EXHIBIT 10.6a
AMENDMENT 14
TO THE AGREEMENT
BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTHPLAN, INC.
FOR HEALTH SERVICES
TO THE
MEDICAID STAR PROGRAM
IN THE
BEXAR SERVICE DELIVERY AREA
AMENDMENT 14
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION AND SUPERIOR HEALTHPLAN, INC.
FOR HEALTH SERVICES TO THE MEDICAID STAR PROGRAM
IN THE BEXAR SERVICE DELIVERY AREA
TABLE OF CONTENTS
ARTICLE 1. PURPOSE..................................................................................... 1
SECTION 1.01 AUTHORIZATION............................................................................ 1
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES......................................................... 1
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES................................................ 1
SECTION 2.01 GENERAL.................................................................................. 1
SECTION 2.02 MODIFICATION OF ARTICLE 2, DEFINITIONS................................................... 1
SECTION 2.03 MODIFICATION TO ARTICLE 3.2, NON-PROVIDER SUBCONTRACTS................................... 3
SECTION 2.04 MODIFICATION TO SECTION 3.5, RECORDS REQUIREMENTS AND RECORDS RETENTION.................. 3
SECTION 2.05 MODIFICATION TO SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS............................. 3
SECTION 2.06 ADDITION TO ARTICLE 5, STATUTORY AND REGULATORY COMPLIANCE REQUIREMENTS.................. 4
SECTION 2.07 SECTION 6.1, SCOPE OF SERVICES........................................................... 4
SECTION 2.08 ADDITION TO SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK PROVIDERS................. 5
SECTION 2.09 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES.......................................... 5
SECTION 2.10 MODIFICATION OF SECTION 6.13, PEOPLE WITH DISABILITIES, SPECIAL HEALTH CARE
NEEDS OR CHRONIC OR COMPLEX CONDITIONS.............................................................. 7
SECTION 2.11 MODIFICATION OF SECTION 7.1.3, TIMEFRAMES FOR ACCESS REQUIREMENTS........................ 10
SECTION 2.12 MODIFICATION OF SECTION 7.2, PROVIDER CONTRACTS.......................................... 10
SECTION 2.13 MODIFICATION OF SECTION 7.7, PROVIDER QUALIFICATIONS - GENERAL........................... 10
SECTION 2.14 MODIFICATION OF SECTION 7.8, PRIMARY CARE PROVIDERS...................................... 13
SECTION 2.15 MODIFICATION OF SECTION 8.2, MEMBER HANDBOOK............................................. 13
SECTION 2.16 MODIFICATION OF SECTION 8.5, MEMBER COMPLAINTS........................................... 14
SECTION 2.17 DELETION OF SECTION 8.6, MEMBER NOTICE, APPEALS AND FAIR HEARINGS........................ 21
SECTION 2.18 MODIFICATION OF SECTION 9.01, MARKETING MATERIAL MEDIA AND DISTRIBUTION.................. 21
SECTION 2.19 MODIFICATION OF SECTION 10.7, UTILIZATION/QUALITY IMPROVEMENT SUBSYSTEM.................. 21
SECTION 2.20 MODIFICATION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE............................................................... 22
SECTION 2.21 MODIFICATION OF SECTION 11.1, QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM................................................................................. 22
SECTION 2.22 MODIFICATION TO ARTICLE 11, QUALITY ASSURANCE AND QUALITY IMPROVEMENT
PROGRAM............................................................................................. 22
SECTION 2.23 MODIFICATION OF ARTICLE 12, REPORTING REQUIREMENTS....................................... 23
SECTION 2.24 MODIFICATION OF SECTION 12.10, QUALITY IMPROVEMENT REPORTS............................... 23
SECTION 2.25 MODIFICATION OF SECTION 13.1, CAPITATION AMOUNTS......................................... 24
SECTION 2.26 MODIFICATION OF SECTION 13.3, PERFORMANCE OBJECTIVES..................................... 24
SECTION 2.27 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS.......................................................................................... 25
SECTION 2.28 MODIFICATION OF SECTION 14.1, ELIGIBILITY DETERMINATION.................................. 25
SECTION 2.29 MODIFICATION OF ARTICLE 15, GENERAL PROVISIONS........................................... 25
SECTION 2.30 MODIFICATION OF SECTION 16.3, DEFAULT BY HMO............................................. 25
SECTION 2.31 MODIFICATION OF SECTION 18.8, CIVIL MONETARY PENALTIES................................... 26
SECTION 2.32 MODIFICATION OF ARTICLE 19, TERM......................................................... 26
SECTION 2.33 MODIFICATION TO APPENDIX A, STANDARDS FOR QUALITY IMPROVEMENT PROGRAMS................... 26
SECTION 2.34 MODIFICATION TO APPENDIX D, CRITICAL ELEMENTS............................................ 26
SECTION 2.35 MODIFICATION OF APPENDIX E, TRANSPLANT FACILITIES........................................ 26
SECTION 2.36 ADDITION OF NEW APPENDIX O, STANDARD FOR MEDICAL RECORDS................................. 26
SECTION 2.37 MODIFICATION TO APPENDIX K, PERFORMANCE OBJECTIVES....................................... 26
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES................................................ 27
i
HHSC CONTRACT NO. 529-03-042-N
STATE OF TEXAS
COUNTY OF TRAVIS
AMENDMENT 14
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
SUPERIOR HEALTHPLAN, INC.
FOR HEALTH SERVICES
TO THE
STAR PROGRAM
IN THE
BEXAR SERVICE DELIVERY AREA
THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the
HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the
executive department of the State of Texas, and Superior HealthPlan, Inc.
("CONTRACTOR"), a health maintenance organization organized under the laws of
the State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at 2100 S. IH 35, Suite 202, Austin, Texas 78704.
HHSC and CONTRACTOR may be referred to in this Amendment individually as a
"Party" and collectively as the "Parties."
The Parties hereby agree to amend their Agreement as set forth in
Article 2 of this Amendment.
ARTICLE 1. PURPOSE.
SECTION 1.01 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article
15.2 of the Agreement.
SECTION 1.02 GENERAL EFFECTIVE DATE OF CHANGES.
This Amendment is effective August 13, 2003.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 GENERAL
This Amendment is to incorporate Federal regulations pertaining to
recent amendments to the Balanced Budget Act. These regulations are found in 42
C.F.R. Parts 400, 430, 431, 434, 435, 438, 440, and 447.
SECTION 2.02 MODIFICATION OF ARTICLE 2, DEFINITIONS
The following provisions amend, modify and add to the definitions set
forth in Article 2:
"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 service; failure to provide services in a timely manner,
the failure of an HMO to act within the timeframes set forth
in this agreement and 42 C.F.R. Section 438.408(b); or
HHSC Contract 529-03-042-N 1 of 27
for a resident of a rural area with only one HMO, the denial
of a Medicaid Members' request to obtain services outside of
the network.
APPEAL means the formal process by which a Member or
his or her representative request a review of an HMO's action,
as defined above.
COLD-CALL MARKETING means any unsolicited personal
contact by the HMO with a potential Member for the purpose of
marketing.
MEMBER COMPLAINT or GRIEVANCE means an expression of
dissatisfaction about any matter other than an action, as
defined above. As provided by 42 C.F.R. Section 438.400,
possible subjects for complaints or grievances include, but
are not limited to, the quality of care of services provided,
and aspects of interpersonal relationships such as rudeness of
a provider or employee, or failure to respect the Member's
rights.
EMERGENCY MEDICAL CONDITION, means a medical
condition manifesting itself by acute symptoms of recent onset
and 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 care could result in:
(a) placing the patient's health in serious jeopardy;
(b) serious impairment to bodily functions;
(c) serious dysfunction of any bodily organ or part;
(d) serious disfigurement; or
(e) in the case of a pregnant women, serious jeopardy
to the health of a woman or her unborn child.
EXPERIENCE REBATE means the portion of the HMO's net
income before taxes (financial Statistical Report, Part 1,
Line 14) that is returned to the state in accordance with
Section 13.2.
EXPEDITED APPEAL means an appeal to the HMO in which
the decision is required quickly based on the Member's health
status and taking the time for a standard appeal could
jeopardize the Member's life or health or ability to attain,
maintain, or regain maximum function.
