EXHIBIT 10.21
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
SOLICITATION, OFFER AND AWARD
CONTRACT NO: YH8-0001-05 RFP NO: YH8-0001 DATE ISSUED: FEBRUARY 10, 1997
REVISED: APRIL 14, 1997
ISSUED BY: AHCCCSA
CONTRACTS AND PURCHASING SUBJECT OF SOLICITATION:
701 E. JEFFERSON AVENUE ACUTE CARE SERVICES - CYE 98
PHOENIX, AZ 85034 (TERM OF CONTRACT: 10/1/97-9/30/97)
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I. SOLICITATION
Sealed Offers (Original and 5 copies) for providing the services described
herein will be received at the issuing office (above until 3:00 p.m. local time
May 12, 1997. For information call:
Mark Renshaw, Contracts and Purchasing Phone (602) 417-4577
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TABLE OF CONTENTS
A. SOLICITATION OFFER AND AWARD
FORM...........................................1 F. LIST OF ATTACHMENT.............................63
B. RATES..........................................2 G. REPRESENTATIONS &
C. DEFINITIONS..................................3-7 CERTIFICATIONS...............................64-71
D. PROGRAM REQUIREMENTS........................8-52 H. INSTRUCTIONS TO OFFERORS.....................72-84
E. CONTRACT CLAUSES...........................53-62 I. EVALUATION FACTORS...........................85-87
ATTACHMENTS
II. OFFER (Must be fully completed by Offeror)
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The undersigned Offeror hereby agrees, if this offer is accepted within 120 days
of bid opening to provide all services in accordance with the terms and
requirements stated herein, including all attachments, amendments, and best-and
final offer (if any).
NAME OF OFFEROR: HEALTH CHOICE ARIZONA, INC. PHONE: (602) 968-6866
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ADDRESS: 1600 West Broadway Suite 260
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CITY/STATE: Tempe, Arizona ZIP: 85282
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NAME OF THE PERSON AUTHORIZED
TO SIGN OFFER: Patricia E. Levin TITLE: President/CEO
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OFFEROR'S SIGNATURE: /s/ Patricia E. Levin DATE: 5/2/97
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III. AWARD (To be completed by AHCCCSA)
The offer, including all attachments, amendments and best-and-final offer (if
any), contained herein, is accepted.
NAME OF AHCCCSA CONTRACTING OFFICER: Michael Veit DATE: June 24, 1997
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SIGNATURE OF AHCCCSA CONTRACTING OFFICER: /s/ Michael Veit
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SECTION B: CAPITATION RATES
1. The Contractor shall provide services as described in this
solicitation.
2. Attachment B, Service Area Minimum Network Standards, describes
location requirements by Geographic Service Area (GSA).
3. The following capitation rate table, shown for example only, will be
generated by the capitation rate computer program described in
Attachment E. The Offeror must complete one such rate table for each
Geographic Service Area (see Section H, Paragraph 9, Award of Contract)
it is bidding. The Offeror should insert between this page and the
following page the computer-generated printout of all such proposed
rate tables.
4. In preparing capitation rate bids, offerors, especially continuing
offerors, should note the program changes described in the following
paragraphs:
Section D, Paragraph 39, Reinsurance
Section D, Paragraphs 1 and 6, regarding Family Planning
Extension Program Section D, Paragraph 6, regarding Health
Plan Choice and Prior Period Coverage Section H, Paragraph 9,
regarding bidding by Geographic Service Areas
5. Offerors are encouraged to negotiate discounts for inpatient,
outpatient and other medical services to provide for the most
cost-effective capitation rates.
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SAMPLE ONLY
PROPOSED CAPITATION RATES:
(1) GEOGRAPHIC SERVICE AREA:
SUPPLEMENTAL
RATE CODE AND AGE/SEX CAPITATION RATE PER MEMBER PER PAYMENT PER SOBRA
CLASSIFICATION MONTH: BIRTH:
TANF AND CCP AGE/SEX:
< 1 YEAR M + F $
----------------------------------
1-13 YEARS M + F
----------------------------------
14-44 YEARS F
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14-44 YEARS M
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45+ YEARS M + F
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SSI WITH MEDICARE
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SSI WITHOUT MEDICARE
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MN/MI *
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SOBRA FAMILY PLANNING
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SOBRA SUPPLEMENTAL $
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* All MN/MI's (i.e. with and without Medicare) are grouped together for
capitation purposes.
SECTION C: DEFINITIONS
AAC See "Arizona Administrative Code".
AGENT Any person who has been delegated the authority to
obligate or act on behalf of a provider.
AID TO FAMILIES A federal assistance program under Title IV-A of the Social
WITH DEPENDENT Security Act. Replaced by the Temporary Assistance to Needy
CHILDREN (AFDC) Families (TANF) program.
AHCCCS Arizona Health Care Cost Containment System as defined by
ARS 36-2901.
AHCCCSA Arizona Health Care Cost Containment System Administration.
AHCCCS BENEFITS See "COVERED SERVICES".
AHCCCS MEMBER See "MEMBER".
ALTCS The Arizona Long Term Care System (ALTCS), a program under
AHCCCSA that delivers long term, acute and behavioral health
care services to eligible members, as authorized by ARS ss.
36-2931 et seq.
AMBULATORY CARE Preventive, diagnostic and treatment services provided
on an outpatient basis by physicians, nurse practitioners,
physician assistants and other primary care providers.
AMPM The AHCCCS Medical Policy Manual.
ARIZONA State regulations established pursuant to relevant statutes.
ADMINISTRATIVE For purposes of this solicitation, the relevant sections of
CODE (AAC) the AAC are referred to throughout this document as "AHCCCS
Rules".
ARS Arizona Revised Statutes.
AT RISK Refers to the period of time that a member is enrolled
with a contractor during which time the Contractor is
responsible to provide AHCCCS covered services under
capitation.
BIDDERS LIBRARY As referred to in this RFP, a repository of manuals,
statutes, rules and other reference material located at the
AHCCCS office in Phoenix.
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BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
CAPITATION A method by which a contractor is paid to deliver covered
services for the duration of a contract to members based on
a fixed rate per member notwithstanding (a) the actual
number of members who receive care from the contractor, and
(b) the amount of health care services provided to any
member, a cost containment alternative to fee-for-service
payments.
CATEGORICALLY A member who is eligible for Medicaid.
ELIGIBLE MEMBER
COMPETITIVE BID A state procurement system used to select contractors to
PROCESS provide covered services on a geographic basis.
CONTINUING OFFEROR An AHCCCS contractor during CYE 97 that submits a proposal
pursuant to this solicitation.
CONTRACT SERVICES See "COVERED SERVICES".
CONTRACT YEAR (CY) Corresponds to federal fiscal year (Oct. 1 through Sept. 30)
For example, Contract Year 98 is 10/1/97 - 9/30/98.
CONTRACTOR A person, organization or entity agreeing through a direct
contracting relationship with AHCCCSA to provide the goods
and services specified by this contract in conformance with
the stated contract requirements, AHCCCS statute and rules
and federal law and regulations.
CONVICTED A judgment of conviction has been entered by a federal,
state or local court regardless of whether an appeal from
that judgment is pending.
CO-PAYMENT An amount which the member pays directly to a contractor or
provider at the time covered services are rendered.
COUNTY Amount of funds contributed to the AHCCCSA fund by each
CONTRIBUTION Arizona county based on funding formulas established by law.
COVERED SERVICES Health care services to be delivered by a contractor which
are so designated in Section D of this contract and also
AHCCCS Rules R9-22-202 et seq.
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CRS Children's Rehabilitative Services (See Section D,
Paragraph 1, Covered Services).
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified.
DHS Arizona Department of Health Services.
DIRECTOR The Director of AHCCCSA.
DISCLOSING ENTITY An AHCCCS provider or a fiscal agent.
DME Durable Medical Equipment; sturdy, long-lasting items and
appliances that can withstand repeated use, are designed to
serve a medical purpose, and are not generally useful to a
person in the absence of a medical condition, illness or
injury.
DUAL ELIGIBLE A member who is eligible for both Medicare and Medicaid.
DUAL ELIGIBLE A person who is entitled to Medicare Part A insurance and who
QUALIFIED MEDICARE meets certain income, resource and residency requirements of the
BENEFICIARY Qualified Medicare Beneficiary program, and is categorically
eligible for full AHCCCS benefits.
EAC Eligible Assistance Child as defined in ARS 36-2905.03(B);
an AHCCCS state program for children under age 14 receiving
food stamps.
ELIC Eligible Low-Income Child as defined in ARS 36-2905.05(c)
and (D); an AHCCCS state program for children under age 14
whose household income exceeds the income limit for the
MN/MI program but is less than 100% of the federal poverty
level.
ELIGIBLE PERSON A person who meets all eligibility requirements for the
AHCCCS acute care program but who has not yet been enrolled
with an AHCCCS acute care contractor.
ELIGIBILITY A process of determining, through a written application, including
DETERMINATION required documentation, whether an applicant meets the
qualifications for federal (categorical) and/or state only
eligibility.
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ENCOUNTER An encounter is a record of a medically related service
rendered by a provider or providers registered with AHCCCSA
to a member who is enrolled with a contractor on the date of
service. It includes all services for which the contractor
incurred any financial liability.
ENROLLMENT The process by which a person who has been determined
eligible becomes a member with a contractor subject to the
limitations specified in AHCCCS Rule R9-22-333.
EPSDT Early and Periodic Screening, Diagnosis and Treatment; these
services provide comprehensive health care, as defined in
Rule R9-22-213, through primary prevention, early
intervention, diagnosis and medically necessary treatment of
physical and behavioral health problems for AHCCCS members
under 21 years of age.
FEE-FOR-SERVICE (FFS) A method of payment to registered providers on an
amount-per-service basis.
FEDERALLY QUALIFIED An entity which meets the requirements and receives a grant
HEALTH CENTER (FQHC) and funding pursuant to Section 330 of the Public Health
Service Act. An FQHC includes an outpatient health program
or facility operated by a tribe or tribal organization
under the Indian Self-Determination Act (PL 93-638) or an
urban Indian organization receiving funds under Title V of
the Indian Health Care Improvement Act.
FFP Federal financial participation (FFP) refers to the federal
matching rate that the Federal government makes to the Title
XIX program portion of AHCCCS.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1 through
September 30; State fiscal year: July 1 through June 30.
FULL-TIME EMPLOYEE One who is available at all times to fulfill the
requirements of the position.
GATEKEEPER Primary care provider who is primarily responsible for all
medical treatment rendered and who makes referrals as
necessary and monitors the member's treatment.
GEOGRAPHIC SERVICE A specific county or defined grouping of counties that are
AREA (GSA) available for contract award. An offeror may bid on any or
all GSA's. See Section H, Paragraph 9, Award of Contract.
iv
GROUP OF PROVIDERS Two or more health care professionals who practice their
profession at a common location (whether or not they share
facilities, supporting staff, or equipment).
HCFA Health Care Financing Administration, an organization
within the Department of Health and Human Services, a
federal agency.
HEALTH MAINTENANCE Various forms of plan organization, including staff and group
ORGANIZATION (HMO) models, that meet the HMO licensing requirements of the federal
and/or state government and offer a full array of health
care services to members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported claims which is the liability for
services rendered for which claims have not been received.
IHS Indian Health Service (IHS) is a division of the U.S. Public
Health Service. It administers a system of hospitals and
health centers providing health services to Native Americans
and Native Alaskans.
LIEN A legal claim filed with the County Recorder's office in
which a member resides and in the county an injury was
sustained for the purpose of ensuring that AHCCCS receives
reimbursement for medical services paid. The lien is
attached to any settlement the member may receive as a
result of an injury.
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by means of
arrangements with selected providers to furnish
comprehensive services to members; explicit criteria for the
selection of health care providers; significant financial
incentives for members to use providers and procedures
associated with the plan; and formal programs for quality
assurance and utilization review.
MANAGING EMPLOYEE A general manager, business manager, administrator, director,
or other individual who exercises operational or managerial
control over, or who directly or indirectly conducts the
day-to-day operation of, an institution, organization or
agency.
MANAGEMENT A person or organization who agrees to perform any administrative
SERVICES function or service for the Contractor specifically related to
SUBCONTRACTOR securing or fulfilling the Contractor's obligations to AHCCCSA
under the terms of the contract.
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MATERIAL OMISSION A fact, data or other information excluded from a report, contract,
etc. which could lead to erroneous conclusions following
reasonable review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of the Social
Security Act, as amended, which provides Federal matching
funds for a state-operated medical assistance program for
specified populations. Certain mandatory populations and
services must be included to receive FFP; however, states
may add additional optional populations and services with
HCFA approval and also receive FFP.
MEDICARE A Federal program authorized by Title XVIII of the Social
Security Act, as amended.
MEMBER For purposes of this solicitation, a person eligible for
AHCCCS who is enrolled with a Contractor.
MN/MI Medically Needy/Medically Indigent; state program for
individuals not eligible for Medicaid but who meet the
eligibility requirements for the state program.
NEW OFFEROR The organization, entity or person which submits a proposal
in response to this solicitation and which has not been an
AHCCCS contractor during CYE 97.
NON-CONTRACTING A provider who has a contract or subcontract within the AHCCCS
PROVIDER system and renders covered services to an eligible person or
member to whom such provider bears no contractual obligation.
OFFEROR The organization, entity or person which submits a proposal in
response to the AHCCCS Request for Proposal. An offeror who
is awarded a contract becomes a Contractor.
PERFORMANCE A set of standardized indicators designed to assist AHCCCS in
MEASURES evaluating, comparing and improving the performance of its
contractors. Specific descriptions of health services
measurement goals are found in Section D, Paragraph 16,
Performance Measures.
PMMIS Pre-paid Medicaid Management Information System.
PRIMARY CARE An individual responsible for the management of the member's
PROVIDER (PCP) health care that includes a physician who is generally
a family practitioner, general practitioner, pediatrician,
general internist,
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obstetrician, gynecologist, certified nurse practitioner or,
under the supervision of a physician, a physician's
assistant. The PCP must be an individual, not a group or
association of persons, such as a clinic.
PROVIDER A person or entity who contracts with AHCCCSA or subcontracts
with an AHCCCS health plan to provide AHCCCS covered
services to members.
QUALIFIED MEDICARE A Medicare cost-sharing program established by the Medicare
BENEFICIARY (QMB) Catastrophic Coverage Act of 1988 in which Medicaid pays
the Medicare premiums, coinsurance and deductibles for
Medicare recipients meeting specific eligibility
requirements.
RATE CODE Eligibility classification for capitation payment purposes.
REINSURANCE A risk-sharing program provided by AHCCCSA to contractors for
the reimbursement of certain contract service costs incurred
by a member beyond a certain monetary threshold.
RELATED PARTY A party that has, or may have, the ability to control or
significantly influence a contractor, or a party that is, or
may be, controlled or significantly influenced by a
contractor. "Related parties" include, but are not limited
to, agents, managing employees, persons with an ownership or
controlling interest in the disclosing entity, and their
immediate families, subcontractors, wholly-owned
subsidiaries or suppliers, parent companies, sister
companies, holding companies, and other entities controlled
or managed by any such entities or persons.
RFP Request For Proposal document prepared by AHCCCSA which describes
the services required and which instructs prospective
offerors how to prepare a response (proposal).
SCOPE OF SERVICES See "COVERED SERVICES".
SERIOUSLY MENTALLY An adult whose emotional or behavioral functioning is so impaired
ILL (SMI) as to interfere with his (or her) capacity to remain in the
community without supportive treatment or services of a
long-term or indefinite duration. The mental disability is
severe and persistent and may result in a long-term
limitation of his capacities for primary activities of daily
living, interpersonal relationships, home-making, self-care,
employment or recreation.
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SOBRA Refers to a federal law (Sixth Omnibus Budget and Reconciliation Act)
passed in 1986 and subsequently amended, which establishes
eligibility for pregnant women and children based on a
percentage of the federal poverty level (FPL). Currently,
AHCCCS covers pregnant women and infants up to age one with
income up to 140% of FPL, children from 1 through 5 years
with income up to 133% of FPL and children born on or after
September 30, 1983 with income up to 100% of FPL.
