills /s/ Melanie Bella
- ---------------------------- ------------------------------
Rita Johnson-Mills, CEO Melanie Bella
Coordinated Care Corporation Assistant Secretary
Indiana, Inc. Office of Medicaid Policy &
Planning
Date: Date:
------------------------- -------------------------
/s/ Kathryn H. Moses
------------------------------
Kathryn H. Moses, Director
Children's Health Insurance
Program
Date:
-------------------------
APPROVED: APPROVED:
/s/ Marilyn Schultz /s/ David Perlini
- ------------------------------ ------------------------------
Marilyn Schultz, Director David Perlini, Commissioner
State Budget Agency Department of Administration
Date: Date:
------------------------ ------------------------
APPROVED AS TO FORM AND LEGALITY
/s/ Stephen Carter
- ------------------------------
Stephen Carter
Attorney General of Indiana
Date:
------------------------
MCO Renewel Contract Page 27 of 27 Managed Health Services