MARKETING means any communication from an HMO to a
Medicaid recipient who is not enrolled with the HMO that can
reasonably be interpreted as intended to influence the
recipient to enroll in that particular HMO's Medicaid product,
or either to not enroll in, or to disenroll from another HMO's
Medicaid product.
MARKETING MATERIALS means materials that are produced
in any medium by or on behalf of an HMO and can reasonably be
interpreted as intended to market to potential enrollees.
MEMBER or ENROLLEE, means a person who: is entitled
to benefits under Title XIX of the Social Security Act and the
Texas Medical Assistance Program (Medicaid), is in a Medicaid
eligibility category included in the STAR Program, and is
enrolled in the STAR Program.
POST-STABILIZATION CARE SERVICES means covered
services, related to an emergency medical condition that are
provided after an Member is
HHSC Contract 529-03-042-N 2 of 27
stabilized in order to maintain the stabilized condition, or,
under the circumstances described in 42 C.F.R. Section
438.114(b)&(e) and 42 C.F.R. Section 422.113(c)(iii) to
improve or resolve the Member's condition.
SPECIAL HEALTH CARE NEEDS means Member with an
increased prevalence of risk of disability, including but not
limited to: chronic physical or developmental condition;
severe and persistent mental illness; behavioral or emotional
condition that accompanies the Member's physical or
developmental condition.
STABILIZE means to provide such medical care as to
assure within reasonable medical probability that no
deterioration of the condition is likely to result from, or
occur from, or occur during discharge, transfer, or admission
of the Member."
SECTION 2.03 MODIFICATION TO ARTICLE 3.2, NON-PROVIDER SUBCONTRACTS
Section 3.2 is modified to amend Section 3.2.4.3 add new Sections 3.2.6
and 3.2.7, as follows:
"3.2.4.3 [Contractor] understands and agrees that
neither HHSC, nor the HMO's Medicaid Members, are liable or
responsible for payment for any services authorized and
provided under this contract.
3.2.6 In accordance with 42 C.F.R.
Section 438.230(b)(3), all subcontractors must be subject to a
written monitoring plan, for any subcontractor carrying out a
major function of the HMO's responsibility under this
contract. For all subcontractors carrying out a major function
of the HMO's contract responsibility, the HMO must prepare a
formal monitoring process at least annually. HHSC may request
copies of written monitoring plans and the results of the
HMO's formal monitoring process.
3.2.7 In accordance with 42 C.F.R. Section
438.210(e), HMO may not structure compensation to utilization
management subcontractors or entities to provide incentives to
deny, limit, reduce, or discontinue medically necessary
services to any Member."
SECTION 2.04 MODIFICATION TO SECTION 3.5, RECORDS REQUIREMENTS AND RECORDS
RETENTION
Section 3.5.5, Medical Records, is modified as follows:
"3.5.5 Medical Records. HMO must require, through
contractual provisions or provider manual, providers to create
and keep medical records in compliance with the medical
records standards contained in Appendix O, Standards for
Medical Records. All medical records must be kept for at least
five (5) years, except for records of rural health clinics,
which must be kept for a period of six (6) years from the date
of service."
SECTION 2.05 MODIFICATION TO SECTION 4.10, CLAIMS PROCESSING REQUIREMENTS
Section 4.10.8 is modified as follows:
"4.10.8 HMO must comply with the standards adopted
by the U.S. Department of Health and Human Services under the
Health Insurance Portability and Accountability Act of 1996
(HIPAA), Public Law 104-191, regarding submitting and
receiving claims information through electronic data
interchange (EDI) that allows for automated
HHSC Contract 529-03-042-N 3 of 27
processing and adjudication of claims within the federally
mandated timeframes (see 45 C.F.R. parts 160 through 164)."
SECTION 2.06 ADDITION TO ARTICLE 5, STATUTORY AND REGULATORY COMPLIANCE
REQUIREMENTS
Section 5.11 is added as follows:
"5.11 DATA CERTIFICATION
5.11.1 In accordance with 42 C.F.R. Sections
438.604 and 438.606, HMO must certify in writing:
(a) encounter data;
(b) delivery supplemental data and other data
submitted pursuant to this agreement or State or Federal law
or regulation relating to payment for services.
5.11.2 The certification must be submitted to HHSC
concurrently with the certified data or other documents.
5.11.3 The certification must:
(a) be signed by the HMO's Chief Executive Officer;
Chief Financial Officer; or an individual with delegated
authority to sign for, and who reports directly to, either the
Chief Executive Officer or Chief Financial Officer; and
(b) contain a statement that to the best knowledge,
information and belief of the signatory, the HMO's certified
data or information are accurate, complete, and truthful."
SECTION 2.07 SECTION 6.1, SCOPE OF SERVICES
Section 6.1 is modified to add new section 6.1.9 as follows:
"6.1.9 In accordance with 42 C.F.R.Section 438.102,
HMO may file an objection to provide, reimburse for, or
provide coverage of, counseling or referral service for a
covered benefit, based on moral or religious grounds.
6.1.9.1 HMO must work with HHSC to develop a work
plan to complete the necessary tasks to be completed and
determine an appropriate date for implementation of the
requested changes to the requirements related to covered
services. The work plan will include timeframes for completing
the necessary contract and waiver amendments, adjustments to
capitation rates, identification of HMO and enrollment
materials needing revision, and notifications to Members.
6.1.9.2 In order to meet the requirements of Section
6.1.9.1, HMO must notify HHSC of grounds for and provide
detail concerning its moral or religious objections and the
specific services covered under the objection, no less than
120 days prior to the proposed effective date of the policy
change.
HHSC Contract 529-03-042-N 4 of 27
6.1.9.3 HMO must notify all current Members of the
intent to change covered services at least 30 days prior to
the effective date of the change in accordance with 42 C.F.R.
Section 438.102(b)(ii)(B).
6.1.9.4 HHSC will provide information to all current
Members on how and where to obtain the service that has been
discontinued by the HMO in accordance with 42 C.F.R.
Section 438.102(c)."
SECTION 2.08 ADDITION TO SECTION 6.4, CONTINUITY OF CARE AND OUT-OF-NETWORK
PROVIDERS
Section 6.4 is modified to add new Sections 6.4.6 and 6.4.7 as follows:
"6.4.6 HMO must provide Members with timely and
adequate access to out-of-network services for as long as
those services are necessary and covered benefits not
available within the network, in accordance with 42 C.F.R.
Section 438.206(b)(4). HMO will not be obligated to provide a
Member with access to out-of-network services if such services
become available from a network provider.
6.4.7 HMO must require through contract provisions
or the provider manual that each Member have access to a
second opinion regarding the use of any health care service. A
Member must be allowed access to a second opinion from a
network provider or out-of-network provider if a network
provider is not available, at no additional cost to the
Member, in accordance with 42 C.F.R. Section 438.206(b)(3)."
SECTION 2.09 MODIFICATION OF SECTION 6.5, EMERGENCY SERVICES
Section 6.5 is deleted in its entirety and replaced with the following
language:
"6.5.1 HMO policy and procedures, covered benefits,
claims adjudication methodology, and reimbursement performance
for emergency services must comply with all applicable state
and federal laws and regulations including 42 C.F.R.
Section 438.114, whether the provider is in network or out of
network.
6.5.2 HMO must pay for the professional, facility,
and ancillary services that are medically necessary to perform
the medical screening examination and stabilization of HMO
Member presenting as an emergency medical condition or an
emergency behavioral health condition to the hospital
emergency department, 24 hours a day, 7 days a week, rendered
by either HMO's in-network or out-of-network providers.
6.5.2.1 For all out-of-network emergency services
providers, HMO will pay a reasonable and customary amount for
emergency services. HMO policies and procedures must be
consistent with this agreement's prudent lay person definition
of an emergency medical condition and claims adjudication
processes required under Section 7.6 of this agreement and 42
C.F.R. Section 438.114.
HMO will pay a reasonable and customary amount for
services for all out-of-network emergency services provider
claims with dates of service between September 1, 2002 and
November 30,
HHSC Contract 529-03-042-N 5 of 27
2002. HMO must forward any complaints submitted by
out-of-network emergency services providers during this time
to HHSC. HHSC will review all complaints and determine whether
payments were reasonable and customary. HHSC will direct the
HMO to pay a reasonable and customary amount, as determined by
HHSC, if it concludes that the payments were not reasonable
and customary for the provider.