STATE The state of Arizona.
STATE PLAN The written agreement between the State and HCFA which describes
how the AHCCCS program meets HCFA requirements for
participation in the Medicaid program.
SUBCONTRACT An agreement entered into by Contractor with a provider of health
care services who agrees to furnish covered services to
members, or with a marketing organization, or with any other
organization or person who agrees to perform any
administrative function or service for Contractor
specifically related to fulfilling Contractor's obligations
to AHCCCSA under the terms of this contract.
SUBCONTRACTOR (1) A person, agency or organization to which a contractor has
contracted or delegated some of its management functions or
responsibilities to provide covered services to its members;
or (2) A person, agency or organization with which a fiscal
agent has entered into a contract, agreement, purchase order
or lease (or leases of real property) to obtain space,
supplies, equipment or services provided under the AHCCCS
agreement.
SUPPLEMENTAL A federal assistance program under Title XVI of the Social
SECURITY INCOME (SSI) Security Act.
TEFRA RISK HMO A Health Maintenance Organization or Comprehensive Medical
Plan which provides Medicare services to Medicare
beneficiaries pursuant to a Medicare risk contract with HCFA
under ss. 1876 of the Social Security Act.
THIRD PARTY An individual, entity or program that is or may be liable
to pay all or part of the medical cost of injury, disease or
disability of an AHCCCS applicant or member. Filing of liens
is a method of securing reimbursement from third parties.
THIRD PARTY The resources available from a person or entity that is, or may be,
LIABILITY by agreement, circumstance or otherwise, liable to pay all or part
of the medical expenses incurred by an AHCCCS applicant or
eligible person.
YEAR See "Contract Year."
viii
SECTION D: PROGRAM REQUIREMENTS
Table of Contents
PAGE
------
1 Scope of Services ............................................................. D - 1
2 Behavioral Health Services .................................................... D - 7
3 AHCCCS Medical Policy Manual .................................................. D - 9
4 Vaccine for Children Program .................................................. D - 9
5 Denials or Reductions of Services.............................................. D - 9
6 Enrollment And Disenrollment .................................................. D - 10
7 Mainstreaming of AHCCCS Members ............................................... D - 12
8 Member Information ............................................................ D - 13
9 Member Surveys ................................................................ D - 15
10 Marketing Plans ............................................................... D - 15
11 Open Enrollment ............................................................... D - 15
12 Transition of Members ......................................................... D - 16
13 Staff Requirements and Support Services ....................................... D - 17
14 Written Policies, Procedures and Job Descriptions ............................. D - 18
15 Advance Directives ............................................................ D - 19
16 Performance Measures .......................................................... D - 19
17 Quality Management and Utilization Management (QM/UM) ......................... D - 21
18 Physician Incentives .......................................................... D - 22
19 Appointment Standards ......................................................... D - 22
20 Referral Procedures and Standards.............................................. D - 23
21 Provider Manual ............................................................... D - 23
22 Primary Care Provider Standards ............................................... D - 24
23 Other Provider Standards ...................................................... D - 25
24 Network Development ........................................................... D - 26
25 Network Management ............................................................ D - 27
26 Federally Qualified Health Centers (FQHC) ..................................... D - 27
27 Provider Registration ......................................................... D - 29
28 Provider Affiliation Tape ..................................................... D - 29
29 Periodic Report Requirements .................................................. D - 29
30 Dissemination of Information .................................................. D - 30
31 Requests for Information ...................................................... D - 30
32 Operational and Financial Readiness Reviews ................................... D - 30
33 Operational and Financial Reviews ............................................. D - 30
34 Claims Payment System ......................................................... D - 31
35 Hospital Reimbursement ........................................................ D - 32
36 Nursing Facility Reimbursement ................................................ D - 33
37 Compensation .................................................................. D - 33
38 Capitation Adjustments ........................................................ D - 35
39 Reinsurance ................................................................... D - 35
40 Coordination of Benefits/Third Party Liability ................................ D - 37
41 Medicare Services and Cost Sharing ............................................ D - 39
42 Copayments .................................................................... D - 41
43 Records Retention ............................................................. D - 41
44 Medical Records ............................................................... D - 42
45 Advances, Distributions, Loans and Investments ................................ D - 43
46 Accumulated Fund Deficit ...................................................... D - 43
47 Data Exchange Requirement ..................................................... D - 43
48 Encounter Data Reporting ...................................................... D - 44
49 Monthly Roster Reconciliation ................................................. D - 45
50 Term of Contract and Option to Renew .......................................... D - 45
51 Subcontracts .................................................................. D - 46
52 Specialty Contracts ........................................................... D - 48
53 Management Services Subcontractors ............................................ D - 48
54 Management Services Subcontractor Audits ...................................... D - 49
55 Minimum Capitalization Requirements ........................................... D - 49
56 Performance Bond or Bond Substitute ........................................... D - 50
57 Amount of Performance Bond .................................................... D - 50
58 Financial Viability Criteria/Performance Measures ............................. D - 51
59 Merger, Reorganization and Change of Ownership ................................ D - 51
60 Sanctions ..................................................................... D - 52
61 Auto-Assignment Algorithm ..................................................... D - 52
62 Grievance Process and Standards ............................................... D - 53
63 Quarterly Grievance Report .................................................... D - 53
64 Pending Legislative Issues .................................................... D - 53
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SECTION D: PROGRAM REQUIREMENTS
Note to Prospective Offerors: Attachment L, Offeror's Checklist, has
been added to this RFP as a convenience to offerors. It is believed to
be a complete list of all submission requirements pursuant to this RFP.
However, if a requirement is stated anywhere in the RFP text yet does
not appear in the Offeror's Checklist, the text statement takes
precedence over the omission of that requirement in the Offeror's
Checklist.
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, state and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22-202 et seq., the AHCCCS Medical Policy
Manual, the AHCCCS Behavioral Health Policy Manual, and the document entitled
"AHCCCS Health Plan Performance Indicators", all of which are incorporated
herein by reference and may be found in the Bidder's Library. The covered
services are briefly described below. Covered services must be medically
necessary and provided by, or coordinated with, a primary care provider, except
for behavioral health and children's preventive dental services. Services must
be rendered by providers that are appropriately licensed, operating within their
scope of practice, and registered as an AHCCCS provider. The Contractor shall
provide the same standard of care for all members regardless of the member's
eligibility category. In situations where a medical policy will not become
effective until 10/1/97 but will affect the bidding or negotiation processes,
relevant information regarding the policy will be available in the Bidder's
Library.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options.
Ambulatory Surgery and Anesthesiology: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a free-standing surgical center or a
hospital based outpatient surgical setting.
Audiology: The Contractor shall provide audiology services to EPSDT members
including the identification and evaluation of hearing loss and rehabilitation
of the hearing loss through other than medical or surgical means (i.e. hearing
aids). Only the identification and evaluation of hearing loss are covered for
members 21 years of age and older unless the hearing loss is due to an accident
or injury-related emergent condition.
Behavioral Health: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2. Behavioral Health Services. For
non-categorical members (MN/MI, EAC, ELIC) behavioral health services are
limited to up to the first 72 hours per episode of
D-1
emergency/ crisis stabilization, not to exceed 12 days per contract year. See
also the AHCCCS Medical Policy Manual and the AHCCCS Behavioral Health Policy
Manual for details on covered behavioral health services.
CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for CRS-covered conditions
is administered by the Arizona Department of Health Services (ADHS) for children
who meet CRS eligibility criteria. The Contractor is responsible for referring
children to the CRS program who are potentially eligible for these services.
Eligibility criteria and the referral process are described in the CRS Policy
and Procedures Manual available in the Bidder's Library. The Contractor is also
responsible for providing primary medical care, including emergency services and
initial care of newborn infants, for members who are also CRS eligible, and to
require the members Primary Care Provider (PCP) to coordinate their care with
the CRS program. All services provided must be included in the members medical
record maintained by the PCP.
DENTAl: The Contractor shall provide EPSDT members all medically necessary
dental services including emergency dental services; dental screening and
preventive services in accordance with the AHCCCS periodicity schedule;
therapeutic dental services; dentures; and pre-transplantation dental services.
The Contractor shall monitor compliance with the EPSDT periodicity schedule for
dental screening services and ensure that dental service reports are included in
the member's medical record maintained by the PCP. The Contractor is required to
meet specific utilization rates for EPSDT members described in Section D,
Paragraph 16, Performance Measures. The Contractor shall ensure that EPSDT
members are notified when dental screenings are due if the member has not been
scheduled for a visit. If no response is received, a second notice must be sent.
EPSDT members may request dental services without referral from their PCP and
may choose a dental provider from the Contractor's provider network. Members 21
years of age and older are eligible for emergency dental services medically
necessary dentures and pre-transplantation dental services only. Dental
standards may be found in the AHCCCS Medical Policy Manual which is incorporated
herein by reference and which may be found in the Bidder's Library.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment for members
under age 21. The Contractor shall ensure that EPSDT members receive required
health screenings in compliance with the AHCCCS periodicity schedule to take
effect 10/1/97 (included herein as Attachment K) and to submit to the AHCCCS
Office of the Medical Director/Acute Care Unit, all EPSDT reports as required by
AHCCCS medical policy. The Contractor is required to meet specific
participation/utilization rates far EPSDT members; these are described in
Section D, Paragraph 16, Performance Measures.
D-2
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a 24-hour-a-day,
7-day-a-week basis, for the sudden onset of a medically emergent condition as
defined by AHCCCS Rule R9-22-l01. The Contractor is encouraged to contract with
emergency service facilities for the provision of emergency services. The
Contractor is encouraged to contract with or employ the services of
non-emergency facilities (e.g. urgent care centers) to address member
non-emergency care issues occurring after regular office hours or on weekends.
The Contractor shall be responsible for educating members and providers
regarding appropriate utilization of emergency room services. The Contractor
shall monitor emergency services utilization (by both provider and member) and
shall have guidelines for implementing corrective action for inappropriate
utilization.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse,
physician assistant or nurse practitioner for advice in emergent or
urgent situations, 24 hours per day, 7 days per week.
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for
conditions of the eye for EPSDT members. For members who are 21 years of age and
older, the Contractor shall provide emergency care for eye conditions which meet
the definition of an emergency medical condition, cataract removal, and/or
medically necessary vision examinations and prescriptive lenses if required
following cataract removal and other eye conditions as specified in the AHCCCS
Medical Policy Manual (AMPM).
FAMILY PLANNING: The Contractor shall provide family planning services for all
members who choose to delay or prevent pregnancy, including medical, surgical,
pharmacological and laboratory services, as well as contraceptive devices,
information and counseling necessary to allow the members to make informed
decisions regarding family planning methods. If the Contractor does not provide
family planning services, it must contract for these services through another
health care delivery system which allows members freedom of choice in selecting
a provider. A prospective offeror may discuss arrangements for family planning
services only with other prospective offerors during the RFP process for the
purpose of making arrangements for the provision of family planning services. In
addition, the Contractor shall provide services to members enrolled in the
Family Planning Services Extension Program, a program that provides only family
planning services for a maximum of 24 months to women whose SOBRA eligibility
has terminated. The Data Book contains cost-related information for this
population and is available in the Bidder's Library.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually-transmitted diseases, tuberculosis and
HIV/AIDS, mammographies and prostate screenings: physical examinations and
diagnostic work-ups; and immunizations. Assessment and screening services for
members under age 21 are based on the AHCCCS EPSDT periodicity schedule.
D-3
HOME HEALTH: The Contractor shall provide these services when members require
part-time or intermittent care but do not require hospital care under the daily
direction of a physician to prevent re-hospitalization or institutionalization
and may include skilled nursing, therapies, supplies and home health aide
services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis stabilization. If the member's
medical condition requires isolation, private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the above
services which may be provided on an outpatient or ambulatory basis (i.e.
laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if determined
reasonable and necessary to decide whether the member should be admitted for
inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. EPSDT immunization requirements include
diptheria, tetanus, pertussis vaccine (DPT), oral polio vaccine, measles, mumps,
rubella vaccine (MMR), H. influenza, type B (HIB), hepatitis B (Hep B), combined
3-antigen rate (4 DPT, 3 OPV, 1 MMR) and varicella vaccine. The Contractor is
required to meet specific immunization rates for EPSDT members which are
described in Section D, Paragraph 16, Performance Measures.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending physician
or dentist, and provided by a CLIA (Clinical Laboratory Improvement Act)
approved hospital, clinic, physician office or other health care facility
laboratory.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants or nurse practitioners certified in
midwifery. Members may select or be assigned to a PCP specializing in
obstetrics. Circumcisions are covered if performed during the newborn's hospital
stay after birth, or on an outpatient basis within one month of the infant's
hospital discharge. Members anticipated to have a low-risk delivery may elect to
receive labor and delivery services in their home from their maternity provider
if this setting is included in allowable settings for the Contractor, and the
Contractor has providers in its network that offer home labor and delivery
services. Members anticipated to have a low-risk prenatal course and delivery
may elect to receive maternity services of prenatal care, labor and delivery and
postpartum care provided by licensed midwives if they are in the Contractor's
provider network. All licensed midwife labor and delivery services must be
provided in the member's home since licensed midwives do not have admitting
privileges in hospitals or AHCCCS registered free-standing birthing centers.
D-4
Members receiving maternity services from a licensed midwife must also be
assigned to a PCP for other health care and medical services.
MEDICALLY NECESSARY ABORTIONS: These services are covered when the pregnancy
would endanger the life of the mother if the fetus were to be carried to term
or, for Title XIX members, if the pregnancy is the result of rape or incest.
Providers must document and submit to the Contractor a Certificate of Medical
Necessity for Pregnancy Termination and prior authorization is required. If the
procedure is performed on an emergency basis, documentation must be submitted to
the Contractor within two working days. Additional documentation, outlined in
the AMPM, is required for members under 13 years of age who seek medically
necessary abortion due to rape or incest.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP, other
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide nursing facility services for
members who require short-term convalescent care not to exceed 90 days per
contract year. Services must be provided in a dually-certified Medicare/Medicaid
facility which includes in the per-diem rate: nursing services, basic patient
care equipment and sickroom supplies, dietary services, administrative physician
visits, non-customized DME, necessary maintenance rehabilitation therapies,
over-the-counter medications, social, recreational and spiritual activities, and
administrative, operational medical direction services. The Contractor shall
continue medically necessary nursing facility services for any member who has
not been determined ALTCS eligible but is currently residing in a nursing
facility and is eligible for services provided under this contract. If the
member becomes ALTCS eligible and is enrolled with an ALTCS Program Contractor
before the end of the maximum 90 days of nursing facility coverage, the
Contractor is only responsible for nursing facility coverage during the time the
member is enrolled with the Contractor.
NUTRITION: The Contractor shall provide nutritional assessment and nutritional
supplements including oral supplements for EPSDT members when medically
necessary. Total parenteral nutrition (TPN) is covered for all members when it
is the sole source of nutrition due to severe pathology of the alimentary tract.
TPN may also be used to supplement nutrition for EPSDT members when medically
necessary but need not be the member's sole source of nutrition.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
D-5
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS AND PHARMACY: Medications ordered by a PCP, attending
physician or dentist and dispensed under the direction of a licensed pharmacist
are covered subject to limitations related to prescription supply amounts.
Contractor formularies and prior authorization requirements, as well as
restrictions for immunosuppressant drugs addressed in AHCCCS medical policies
for transplantations.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member for specialty medical services,
behavioral health and dental services. The PCP is responsible for maintaining
the member's primary medical record which contains documentation of all health
risk assessments and health care services, including those provided by the PCP
and through referral.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those 21 and over; physical therapy for
all members and occupational and speech therapies for EPSDT members are covered
on both an inpatient and outpatient basis if not used as a maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient basis
when prescribed by the member's PCP or attending physician and is necessary to
restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services include bone marrow, heart, lung, heart-lung, kidney, liver and cornea
transplantations (all with related immunosuppressant medications), and are
covered within limitations defined in the AMPM, Chapter 300 for members
diagnosed with specified medical conditions. Such limitations include whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions which substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service.
