EXHIBIT 10.2a
CONTRACT AMENDMENT FOR MEDICAID SERVICES
BETWEEN HMO AND WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES
The agreement entered into for the period of January 1, 2002 through December
31, 2003, between the State of Wisconsin acting by or through the Department of
Health and Family Services, hereinafter referred to as the "Department" and HMO,
an insurer with a certificate of authority to do business in Wisconsin is
amended, effective August 13, 2003, as follows:
1. In Article III, B.5, amended to read: "The Department will give the
HMO at least 30 days notice before the intended effective date 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."
2. In Article III, D, amended to read: "The HMOs must promptly provide or
pay for needed contract services for emergency medical conditions and
post-stabilization services as defined in Article I, regardless of
whether the provider that furnishes the service has a contract with the
entity."
3. In Article III, K, (added a second paragraph to this section) to read:
"The HMO must ensure that the services are sufficient in amount,
duration, or scope to reasonably be expected to achieve the purpose for
which the services are furnished,"
4. In Article III, L, (added a second paragraph to this section) to read:
The HMO will not discriminate against individuals eligible to enroll on
the basis of race, color, or national origin and will not use any
policy or practice that has the effect of discriminating on the basis
of race, color, or national origin."
5. In Article III, T.4, amended to read: "Any activities must occur in its
entire service area and only as indicated in the agreement."
6. In Article III, W.6.a, (added a second paragraph to this section) to
read: "The HMO may not employ or contract with providers excluded in
Federal Health Care programs under either Section 1128 or Section 1128A
of the Social Security Act."
7. In Article III, W.6.d, (added a second paragraph to this section) to
read: "If the HMO declines to include individual groups of providers in
its network, the HMO must give the affected provider written notice of
the reason for its decision."
8. In Article III, W.9, d, (added a paragraph at the end of section) to
read: "On the date that the timeframes expire, HMO gives notice that
service authorization decisions are not reached. Untimely service
authorizations constitute a denial and are thus adverse actions.
9. Article III, Z, amended to read: "In the provision of services under
this agreement, the Contractor and its subcontractors shall comply with
all applicable federal and state statutes and regulations, and all
amendments thereto, that are in effect when the agreement is signed, or
that come into effect during the term of the agreement. This includes,
but is not limited to Title XIX of the Social Security Act and Title 42
of the CFR."
Federal funds have not been used for lobbying.
10. In Article III, II, amended to read: "Maintain written policies and
procedures related to advance directives, (Written information provided
must reflect changes in state law as soon as possible, but no later
than 90 days after effective date of change.)"
11. In Article V, A, delete the following language: "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."
12. In Article VII, K, amended to read: "A voluntary disenrollment shall be
effective no later than the first day of the second month following the
month in which the enrollee requests termination."
13. In Article VII, K, (added paragraph at end of this section) to read:
"If the entity or State agency fails to make a disenrollment
determination within the timeframes specified, the disenrollment is
considered approved."
14. In Article VII, O, amended to read: "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 without cause."
15. In Article VIII, A, 3, amended to read: "Operate an informal, oral
grievance process which enrollees can use to get problems resolved
without going through the formal, written grievance process."
16. In Article VIII, B, 3rd paragraph amended to read: "For an expedited
grievance, the HMO must resolve all issues within two business days of
receiving the written request for an expedited grievance. The HMO must
make reasonable effort to provide oral notice, in addition to written
notice for the resolution."
17. In Article VIII, B, (added paragraph at the end of this section) to
read: "The HMO must ensure that punitive action is not taken against
anyone who either requests an expedited resolution or submits an
appeal."
18. In Article VIII, C, 1, amended to read: "When an HMO, its gatekeepers,*
or its IPAs discontinues, terminates, suspends, limits or reduces a
service (including services authorized by an HMO and 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), at
least 10 days before the date of action, in writing of ..."
19. In Article VIII, C, 1, i, amended to read: "The process for requesting
an oral or written expedited grievance."
20. In Article VIII, C, 2, amended to read: "If the enrollee files a
request for a hearing with the Division of Hearings and Appeals on or
before the later of the effective date or within 10 days of the MCO
mailing the notice of action to reduce, terminate, or suspend benefits,
upon notification by the Division of Hearings and Appeals ..."
21. In Article VIII, C, 2, (added a "c" to this section) to read: "Under
FFS status the benefits must be continued until one of the following
occurs;
- The enrollee withdraws the appeal.
- A state fair hearing decision adverse to the enrollee is made.
- The authorization expires or the authorization service is met.
22. In Addendum I, 4, g, amended to read: "The HMO must send written
notification not less than 30 days prior to the effective date of the
termination, to enrollees whose PCP, mental health provider, gatekeeper
or dental clinic terminates a contract with the HMO."
All terms and conditions in the agreement that are not affected by this
amendment shall remain in full force and effect.
In WITNESS WHEREOF, the State of Wisconsin and the HMO has executed this
agreement:
HMO ORGANIZATION DEPARTMENT OF HEALTH AND FAMILY SERVICES
Official Signature Official Signature
/s/ Kathleen R. Crampton /s/ Pris Baroniec
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Title Title Chief Executive Officer
Associate Administrator Division of Health Care Financing
Date Date
8/18/03 9/9/03
CONTRACT AMENDMENT FOR MEDICAID AND BADGERCARE
HMO SERVICES
MANAGED HEALTH SERVICES INS. CORP.
The Contract entered into for the period January 1, 2002, through
December 31, 2003, between the State of Wisconsin acting by or through the
Department of Health and Family Services, hereinafter referred to as
"Department," and Managed Health Services Ins. Corp., 1205 South 70th Street,
Suite 500, West Allis, WI 53214, hereinafter referred to as the "Contractor," is
hereby amended as follows:
1. Article XV, HMO SPECIFIC CONTRACT TERM, is amended as follows:
a. The initial contract period is extended through April 30,
2004.
b. The capitation rate for the four-month extension period will
be the rate identified in Addendum VII for CY 2003. The
Department will not make retroactive capitation payment
adjustments for the extension period.
2. All terms and conditions of the January 1, 2002, through December 31,
2003, contract and any prior amendments that are not affected by this Amendment
shall remain in full force and effect through the extension period.
Managed Health Services Ins. Corp, State of Wisconsin Department of
Health and Family Services
By: /s/ Kathleen R. Crampton By: /s/ Mark B. Moody
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Date: 12/23/03 Date:----------------------------