6.5.2.2 For all out-of-network emergency services
provider claims with dates of service on or after December 1,
2002, HMO must pay providers a reasonable and customary amount
consistent with a methodology approved by HHSC. HMO must
submit its methodology, along with any supporting
documentation, to HHSC by September 30, 2002. HHSC will review
and respond to the information by November 15, 2002. HMO must
forward any complaints by out-of-network emergency services
providers to HHSC, which will review all complaints. If HHSC
determines that payment is not consistent with the HMO's
approved methodology, the HMO must pay the emergency services
provider a rate, using the approved reasonable and customary
methodology, as determined by HHSC. Failure to comply with
this provision constitutes a default under Article 16, Default
and Remedies.
6.5.3 HMO must ensure that its network primary
care providers (PCPs) have after-hours telephone availability
that is consistent with Section 7.8.10 of this contract. This
telephone access must be available 24 hours a day, 7 days a
week throughout the service area.
6.5.4 HMO cannot require prior authorization as a
condition for payment for an emergency medical condition, an
emergency behavioral health condition, or labor and delivery.
HMO cannot limit what constitutes an emergency medical
condition on the basis of lists of diagnoses or symptoms. HMO
cannot refuse to cover emergency services based on the
emergency room provider, hospital, or fiscal agent not
notifying the Member's primary care provider or HMO of the
Member's screening and treatment within 10 calendar days of
presentation for emergency services. HMO may not hold the
Member who has an emergency medical condition liable for
payment of subsequent screening and treatment needed to
diagnose the specific condition or stabilize the patient. HMO
must accept the emergency physician or provider's
determination of when the Member is sufficiently stabilized
for transfer or discharge.
6.5.5 Medical Screening Examination for emergency
services. A medical screening examination needed to diagnose
an emergency medical condition shall be provided in a hospital
based emergency department that meets the requirements of the
Emergency Medical Treatment and Active Labor Act (EMTALA) 42
C.F.R. Section 489.20, Section 489.24 and Section
438.114(b)&(c). HMO must pay for the emergency medical
screening examination, as required by 42 U.S.C. Section
1395dd. HMOs must reimburse for both the physician's services
and the hospital's emergency services, including the emergency
room and its ancillary services.
6.5.6 Stabilization Services. When the medical
screening examination determines that an emergency medical
condition exists,
HHSC Contract 529-03-042-N 6 of 27
HMO must pay for emergency services performed to stabilize the
Member. The emergency physician must document these services
in the Member's medical record. HMOs must reimburse for both
the physician's and hospital's emergency stabilization
services including the emergency room and its ancillary
services.
6.5.7 Post-stabilization Care Services. HMO must
cover and pay for post-stabilization care services in the
amount, duration, and scope necessary to comply with 42 C.F.R.
Section 438.114(b)&(e) and 42 C.F.R. 422.113(c)(iii). The HMO
is financially responsible for post- stabilization care
services obtained within or outside the network that are not
pre-approved by a plan provider or other HMO representative,
but administered to maintain, improve, or resolve the Member's
stabilized condition if:
(a) the HMO does not respond to a request for
preapproval within 1 hour;
(b) the HMO cannot be contacted;
(c) or the HMO representative and the treating
physician cannot reach an agreement concerning the Member's
care and a plan physician is not available for consultation.
In this situation, the HMO must give the treating physician
the opportunity to consult with a plan physician and the
treating physician may continue with care of the patient until
an HMO physician is reached or the HMO's financial
responsibility ends as follows: the HMO physician with
privileges at the treating hospital assumes responsibility for
the Member's care; the HMO physician assumes responsibility
for the Member's care through transfer; the HMO representative
and the treating physician reach an agreement concerning the
Member's care; or the Member is discharged.
6.5.8 HMO must provide access to the
HHSC-designated Level I and Level II trauma centers within the
State or hospitals meeting the equivalent level of trauma
care. HMOs may make out-of-network reimbursement arrangements
with the HHSC-designated Level I and Level II trauma centers
to satisfy this access requirement."
SECTION 2.10 MODIFICATION OF SECTION 6.13, PEOPLE WITH DISABILITIES, SPECIAL
HEALTH CARE NEEDS OR CHRONIC OR COMPLEX CONDITIONS
Section 6.13 is deleted in its entirety and replaced with the
following:
"6.13.1 HMO shall provide the following services to
persons with disabilities, special health care needs, or
chronic or complex conditions. These services are in addition
to the covered services described in detail in the Texas
Medicaid Provider Procedures Manual (Provider Procedures
Manual) and the Texas Medicaid Bulletin, which is the
bi-monthly update to the Provider Procedures Manual. Clinical
information regarding covered services is published by the
Texas Medicaid program in the Texas Medicaid Service Delivery
Guide.
6.13.2 HMO must develop and maintain a system and
procedures for identifying Members who have disabilities,
special health care needs or chronic or complex medical and
behavioral health
HHSC Contract 529-03-042-N 7 of 27
conditions. Once identified, HMO must have effective health
delivery systems to provide the covered services to meet the
special preventive, primary acute, and specialty health care
needs appropriate for treatment of the individual's condition.
The guidelines and standards established by the American
Academy of Pediatrics, the American College of
Obstetrics/Gynecologists, the U.S. Public Health Service, and
other medical and professional health organizations and
associations' practice guidelines whose standards are
recognized by HHSC must be used in determining the medically
necessary services, assessment and plan of care for each
individual.
6.13.2.1 In accordance with 42 C.F.R. 438.208(b)(3),
HMO shall provide information that identifies Members who the
HMO has assessed as special health care needs Members to the
State's enrollment broker. The information will be provided in
a format to be specified by HHSC and updated by the 10th day
of each month. In the event that a special health care needs
Member changes health plans, HMO will work with receiving HMO
to provide information concerning the results of the HMO's
identification and assessment of that Member's needs, to
prevent duplication of those activities.
6.13.3 HMO must require that the PCP for all
persons with disabilities, special health care needs or
chronic or complex conditions develop a plan of care to meet
the needs of the Member. The plan of care must be based on
health needs, specialist(s) recommendations, and periodic
reassessment of the Member's developmental and functional
status and service delivery needs. HMO must require providers
to maintain record keeping systems to ensure that each Member
who has been identified with a disability or chronic or
complex condition has an initial plan of care in the primary
care provider's medical records, that Member agrees to that
plan of care, and that the plan is updated as often as the
Member's needs change, but at least annually.
6.13.4 HMO must provide a primary care and
specialty care provider network for persons with disabilities,
special health care needs, or chronic or complex conditions.
Specialty and subspecialty providers serving all Members must
be Board Certified/Board Eligible in their specialty. HMO may
request exceptions from HHSC for approval of traditional
providers who are not board-certified or board-eligible but
who otherwise meet HMO's credentialing requirements.
6.13.5 HMO must have in its network PCPs and
specialty care providers that have documented experience in
treating people with disabilities, special health care needs,
or chronic or complex conditions, including children. For
services to children with disabilities, special health care
needs, or chronic or complex conditions, HMO must have in its
network PCPs and specialty care providers that have
demonstrated experience with children with disabilities,
special health care needs, or chronic or complex conditions in
pediatric specialty centers such as children's hospitals,
medical schools, teaching hospitals and tertiary center
levels.
6.13.6 HMO must provide information, education and
training programs to Members, families, PCPs, specialty
physicians, and community agencies about the care and
treatment available in
HHSC Contract 529-03-042-N 8 of 27
HMO's plan for Members with disabilities, special health care
needs, or chronic or complex conditions.
HMO must ensure Members with disabilities, special
health care needs, or chronic or complex conditions have
direct access to a specialist.
6.13.7 HMO must coordinate care and establish
linkages, as appropriate for a particular Member, with
existing community-based entities and services, including but
not limited to: Maternal and Child Health, Children with
Special Health Care Needs (CSHCN), the Medically Dependent
Children Program (MDCP), Community Resource Coordination
Groups (CRCGs), Interagency Council on Early Childhood
Intervention (ECI), Home and Community-based Services (HCS),
Community Living Assistance and Support Services (CLASS),
Community Based Alternatives (CBA), In Home Family Support,
Primary Home Care, Day Activity and Health Services (DAHS),
Deaf/Blind Multiple Disabled waiver program and Medical
Transportation Program (MTP).