Services include: pre-transplant inpatient or outpatient evaluation; donor
search; organ/tissue harvesting or procurement; preparation and transplantation
services; and convalescent care. In addition, if a member receives a transplant
covered by a source other than AHCCCS, medically
D-6
necessary non-experimental services are provided within limitations after the
discharge from the acute care hospitalization for the transplantation. AHCCCS
has contracted with transplantation providers for the Contractor's use or the
Contractor may select its own transplantation provider. However, the quality of
services must be equal to or exceed those from the AHCCCS provider and the rate
paid can not exceed the AHCCCS provider's negotiated rate. Transplantations for
the MN/MI population are subject to available funding.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. In an emergency, the member shall be taken to the
nearest appropriate emergency facility. Non-emergency transportation shall be
provided for members who are unable to provide their own transportation for
medically necessary services.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine services necessary to alleviate or stabilize the
emergent condition. The provider must notify the Contractor within 12 hours of
the member's registration with the facility for emergency services. Supporting
documentation for services rendered must be provided when reporting or billing a
service. Triage/screening services must be reasonable, cost effective and meet
the criteria for severity of illness and intensity of service.
2. BEHAVIORAL HEALTH SERVICES
The Contractor is responsible for the provision of Title XIX covered behavioral
health services to members as described below:
CATEGORICAL MEMBERS:
UNDER AGE 18; AGE 21 AND OVER; SMI: On and after the effective date of
enrollment, the Contractor is responsible for up to 72 hours of emergency
behavioral health services provided to categorical members not enrolled with
ADHS. The Contractor is also responsible for referring categorically eligible
members under the age of 18, age 21 and older, and SMI members of any age to the
Regional Behavioral Health Authorities (RBHAs) for the provision of Title XIX
covered behavioral health services. (The RBHAs may, in turn, contract with local
providers.) The Contractor is responsible for ensuring that a medical record is
established by the PCP when information is received about an assigned member
even if the PCP has not yet seen the assigned member. The Contractor shall also
communicate information pertaining to ADHS enrolled members to the ADHS RBHAs
including, but not limited to, current diagnosis, medication, pertinent
laboratory results, last PCP visit, and last hospitalization. For prior period
coverage, the Contractor is responsible for payment of all claims for medically
necessary covered behavioral health services to eligible persons not enrolled
with ADHS.
D-7
NON-SMI, AGE 18, 19 AND 20: The Contractor is responsible for providing Title
XIX covered behavioral health services to categorically eligible non-SMI members
age 18, 19 and 20 in accordance with AHCCCS Rule R9-22-1204 and the AHCCCS
Behavioral Health Policy Manual. Covered services include: inpatient hospital,
inpatient psychiatric facility for individuals under the age of 21, individual
therapy and counseling, group and/or family therapy and counseling, psychotropic
medication adjustment and monitoring, partial care, emergency crisis services,
behavior management, psychosocial rehabilitation, screening, evaluation and
diagnosis, case management, psychotropic medications, and medically necessary
transportation.
REFERRALS: Categorically eligible members age 18, 19 and 20 may be
referred directly for the provision of behavioral health services by
the PCP, family members, self-referrals, schools, other service
providers, and members of the community and State agencies as well as
the Contractor's staff. The same referral procedures which are
applicable to other health care services apply to behavioral health
services.
SERVICE PLAN: The Contractor is responsible for developing a Service
Plan for each categorically eligible member age 18, 19 and 20 requiring
behavioral health services. Service Plans shall be developed within two
weeks of assessment and services shall be authorized and provided
within 30 days from completion of the screening. The Service Plan is to
be included as part of the member's medical record.
CASE MANAGEMENT, CASE COORDINATION: The Contractor is responsible for
providing case management services, when medically necessary. Case
management services may vary in scope and frequency, depending on the
eligible person's intensity of need. Case management services consist
of a set of services and activities through which appropriate and
cost-effective Title XIX covered services are identified, planned,
coordinated, obtained, monitored and continuously evaluated. Case
coordination is provided to categorically eligible members age 18, 19
and 20 who are in need of behavioral health services but who do not
require case management services which are more intensive. Case
coordination is limited to Service Plan development, identification of
service providers, monitoring, updates and follow-up, when necessary.
QUALITY MANAGEMENT/UTILIZATION, MANAGEMENT (QM/UM) REQUIREMENTS:
Quality management QM/UM for behavioral health services must be
integrated into the Contractors QM/UM plans and must meet the QM/UM
requirements established by AHCCCSA.
PROVIDER NETWORK: The Contractor is responsible for contracting with
behavioral health providers who meet ADHS licensure and/or
certification standards and who are registered as a behavioral health
provider with AHCCCSA. The Contractor may, at its option, contract with
ADHS RBHAs for the provision of behavioral health services. The
Contractor must ensure that a sufficient number of qualified behavioral
health providers are in their provider network and that providers
comply with subcontracting, appointment standards and other provider
related requirements in this document.
D-8
NOTIFICATION REQUIREMENTS: The Contractor is responsible for notifying
AHCCCSA monthly of 18-19-and 20-year-old categorical. non-SMI members
referred and receiving behavioral health services. The information is
to be submitted to the AHCCCS Office of Managed Care using the
reporting format developed by AHCCCSA and available in the Bidder's
Library.
MN/MI, EAC, ELIC MEMBERS:
For non-categorical members (MN/MI, EAC, ELIC) behavioral health services are
limited to up to 72 hours per episode of emergency/crisis stabilization, not to
exceed 12 days per contract year.
3. AHCCCS MEDICAL POLICY MANUAL (AMPM)
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. AHCCCSA will provide three copies of the AMPM to the Contractor
(for use by the CEO, Medical Director and Quality Management staff). Updates to
medical policies will be distributed quarterly. The Contractor is responsible
for maintaining the AMPM with these updates and for complying with the
requirements set forth therein.
4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program the federal government purchases, and
makes available to the states free of charge, vaccines for children under age 19
who are Title XIX eligible (or Native American) and not insured, or whose
insurance does not cover immunizations. Any provider licensed by the State to
administer immunizations may register with ADHS as a "VFC provider" and receive
free vaccines. State money to purchase vaccines is not available since the
program is 100% funded by the federal government. The Contractor shall comply
with all VFC requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS EPSDT members, the providers are registered with
ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When a covered service is denied, reduced, suspended or terminated, the
Contractor shall comply with the notice and continuation of benefits
requirements specified in 42 CFR 431.200 et seq. and further prescribed in Perry
V. Chen, now referred to as Perry v. Kelly.
D-9
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
Social Security Administration (SSA) SSA determines eligibility for
the Supplementary Security Income
(SSI) cash program. SSI Cash
recipients are automatically
eligible for AHCCCS coverage.
Department of Economic Security (DES) DES determines eligibility for the
Temporary Assistance to Needy
Families (TANF) program (formerly
Aid to Families with Dependent
Children), TANF Medical Assistance
Only (MAO) groups (including SOBRA
women and children), the Eligible
Assistance Children state program
(EAC) and the Federal Emergency
Services program (FES) related to
the TANF or SOBRA programs.
AHCCCSA AHCCCSA determines eligibility for
the SSI/MAO groups, including the
FES program related to the SSI-Cash
program (aged, disabled, blind), the
Arizona Long-Term Care System
(ALTCS), and the Qualified Medicare
Beneficiary program.
Arizona's 15 Counties Each county determines eligibility
for the Medically Needy/Medically
Indigent (MN/MI), Eligible Low
Income Children (ELIC), and the
State Emergency Services state
programs.
AHCCCS acute care eligible members are enrolled with contractors in accordance
with the rules set forth in R9-23-333, R9-22-334, R9-22-335, R9-22-337,
R9-22-339, R9-22-340, R9-22-342 and R9-22-707.
HEALTH PLAN CHOICE
All members except for those eligible under the MN/MI program have a choice of
available health plans. AHCCCSA anticipates that a listing of the available
health plans and their telephone numbers will be given to each member applicant
during the application process for AHCCCS benefits. Also included are
instructions to member applicants to call the health plans directly with
specific questions concerning the health plan. If there is only one health plan
available for the member applicant's Geographical Service Area, no choice is
offered. Members who do not choose prior to AHCCCSA's being notified of their
eligibility are anticipated to be
D-10
automatically assigned to a health plan based on family continuity or the
auto-assignment algorithm.
AHCCCSA assigns MN/MI eligible members to an available health plan based on
family continuity or through AHCCCSA's auto-assignment algorithm. These members
do not get a choice of available contractors until the annual open enrollment
period.
Exceptions to the above enrollment policies include: Previously eligible and
enrolled members who have been disenrolled for less than 90 days will be
automatically enrolled with the same contractor if that contractor is still
available. Also, women whose SOBRA eligibility has terminated and have become
enrolled in the Family Planning Services Extension Program will automatically
remain assigned to the same health plan. The Family Planning Services Extension
Program provides a maximum of 24 months of family planning services.
The effective date of enrollment of a new member with the Contractor will
generally be the day prior to the date the Contractor receives notification from
AHCCCSA via the daily roster. However, the Contractor is responsible for payment
of medically necessary covered services retroactive to the member's beginning
date of eligibility.
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for categorical and
non-categorical members. For categorical members, prior period coverage starts
from the first day of the month of application, or first eligible month. The
Contractor is responsible for payment of all claims for medically necessary
covered services provided to categorical members during prior period coverage.
For non-categorical members (MN/MI, ELIC) prior period coverage is generally
limited to the two days prior to the date of AHCCCSA being notified of
eligibility. However, prior period coverage could include additional days prior
to the date of enrollment. The Contractor is responsible for payment of all
claims for medically necessary covered services provided on an emergency basis
to non-categorical members pursuant to ARS ss. 36-2908 for the first two days of
the prior period coverage. Any additional prior period coverage for
non-categorical members will include all claims for medically necessary covered
services. This may include services provided prior to 10/1/97. (See Section D,
Paragraph 37, Compensation, for a description of the Contractor's reimbursement
from AHCCCSA for this eligibility time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers who were enrolled at the time
of the child's birth and whose newborn notification was received by AHCCCSA will
be enrolled with the mother's contractor. The Contractor is responsible for
notifying AHCCCSA of a child's birth to an enrolled member and, for capitation
purposes, the effective date of the newborn's enrollment is the date AHCCCSA
receives such notification. Note that AHCCCSA is currently available to receive
these calls Monday through Friday from 8 am to 5 pm. The effective date of
enrollment will be the date notification is received and capitation will begin
on that date. Categorically eligible mothers or newborns are sent a letter
advising them of their right to choose a different contractor for their child;
otherwise the child will remain with the mother's contractor. The Contractor is
responsible for all covered services to the newborn whether or not AHCCCSA has
received notification of the child's birth. Newborns of MN/MI mothers are
enrolled with the mother's contractor for a minimum of 30 days up to a maximum
of 60 days.
D-11
AHCCCS Rules R9-22-342 and R9-22-707 contain additional information concerning
newborn enrollment and payment.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a categorically
eligible member, or as an Eligible Assistance Child (EAC), the member is
guaranteed a minimum of five full months of continuous enrollment. Enrollment
guarantees do not apply to Native Americans who choose to obtain their covered
services through Indian Health Services (IHS) on a fee-for-service basis. The
enrollment guarantee applies a maximum of one time per member as a categorical
member and one time as an EAC member. If a member changes from one contractor to
another within the enrollment guarantee period, the remainder of the guarantee
period applies to the new contractor. The enrollment guarantee may not be
granted or may be terminated if the member is incarcerated or, if a minor child,
is adopted. AHCCCS Rule R9-22-337 describes other reasons for which the
enrollment guarantee may not apply.
NATIVE AMERICANS: Native Americans eligible under any coverage group other than
MN/MI, on or off-reservation, have a choice of Indian Health Services (IHS) or
any available contractor. If choice is not made within the specified time limit,
Native American members living on-reservation will be assigned to IHS and Native
American members living off-reservation will be assigned to an available
contractor using AHCCCSA's family continuity policy and auto-assignment
algorithm. Native American members eligible under the MN/MI coverage group
living on-reservation will be assigned to Indian Health Services (IHS) and those
living off-reservation will be assigned to a contractor using regular MN/MI
enrollment policy. Native Americans may change from IHS to a contractor or from
a contractor to IHS at any time.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, or physical or mental handicap, except where
medically indicated. Examples of prohibited practices include, but are not
limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
d. The assignment of tunes or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
D-12
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e., the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. Information shall be submitted on
disk, saved as a text file (.txt) along with a hard copy printout. Information
shall be provided in English and a second language when 200 members or 5% of the
Contractor's enrolled population, whichever is greater, are non-English
speaking. (AHCCCSA will advise the Contractor when and if this requirement
applies.) When there are program or service site changes notification will be
provided to the affected members at least 14 days before implementation. The
Contractor shall review and update the Member Handbook at least once a year. The
Handbook must be submitted to AHCCCSA Office of Managed Care for approval by
Sept. 1 of each contract year, or within four weeks of receiving the annual
renewal amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A Member Handbook which, at a minimum, shall include:
a. A table of contents
b. A general description of how managed care works, particularly in
regards to member responsibilities, appropriate utilization of services
and the PCP's role as gatekeeper of services
c. A description of all available covered services and an explanation of
any service limitations or exclusions from coverage and a notice
stating that the Contractor will be liable only for those services
authorized by the Contractor. The description should include a brief
explanation of the Contractor's approval and denial process.
d. Information on what to do when family size changes
e. How to obtain a PCP
f. How to change PCPs
g. How to make, change and cancel appointments with a PCP
h. List of applicable copayments (including a statement that care will not
be denied due to lack of copayment). The member handbook must clearly
state that members cannot be billed for covered services (other than
applicable copayments) and under what circumstances a member may be
billed for non-covered services.
D-13
i. Dual eligibility (i.e. Medicare and Medicaid); services received in and
out of the Contractor's network, copayments. See Section D, Paragraph
41, Medicare Services and Cost Sharing.
j. The process of referral to specialists and other providers, including
access to behavioral health services provided by the ADHS RBHA system
for members under age 18, 21 and older, and SMI members of any age.
k. How to contact Member Services and a description of its function
1. What to do in case of an emergency and instructions for receiving
advice on getting care in case of an emergency. In a life-threatening
situation, the member handbook should instruct members to use the
emergency medical services (EMS) available and/or activate EMS by
dialing 9-1-1. Handbook should contain information on proper emergency
service utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. Screenings include a comprehensive and developmental
history, comprehensive, unclothed physical examination, appropriate
vision testing, hearing testing, laboratory tests, dental screening and
immunizations.
o. Maternity and family planning services
p. Listing of covered behavioral health services
q. Listing of all covered dental services for members under 21 and how to
access these services
r. Out of county/out of state moves
s. Grievance procedures, including a clear explanation of the member's
right to file a grievance and to appeal any decision that affects the
member's receipt of covered services.
t. Contributions the member can make towards his/her own health, member
responsibilities, appropriate and inappropriate behavior, and any other
information deemed essential by the Contractor or AHCCCS. This shall
include a statement that the member is responsible for protecting his
or her ID card and that misuse of the card, including loaning, selling
or giving it to others could result in loss of the member's eligibility
and/or legal action.
u. How to access after-hours care (urgent care).
v. Advance directives for adults
w. Use of other sources of insurance. See Section D, Paragraph 40,
Coordination of Benefits.
x. The last revision date
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type-style and size which can easily be read by members with
varying degrees of visual impairment. At a minimum, the member handbook shall
also contain the following language regarding questions, problems and grievances
(Ref. AHCCCS Rule 9-22-518):
Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call _________ and ask to
talk to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
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Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 35 days after the date of the
action, decision, or incident.
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
II. A list of the names, telephone numbers and service site addresses of
PCPs available for selection by the member and a description of the selection
process.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs, communication
between members and the Contractor, and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in this survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, the Contractor shall perform its own annual general
or focused member survey. All such contractor surveys must be approved in
advance by AHCCCSA.
10. MARKETING PLANS
The Contractor shall submit all proposed marketing plans and materials to
AHCCCSA for prior approval in accordance with the AHCCCS Health Plan Marketing
Policy, a copy of which is available in the Bidder's Library. The Contractor
must have signed contracts with hospitals (in Maricopa and Pima counties), PCPs,
specialists and pharmacies in order for them to be included in marketing
materials.