6.13.8 HMO must include TDH approved pediatric
transplant centers, TDH designated trauma centers, and TDH
designated hemophilia centers in its provider network (see
Appendices E, F, and G for a listing of these facilities).
6.13.9 HMO must ensure Members with disabilities or
chronic or complex conditions have access to treatment by a
multidisciplinary team when determined by the Member's PCP to
be medically necessary for effective treatment, or to avoid
separate and fragmented evaluations and service plans. The
teams must include both physician and non-physician providers
determined to be necessary by the Member's PCP for the
comprehensive treatment of the Member. The team must:
6.13.9.1 Participate in hospital discharge planning;
6.13.9.2 Participate in pre-admission hospital
planning for non-emergency hospitalizations;
6.13.9.3 Develop specialty care and support service
recommendations to be incorporated into the primary care
provider's plan of care;
6.13.9.4 Provide information to the Member and the
Member's family concerning the specialty care recommendations;
and
6.13.9.5 HMO must develop and implement training
programs for primary care providers, community agencies,
ancillary care providers, and families concerning the care and
treatment of a Member with a disability or chronic or complex
conditions.
6.13.10 HMO must identify coordinators of medical
care to assist providers who serve Members with disabilities
and chronic or complex conditions and the Members and their
families in locating and accessing appropriate providers
inside and outside HMO's network.
HHSC Contract 529-03-042-N 9 of 27
6.13.11 HMO must assist, through information and
referral, eligible Members in accessing providers of
non-capitated Medicaid services listed in Article 6.1.8, as
applicable.
6.13.12 HMO must ensure that Members who require
routine or regular laboratory and ancillary medical tests or
procedures to monitor disabilities, special health care needs,
or chronic or complex conditions are allowed by HMO to receive
the services from the provider in the provider's office or at
a contracted lab located at or near the provider's office."
SECTION 2.11 MODIFICATION OF SECTION 7.1.3, TIMEFRAMES FOR ACCESS REQUIREMENTS
Section 7.1.3 is amended to add new Section 7.1.3.5, as follows:
"7.1.3.5 Prenatal Care within 2 weeks of request."
SECTION 2.12 MODIFICATION OF SECTION 7.2, PROVIDER CONTRACTS
Section 7.2.8.2.1 is added and Section 7.2.9.2 is modified, as follows:
"7.2.8.2.1 [Provider] understands and agrees that the
HMO's Medicaid enrollees are not to be held liable for the
HMO's debts in the event of the entity's insolvency in
accordance with 42 C.F.R. Section 438.106(a).
7.2.9.2 A provider who is terminated is entitled to
an expedited review process by HMO on request by the provider.
HMO must make a good faith effort to provide written notice of
the provider's termination to HMO's Members receiving primary
care from, or who were seen on a regular basis by, the
terminated provider within 15 days after receipt or issuance
of the termination notice, in accordance with 42 C.F.R.
Section 438.10(f)(5). If a provider is terminated for reasons
related to imminent harm to patient health, HMO must notify
its Members immediately of the provider's termination.
7.2.12 Notice to Rejected Providers. In accordance
with 42 C.F.R.Section 438.129(a)(2), if an HMO declines to
include individual or groups of providers in its network, it
must give the affected providers written notice of the reason
for its decision."
SECTION 2.13 MODIFICATION OF SECTION 7.7, PROVIDER QUALIFICATIONS - GENERAL
The qualifications for a "Hospital" in Section 7.7 is replaced with the
following language. Section 7.7 is retitled Section 7.7.1 and new
Section 7.7.2, Provider Credentialing and Recredentialing is added to
Section 7.7:
"7.7.1 PROVIDER QUALIFICATIONS - GENERAL
PROVIDER QUALIFICATION
Hospital An institution licensed as a general or special hospital by the
State of Texas under Chapter 241 of the Health and Safety Code,
which is enrolled as a provider in the Texas Medicaid Program. HMO
will require that all facilities in the network used for acute
inpatient specialty care for people under age 21 with
disabilities, special health care needs, or chronic or complex
conditions will have a designated pediatric unit; 24 hour
laboratory and blood bank
HHSC Contract 529-03-042-N 10 of 27
PROVIDER QUALIFICATION
availability; pediatric radiological capability; meet JCAHO
standards; and have discharge planning and social service units.
HMO may request exceptions to this requirement for specific
hospitals within their networks, from HHSC."
"7.7.2 PROVIDER CREDENTIALING AND RECREDENTIALING
In accordance with 42 C.F.R. Section 438.214, HMO's
standard credentialing and recredentialing process must
include the following provisions to determine whether
physicians and other health care professionals, who are
licensed by the State and who are under contract with HMO, are
qualified to perform their services.
7.7.2.1 Written Policies and Procedures. MCO has
written policies and procedures for the credentialing process
that includes MCO's initial credentialing of practitioners as
well as its subsequent recredentialing, recertifying and/or
reappointment of practitioners.
7.7.2.2 Oversight by Governing Body. The Governing
Body, or the group or individual to which the Governing Body
has formally delegated the credentialing function, has
reviewed and approved the credentialing policies and
procedures.
7.7.2.3 Credentialing Entity. The plan designates a
credentialing committee or other peer review body, which makes
recommendations regarding credentialing decisions.
7.7.2.4 Scope. The plan identifies those
practitioners who fall under its scope of authority and
action. This shall include, at a minimum, all physicians,
dentists, and other licensed health practitioners included in
the review organization's literature for Members, as an
indication of those practitioners whose service to Members is
contracted or anticipated.
7.7.2.5 Process. The initial credentialing process
obtains and reviews verification of the following information,
at a minimum:
a) The practitioner holds a current valid license to
practice;
b) Valid DEA or CDS certificate, as applicable;
c) Graduation from medical school and completion of a
residency or other post-graduate training, as applicable;
d) Work history;
e) Professional liability claims history;
f) The practitioner holds current, adequate
malpractice insurance according to the plan's policy;
g) Any revocation or suspension of a state license or
DEA/BNDD number;
HHSC Contract 529-03-042-N 11 of 27
h) Any curtailment or suspension of medical staff
privileges (other than for incomplete medical records);
i) Any sanctions imposed by Medicaid and/or Medicare;
j) Any censure by the State or County Medical
Association;
k) MCO requests information on the practitioner from
the National Practitioner Data Bank and the State Board of
Medical Examiners;
l) The application process includes a statement by
the Applicant regarding: (This information should be used to
evaluate the practitioner's current ability to practice.)
m) Any physical or mental health problems that may
affect current ability to provide health care;
n) Any history of chemical dependency/substance
abuse;
o) History of loss of license and/or felony
convictions;
p) History of loss or limitation of privileges or
disciplinary activity; and
q) An attestation to correctness/completeness of the
application.
7.2.2.6 There is an initial visit to each potential
primary care practitioner's office, including documentation of
a structured review of the site and medical record keeping
practices to ensure conformance with MCO's standards.
7.7.2.7 Recredentialing. A process for the periodic
reverification of clinical credentials (recredentialing,
reappointment, or recertification) is described in MCO's
policies and procedures.
7.7.2.8 There is evidence that the procedure is
implemented at least every three years.
7.7.2.9 MCO conducts periodic review of information
from the National Practitioner Data Bank, along with
performance data on all physicians, to decide whether to renew
the participating physician agreement. At a minimum, the
recredentialing, recertification or reappointment process is
organized to verify current standing on items listed in "E-1"
through "E-7" and item "E-13" above.
7.7.2.10 The recredentialing, recertification or
reappointment process also includes review of data from: a)
Member complaints and b) results of quality reviews.
7.7.2.11 Delegation of Credentialing Activities. If
MCO delegates credentialing (and recredentialing,
recertification, or reappointment) activities, there is a
written description of the delegated activities, and the
delegate's accountability for these activities. There is also
evidence that the delegate accomplished the credentialing
activities. MCO monitors the effectiveness of the delegate's
credentialing and reappointment or recertification process.
7.7.2.12 Retention of Credentialing Authority. MCO
retains the right to approve new providers and sites and to
terminate or
HHSC Contract 529-03-042-N 12 of 27
suspend individual providers. MCO has policies and procedures
for the suspension, reduction or termination of practitioner
privileges.
7.7.2.13 Reporting Requirement. There is a mechanism
for, and evidence of implementation of, the reporting of
serious quality deficiencies resulting in suspension or
termination of a practitioner, to the appropriate authorities.
MCO will implement and maintain policies and procedures for
disciplinary actions including reducing, suspending, or
terminating a practitioner's privileges.
7.7.2.14 Appeals Process. There is a provider
appellate process for instances where MCO chooses to reduce,
suspend or terminate a practitioner's privileges with the
organization.
SECTION 2.14 MODIFICATION OF SECTION 7.8, PRIMARY CARE PROVIDERS
Section 7.8.1.1 is added and Sections 7.8.8 and 7.8.11.4 are modified
with the following language:
"7.8.1.1 HMO must provide supporting documentation,
as specified and requested by the State, to verify that their
provider network meets the requirements of this contract at
the time the HMO enters into a contract and at the time of a
significant change as required by 42 C.F.R. Section
438.207(b). A significant change can be, but is not limited
to, change in ownership (purchase, merger, acquisition), new
start-up, bankruptcy, and/or a major subcontractor change
directly affecting a provider network such as (IPA's, BHO,
medical groups, etc.).
7.8.8 The PCP for a Member with disabilities,
special health care needs, or chronic or complex conditions
may be a specialist who agrees to provide PCP services to the
Member. The specialty provider must agree to perform all PCP
duties required in the contract and PCP duties must be within
the scope of the specialist's license. Any interested person
may initiate the request for a specialist to serve as a PCP
for a Member with disabilities, special health care needs, or
chronic or complex conditions.
7.8.11.4 HMO must require PCPs for children under the
age of 21 to provide or arrange to have provided all services
required under Section 6.8 relating to Texas Health Steps,
Section 6.9 relating to Perinatal Services, Section 6.10
relating to Early Childhood Intervention, Section 6.11
relating to WIC, Section 6.13 relating to People With
Disabilities, special health care needs, or chronic or complex
conditions, and Section 6.14 relating to Health Education and
Wellness and Prevention Plans. PCP must cooperate and
coordinate with HMO to provide Member and the Member's family
with knowledge of and access to available services."
SECTION 2.15 MODIFICATION OF SECTION 8.2, MEMBER HANDBOOK
Section 8.2.4 is added with the following language:
"8.2.4 In accordance with 42 C.F.R. Section
438.100, HMO must maintain written policies and procedures for
informing Members of their rights and responsibilities. HMO
must notify its Members of their right to request a copy of
these rights and responsibilities."
HHSC Contract 529-03-042-N 13 of 27
SECTION 2.16 MODIFICATION OF SECTION 8.5, MEMBER COMPLAINTS
Section 8.5 is deleted in its entirety and replaced with the following
language:
"8.5 MEMBER COMPLAINT AND APPEAL SYSTEM
HMO must develop, implement and maintain a Member
complaint and appeal system that complies with the
requirements in applicable federal and state laws and
regulations, including 42 C.F.R. Section 431.200 and 42 C.F.R.
Part 483, Subpart F, "Grievance System;" and the provisions of
1 T.A.C. Chapter 357 relating to managed care organizations.
The complaint and appeal system must include a complaint
process, an appeal process, and access to HHSC's Fair Hearing
System. The procedures must be reviewed and approved in
writing by HHSC. Modifications and amendments to the Member
complaint and appeal system must be submitted to HHSC at least
30 days prior to the implementation of the modification or
amendment.
For purposes of Section 8.5., an "authorized
representative" is any person or entity acting on behalf of
the Member and with the Member's written consent. A provider
may be an "authorized representative."
8.5.1 MEMBER COMPLAINT PROCESS
8.5.1.1 HMO must have written policies and
procedures for receiving, tracking, responding to, reviewing,
reporting and resolving complaints by Members or their
authorized representatives.
8.5.1.2 HMO must resolve complaints within 30 days
from the date that the complaint was received. The complaint
procedure must be the same for all Members under this
contract. The Member or Member's authorized representative may
file a complaint either orally or in writing. HMO must also
inform Members how to file a complaint directly with HHSC.
8.5.1.3 HMO must designate an officer of HMO who has
primary responsibility for ensuring that complaints are
resolved in compliance with written policy and within the time
required. An "officer" of HMO means a president, vice
president, secretary, treasurer, or chairperson of the board
for a corporation, the sole proprietor, the managing general
partner of a partnership, or a person having similar executive
authority in the organization.
8.5.1.4 HMO must have a routine process to detect
patterns of complaints. The process must involve management,
supervisory, and quality improvement staff in the development
of policy and procedural improvements to address the
complaints.
8.5.1.5 HMO's complaint procedures must be provided
to Members in writing and through oral interpretive services.
A written description of HMO's complaint procedures must be
available in prevalent non-English languages identified by
HHSC, at a 4th to 6th grade reading level. HMO must include a
written description of the complaint process in the Member
Handbook. HMO must maintain and
HHSC Contract 529-03-042-N 14 of 27
publish in the Member Handbook, at least one local and one
toll-free telephone number with
TeleTypewriter/Telecommunications Device for the Deaf
(TTY/TTD) and interpreter capabilities for making complaints.
8.5.1.6 HMO's process must require that every
complaint received in person, by telephone or in writing must
be acknowledged and recorded in a written record and logged
with the following details: date; identification of the
individual filing the complaint; identification of the
individual recording the complaint; nature of the complaint;
disposition of the complaint (i.e., how the HMO resolved the
complaint); corrective action required; and date resolved.
8.5.1.7 HMO is prohibited from discriminating or
taking punitive action against a Member or his or her
representative for making a complaint.
8.5.1.8 If the Member makes a request for
disenrollment, the HMO shall give the Member information on
the disenrollment process and direct the Member to the
Enrollment Broker. If the request for disenrollment includes a
complaint by the Member, the complaint will be processed
separately from the disenrollment request, through the
complaint process.
8.5.1.9 HMO will cooperate with the Enrollment
Broker, HHSC, and HHSC's Member resolution service contractors
to resolve all Member complaints. Such cooperation may
include, but is not limited to, providing information or
assistance to internal complaint committees.
8.5.1.10 HMO must provide designated staff to assist
Members in understanding and using HMO's complaint system.
HMO's designated staff must assist Members in writing or
filing a complaint and monitoring the complaint through the
HMO's complaint process until the issue is resolved.
8.5.2 STANDARD MEMBER APPEAL PROCESS
8.5.2.1 HMO must develop, implement and maintain an
appeal procedure that complies with the requirements in
federal laws and regulations, including 42 C.F.R. Section
431.200 and 42 C.F.R. Part 438, Subpart F, "Grievance System."
An appeal is a disagreement with an "action" as defined in
Article 2 of the Contract. The appeal procedure must be the
same for all Members. When a Member or his or her authorized
representative expresses orally or in writing any
dissatisfaction or disagreement with an action, the HMO must
regard the expression of dissatisfaction as a request to
appeal an action.
8.5.2.2 A Member must file a request for an internal
appeal within 30 days from receipt of the notice of the
action. To ensure continuation of currently authorized
services, however, the Member must file the appeal on or
before the later of: 10 days following the HMO's mailing of
the notice of the action or the intended effective date of the
proposed action.
HHSC Contract 529-03-042-N 15 of 27
8.5.2.3 HMO must designate an officer who has
primary responsibility for ensuring that appeals are resolved
in compliance with written policy and within the time
required. An "officer" of HMO means a president, vice
president, secretary, treasurer, or chairperson of the board
for a corporation, the sole proprietor, the managing general
partner of a partnership, or a person having similar executive
authority in the organization.