11. OPEN ENROLLMENT
AHCCCSA conducts an open enrollment for members once per contract year, usually
in August or September. AHCCCSA may hold additional open enrollments on a
limited basis as deemed necessary. During open enrollment members may change
contractors subject to the availability of other contractors within their area.
Members are mailed a printed enrollment form and may
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choose a new contractor by contacting AHCCCSA to complete the enrollment
process. If the member does not participate in open enrollment, no change of
contractor will be made (except for approved changes under the Change of Plan
policy) for the new contract year provided the Contractor's contract is renewed
and the member continues to live in the Contractor's service area. The
Contractor shall comply with the Office of Managed Care Member Transition for
Open Enrollment policy.
12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM standards for member transitions
between health plans or GSA's, to or from an ALTCS program contractor, and upon
termination or expiration of a contract. The Contractor shall develop and
implement policies and procedures which comply with AHCCCS medical policy to
address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as behavioral health,
dialysis, home health, chemotherapy and/or radiation therapy or who are
hospitalized at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services. The Contractor shall comply
with the AHCCCS Behavioral Health Policy Manual for transition of members in
need of behavioral health services to be provided through the ADHS RBHA system.
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
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a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
1) A monthly claims aging report by provider/creditor including
IBNR amounts;
2) A monthly summary of cash disbursements;
3) Copies of all bank statements received by the Contractor.
Such reports shall be due on the fifth day of each succeeding month for
the prior month.
d. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnity AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
e. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
f. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
HOSPITAL REIMBURSEMENT PILOT PROGRAM - MARICOPA AND PIMA COUNTIES ONLY: Members
transferred from non-contracting hospitals shall be done in accordance with the
AHCCCS Medical Policy pertaining to member transfers dated 10/1/94.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. At a
minimum, the following staff are required.
a. A full-time Administrator who is available at all times to fulfill the
responsibilities of the position and to oversee the entire operation of
the health plan.
b. A Medical Director who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A full-time Chief Financial Officer who is available at all times to
fulfill the responsibilities of the position and to oversee the budget
and accounting systems implemented by the Contractor.
d. A Quality Management/Utilization Management Coordinator who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A Maternal Health/EPSDT Coordinator who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
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f. A Behavioral Health Coordinator who shall be a behavioral health
professional as described in Health Services Rule R9-20-306.B.
g. Prior Authorization staff to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. Concurrent Review staff to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. Member Services Manager and staff to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems.
j. Provider Services Manager and staff to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A Claims Administrator and Claims Processors to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
l. Encounter Processors to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A Grievance Coordinator who will manage and adjudicate member and
provider grievances.
n. Clerical and Support staff to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCSA, Office of Managed Care, in writing within
seven days of staffing changes in the following key positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/EPSDT Coordinator Quality Management/Utilization
Grievance Coordinator Management Coordinator
Behavioral Health Coordinator
The Contractor shall ensure that all staff have appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and
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signed by the Contractor's appropriate manager, coordinator, director or
administrator. All medical and quality management policies must be approved and
signed by the Contractor's Medical Director. Job descriptions shall be reviewed
at least annually to ensure that current duties performed by the employee
reflect written requirements.
15. ADVANCE DIRECTIVES
The Contractor shall specify in the contract or agreement with each hospital,
nursing facility, provider of home health care, hospice or personal care
services that the provider must comply with federal and State law regarding
advance directives for adult members. At a minimum, the providers (hospitals,
nursing facilities, home health care, hospice and personal services) shall:
a. Maintain written policies for adult members receiving care through
their organization regarding the member's right to make decisions about
medical care, including the right to accept or refuse medical care and
the right to execute an advance directive. The information must contain
an explanation of any conscientious objection the provider may have in
carrying out the advance directive. (The Contractor is not prohibited
from making such objection when made pursuant to ARS 36-3205 (C.l)
b. Provide written information to adult members regarding an individual's
rights under State law to make decisions regarding medical care and the
provider's written policies concerning advance directives.
c. Require documentation in the member's medical record as to whether the
adult member has executed an advance directive.
d. Not condition the provision of care or discriminate against a member
because of his or her decision to execute or not execute an advance
directive.
e. Provide education for staff on issues concerning advance directives.
f. Ensure compliance with requirements of federal and State law regarding
advance directives.
The Contractor shall also maintain policies and procedures on advance directives
with respect to all adult members. These policies and procedures must contain
the same information described immediately above.
16. PERFORMANCE MEASURES
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program to at least 80% of all enrolled EPSDT
members during CYE 98. "Participation" is defined as at least one initial and
periodic screening or one preventive or treatment visit. AHCCCSA will measure
participation levels through encounter data and will not use information from
prior period coverage (see Paragraph D.6. Prior Period Coverage) in evaluating
the Contractor's performance.
If the Contractor has not achieved at least the statewide average
participation/utilization rates for EPSDT services by the end of the contract
year, as indicated through notification from AHCCCSA, the Contractor shall
submit a corrective action plan to AHCCCSA. The plan shall
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be submitted within 30 days of the Contractor's receipt of
participation/utilization rate notification from AHCCCSA. In addition, AHCCCSA
may conduct one or more follow-up on-site reviews to verify compliance with the
corrective action plan.
If the Contractor's rate is higher than the statewide average for EPSDT
participation. but lower than 80%, AHCCCSA may require the Contractor to submit
a corrective action plan within specified time lines.
EPSDT IMMUNIZATIONS: The Contractor shall ensure EPSDT members receive
age-appropriate immunizations as specified in the AHCCCS Medical Policy Manual.
The AHCCCSA long range goal is to reach or exceed the Healthy People Year 2000
goal of 90% immunization for two year old members. During CYE98, the Contractor
shall meet or exceed the following:
Percentage of Number of
Immunization Members Immunized Doses
Diptheria, Tetanus, Pertussis vaccine (DPT) 80% 4
Oral Polio Vaccine 85% 3
Measles, Mumps, Rubella Vaccine (M7MR) 90% 1
H. Influenza, Type B (HIB) 90% 1
Hepatitis B (Hep B) 85% 3
Combined 3-Antigen Rate (4DPT, 3 OPV, 1MMR) 80% N/A
Combined All Antigens 70% N/A
Varicella Vaccine N/A N/A
The Contractor shall conduct an annual immunization audit based on random
sampling to assess and verify the immunization status of two year old EPSDT
members. AHCCCSA will provide the Contractor, within two weeks after the end of
the contract year, with the selected sample, specifications for conducting the
audit, the AHCCCSA reporting requirements, and technical assistance. The
Contractor shall identify the children's PCP, conduct the assessment, and report
to AHCCCSA in the required format all immunization rates for the sampled
two-year-old children no later than December 15 after the end of the contract
year. If medical records are missing for more than 5% of the sample group, the
Contractor is subject to sanctions by AHCCCSA. Health Services Advisory Group
(HSAG) will conduct a study to validate the Contractor's reported rates.
AHCCCSA will provide the statewide average immunization rates to the Contractor.
If the Contractor has not achieved at least these statewide averages by the end
of the contract year, the Contractor shall submit a corrective action plan to
AHCCCSA. The plan shall be submitted within 60 days of the Contractor's receipt
of utilization rate notification from AHCCCSA. In addition, AHCCCSA may conduct
one or more follow-up on-site reviews to verify compliance with the corrective
action plan.
If the Contractor's immunization rates are higher than the statewide average for
immunizations, but lower than the stated goals set forth in this contract,
AHCCCSA may require the Contractor to submit a corrective action plan within
specified time lines.
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PERFORMANCE INDICATORS: The AHCCCS goal for quality of care is to meet or exceed
the Healthy People Year 2000 national goals. For CYE 98, the Contractor shall
comply with AHCCCS quality management requirements to improve performance of at
least the following established performance indicators: low birth weight;
mammography screening; and cervical cancer screening.
If the Contractor has not achieved at least the statewide average for each
performance indicator by the end of the contract year, it shall submit to
AHCCCS, Office of the Medical Director, Acute Care Unit, a quality improvement
plan. The plan shall be submitted within 60 days after the Contractor's receipt
of performance measurement notification from AHCCCA.
A quality improvement plan may be required for each performance indicator in
which the Contractors performance rate is above the statewide average for all
contractors but below the midpoint between the statewide average and the
best-performing health plan.
EPSDT DENTAL SERVICES: The Contractor shall take affirmative steps to increase
utilization of dental services for EPSDT members. At least 50% of all enrolled
members under age 21 shall have at least one dental visit during CYE98. AHCCCSA
will monitor utilization through reported encounter data.
If the Contractor has not achieved at least the statewide average rate for
utilization of dental services by the end of the contract year, as indicated
through notification from AHCCCSA, the Contractor shall submit a corrective
action plan to AHCCCSA. The plan shall be submitted within 30 days of the
Contractor's receipt of utilization rate notification from AHCCCSA. In addition,
AHCCCSA may conduct one or more follow-up on-site reviews to verify compliance
with the corrective action plan. If the Contractor's rate is higher than the
statewide average for EPSDT dental services, but lower than 50%, AHCCCSA may
require the Contractor to submit a corrective action plan within specified time
lines.
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
The Contractor shall provide to members quality medical care as described in the
AHCCCS Medical Policy Manual, Chapter 900, regardless of payer source or
eligibility category. The Contractor shall institute processes to assess, plan,
implement and evaluate quality improvement activities. The Contractor shall
conduct two clinical studies each contract year as required in Chapter 900 of
the AHCCCS Medical Policy Manual. AHCCCSA will determine the subject matter and
study methodology for one of the annual studies and the Contractor shall submit
to AHCCCSA by November 15 of each contract year its proposed subject matter and
methodology for the other. The results of the studies shall be submitted to
AHCCCS, Office of the Medical Director, within 90 days after the end of each
contract year.
The Contractor must maintain a written QM/UM plan which details plans for
compliance with the AHCCCS Medical Policy Manual. The Contractor shall
incorporate in its QM/UM plan an action plan for improving the performance rates
for those indicators with established baselines.
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18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFPR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. AHCCCSA has
accumulated all available information from HCFA regarding physician incentives
in a binder marked "Physician Incentive Guidelines" in the Bidder's Library. Due
to recent verbal communication with HCFA representatives regarding physician
incentives, AHCCCSA is postponing its development of the "AHCCCS Physician
Incentive Guidelines"; therefore, offerors are instructed to use the information
described above.
19. APPOINTMENT STANDARDS
For purposes of this section "urgent" is defined as an acute but not necessarily
severe disorder which, if not attended to, could endanger the patient's health.
The Contractor shall have procedures in place that ensure the following
standards are met: a. Emergency PCP appointments - same day b. Urgent care PCP
appointments - within two days c. Routine care PCP appointments - within 21 days
For specialty referrals and dental appointments, the Contractor shall be able to
provide:
a. Emergency appointments- within 24 hours of referral
b. Urgent care appointments - within 3 days of referral
c. Routine care appointments - within 30 days of referral
For maternity care, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within 3 days of request
d. High risk pregnancies - within 3 days of identification of high risk by
the Contractor or maternity care provider, or
immediately if an emergency exists
For behavioral health services to members 18-20 years of age, non-seriously
mentally ill, the Contractor shall be able to provide appointments as follows:
a. Emergency screening and evaluation - within 24 hours of referral or
request for services
b. Behavioral health screening - within seven days of referral
c. Non-emergency appointments - within 30 days of referral or behavioral
health screening
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If a member needs medically-necessary transportation, the Contractor shall
require its transportation provider to schedule the transportation so that the
member arrives no sooner than one hour before the appointment; does not have to
wait more than one hour after making the call to be picked up; nor have to wait
for more than one hour after conclusion of the appointment for transportation
home.
The Contractor shall monitor the adequacy of its appointment processes and
reduce the unnecessary use of alternative methods such as emergency room visits.
The Contractor shall monitor and ensure that a member's waiting time for a
scheduled appointment at the PCP's or specialist's office is no more than 45
minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network about appointment time requirements. The Contractor must assign
a specific staff member or unit within its organization to monitor compliance
with appointment standards and shall require a corrective action plan when
appointment standards are not met.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists to include, as a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up of
all referrals including EPSDT referrals for behavioral health services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of the provider
c. Overview of the Contractor's Provider Service department and function
D-23
d. Listing and description of covered and non-covered services, requirements
and limitations
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive and developmental
history, comprehensive unclothed physical examination, appropriate vision
testing, hearing testing, laboratory tests, dental screenings and
immunizations
g. Dental services
h. Maternity/Family Planning services
i. Listing of behavioral health services
j. The Contractor's policy regarding PCP assignments
k. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS RBHA system for members
under age 18, 21 and older and SMI members of any age
l. Grievance and appeal rights
m. Billing and encounter submission information
- indicate which form, UB92, HCFA 1500, or Form C is to be used
for services
- indicate which fields are required for a claim to be considered
acceptable by the Contractor. A completed sample of each form shall
be included
n. Contractor's written policies and procedures which affect the provider(s)
and/or the provider network
o. Claims re-submission policy and procedure
p. Reimbursement, including reimbursement for dual eligibles (i.e. Medicare
and Medicaid) or members with other insurance
q. Explanation of remittance advice
r. Prior authorization requirement
s. Claims medical review
t. Concurrent review
u. Fraud and Abuse
v. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
w. AHCCCS appointment standards
22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics or pediatrics; certified nurse practitioners or certified nurse
midwifes; or physician's assistants.
At a minimum, the Contractor's number of full-time equivalent PCPs to enrolled
members shall not exceed a ratio of 1:1800 for adults and 1:1200 for children
who are 12 or younger. If the PCP contracts with more than one AHCCCS health
plan, the ratio shall be adjusted by the Contractor to ensure the total number
of AHCCCS members does not exceed the above ratio. The
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Contractor should consider the PCP's total patient panel size (i.e., AHCCCS and
non-AHCCCS patients) when assessing the PCP's ability to meet AHCCCS'
appointment and other standards. In addition, AHCCCS members shall not comprise
the majority of the PCP's panel of patients. The Contractor shall also reduce
the number of members assigned to its network PCPs as necessary to meet the
appointment standards specified in Section D, Paragraph 19, Appointment
Standards. Any variation to the above standards must be submitted to AHCCCSA
Office of the Medical Director for prior approval. PCPs with assigned members
diagnosed with AIDS or as HIV-positive shall meet criteria and standards set
forth in AHCCCS Medical Policy and AHCCCS AIDS Advisory Committee Guidelines.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions who are age 12 and younger to Board-certified
pediatricians.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP assignment, should the member desire to do so. The
Contractor shall confirm any PCP change in writing to the member. Members may
make both their initial PCP selection and any subsequent PCP changes either
verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of the Medical Director. PCPs and specialists who provide
inpatient services to the Contractor's members shall have admitting and
treatment privileges in a minimum of one general acute care hospital that is
located within the Contractor's service area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
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a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet the
medical needs of its members.
b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members.
Contractor policies shall be subject to approval by AHCCCS, Office of the
Medical Director and shall be monitored through operational audits at least
annually.
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services.
b. Specialty physicians shall not begin a course of treatment for a medical
condition other than that for which the member was referred, unless
approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies of test results
if applicable, treatment services provided and the resulting outcome for
each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are general
practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians and certified nurse practitioners and certified nurse midwives who
include such services within their practice.
24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient professional and
paramedical personnel for the provision of covered services,
D-26
including emergency medical care on a 24-hour-a-day, 7-days-a-week basis. The
proposed network shall be sufficient to provide covered services within
designated time and distance limits.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertain to all
service specifications described in the AHCCCS Medical Policy Manual, Chapters
300, 600 and 900. In addition, the Contractor shall have policies on how the
Contractor will:
a. Communicate with the network regarding contractual and/or program changes
and requirements
b. Monitor and control network compliance with policies and rules of AHCCCSA
and the Contractor
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service area
e. Monitor network capacity to ensure that there are sufficient providers to
handle the volume of members
f. Ensure service accessibility, including monitoring appointment procedures
standards, appointment waiting times, and service provision standards
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this solicitation.
The Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates in OBRA 89 and OBRA 90. This
legislation gives FQHCs the option to require state Medicaid programs to
reimburse the FQHC at 100% of reasonable costs
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for the services delivered. AHCCCSA and its contractors are required to comply
with this legislation.
At the time of contracting, the Contractor must offer the FQHC the option to
elect reasonable cost reimbursement for categorically eligible members. This
provision should be within the contract between the FQHC and the Contractor. If
the FQHC does not elect reasonable cost reimbursement, the FQHC waives the
opportunity to receive reasonable cost reimbursement for that contract period.
No retroactive elections shall be permitted.
If the FQHC elects reasonable cost reimbursement, the Contractor must notify the
AHCCCSA Office of Managed Care within seven days of the subcontract signing. If
the FQHC elects reasonable cost reimbursement, the Contractor may, at its
discretion, pay reasonable cost reimbursement, or pay using some other method of
payment, such as capitation, since the requirement to pay reasonable costs
applies to the State Medicaid Agency, not to the Contractor.
For example, the Contractor contracts with an FQHC that elects reasonable cost
reimbursement. The method of payment throughout the contract period could be
capitation. Throughout the year, the Contractor would be required to file a
quarterly cost report with AHCCCS. (The instructions for the health plan
quarterly reports can be obtained from the Office of Managed Care.) At the end
of the year, the FQHC must complete certain reporting requirements outlined in
the Arizona Health Care Cost Containment System Reasonable Cost Reimbursement
Cost Report & Instructions. These two reporting packages will enable AHCCCSA to
determine reasonable costs, in comparison to actual capitation paid by the
Contractor. AHCCCSA would reimburse the FQHC if the capitation payments were
less than reasonable costs. Likewise, AHCCCSA would recoup payments in excess of
reasonable costs.
In determining the reasonableness of the capitation payments made by the
Contractor to the FQHC, AHCCCSA will value the per member per month capitation
payment at a rate which approximates the average rate being paid by the
Contractor in the community to other similar providers. If there are no other
providers from which to develop an average rate, other means will be used to
determine the average for the area. If the actual capitation rate paid by the
Contractor to the FQHC is less than the average rate being paid by the
Contractor to other providers, the Contractor must reimburse the FQHC for this
difference. AHCCCSA would reimburse the difference between reasonable cost and
the average capitation rate.
The Contractor shall adhere to the AHCCCS Federally Qualified Health Centers
Cost Resort Instructions-General Instructions which describes the reporting
requirements applicable to the Contractor's contracting with a FQHC that elects
cost reimbursement. A copy of these requirements is available in the Bidder's
Library. Included among the FQHCs currently recognized by HCFA are the
following:
Clinica Adelante
West Pinal Family Health Center
Valley Health Center
United Community Health Center
Mariposa Community Health Center
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Lake Powell Medical Center
Mountain Park Health Center
El Rio Santa Cruz Neighborhood Health Center
Native American Health Care Center
Traditional Indian Alliance
Native Americans for Community Action, Inc.
27. PROVIDER REGISTRATION
The Contractor shall ensure that each of its subcontractors register with
AHCCCSA as an approved service provider and receive an AHCCCS Provider ID
Number. A Provider Participation Agreement must be signed with each provider who
does not already have a current AHCCCS ID number. The original shall be
forwarded to AHCCCSA. This provider registration process must be completed in
order for the Contractor to report services a subcontractor renders to enrolled
members and for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TAPE
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Tape User Manual on October 15, January 15, April 15, and
July 15 of each contract year. The Manual may be found in the Bidder's Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its HCFA grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on or before
scheduled due dates.
b. Accuracy: Reports or other required data shall be prepared in strict
conformity with appropriate authoritative sources and/or AHCCCS defined
standards.
c. Completeness: All required information shall be fully disclosed in a
manner that is both responsive and pertinent to report intent with no
material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
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The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA, or the federal government, to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials which are produced by the Contractor and
refer to covered services shall state that such services are funded under
contract with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business for the contract year beginning 10/1/97. The
purpose of Readiness Reviews is to assess new contractors' readiness and ability
to provide contract services to members at the start of the contract year. A new
contractor will be permitted to commence operations only if the Readiness Review
factors are met to AHCCCSA's satisfaction.
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with HCFA requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The
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Contractor shall comply with all other medical audit provisions as required by
AHCCCS Rule R9-22-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful. AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel as identified in advance shall be
available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
work space, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the Contractor has obtained accreditation from NCQA or
any other nationally recognized accrediting body. The Contractor must submit the
entire NCQA report to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in implementing recommendations and
achieving program compliance. Follow-up reviews may be conducted at any time
after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost-avoiding and paying claims in accordance with AHCCCS Rule
R9-22-705, a copy of which may be found in the Bidder's Library. In the absence
of a subcontract provision to the contrary, claims submission deadlines shall be
calculated from the date of service or the elective date of enrollment,
whichever is later. Remittance advices accompanying the Contractor's payments to
providers must contain, at a minimum, adequate descriptions of all denials and
adjustments, the reasons for such denials and adjustments, the amount billed,
the amount paid, and grievance rights. The Contractor's claims payment system,
as well as its prior authorization and concurrent review process, must minimize
the likelihood of having to recoup already-paid claims. Any
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recoupment in excess of $50,000 per provider within a contract year must be
approved in advance by AHCCCSA, Office of Managed Care.
During the term of this contract, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout. All formats are subject to changes initiated by the
Kennedy-Kassebaum legislation. Reasonable implementation timeframes will be
negotiated with each plan.
35. HOSPITAL REIMBURSEMENT
MARICOPA AND PIMA COUNTIES ONLY: The Arizona Laws of 1996 Chapter 288 Section 20
sets forth the Hospital Reimbursement Pilot Program (Pilot), which is effective
from October 1, 1997, through September 30, 2000. The Pilot as defined by AHCCCS
Rule R9-22-7l8 requires hospital subcontracts to be negotiated between health
plans in Maricopa and Pima counties and hospitals to establish reimbursement
levels, terms and conditions. Subcontracts shall be negotiated by the Contractor
and hospitals to cover operational concerns, such as timeliness of claims
submission and payment, payment of discounts or penalties, legal resolution,
which may. as an option, include establishing arbitration procedures. These
negotiated subcontracts shall remain under close scrutiny by AHCCCSA to insure
availability of quality services within specific service districts, equity of
related party interests, reasonableness of rates, and only marketing of
contracted organizations. The general provisions of this program encompass acute
care hospital services and outpatient hospital services that result in an
admission. The Contractor shall submit all hospital subcontracts and any
amendments to AHCCCSA Office of Managed Care, for prior approval. For
non-emergency patient-days, the Contractor shall ensure that at least 35% of its
members use contracted hospitals. AHCCCSA reserves the right to subsequently
adjust the 85% standard. Further, if in AHCCCSA's judgment the number of
emergency days at a particular non-contracted hospital becomes significant,
AHCCCSA may require a subcontract at that hospital. Hospitals and health
plans/program contractors outside of Maricopa and Pima counties are not included
in this Pilot. Offerors should refer to the "Hospital Reimbursement Pilot
Program Packet" for additional information and requirements.
ALL GSA'S EXCEPT MARICOPA AND PIMA: The Contractor shall reimburse hospitals for
member care in accordance with AHCCCS Rule R9-22-705. The Contractor is
encouraged to obtain contracts with hospitals in all other GSA's and must submit
copies of these contracts to AHCCCSA, Office of Managed Care, at least seven
days prior to the effective dates thereof.
FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor
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fails to identify lack of medical necessity through concurrent review and/or
prepayment medical review, lack of medical necessity identified during
postpayment medical review shall not constitute a basis to recoupment by the
Contractor. See also Section D, Paragraph 34, Claims Payment System. For a more
complete description at the guidelines for hospital reimbursement, please
consult the Bidder's Library for applicable statutes and rules.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment. The Contractor is
responsible for payment of services while the member is enrolled with the
Contractor. The Contractor is not responsible for the full 90 days of nursing
facility coverage if ALTCS enrollment occurs before the 90 days has ended.
37. COMPENSATION
The method of compensation under this contract will be capitation. SOBRA
supplement, HIV-AIDS supplement, reinsurance, and third party liability, as
described and defined within this contract and appropriate laws, regulations or
policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of ARS Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or NACHA transfer
and will provide the Contractor at least 30 days notice prior to the effective
date of any such change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, any
savings remaining to the Contractor as a result of favorable claims experience
and efficiencies in service delivery at the end of the contract term may be kept
by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
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Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in ARS ss.36-2913. An error discovered by the State with or
without an audit in the amount of fees paid to Contractor will be subject to
adjustment or repayment by Contractor making a corresponding decrease in a
current Contractor's payment or by making an additional payment by AHCCCSA to
the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
CAPITATION: The Contractor will be paid capitation for all prospective member
months, including partial member months. This capitation includes the cost of
providing medically necessary covered services to members during prior period
coverage. AHCCCSA will make monthly capitation payments to the Contractor for
each member enrolled with the Contractor on the first of the month as payment in
full for any and all covered services provided to the member including covered
services provided during prior period coverage. (See Section D, Paragraph 6,
Enrollment and Disenrollment, for clarification of prior period coverage.)
Payment shall be made no later than the fifth working day of the month for which
payment is due. For members enrolled at any time after the beginning of the
month's payment cycle, capitation will be prorated from the effective date of
enrollment through the remainder of the month of enrollment. These payments will
be made by AHCCCS to Contractor on a weekly basis.
SOBRA SUPPLEMENT: When the Contractor has an enrolled SOBRA woman who delivers
during an enrollment period, the Contractor will be entitled to a SOBRA payment.
AHCCCSA reserves the right at any time during the term of this contract to
adjust the amount of this SOBRA payment for women who deliver at home. The
Contractor is responsible for meeting the newborn notification requirements
defined in AHCCCS Rule R9-22-342 before this payment will be made to the
Contractor.
HIV/AIDS SUPPLEMENT: In addition to the capitation payment described above, a
separate and additional payment will be made to the Contractor to help defray
costs for members receiving approved protease inhibitors and associated lab work
related to their treatment for HIV/AIDS. The list of AHCCCSA-approved protease
inhibitors is available in the Bidder's Library.
On a quarterly basis, the Contractor shall submit to AHCCCSA, Office of Managed
Care, an unduplicated monthly count or members, by rate code, who are using
approved protease inhibitors. The report shall be submitted, along with the
quarterly financial reporting package, within 60 days after the end at each
quarter. (A sample or this reporting form may be found in the Bidder's Library.)
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The rate of reimbursement for this separate payment will be $634.50 per month
and is subject to review during the term of the contract. Payment will be made
quarterly to the Contractor based on the reported eligible members for the
preceding quarter. AHCCCSA will review this HIV/AIDS-related data at least
annually as part of its Operational and Financial Review and reserves the right
to recoup any amounts paid for ineligible members as determined through this
review as well as an associated penalty for incorrect reporting.
38. CAPITATION ADJUSTMENTS
Except for changes made specifically in accordance with this contract, the rates
set forth in Section B shall not be subject to re-negotiation or modification
during the contract period. AHCCCSA may, at its option, review the effect of a
program change and determine if a capitation adjustment is needed. In these
instances the adjustment will be prospective with assumptions discussed with the
Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable;
AHCCCSA will not unreasonably withhold such a review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
a. death of a member
b. member's incarceration (nor eligible for AHCCCS benefits)
c. duplicate capitation to the same contractor
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE REINSURANCE: Reinsurance is a stop-loss program provided by
AHCCCSA to the Contractor for the partial reimbursement of covered inpatient
facility medical services incurred for a member with an acute medical condition
beyond an annual deductible (AHCCCS Rule R9-22-503). Per diem rates paid for
nursing facility services, including room and board, provided in lieu of
hospitalization for up to 90 days in any contract year shall be eligible for
reinsurance coverage (see AHCCCS Rule R9-22-203 subsection B for excluded
services). Reinsurance for the Hospital Reimbursement Pilot Program (See Section
D, Paragraph 35, Hospital Reimbursement), will be paid in accordance with AHCCCS
Rule R9-22-503.
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AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Reinsurance coverage applies to both prospective and prior period coverage
periods. The deductible level the Contractor is eligible for is based on the
Contractor's statewide AHCCCS acute care enrollment as of October 1st each
contract year for all rate codes and counties, as shown in the following table.
These deductible levels are subject to change by AHCCCSA during the term of this
contract.
REGULAR REINSURANCE:
Statewide Plan Enrollment Deductible - MN/MI Deductible-Others Coinsurance %
0 - 19,999 $ 15,000 $ 20,000 75%
20,000 - 49,999 $ 15,000 $ 35,000 75%
50,000 and over $ 15,000 $ 50,000 75%
If a Contractor's actual non-MN/MI deductible is $35,000 or $50,000, AHCCCSA
will increase the Contractor's capitation rate awarded by defined amounts for
each capitation risk group. These specific capitation adjustments are available
in the Bidder's Library. A Contractor whose enrollment qualifies it for the
$35,000 or $50,000 non-NM/MI deductible level may, prior to the start of the
contract period, elect one of the lower deductible levels indicated in the above
table.
AHCCCSA will use inpatient encounter data to determine regular reinsurance
benefits. Reimbursement for regular reinsurance benefits will be made to the
Contractor each month. AHCCCSA will also provide for a reconciliation of
reinsurance payments in the case where encounters used in the calculation of
reinsurance benefits are subsequently adjusted or voided.
The Contractor shall be subject to utilization and other reviews by AHCCCSA of
care provided to a member which results in a reinsurance claim as referenced in
R9-22-503 (G.3).
Medical review on regular reinsurance cases will be determined based on
statistically valid random sampling. AHCCCSA, Office of the Medical Director,
will generate the sampling and will notify the Contractor of documentation
needed for the retrospective medical review process to occur at the Contractor's
offices. The results of the medical review sampling will be extrapolated to the
entire regular reinsurance reimbursement population of the Contractor. A
recoupment of reinsurance reimbursements made to the Contractor may occur based
on the results of the medical review sampling. AHCCCSA will give the Contractor
at least 45 days advance notice of any on-site review. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor representative shall be available to the
Review Team at all times during AHCCCSA on-site review activities. While
on-site, the Contractor shall provide the Review Team with work space, access to
a telephone, electrical outlets and privacy for conferences. The Contractor will
be furnished a copy of the
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Regular Acute Reinsurance Review Report within 60 days of the onsite review and
given an opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia and members who receive covered organ and tissue transplantation
including bone marrow, heart and other organ transplantation. For additional
detail and restrictions see AHCCCS Rule R9-222-202. There is no deductible for
catastrophic reinsurance cases and AHCCCS will reimburse the Contractor at 85%
of the Contractor's covered costs. All catastrophic claims will be subject to
medical review by AHCCCSA.
HEMOPHILIA: When an eligible member is identified as being catastrophically
eligible by AHCCCSA due to a specific diagnosis of hemophilia (ICD9 286.0,
286.1, 286.2 and 286.4), all medically necessary covered services provided
during the contract year shall be eligible for reimbursement at 85% of the
Contract's paid amount. Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDA VP responders
that are dependent on Plasma Factor VIII. The Contractor must promptly notify
AHCCCS Office of the Medical Director, Reinsurance Unit after diagnosis.
Catastrophic reinsurance will be paid for a maximum 30-day retroactive period
from the date of notification to AHCCCSA.
TRANSPLANTS: Bone grafts, kidney and cornea transplantation services are not
eligible for catastrophic reinsurance coverage but are eligible under the
regular (non-catastrophic) reinsurance program. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor-paid amount
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library.
Encounter data will not be used to determine catastrophic reinsurance benefits.
However, this does not relieve the Contractor of the responsibility for
submitting encounters for catastrophic reinsurance services. The initial claims
for reimbursement under the catastrophic reinsurance program must be filed no
later than June 30th of the year following the contract year. Catastrophic
reinsurance claims that are submitted within this time limit and are denied or
adjusted, may be corrected until September 30th of the year following the
contract year. All catastrophic reinsurance claims must be submitted in
accordance with the AHCCCS Reinsurance Policy/Procedure Manual.
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. See Section D, Paragraph 41, Medicare
Services and Cost Sharing.