8.5.2.4 The provisions of Article 21.58A, Texas
Insurance Code, relating to a Member's right to appeal an
adverse determination made by HMO or a utilization review
agent by an independent review organization, do not apply to a
Medicaid recipient. Federal fair hearing requirements (Social
Security Act Section 1902a(3), codified at 42 C.F.R. Section
431.200 et. seq.) require the agency to make a final decision
after a fair hearing, which conflicts with the State
requirement that the IRO make a final decision. Therefore,
Article 21.58A is pre-empted by the federal requirement.
8.5.2.5 HMO must have policies and procedures in
place outlining the role of HMO's Medical Director for an
appeal of an action. The Medical Director must have a
significant role in monitoring, investigating and hearing
appeals. In accordance with 42 C.F.R. Section 438.406, the
HMO's policies and procedures must require that individuals
who make decisions on appeals were not involved in any
previous level of review or decision-making, and, are health
care professionals who have the appropriate clinical
expertise, as determined by HHSC, in treating the Member's
condition or disease.
8.5.2.6 HMO must provide designated staff to assist
Members in understanding and using HMO's appeal process. HMO's
designated staff must assist Members in writing or filing an
appeal and monitoring the appeal through the HMO's appeal
process until the issue is resolved.
8.5.2.7 HMO must have a routine process to detect
patterns of appeals. The process must involve management,
supervisory, and quality improvement staff in the development
of policy and procedural improvements to address the appeals.
8.5.2.8 HMO's appeal procedures must be provided to
Members in writing and through oral interpretive services. A
written description of HMO's appeal procedures must be
available in prevalent non-English languages identified by
HHSC, at a 4th to 6th grade reading level. HMO must include a
written description in the Member Handbook. HMO must maintain
and publish in the Member Handbook at least one local and one
toll-free telephone number with TTY/TTD and interpreter
capabilities for requesting an appeal of an action.
8.5.2.9 HMO's process must require that every oral
appeal received must be confirmed by a written, signed appeal
by the Member or his or her representative, unless the Member
or his or her representative requests an expedited resolution.
All appeals must be recorded in a written record and logged
with the following details: date notice is sent; effective
date of the action; date the Member or his or her
representative requested the appeal; date the appeal was
followed
HHSC Contract 529-03-042-N 16 of 27
up in writing; identification of the individual filing; nature
of the appeal; disposition of the appeal; notice of
disposition to Member.
8.5.2.10 HMO must send a letter to the Member within
5 business days acknowledging receipt of the appeal request.
Except as provided in Section 8.5.3.2, HMO must complete the
entire appeal process within 30 calendar days after receipt of
the initial written or oral request for appeal. The timeframe
may be extended up to 14 calendar days if the Member requests
an extension; or the HMO shows that there is a need for
additional information and how the delay is in the Member's
interest. If the timeframe is extended, the HMO must give the
Member written notice of the reason for delay if the Member
had not requested the delay.
8.5.2.11 During the appeal process, HMO must provide
the Member a reasonable opportunity to present evidence, any
allegations of fact or law, in person as well as in writing.
The HMO must inform the Member of the time available for
providing this information, and in the case of an expedited
resolution, that limited time will be available (see Section
8.5.3.2).
8.5.2.12 HMO must provide the Member and his or her
representative opportunity, before and during the appeals
process, to examine the Member's case file, including medical
records and any other documents considered during the appeal
process. HMO must include, as parties to the appeal, the
Member and his or her representative or the legal
representative of a deceased Member's estate.
8.5.2.13 In accordance with 42.C.F.R. Section
438.420, HMO must continue the Member's benefits currently
being received by the Member, including the benefit that is
the subject of the appeal, if all of the following criteria
are met: 1) the Member or his or her representative files the
appeal timely (as defined in Section 8.5.2.2); 2) the appeal
involves the termination, suspension, or reduction of a
previously authorized course of treatment; 3) the services
were ordered by an authorized provider; 4) the original period
covered by the original authorization has not expired; and 5)
the Member requests an extension of the benefits. If, at the
Member's request, the HMO continues or reinstates the Member's
benefits while the appeal is pending, the benefits must be
continued until one of the following occurs: the Member
withdraws the appeal; 10 days pass after the HMO mails the
notice, providing the resolution of the appeal against the
Member, unless the Member, within the 10-day timeframe, has
requested a State fair hearing with continuation of benefits
until a State fair hearing decision can be reached; a state
fair hearing office issues a hearing decision adverse to the
Member; the time period or service limits of a previously
authorized service has been met.
8.5.2.14 In accordance with 42 C.F.R. Section
438.420(d), if the final resolution of the appeal is adverse
to the Member, and upholds the HMO's action, then to the
extent that the services were furnished to comply with Section
8.5.2.13, the HMO may recover such costs from the Member.
HHSC Contract 529-03-042-N 17 of 27
8.5.2.15 If the HMO or state fair hearing officer
reverses a decision to deny, limit, or delay services that
were not furnished while the appeal was pending, the HMO must
authorize or provide the disputed services promptly, and as
expeditiously as the Member's health condition requires.
8.5.2.16 If the HMO or state fair hearing officer
reverses a decision to deny authorization of services and the
Member received the disputed services while the appeal was
pending, the HMO will be responsible for the payment of
services.
8.5.2.17 HMO is prohibited from discriminating
against a Member or his or her representative for making an
appeal.
8.5.3 EXPEDITED HMO APPEALS
8.5.3.1 In accordance with 42 C.F.R. Section
438.410, HMO must establish and maintain an expedited review
process for appeals, when the HMO determines (for a request
from a Member) or the provider indicates (in making the
request on the Member's behalf or supporting the Member's
request) that taking the time for a standard resolution could
seriously jeopardize the Member's life or health. HMO must
follow all appeal requirements for standard Member appeals, as
set forth in Section 8.5.2, except where differences are
specifically noted. Requests for expedited appeals must be
accepted orally or in writing.
8.5.3.2 HMO must complete investigation and
resolution of an appeal relating to an ongoing emergency or
denial of continued hospitalization: (1) in accordance with
the medical or dental immediacy of the case; and (2) not later
than one business day after the complainant's request for
appeal is received.
8.5.3.3 Members must exhaust the HMO's expedited
appeal process before making a request for an expedited state
fair hearing. After HMO receives the request for an expedited
appeal, it must hear an approved requests for a Member to have
an expedited appeal and notify the Member of the outcome of
the appeal within 3 business days, except as stated in
8.5.3.2. This timeframe may be extended up to 14 calendar days
if the Member requests an extension; or the HMO shows (to the
satisfaction of HHSC, upon HHSC's request) that there is a
need for additional information and how the delay is in the
Member's interest. If the timeframe is extended, the HMO must
give the Member written notice of the reason for delay if the
Member had not requested the delay.
8.5.3.4 If the decision is adverse to the Member,
procedures relating to the notice in Section 8.5.5 must be
followed. The HMO is responsible for notifying the Member of
their rights to access an expedited state fair hearing. HMO
will be responsible for providing documentation to the State
and the Member, indicating how the decision was made, prior to
state's expedited fair hearing.
8.5.3.5 The HMO must ensure that punitive action is
neither taken against a provider who requests an expedited
resolution or supports a Member's request.
HHSC Contract 529-03-042-N 18 of 27
8.5.3.6 If the HMO denies a request for expedited
resolution of an appeal, it must: (1) transfer the appeal to
the timeframe for standard resolution set forth in Section
8.5.2, and (2) make a reasonable effort to give the Member
prompt oral notice of the denial, and follow up within two
calendar days with a written notice.
8.5.4 ACCESS TO STATE FAIR HEARING
8.5.4.1 HMO must inform Members that they generally
have the right to access the state fair hearing process in
lieu of the internal appeal system provided by HMO procedures
set forth in Sections 8.5.2 and 8.5.3. The notice must comply
with the requirements of 1 T.A.C. Chapter 357. In the case of
an expedited State Fair Hearing Process, the HMO must inform
the Member that he or she must first exhaust the HMO's
internal expedited appeal process.
8.5.4.2 HMO must notify Members that they may be
represented by an authorized representative in the state fair
hearing process.