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COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for coinsurance and deductibles is limited
to what the Contractor would have paid for the entire service pursuant to a
written contract with the provider or the AHCCCS fee-for-service rate, less any
amount paid by the third party. (The Contractor must decide whether it is more
cost-effective to provide the service within its network or pay coinsurance and
deductibles for a service outside its network. For continuity of care, the
Contractor may also choose to provide the service within its network.) If the
Contractor refers the member for services to a third-party insurer (other than
Medicare), and the insurer requires payment in advance of all copayments,
coinsurance and deductibles, the Contractor must make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
pre-natal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA's authorized representative:
Uninsured/underinsured motorist insurance
First and third-party liability insurance
Tortfeasors
Adoption recovery
Estate recovery
Worker's Compensation
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The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-1002. The Contractor shall cooperate with
AHCCCSA's authorized representative in all collection efforts. In joint cases
involving both AHCCCS fee-for-service or reinsurance and the Contractor,
AHCCCSA's authorized representative is responsible for performing all research,
investigation and payment of lien-related costs. AHCCCSA's authorized
representative is also responsible for negotiating and acting in the best
interest of all parties to obtain a reasonable settlement in joint cases and may
compromise a settlement in order to maximize overall reimbursement, net of legal
and other costs. For total plan cases involving only payments from the
Contractor, the Contractor is responsible for performing all research,
investigation and payment of lien-related costs.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING: The Contractor may be required to report case level detail of
third-party collections and cost avoidance. The Contractor shall notify
AHCCCSA's authorized representative within five working days of the
identification of a third-party liability case with known reinsurance (often
referred to as joint liability cases). The Contractor shall communicate any
known change in health insurance information, including Medicare to AHCCCS
Administration, Division of Member Services, not later than 10 days from the
date of discovery using the AHCCCS Third-Party Coverage Form found in the
Bidder's Library.
Approximately every four months, AHCCCSA will provide the Contractor with a
complete file of all third-party coverage information (other than Medicare) for
the purpose of updating the Contractor's files. The Contractor shall notify
AHCCCSA of any known changes in coverage within deadlines and in a format
prescribed by AHCCCSA.
41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicare and AHCCCS
services. These members are referred to as "dual eligibles" and include persons
who are Qualified Medicare Beneficiaries (QMB) and non-QMB eligible persons. QMB
eligible persons are entitled to all covered Medicaid services and, in addition,
may receive the following Medicare services which are not covered by AHCCCS or
differ in scope or limitation:
Chiropractic services
Inpatient and outpatient occupational therapy coverage
Inpatient psychiatric services
Psychological services
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Respite services
Any services covered by or added to the Medicare program which are not
covered by AHCCCS
For all dual eligible persons, the Contractor shall be responsible for providing
all AHCCCS covered services and pay all Medicare coinsurance and deductibles for
Medicare services which are covered by AHCCCS and provided on a fee-for-service
basis within the Contractor's network. The Contractor's network is defined as
any contracted provider, or provider used more than 12 times during the course
of the contract year, even if no written contract exists. For QMB eligible
persons, the Contractor shall be responsible for paying the Medicare coinsurance
and deductibles for Medicare services not covered by AHCCCS (described above)
which are provided by a Medicare provider on a fee-for-service basis, regardless
of whether the service is provided in or out of the Contractor's network.
Members shall not be required to pay any coinsurance or deductibles for Medicare
services.
Based on an agreement between AHCCCS and HCFA, Medicare cost sharing
requirements for Medicare services provided on a fee-for-service basis (FFS) and
those services provided by a Medicare HMO are different. Please refer to the
table below:
CONTRACTOR LIABILITY FOR MEDICARE BENEFICIARIES
Cost Sharing for Members with Cost Sharing for Members
Fee-For-Service Medicare with Medicare HMO
- ----------------------------------------------------------------------------------------------------------------------
Contractor Full amount of the Full amount of the Medicare co-payments,
Responsibility: co-insurance and co-insurance and deductibles or premiums
deductibles for Medicare deductibles for Medicare assessed by Medicare HMO
services provided by a services not covered by for dual eligibles.
Medicare provider on a FFS AHCCCS and provided by a
basis in the Contractor's Medicare provider on a FFS
network. basis (in or
out-of-network)
- ----------------------------------------------------------------------------------------------------------------------
QMB - DUALS YES YES NO
Persons who are eligible for
Medicaid, who meet QMB income
and resource requirements and
who have Medicare Part A and
Part B. AHCCCS pays the Part
B premium.
- ----------------------------------------------------------------------------------------------------------------------
NON-QMBS YES NO NO
Persons who are eligible for
Medicaid, who do not meet the
QMB income and resource
requirements and who have
Medicare Part A. AHCCCS pays
the Part B premium in certain
instances.
- ----------------------------------------------------------------------------------------------------------------------
MN/MI WITH MEDICARE YES NO NO
- ----------------------------------------------------------------------------------------------------------------------
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The Contractor shall not deny payment of coinsurance and deductibles for
Medicare services provided in network or Medicare-only services provided
out-of-network if the reason for such denial is the failure of the provider to
obtain prior authorization for payment of coinsurance and deductibles.
Since AHCCCSA is the payer of last resort, all Medicare covered services which
are provided to dual eligibles who are not enrolled in a Medicare TEFRA Risk HMO
shall be billed to Medicare or any other third party liability source.
If a dual eligible is enrolled with a Medicare TEFRA Risk HMO, Medicare will not
reimburse the Contractor for Medicare covered services provided by the
Contractor. Therefore, the Contractor shall refer the member to the Medicare
TEFRA Risk HMO for all Medicare covered services and shall not be responsible
for the payment of any Medicare copayments, deductibles or premiums assessed by
the Medicare TEFRA Risk HMO. The Contractor shall be responsible for any AHCCCS
covered services not provided by the Medicare TEFRA Risk HMO.
As of July 1, 1996, persons who are eligible for Medicare and who can receive
Medicare covered services through a Medicare HMO will generally not be approved
or re-approved for the MN/MI program. The following individuals are not eligible
to enroll in a Medicare HMO: (1) those who are taking immunosuppressant drugs
following a transplant, (2) those who have end-stage renal disease, or (3) those
who receive Medicare hospice services. Persons who are not enrolled with
Medicare Part B or a Medicare HMO at the time of application or re-determination
for MN/MI, may receive MN/MI benefits until they can enroll in Medicare Part B
and/or a Medicare HMO.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-711.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or federal government.
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The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
a. If this contract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for
a period of five years from the date of any such termination.
b. Records which relate to grievances, disputes, litigation or the settlement
of claims arising out of the performance of this contract, or costs and
expenses of this contract to which exception has been taken by AHCCCSA,
shall be retained by the Contractor for a period of five years after the
date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request. The Contractor is responsible for ensuring that a medical
record is established when information is received about a member. If the PCP
has not yet seen the member, such information may be kept temporarily in an
appropriately labeled file, in lieu of actually establishing a medical record,
but must be associated with the member's medical record as soon as one is
established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AHCCCS
Medical Policy Manual, a copy of which may be found in the Bidder's Library.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
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Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (ARSss.36-6641)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSA's as a result of an accumulated deficit, even if unaudited.
47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
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The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCSA shall be responsible for
any incorrect or delayed payment to the Contractor's AHCCCS services providers
(subcontractors) resulting from such error, omission, deletion, or erroneous
input data caused by the Contractor in the submission of AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
ELECTRONIC DATA INTERCHANGE (EDI): In addition to the requirements outlined in
Section D, Paragraph 34, Claims Payment System, the Contractor will be required
to comply with all EDI standards which result from the Kennedy-Kassebaum
legislation. This law requires the Department of Health and Human Services to
provide national electronic submission standards for health care data and may
include compliance with National Provider Identifier requirements. The Secretary
has 18 months to develop these standards. As the standards are finalized,
AHCCCSA will phase in the implementation. Electronic standards which may be
implemented include, but are not limited to, encounters, enrollment and
capitation payments.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance measures. The
Contractor shall submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability,
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including services provided during prior period coverage. This requirement is a
condition of the HCFA grant award.
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA-supplied formats. Formatting and specific
requirements for encounter data are described in the AHCCCS Encounter Reporting
User Manual and the AHCCCS Technical Interface Guidelines, copies of which may
be found in the Bidder's Library. The Encounter Submission Requirements are
included herein as Attachment I.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data which the Contractor shall
use to update its member records. The daily roster which is run prior to the
monthly roster is referred to as the "last daily" and will contain all rate code
changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next month. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The term of this contract shall be 10/1/97 through 9/30/98. In addition, AHCCCSA
reserves the sole option to extend the term of the contract, not to exceed a
total contracting period of five years. The terms and conditions of any such
contract extension shall remain the same as the original contract, as amended.
Any contract extension, however, shall not affect the maximum contracting period
of five years. All contract extensions shall be through contract amendment. If,
in conjunction with a contract extension, AHCCCSA elects to increase the
capitation rate for any rate code category, such increase will not exceed the
inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contact in one GSA but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
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AHCCCSA may require a contractor to renew all GSA's, or may terminate remaining
GSA's if the Contractor does not agree to renew all GSA's.
When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses to sign the extension amendment. If the Contractor provides such
notification, AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 120 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See policy on claims processing by
subcontracted providers in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
See also Section D, Paragraph 35, Hospital Reimbursement, regarding required
submission of hospital subcontracts.
The Contractor shall maintain a fully executed original of all subcontracts
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is voidable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of
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AHCCCSA. All subcontracts shall comply with the applicable provisions of federal
and State laws, regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the contract
year refuses to enter into a written agreement with the Contractor, the
Contractor shall submit documentation of such refusal to AHCCCS Office of
Managed Care within seven days of its final attempt to gain such
agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor.
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and for
which compensation will be paid.
e. The term of the subcontract including beginning and ending dates, methods
of extension, termination and renegotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and other
third-party liability coverage and to seek such Medicare or third-party
liability payment before submitting claims to the Contractor/Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality
assurance programs and comply with the utilization control and review
procedures specified in 42 C.F.R. Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in ownership
of a subcontractor that is related to or affiliated with the Contractor
shall require a contract amendment and prior approval of AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population.
l. A provision that the subcontractor shall be fully responsible for all tax
obligations, Workers Compensation Insurance, and all other applicable
insurance coverage
D-47
obligations which arise under this subcontract. For itself and its
employees, and that AHCCCSA shall have no responsibility or liability for
any such taxes or insurance coverage.
m. A provision that the subcontractor must obtain any necessary authorization
from the Contractor or AHCCCSA for services provided to eligible and/or
enrolled members.
n. A provision that the subcontractor must comply with encounter reporting
and claims submission requirements as described in the subcontract.
52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contacts. Specialty contracts shall take
precedence over and supersede existing and future subcontracts for services that
are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement for
transplant surgery exceed that payable under the relevant AHCCCSA specialty
contract.
During the term of specialty contacts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contacts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
AHCCCSA shall provide at least 60 days advance written notice to the Contractor
prior to the implementation of any specialty contact.
53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontractors and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees charged and/or corporate
allocations made. If the fees or allocations actually paid out are determined to
be unjustified or excessive, amounts may be subject to repayment to the
Contractor, the Contractor may be placed on monthly financial reporting, and/or
financial sanctions may be imposed.
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54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are less than $50,000, AHCCCSA will waive the requirement for an audit of that
consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award. Minimum capitalization requirements by GSA are as follows:
Geographic Service Area Capitalization Requirement
1. Yuma $1,400,000
2. Mohave, La Paz 1,150,000
3. Yavapai, Coconino 1,250,000
4. Pinal, Gila 1,450,000
5. Pima 1,250,000
6. Maricopa 2,500,000
7. Graham, Greenlee 350,000
8. Apache, Navajo 650,000
9. Cochise, Santa Cruz 1,450,000
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSAs, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSAs awarded. This requirement is in addition to the
Performance Bond requirements defined in Paragraphs 56 and 57 below and must be
met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above).
D-49
Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the Contractor's obligations to
providers, non-contracting providers, and non-providers: and (2) performance by
the Contractor of its obligations under this contract. The Performance Bond
shall be in a form acceptable to AHCCCSA as described in Performance Bond
Guidelines - Office of Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers and
nonproviders by reason of a breach of the Contractor's obligations under
this contract.
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses incurred
by reason of a breach of the Contractor's obligations under this contract,
including, but not limited to, expenses incurred after termination of this
contract for reasons other than the convenience of the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October, 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement
D-50
must be satisfied by the Contractor not later than 15 days after notification by
AHCCCSA of the amount required. Thereafter, AHCCCSA shall evaluate the
enrollment statistics of the Contractor on a monthly basis. If there is an
increase in capitation payment that exceeds 10% of the performance bond amount,
AHCCCSA may require an increase in the amount of the Performance Bond. The
Contractor shall have 15 days following notification by AHCCCSA to increase the
amount of the Performance Bond. The Performance Bond amount that must be
maintained after the contract term shall be sufficient to cover all outstanding
liabilities and will be determined by AHCCCSA.
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES
AHCCCSA has established the following financial viability criteria/performance
goals:
Current Ratio Current assets divided by current
liabilities. "Current assets" includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%).
Standard: At least 1.00
Equity per Member Equity divided by the number of non-SOBRA
Family Planning Extension Services members
enrolled at the end of the period.
Standard: At least $150
(Failure to meet this standard may result in
an enrollment cap being imposed in any or all
contracted GSA's.)
Note: Equity must be unencumbered with no
liens or obligations against it.
Medical Expense Ratio Total medical expenses divided by total
capitation + SOBRA + TPL + reinsurance.
Standard: 85-90%
Administrative Cost Percentage Total administrative expenses (excluding
income taxes), divided by total capitation +
SOBRA + TPL + reinsurance.
Standard: No more than 10%
Received But Unpaid Claims Received but unpaid claims divided by the
(Days Outstanding) average daily medical expenses for the
period, net of sub-capitation expense
Standard: No more than 45 days
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor
D-51
must submit a detailed merger, reorganization and/or transition plan to AHCCCSA
Contracting Office for AHCCCSA review. The purpose of the plan review is to
ensure uninterrupted services to members, evaluate the new entity's ability to
support the provider network, ensure that services to members are not diminished
and that major components of the organization and AHCCCS programs are not
adversely affected by such merger, reorganization or change in ownership.
60. SANCTIONS
ALHCCCSA may suspend, deny, refuse to renew, or terminate this contract or any
related subcontracts in accordance with AHCCCS Rule R9-22-405 and the terms of
this contract and applicable law and regulations. AHCCCSA may, in addition to
these remedies, impose monetary sanctions if the Contractor violates any
provision stated in law or this contract in accordance with AHCCCS Rule
R9-22-406 and the provisions of this contract, applicable law and regulations.
Written notice will be provided to the Contractor specifying the sanction to be
imposed, the grounds for such sanction and either the length of suspension or
the amount of capitation prepayment to be withheld. The Contractor may appeal
the decision to impose a sanction in accordance with AHCCCS Rule R9-22-804.
In addition to the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS financial viability standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
Cure Notice Process - Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right, are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals. The algorithm favors those
contractors with lower capitation rates. For further details on the AHCCCS
Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any
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time during the term of the contract and frequently does so in response to
contractor-specific issues of non-compliance (e.g. imposition or an enrollment
cap). The Contractor should consider this in preparing its response to this RFP.
AHCCCSA is not obligated to adjust for any financial impacts this may have on
the Contractor.
62. GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22-802; and R9-22-804. The grievance process
may not be delegated or subcontracted outside of the health plan. Refer to
Attachment H for a complete description of grievance process requirements.
63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Grievance and Appeals, using the Quarterly Grievance Report Format on file in
the Bidder's Library. The Quarterly Grievance Report must be received by the
AHCCCSA, Office of Grievance and Appeals, no later than 45 days from the end of
the quarter.
64. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that could have an impact on services provided by the
Contractor on or after October 1, 1997. The following is a brief description of
the issues that AHCCCS is aware of at the time of the issuance of this RFP:
ELIGIBILITY BASED ON 100% OF THE FEDERAL POVERTY LEVEL (FPL): Through a
successful initiative effort, eligibility for AHCCCS has been expanded to allow
persons with income up to 100% of the FPL to become eligible for the Medicaid
program. Legislative action will be required to implement this new eligibility
guideline and HCFA must approve the expansion. If HCFA approval is granted,
there will be a significant number of new persons who will be eligible for the
program and enrolled with the health plans at some future date.
MANDATORY 48 HOUR MATERNITY STAY: Effective January 1, 1998, a new federal law
requires all group health insurers to allow women and their newborns to receive
48 hours of inpatient hospital care after a normal vaginal delivery and up to 96
hours of inpatient care after a cesarean delivery. The attending health care
provider, in consultation with the mother, may discharge the mother or newborn
prior to the minimum length of stay. HCFA has advised that the mandatory stay
provisions will apply to Medicaid. In preparing their capitation rate proposals,
offerors must assume any additional costs associated with this new requirement.
AHCCCSA will not compensate for additional costs effective January 1, 1998.
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PREMIUM SHARING: The Arizona legislature passed legislation (Chapter 368, Laws
of 1996) which authorizes a 6-member legislative committee to make
recommendations for a three-year premium sharing demonstration program for
persons whose income does not exceed 300% of FPL. If enacted, the premium
sharing program would add additional people to the AHCCCS program. The program
is scheduled to begin October 1, 1997 but will be repealed if the legislature
does not implement a program by December 31, 1997.
WELFARE REFORM: The Personal Responsibility and Work Opportunity Act of 1996
replaces the AFDC entitlement program with Temporary Assistance to Needy
Families block grants to the states. In addition, states were given an option to
provide full Medicaid services or only emergency services to several groups of
legal immigrants who were in the United States on or before August 22, 1996. The
legislature will be considering the various options and making decisions about
the level of service to legal immigrants. Depending on the outcome of
legislative deliberations, there may be changes to AHCCCS eligibility.
GRADUATE MEDICAL EDUCATION (GME): The legislature may be making changes to the
funding formula for GME. Currently, GME is funded as an add-on to the AHCCCS
tiered per diem inpatient hospital rates. There is legislation to remove the GME
component from the hospital rates and establish a separate GME fund. For
purposes of your response to the RFP, please assume that GME will not be
included in the AHCCCS tiered per diem rates.
[END OF SECTION D]
D-54
SECTION E: CONTRACT CLAUSES
TABLE OF CONTENTS
1. APPLICABLE LAW.......................................................... 1
2. AUTHORITY............................................................... 1
3. ORDER OF PRECEDENCE..................................................... 1
4. CONTRACT INTERPRETATION AND AMENDMENT................................... 1
5. SEVERABILITY............................................................ 2
6. RELATIONSHIP OF PARTIES................................................. 2
7. ASSIGNMENT AND DELEGATION............................................... 2
8. GENERAL INDEMNIFICATION................................................. 2
9. INDEMNIFICATION - PATENT AND COPYRIGHT.................................. 2
10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS.................. 2
11. ADVERTISING AND PROMOTION OF CONTRACT................................... 3
12. PROPERTY OF THE STATE................................................... 3
13. THIRD PARTY ANTITRUST VIOLATIONS........................................ 3
14. RIGHT TO ASSURANCE...................................................... 3
15. TERMINATION FOR CONFLICT OF INTEREST.................................... 3
16. GRATUITIES.............................................................. 3
17. SUSPENSION OR DEBARMENT................................................. 4
18. TERMINATION FOR CONVENIENCE............................................. 4
19. TERMINATION FOR DEFAULT................................................. 4
20. TERMINATION - AVAILABILITY OF FUNDS..................................... 5
21. RIGHT OF OFFSET......................................................... 5
22. NON-EXCLUSIVE REMEDIES.................................................. 5
23. NON-DISCRIMINATION...................................................... 5
24. EFFECTIVE DATE.......................................................... 5
25. INSURANCE............................................................... 5
26. DISPUTES................................................................ 6
27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS............................. 6
28. INCORPORATION BY REFERENCE.............................................. 6
29. COVENANT AGAINST CONTINGENT FEES........................................ 7
30. CHANGES................................................................. 7
31. TYPE OF CONTRACT........................................................ 7
32. AMERICANS WITH DISABILITIES ACT......................................... 7
33. WARRANTY OF SERVICES.................................................... 7
34. NO GUARANTEED QUANTITIES................................................ 8
35. CONFLICT OF INTEREST.................................................... 8
36. DISCLOSURE OF CONFIDENTIAL INFORMATION.................................. 8
37. COOPERATION WITH OTHER CONTRACTORS...................................... 8
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY................................... 8
39. OWNERSHIP OF INFORMATION AND DATA....................................... 8
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR..................................... 9
41. AUDITS AND INSPECTIONS.................................................. 9
42. FRAUD AND ABUSE......................................................... 10
43. LOBBYING................................................................ 10
44. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK / LABORATORY TESTING........ 12
i
SECTION E: CONTRACT CLAUSES
1. APPLICABLE LAW
Arizona Law - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.
Implied Contract Terms - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.
2. AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3. ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order. The Constitution and laws of
the United States and applicable federal regulations; the terms of the HCFA 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this conflict, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4. CONTRACT INTERPRETATION AND AMENDMENT
No Parol Evidence - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
No Waiver - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.
1
Written Contract Amendments - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5. SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract which may remain in effect without the invalid
provision or application.
6. RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
7. ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8. GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to injury, disease, or
death of persons or damage to or loss of property resulting from or in
connection with the negligent performance of this contract by the Contractor,
its agents, employees, and subcontractors or anyone for whom the Contractor may
be responsible. The obligations, indemnities and liabilities assumed by the
Contractor under this paragraph shall not extend to any liability caused by the
negligence of the State or its employees. The Contractor's liability shall not
be limited by any provisions or limits of insurance set forth in this contract.
The State shall reasonably notify the Contractor of any claim for which it may
be liable under this paragraph.
9. INDEMNIFICATION - PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The Stale shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The materials and services supplied under this conflict shall comply with all
applicable federal, state and local laws, and the Contractor shall maintain all
applicable licenses and permits.
2
11. ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12. PROPERTY OF THE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
13. THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14. RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified mail, return
receipt required. Failure by the Contractor to provide written assurance within
the number of days specified in the demand may, at the State's option, be the
basis for terminating the contract.
15. TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
16. GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCSA, in addition to any other
3
rights or remedies, shall be entitled to recover exemplary damages in the amount
of three times the value of the maturity offered by the Contractor.
17. SUSPENSION OR DEBARMENT
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18. TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19. TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
4
20. TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
21. RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
22. NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23. NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 75-5, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable federal and state laws, rules and regulations, including
the Americans with Disabilities Act. The Contractor shall take positive action
to ensure that applicants for employment, employees, and persons to whom it
provides service are not discriminated against due to race, creed, color,
religion, sex, national origin or disability.
24. EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
25. INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000
for each occurrence for each bodily injury and property damage to others as a
result of accidents on the premises of or as the result of operations of the
Contractor.
b. Commercial Automobile Liability: Provides coverage of at least
$1,000,000 for each occurrence for bodily injury and property damage to others
resulting from accidents caused by vehicles operated by the Contractor.
5
c. Workers Compensation: Provides coverage to employees of the Contractor
for injuries sustained in the course of their employment. Coverage must meet the
obligations imposed by federal and state statutes and roust also include
Employer's Liability minimum coverage of $100,000. Evidence of qualified
self-insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance of a
professional act of service. The above coverages may be evidenced by either one
of the following:
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the form. The
Contractor's agent or broker must fill in the pertinent policy information and
ensure the required special conditions are included in the Contractor's policy.
e. Accord form: This standard insurance industry certificate of insurance
does not contain the preprinted special conditions required by this contract.
These conditions must be entered on the certificate by the agent or broker and
read as follows:
The State of Arizona and Arizona Health Care Cost Containment System
are hereby added as additional insureds. Coverages afforded under this
Certificate shall be primary and any insurance earned by the State or
any of its agencies, boards, departments or commissions shall be in
excess of that provided by the insured Contractor. No policy shall
expire, be canceled or materially changed without 30 days written
notice to the State. This Certificate is not valid unless countersigned
by an authorized representative of the insurance company.
26. DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with AHCCCS Rule R9-28-804(C).
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor which is related to the performance
of this contract, in accordance with ARS ss.41-2547.
28. INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
6
29. COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30. CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section E, Paragraph 26, Disputes,
and be administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31. TYPE OF CONTRACT
Firm Fixed-Price
32. AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Mark Renshaw at (602) 417-4577.
33. WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's expense, require prompt correction of any services failing to meet
the Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
7
34. NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35. CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose any situation which may present a conflict of interest. If
the Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.
36. DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCSA.
37. COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39. OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by Contractor pursuant to this contract, shall be deemed to
be owned by AHCCCSA. The federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish,
8
or otherwise use and to authorize others to use for federal government purposes,
such data or information system, software, documentation and manuals.
Proprietary software which is provided at established catalog or market prices
and sold or leased to the general public shall not be subject to the ownership
or licensing provisions of this section.
Data, information and reports collected or prepared by Contractor in the course
of performing its duties and obligations under this contract shall be deemed to
be owned by AHCCCSA. The ownership provision is in consideration of Contractor's
use of public funds in collecting or preparing such data, information and
reports.
These items shall not be used by Contractor for any independent project of
Contractor or publicized by Contractor without the prior written permission of
AHCCCSA. Subject to applicable state and federal laws and regulations.
AHCCCSA shall have full and complete rights to reproduce, duplicate, disclose
and otherwise use all such information. At the termination of the contract,
Contractor shall make available all such data to AHCCCSA within 30 days
following termination of the contract or such longer period as approved by
AHCCCSA, Office of the Director. For purposes of this subsection, the term
"data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by Contractor in the course of performance of this
contract, the federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or federal
government purposes. Contractor shall additionally be subject to the applicable
provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, Contractor's performance is in material breach
of the contract or Contractor is insolvent, AHCCCSA may directly operate
Contractor to assure delivery of care to members enrolled with Contractor until
cure by Contractor of its breach, by demonstrated financial solvency or until
the successful transition of those members to other contractors.
41. AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and -521 and AHCCCS policies and procedures relating to the
audit of Contractor's records and the inspection of Contractor's facilities.
Contractor shall fully cooperate with AHCCCSA staff and allow them reasonable
access to Contractor's staff, subcontractors, members, and records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
9
AHCCCSA and the federal government may evaluate through on-site inspection or
other means, the quality, appropriateness and timeliness of services performed
under this contract.
42. FRAUD AND ABUSE
It shall be the responsibility of the Contractor to report all cases of
suspected fraud and abuse by subcontractors, members or employees. The
Contractor shall provide written notification of all such incidents to AHCCCSA.
The Contractor shall comply with the [AHCCCS Health Plans and Program
Contractors Policy for Prevention, Detection and Reporting of Fraud and Abuse]
which is available in the Bidder's Library and incorporated herein by reference.
As stated in ARS ss. 13-2310, incorporated herein by reference, any person who
knowingly obtains any benefit by means of false or fraudulent pretenses,
representations, promises or material omissions is guilty of a class felony.
43. LOBBYING
No funds paid to the Contractor by AHCCCSA. or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any federal or State agency, a member of he United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any federal or
State contract, the making of any federal or State grant, the making of any
federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds other than those paid to the Contractor by AHCCCSA have
been used or will be used to influence the persons and entities indicated above
and will assist AHCCCSA in making such disclosures to HCFA.
[END OF SECTION E]
10
SECTION F: LIST OF ATTACHMENTS
Attachment A: Minimum Subcontract Provisions
Attachment B: Geographic Service Area Minimum Network Requirements
Attachment C: Management Services Subcontractor Statement
Attachment D: Sample Letter of Intent; Network Summary Form
Attachment E: Instructions for Preparing Capitalization Proposal on
Computer Disk.
Attachment F: Periodic Report Requirements
Attachment G: Auto-Assignment Algorithm
Attachment H: Grievance Process and Standards
Attachment I: Encounter Submission Requirements
Attachment J: New Offeror Review Guide
Attachment K: EPSDT Periodicity Schedule
Attachment L: Offeror's Checklist
11
SECTION G: REPRESENTATIONS AND CERTIFICATIONS OF OFFEROR
The Offeror must complete all information requested below.
1. CERTIFICATION OF ACCURACY OF INFORMATION PROVIDED
By signing this offer the Offeror certifies, under penalty of law, that the
information provided herein is true, correct and complete to the best of
Offeror's knowledge and belief. Offeror also acknowledges that should
investigation at any time disclose any misrepresentation or falsification, any
subsequent contract may be terminated by AHCCCSA without penalty to or further
obligation by AHCCCSA.
2. CERTIFICATION OF NON-COERCION
By signing this offer the Offeror certifies, under penalty of law, that it has
not made to any provider any requests or inducements not to contract with
another potential program contractor in relation to this solicitation.
3. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK / LABORATORY TESTING
By signing this offer, the Offeror certifies that it has not engaged and will
not engage in any violation of the Medicare Anti-Kickback or the "Stark I" and
"Stark II" laws governing related-entity and compensation therefrom. If the
Offeror provides laboratory testing, it certifies that it has complied with and
has sent to AHCCCSA simultaneous copies of the information required to be sent
to the Health Care Financing Administration. (See 42 USC ss.1320a-7b, PL
101-239, PL 101-432, and 42 CFR ss.411.361.)
4. AUTHORIZED SIGNATORY
Authorized Signatory for
-------------------------------------------------------
[OFFEROR'S Name]
- ----------------------------------- -------------------------------
(INDIVIDUAL'S Name] [Title]
is the person authorized to sign this contract on behalf of Offeror.
12
5. OFFEROR'S MAILING ADDRESS
AHCCCSA should address all notices relative to this offer to the attention of:
- --------------------------------------------------------------------------------
Name Title
- --------------------------------------------------------------------------------
Address Telephone Number
- --------------------------------------------------------------------------------
City State ZIP
13
OFFEROR GENERAL INFORMATION
1. LICENSE/CERTIFICATION: Have any licenses in accordance with ARS
ss.20-l065 et. seq., been denied, revoked or suspended within the past 10 years?
Yes ___ No____ If yes, please explain.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
2. CIVIL RIGHTS COMPLIANCE DATA: Has any federal or state agency ever made
a finding of noncompliance with any civil rights requirements with respect to
your program? Yes ___ No____ If yes, please explain.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
3. HANDICAPPED ASSURANCE: Does your organization provide assurance that no
qualified handicapped person will be denied benefits of or excluded from
participation in a program or activity because the Offeror's facilities
(including subcontractors) are inaccessible to or unusable by handicapped
persons? (Note: Check local zoning ordinances for handicapped requirements).
Yes____ No____ If yes. describe how such assurance is provided or how your
organization is taking affirmative steps to provide assurance.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
4. PRIOR CONVICTIONS: List all felony convictions within the past 15 years
of any key personnel (i.e., Administrator, Medical Director, financial officers,
major stockholders or those with controlling interest, etc.). Failure to make
full and complete disclosure shall result in the rejection of your proposal.
5. FEDERAL GOVERNMENT SUSPENSION/EXCLUSION: Has Offeror been suspended or
excluded from any federal government programs for any reason? Yes ___ No____
If yes, please explain.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
6. WAS AN ACTUARIAL FIRM USED TO ASSIST IN DEVELOPING CAPITALIZATION RATES
Yes ____ No____ If yes, what is name of actuary and actuarial firm?
- --------------------------------------------------------------------------------
7. DID A FIRM OR ORGANIZATION PROVIDE THE OFFEROR WITH ANY ASSISTANCE IN MAKING
THIS OFFER (TO INCLUDE DEVELOPING CAPITALIZATION RATES OR PROVIDING ANY OTHER
TECHNICAL ASSISTANCE)? Yes___ No___. If yes, what is the name of this firm or
organization?
- --------------------------------------------------------------------------------
Name
- --------------------------------------------------------------------------------
Address City State
14
8. HAS THE OFFEROR CONTRACTED OR ARRANGED FOR MANAGEMENT INFORMATION
SYSTEMS, SOFTWARE OR HARDWARE, FOR THE TERM OF THE CONTRACT? Yes ___ No___ If
yes, is the Management Information System being obtained from a vendor? Yes ___
No ___. If yes, please provide the vendor's name, the vendor's background with
AHCCCSA, the vendor's background with other HMOs, and the vendor's background
with other Medicaid programs.