8.5.5 NOTICES OF ACTION AND DISPOSITION OF APPEALS
8.5.5.1 NOTICE OF ACTION. HMO must notify the
Member, in accordance with 1 T.A.C. Chapter 357, whenever HMO
takes an action as defined in Article 2 of this contract. The
notice must contain the following information:
(a) the action the HMO or its contractor has taken or
intends to take;
(b) the reasons for the action;
(c) the Member's right to access the HMO internal
appeal process, as set forth in Sections 8.5.2 and 8.5.3,
and/or to access to the State Fair Hearing Process as provided
in Section 8.5.4;
(d) the procedures by which Member may appeal HMO's
action;
(e) the circumstances under which expedited
resolution is available and how to request it;
(f) the circumstances under which a Member can
continue to receive benefits pending resolution of the appeal
(see Section 8.5.2.13), how to request that benefits be
continued, and the circumstances under which the Member may be
required to pay the costs of these services;
(g) the date the action will be taken;
(h) a reference to the HMO policies and procedures
supporting the HMO's action;
(i) an address where written requests may be sent and
a toll-free number that the Member can call to request the
assistance of a Member representative, file an appeal, or
request a Fair Hearing;
HHSC Contract 529-03-042-N 19 of 27
(j) an explanation that Members may represent
themselves, or be represented by a provider, a friend, a
relative, legal counsel or another spokesperson;
(k) a statement that if the Member wants a HHSC Fair
Hearing on the action, Member must make, in writing, the
request for a Fair Hearing within 90 days of the date on the
notice or the right to request a hearing is waived;
(l) a statement explaining that HMO must make its
decision within 30 days from the date the appeal is received
by HMO, or 3 business days in the case of an expedited appeal;
and a statement explaining that the hearing officer must make
a final decision within 90 days from the date a Fair Hearing
is requested; and
(m) any other information required by 1 T.A.C.
Chapter 357 that relates to a managed care organization's
notice of action.
8.5.5.2 TIMEFRAME FOR NOTICE OF ACTION
In accordance with 42 C.F.R. Section 438.404(c), the
HMO must mail a notice of action within the following
timeframes:
(1) For termination, suspension, or reduction of
previously authorized Medicaid-covered services, within the
timeframes specified in 42 C.F.R. Sections 431.211, 431.213,
and 431.214.
(2) For denial of payment, at the time of any action
affecting the claim.
(3) For standard service authorization decisions that
deny or limit services, within the timeframe specified in 42
C.F.R. Section 438.210(d)(1).
(4) If the HMO extends the timeframe in accordance
with 42 C.F.R. Section 438.210(d)(1), it must--
(a) Give the Member written notice of the reason for
the decision to extend the timeframe and inform the Member of
the right to file a grievance if he or she disagrees with that
decision; and
(b) Issue and carry out its determination as
expeditiously as the Member's health condition requires and no
later than the date the extension expires.
(5) For service authorization decisions not reached
within the timeframes specified in 42 C.F.R. Section
438.210(d) (which constitutes a denial and is thus an adverse
action), on the date that the timeframes expire.
(6) For expedited service authorization decisions,
within the timeframes specified in 42 C.F.R. Section
438.210(d).
8.5.5.3. NOTICE OF DISPOSITION OF APPEAL. In
accordance with 42 C.F.R. Section 438.408(e), HMO must provide
written
HHSC Contract 529-03-042-N 20 of 27
notice of disposition of all appeals including expedited
appeals. The written resolution notice must include the
results and date of the appeal resolution. For decisions not
wholly in the Members favor, the notice must contain:
(a) the right to request a fair hearing,
(b) how to request a state fair hearing,
(c) the circumstances under which the Member can
continue to receive benefits pending a hearing (see Section
8.5.2.13),
(d) how to request the continuation of benefits,
(e) if the HMO's action is upheld in a hearing, the
Member may be liable for the cost of any services furnished to
the Member while the appeal is pending; and
(f) any other information required by 1 T.A.C.
Chapter 357 that relates to a managed care organization's
notice of disposition of an appeal."
8.5.5.4 TIMEFRAME FOR NOTICE OF RESOLUTION OF
APPEALS. In accordance with 42 C.F.R. Section 438.408, HMO
must provide written notice of resolution of appeals,
including expedited appeals, as expeditiously as the Member's
health condition requires, but the notice must not exceed the
timelines as provided in 8.5.2 or 8.5.3. For expedited
resolution of appeals, HMO must make reasonable efforts to
give the Member prompt oral notice of resolution of the
appeal, and follow up with a written notice within the
timeframes set forth in Section 8.5.3. If the HMO denies a
request for expedited resolution of an appeal, HMO must
transfer the appeal to the timeframe for standard resolution
as provided in Section 8.5.2. and make reasonable efforts to
give the Member prompt oral notice of the denial, and follow
up within two calendar days with a written notice."
SECTION 2.17 DELETION OF SECTION 8.6, MEMBER NOTICE, APPEALS AND FAIR HEARINGS
Section 8.6 is deleted in its entirety. (Information concerning Member
appeals and fair hearings is now located in Section 8.5 above.)
8.6 [deleted]
SECTION 2.18 MODIFICATION OF SECTION 9.01, MARKETING MATERIAL MEDIA AND
DISTRIBUTION
New Section 9.1.1 is added as follows:
"9.1.1 HMO may not make any assertion or statement
(orally or in writing) it is endorsed by the CMS, a Federal or
State government or agency, or similar entity."
SECTION 2.19 MODIFICATION OF SECTION 10.7, UTILIZATION/QUALITY IMPROVEMENT
SUBSYSTEM
In Section 10.7, requirements 5 and 9 from the "Functions and Features"
provision are deleted.
HHSC Contract 529-03-042-N 21 of 27
SECTION 2.20 MODIFICATION OF SECTION 10.12, HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) COMPLIANCE
Section 10.12 is modified to add new Section 10.12.1 as follows:
"10.12.1 HMO must provide its Members with a privacy
notice as required by HIPAA. The 4th to 6th grade reading
level has been waived for the notices and are allowable at a
12th grade reading level. The HMO is not required to send the
notice out in Spanish but must reference on their English
notice, in Spanish, where to call to obtain a copy. HMO must
provide HHSC with a copy of their privacy notice for filing,
but does not need to have HHSC approval."
SECTION 2.21 MODIFICATION OF SECTION 11.1, QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM
Sections 11.1, and 11.5 are deleted and replaced with the following
language:
"11.1 QUALITY ASSESSMENT AND PERFORMANCE
IMPROVEMENT PROGRAM
HMO must develop, maintain, and operate a quality
assessment and performance improvement program consistent with
the requirements of 42 C.F.R. Section 438.240 and Sections
10.7, 12.10 and Appendix A of this agreement.
11.5 Behavioral Health Integration into QIP. If
an HMO provides behavioral health services, it must integrate
behavioral health into its quality assessment and performance
improvement program and include a systematic and on-going
process for monitoring, evaluating, and improving the quality
and appropriateness of behavioral health care services
provided to Members. HMO must collect data, monitor and
evaluate for improvements to physical health outcomes
resulting from behavioral health integration into the overall
care of the Member."
SECTION 2.22 MODIFICATION TO ARTICLE 11, QUALITY ASSURANCE AND QUALITY
IMPROVEMENT PROGRAM
Article 11 is modified to add new Section 11.7, Practice Guidelines.
"11.7 PRACTICE GUIDELINES
In accordance with 42 C.F.R. Section 438.236, HMO
must adopt practice guidelines, that are based on valid &
reliable clinical evidence or a consensus of health care
professionals in the particular field; consider the needs of
the HMO's Members; are adopted in consultation with
contracting health care professionals; and are reviewed and
updated periodically as appropriate. The HMO must disseminate
the guidelines to all affected providers and, upon request to
Members and potential Members. The HMO's decisions regarding
utilization management, member education, coverage of
services, and other areas included in the guidelines, must be
consistent with the HMO's guidelines."
HHSC Contract 529-03-042-N 22 of 27
SECTION 2.23 MODIFICATION OF ARTICLE 12, REPORTING REQUIREMENTS
Section 12.6, Member Complaints is replaced with the following
language. Sections 12.8, Utilization Management Reports - Behavioral
Health and 12.9, Utilization Management Reports - Physical Health are
deleted and replaced with new Section 12.8, Utilization Management
Reports, as follows:
"12.6 MEMBER COMPLAINTS & APPEALS
HMO must submit a quarterly summary report of Member
complaints and appeals. HMO must also report complaints and
appeals submitted to its subcontracted risk groups (e.g.,
IPAs). The complaint and appeals report must be submitted not
later than 45 days following the end of the state fiscal
quarter in a format specified by HHSC.
12.8 UTILIZATION MANAGEMENT REPORTS
12.8.1 Written Program Description. MCO has a
written utilization management program description, which
includes, at a minimum, procedures to evaluate medical
necessity, criteria used, information sources and the process
used to review and approve the provision of medical services.
12.8.2 Scope. The program has mechanisms to detect
underutilization as well as overutilization, including but not
limited to generation of provider profiles.
12.8.3 Preauthorization and Concurrent Review
Requirements. For MCOs with preauthorization or concurrent
review program:
12.8.4 Qualified medical professionals supervise
preauthorization and concurrent review decisions.
12.8.5 Efforts are made to obtain all necessary
information, including pertinent clinical information, and
consult with the treating physician as appropriate.
12.9 [deleted]"
SECTION 2.24 MODIFICATION OF SECTION 12.10, QUALITY IMPROVEMENT REPORTS
Sections 12.10.1 through 12.10.3 are deleted. Sections 12.10.5 and
12.10.6 are added as follows:
"12.10.1 [deleted]
12.10.2 [deleted]
12.10.3 [deleted]
12.10.5 Written Annual Report. HMO must file a
written annual report with HHSC describing the HMO's quality
assessment and performance improvement projects.
HHSC Contract 529-03-042-N 23 of 27
12.10.6 Encounter Data. In accordance with 42 C.F.R.
438.240(c)(2), HMO must submit the encounter data identified
in Section 10.5 of this agreement at least monthly to HHSC, so
that HHSC may complete a performance measurement report."
SECTION 2.25 MODIFICATION OF SECTION 13.1, CAPITATION AMOUNTS
Section 13.1.2 is modified as follows:
13.1.2 The monthly capitation amounts and the Delivery Supplemental
Payment (DSP) amount, effective as of September 1, 2003, are
listed below.
BEXAR SDA MONTHLY ____ HMO
RISK GROUP CAPITATION AMOUNTS ____ HHSC
---------- ------------------
TANF Children (> 1 year of age) $ 71.40
TANF Adults $189.24
Pregnant Women $335.46
Newborns* (up to 12 Months of Age) $408.23
Expansion Children (> 1 year of Age) $ 73.46
Federal Mandate Children $ 64.53
Disabled/Blind Administration $ 14.00
* Includes TANF Child & Expansion Children up to 12 months of Age.
Delivery Supplemental Payment. A one-time per pregnancy
supplemental payment for each delivery shall be paid to HMO as
provided below in the following amount: $2,834.10.
SECTION 2.26 MODIFICATION OF SECTION 13.3, PERFORMANCE OBJECTIVES
Section 13.3.1 is amended as follows,, and Sections 13.3.2 - 13.3.10
are deleted in their entirety.
13.3.1 Performance Objectives. Performance
Objectives are contained in Appendix K of this contract. HMO
must meet the benchmarks established by HHSC for each
objective.
13.3.2 [deleted]
13.3.3 [deleted]
13.3.4 [deleted]
13.3.5 [deleted]
13.3.6 [deleted]
13.3.7 [deleted]
13.3.8 [deleted]
13.3.9 [deleted]
13.3.10 [deleted]
HHSC Contract 529-03-042-N 24 of 27
13.3.10.1 [deleted]
SECTION 2.27 MODIFICATION OF SECTION 13.5, NEWBORN AND PREGNANT WOMEN PAYMENT
PROVISIONS
Section 13.5.5 is modified to comply with HIPAA requirements, as
follows:
"13.5.5 The Enrollment Broker will provide a daily
enrollment file, which will list all TP40 Members who received
State- issued Medicaid I.D. numbers, for each HMO. HHSC will
guarantee capitation payments to the HMOs for all TP40 Members
who appear on the capitation and capitation adjustment files.
The Enrollment Broker will provide a pregnant women exception
report to the HMOs, which can be used to reconcile the
pregnant women daily enrollment file with the monthly
enrollment, capitation and capitation adjustment files."
SECTION 2.28 MODIFICATION OF SECTION 14.1, ELIGIBILITY DETERMINATION
Section 14.1.2.8 is modified as follows and 14.1.2.9 is deleted:
"14.1.2.8 FEDERAL MANDATE CHILDREN (MAO) - Children
aged 6-18 whose families' income is below 100% Federal Poverty
Income Limit.
14.1.2.9 [deleted]"
SECTION 2.29 MODIFICATION OF ARTICLE 15, GENERAL PROVISIONS
Article 15 is modified to add new Section 15.14, Global Drafting
Conventions, as follows:
"15.14 GLOBAL DRAFTING CONVENTIONS.
15.14.1 The terms "include," "includes," and
"including" are terms of inclusion, and where used in the
Agreement, are deemed to be followed by the words "without
limitation."
15.14.2 Any references to "Sections," "Exhibits," or
"Attachments" are deemed to be references to Sections,
Exhibits, or Attachments to the Agreement.
15.14.3 Any references to agreements, contracts,
statutes, or administrative rules or regulations in the
Agreement are deemed references to these documents as amended,
modified, or supplemented from time to time during the term of
the Agreement."
SECTION 2.30 MODIFICATION OF SECTION 16.3, DEFAULT BY HMO
Section 16.3.4, Failure to Comply with Federal Laws and Regulations, is
modified to add Section 16.3.4.7 with the following language:
"16.3.4.7 HMO's failure to comply with requirements
related to Members with special health care needs in Section
6.13 of this Contract, pursuant to 42 C.F.R.Section
438.208(c).
16.3.4.8 HMO's failure to comply with requirement in
Sections 7.2.6 and 7.2.8.7 of this Contract, pursuant to 42
C.F.R. 438.102(a).
HHSC Contract 529-03-042-N 25 of 27
SECTION 2.31 MODIFICATION OF SECTION 18.8, CIVIL MONETARY PENALTIES
Sections 18.8.2 and 18.8.7 are modified as follows:
"18.8.2 For a default under 16.3.4.2, for each
default HHSC may assess double the excess amount charged in
the violation of the federal requirements or $25,000,
whichever is greater. HHSC will deduct from the penalty the
amount of the overcharge and return it to the affected
Member(s)
18.8.7 HMO may be subject to civil monetary
penalties under the provisions of 42 C.F.R. Part 1003 and 42
C.F.R. Part 438, Subpart I in addition to or in place of
withholding payments for a default under Section 16.3.4"
SECTION 2.32 MODIFICATION OF ARTICLE 19, TERM
Section 19.1 is modified as follows:
"19.1 The effective date of this contract is
August 31, 1999. This contract and all amendments thereto will
terminate on August 31, 2004, unless extended or terminated
earlier as provided for elsewhere in this contract."
SECTION 2.33 MODIFICATION TO APPENDIX A, STANDARDS FOR QUALITY IMPROVEMENT
PROGRAMS
Appendix A is replaced with the attached Appendix A
and Attachment A-A.
SECTION 2.34 MODIFICATION TO APPENDIX D, CRITICAL ELEMENTS
Appendix D is replaced with the attached Appendix D.
SECTION 2.35 MODIFICATION OF APPENDIX E, TRANSPLANT FACILITIES
Appendix E is replaced with the attached Appendix E.
SECTION 2.36 ADDITION OF NEW APPENDIX O, STANDARD FOR MEDICAL RECORDS
New Appendix O is added to the contract with the
attached Appendix O.
SECTION 2.37 MODIFICATION TO APPENDIX K, PERFORMANCE OBJECTIVES
Appendix K is replaced with the attached Appendix K
HHSC Contract 529-03-042-N 26 of 27
ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES
The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in this
Amendment.
By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were set
out word for word in the Agreement.
IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS
AMENDMENT TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
SUPERIOR HEALTHPLAN, INC. HEALTH & HUMAN SERVICES COMMISSION
By: /s/ Christopher Bowers By: /s/ Albert Hawkins
----------------------------------- -------------------------------
Christopher Bowers Albert Hawkins
President and CEO Commissioner
Date: Date:
--------------------------------- -----------------------------
HHSC Contract 529-03-042-N 27 of 27