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
9. IF OTHER THAN A GOVERNMENT AGENCY, WHEN WAS YOUR ORGANIZATION FORMED?
- --------------------------------------------------------------------------------
15
FINANCIAL DISCLOSURE STATEMENT (Page 1 of 2)
The Offeror must provide the following information as required by 42 CFR
455.103. This Financial Disclosure Statement shall be prepared as of 3/31/97 or
as specified below. However, continuing offerors who have filed the required
Financial Disclosure Statement within the last 12 months need not complete this
section if no significant changes have occurred since the last filing.
1. OWNERSHIP. List the name and address of each person with an ownership
or controlling interest, as defined by 42 CFR 455.101, in the entity submitting
this offer:
Name Address Percent of Ownership or
Control
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
2. SUBCONTRACTOR OWNERSHIP: List the name and address of each person with
an ownership or control interest in any subcontractor in which the disclosing
entity has direct or indirect ownership of 5% or more:
Name Address Percent of Ownership or
Control
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Name of above persons who are related to another as spouse, parent, child or
sibling:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
3. OWNERSHIP IN OTHER ENTITIES: List the name of any other entity in which
a person with an ownership or control interest in the Offeror entity also has an
ownership or control interest:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
16
4. LONG-TERM BUSINESS TRANSACTIONS: List any significant business
transactions, as defined in 42 CFR 455.101, between the Offeror and any
wholly-owned supplier or between the Offeror and any subcontractor during the
five-year period ending on the Contractor's most recent fiscal year end:
Describe Ownership Type of Business Dollar Amount
Of Subcontractors. Transactions with Provider of Transaction
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
5. CRIMINAL OFFENSES: List the name of any person who has ownership or
control interest in the Offeror, or is an agent or managing employee of the
Offeror and has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid or the Title XX services
program since the inception of those programs:
Name Address Title
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
6. CREDITORS: List name and address of each creditor whose loans or
mortgages exceed 5% of total offeror equity and are secured by assets of the
Offeror's company.
Description Amount
Name Address of Debt of Security
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
17
RELATED PARTY TRANSACTIONS (PAGE 1 OF 2)
1. BOARD OF DIRECTORS: List the names and addresses of the Board of
Directors of the Offeror.
Name/Title Address
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
2. HIGHEST-COMPENSATED MANAGEMENT: List names and titles of the 10 highest
compensated management personnel including but not limited to the Chief
Executive Officer, the Chief Financial Officer, Board Chairman, Board Secretary,
and Board Treasurer.
Name Title
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
3. RELATED PARTY TRANSACTIONS: Describe transactions between the Offeror
and any related party in which a transaction or series of transactions during
any one fiscal year exceeds the lesser of $10,000 or 2% of the total operating
expenses of the disclosing entity. List property, goods, services and facilities
in detail noting the dollar amounts or other consideration for each transaction
and the date thereof. Include a justification as to (1) the reasonableness of
the transaction, (2) its potential adverse impact on the fiscal soundness of the
disclosing entity, and (3) that the transaction is without conflict of interest:
a) The sale, exchange or leasing of any property:
Description of Name of Related Dollar Amount for
Transaction Party and Relationship Reporting Period
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Justification:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
18
RELATED PARTY TRANSACTIONS (PAGE 2 OF 2)
b) The furnishing of goods, services or facilities for consideration:
Description of Name of Related Dollar Amount for
Transaction Party and Relationship Reporting Period
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Justification:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
c) Describe all transactions between Offeror and any relaxed party which
includes the lending of money, extensions of credit or any investment in a
related party. This type of transaction requires review and approval in advance
by the Office of the Director:
Description of Name of Related Dollar Amount for
Transaction Party and Relationship Reporting Period
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Justification:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
d) List the name and address of any individual who owns or controls more
than 10% of stock or that has a controlling interest (i.e. formulates,
determines or vetoes business policy decisions):
Name Address Owner of Has controlling
Controller Interest
Yes/No
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
19
OFFEROR'S ADMINISTRATIVE FUNCTIONS SUBCONTRACTORS (PAGE 1 OF 1)
The Offeror must identify any organizational or administrative functions (e.g.
claims processing, marketing, automated data processing, accounting) or key
personnel (e.g. administrator, medical director, chief financial officer, etc.)
which are subcontracted.
Subcontractor's Name:
----------------------------------------------------------
Address:
-----------------------------------------------------------------------
Method Of Payment:
-------------------------------------------------------------
Function Performed:
------------------------------------------------------------
Estimated Value Of Contract: 10/1/96 - 9/30/97 $
-----------------
10/1/97 - 9/30/98 $
-----------------
10/1/98 - 9/30/99 $
-----------------
Subcontractor's Name:
----------------------------------------------------------
Address:
-----------------------------------------------------------------------
Method Of Payment:
-------------------------------------------------------------
Function Performed:
------------------------------------------------------------
Estimated Value of Contract 10/1/96-9/30/97 $
-----------------
10/1/97-9/30/98 $
-----------------
10/1/98-9/30/99 $
-----------------
Subcontractor's Name:
----------------------------------------------------------
Address:
-----------------------------------------------------------------------
Method Of Payment.
--------------------------------------------------------------
Function Performed:
------------------------------------------------------------
Estimated Value Of Contract: 10/1/96 -9/30/97 $
-----------------
10/1/97-9/30/98 $
-----------------
10/1/98 - 9/30/99 $
-----------------
Subcontractor's Name:
----------------------------------------------------------
Address:
-----------------------------------------------------------------------
Method Of Payment:
-------------------------------------------------------------
Function Performed:
------------------------------------------------------------
Estimated Value Of Contract: 10/1/96 - 9/30/97 $
-----------------
10/1/97 - 9/30/98 $
-----------------
10/1/98 - 9/30/99 $
-----------------
20
OFFEROR'S KEY PERSONNEL (Page 1 of 1)
Indicate the names of the persons filling the following positions and the date
(month/year) they began, or will begin, their staff assignment. In addition, the
Offeror must attach detailed professional resumes (two pages maximum) for all
key personnel to include, at a minimum, the following positions. If any of the
following positions are filled by employees who do not spend their full time on
the AHCCCS program, please describe their other duties.
Position: Name Starting Date # of hours per
per week
dedicated to
AHCCCS
program
- -----------------------------------------------------------------------------------------
Administrator
Medical Director
Chief Financial Officer
Claims Administrator
QM/UM Coordinator
Provider Services Manager
Member Services Manager
Behavioral Health Coordinator
Maternal Health/EPSDT Coordinator
Grievance Coordinator
21
SECTION H: INSTRUCTIONS TO OFFERORS
Table of Contents
1. Contents of Offeror's Proposal.....................................73
2. Prospective Offerors' Inquiries....................................80
3. On-site Review.....................................................31
4. Prospective Offerors' Conference...................................31
5. Late Proposals.....................................................81
6. Withdrawal of Proposal.............................................81
7. Amendments to RFP..................................................31
8. Best and Final Offers..............................................31
9. Award of Contract..................................................83
10. RFP Milestone Dates................................................84
11. AHCCCSA Bidder's Library...........................................84
SECTION H: INSTRUCTIONS TO OFFERORS
1. CONTENTS OF OFFEROR'S PROPOSAL
All proposals shall be organized with strict adherence to the Offeror's
Checklist (Attachment L) as described in this section and submitted using the
forms and computer disk provided in this RFP. The Offerer's Checklist refers to
specific RFP page numbers for each requirement. All pages of the Offerer's
proposal must be numbered sequentially with documents placed in sturdy 3-ring
binders. Erasures, interlineations or other modifications in the proposal must
be initialed in original ink by the authorized person signing the offer. AHCCCSA
will not reimburse the Offeror the cost of proposal preparation.
It is the responsibility of the Offeror to examine the entire RFP, seek
clarification of any requirement that may not be clear, and check all responses
for accuracy before submitting its proposal. The proposal becomes a part of the
contract; thus what is stated in the proposal may be evaluated either during the
proposal evaluation process or during other reviews. Proposals may not be
withdrawn after the published due date and time.
All proposals will become the property of AHCCCSA. The Offeror may designate
certain information to be proprietary in nature by typing the word "proprietary"
on top of every page for which nondisclosure is requested. Final determinations
of nondisclosure, however, rest with the AHCCCSA Director. Regardless of such
determinations, all portions of the Offeror's proposal, even pages which are
proprietary, will be provided to HCFA and its evaluation contractor.
All proposals shall be organized according to the following major categories:
I. General Matters
II. Provider Network
III. Capitation
IV. Program Operations
V. Organization
Each section shall be separated by a divider and contain all information
requested in this solicitation. Numbering of pages should continue in sequence
through each separate section. For example, "Provider Network" would begin with
the page number following the last page number in "General Matters". Each
section shall begin with a table of contents.
Proposals that are not submitted in conformance with the guidelines described
herein will not be considered. For a continuing offeror, the CYE 97 Operational
and Financial Reviews (CYE 97 Review), AHCCCS member survey, and other existing
experience with the Offeror will be used as part of the evaluation of the new
proposal submitted for CYE 98.
I. GENERAL MATTERS
See the Offeror's Checklist (Attachment L) for information to be submitted under
this section.
II. PROVIDER NETWORK
The Offeror shall have in place an adequate network of providers capable of
meeting contract requirements. Attachment B lists minimum network requirements
by GSA. The following tables specify the submission requirements for both
continuing and new offerors:
Required Submissions: Network Development
1. CONTINUING OFFERORS:
On or about April 11, 1997 current contractors will receive a disk copy of the
Provider Affiliation Tape with an end date of February 14, 1997. The disk will
contain the Load Detail Report, which provides a complete listing of all
Provider Affiliation Tape (PAT) data loaded to the provider affiliation
database. The records are sorted by county, by city, by provider type, by first
specialty. A sample of the Load Detail Report may be found on page 20 of the
Provider Affiliation Tape User Manual. The report will print four columns of
data representing each provider affiliated with the health plan. A totals page
is created at the end of the report indicating the number of records that were
loaded and printed on the report. You will also receive a hard copy of the Load
Detail Report.
In addition, you will receive a hard copy of the following reports:
SUMMARY TOTALS REPORT - provides summarized information about the records on the
Load Detail Report. The records are sorted by county, by city, by provider type,
by first specialty. A total PCP count is listed for each county. Specialty
totals are listed on the report by the following: OVERALL are the number of
records; PCP is the number or providers with a PCP indicator of "yes"; PCP EPSDT
is the number of providers with a PCP indicator and EPSDT indicator of "yes";
EPSDT indicator is the number of providers with an EPSDT indicator of "yes"; PCP
OB is the number of providers with a PCP indicator of "yes" and an OB indicator
of "yes". The OB is the number of providers with an OB indicator of "yes". BH
(Behavioral Health) is the number of providers with a BH indicator of "yes".
Note that all of these totals represent the totals for a provider within the
given health plan, county, city, provider type and first specialty.
TAPE VALIDATION REPORT - provides information about the status of the submitted
PAT. If all conditions are met, the tape passes and is accepted for loading to
the PAT database. A sample of the Tape Validation Report is found on page 18 of
the Provider Affiliation Tape User Manual.
LOAD EXCEPTIONS BY PROVIDER REPORT - provides a list of all exception errors
that occur during the PAT database load process, sorted by Provider ID. The
report is designed to aid the health plan in error correction. A sample of the
Load Exceptions by Provider Report is found on page 19 of the Provider
Affiliation Tape User Manual.
LOAD EXCEPTIONS BY FIELD REPORT - provides the same list of exception errors
reported on the "by Provider" Exception Report, but it is sorted by the field in
error. The report is designed to aid the health plan in error correction. A
sample of the Load Exceptions by Field Report is found on page 19 of the
Provider Affiliation Tape User Manual.
LOAD SUMMARY REPORT - provides summarized information about the PAT load process
including the total number or records read and the total number of records with
exception errors. A sample of the Load Summary Report is found on page 21 of the
Provider Affiliation Tape User Manual.
PROVIDER AFFILIATION DUPLICATE REPORT - identifies duplicate provider records.
WHAT YOU MUST RETURN TO AHCCCSA WITH YOUR PROPOSAL:
la. The Offeror must submit, with the RFP response, a detailed listing of
its provider network using one of the following methods:
- Submit a hard copy of the Load Detail Report AHCCCS gave you
with any changes written in on the appropriate page. You must
specify if the change is a correction, addition or deletion
using the following codes: A-addition, D-deletion,
C-correction. NOTE: Additions must be supported using Letters
of Intent. If the provider is currently contracted with the
Offeror in the specific service site, the contract signature
sheet should be submitted.
OR:
- Using the disk provided by AHCCCS, input the additions,
deletions and corrections. Print out this detail which now
includes your additions, deletions and corrections and submit
the hard copy only to AHCCCS with the RFP response. You must
specify if the change is a correction, addition or deletion
using the following codes: A-addition, D-deletion,
C-correction. NOTE: Additions must be supported using Letters
of Intent. If the provider is currently contracted with the
Offeror in the specific service site, the contract signature
sheet should be submitted. DO NOT SUBMIT THE DISK TO AHCCCSA.
lb. Submit a summary of your network using the Network Summary Form in
Attachment D. The summary must summarize your network by county, by city, by
provider type, by specialty and by PCP. You may use any one of the two methods
mentioned above to compile your summary; however, the summary must tie in with
your detail. The summary is what AHCCCSA will use to score the network portion
of the RFP. The provider type can be found on the eighth line of each entry on
the Load Detail Report. A list of provider types can also be found in the
Bidder's Library.
2. New offerors: New offerors must submit completed Letters of Intent from
all providers as evidence of its proposed network. Attachment D, Sample Letter
of Intent, is the only acceptable format for these letters. A continuing offeror
seeking an expansion of service area must also submit Letters of Intent from all
providers in its proposed new area. AHCCCSA may, at its option, verify any or
all submitted Letters of Intent by telephone or mail. The Letters of Intent
should be submitted organized by county, by city, by provider type, by
specialty, and by PCP. The Offeror shall also submit a summary of the Letters of
Intent organized in the same order using the Network Summary Form in Attachment
D.
3. All offerors: Submit all signed hospital contracts for Maricopa and
Pima County (see Section D, Paragraph 35, Hospital Reimbursement) and all
contracts with emergency facilities or urgent care facilities, if any.
REQUIRED SUBMISSIONS: Network Management
(Monitoring and Control of the Network)
4. Network monitoring policies and procedures including forms, records and
report layouts
5. Job descriptions for provider services and contracting staff
6. Description of the role of the provider services and contracting
departments (Maximum: 3 pages) (A continuing offeror does not need to
include information about its method of monitoring appointment
standards if it is in full compliance with the CYE 97 Review Standards
DS 2.1, 2.2, 2.3, 3.1 and 3.2 and scored 95% on questions 11, 13 and 14
in the waiting times section of the 1996 AHCCCS member survey.)
(Network Communications)
7. Provider Manual
8. Policies and Procedures regarding communication between the Offeror and
its network
9. Description of the Offeror's communication process with the provider
network (Maximum: 3 pages)
10. Procedure for administering a provider survey, if any
11. Provider survey, if any
(A continuing offeror does not have to submit the provider manual if fully
compliant with the CYE 97 Review Standards DS 4.2 and 4.3. A continuing offeror
does not have to submit materials describing provider education if it is in
compliance with CYE 97 Review Standards DS 4.4 and 4.5.)
(Capacity Analysis)
12. By GSA, by city, the percentage of PCPs with evening and/or weekend
office hours
13. By GSA, by city, the percentage of PCPs offering languages in addition
to English
14. The percentage of PCPs who are Board Certified/Eligible
(Medical Director)
15. Medical Director job description (A continuing offeror does not need to
submit this if it is in full compliance with the CYE 97 Review
Standards MM 4.3 and 4.4.)
16. The number of hours per week the Medical Director devotes to the
Offerer's AHCCCS health plan business.
III. CAPITATION
Capitation is a fixed (per member) monthly payment to Contractor for the
provision of covered services to members. It is an actuarially sound amount to
cover expected utilization and costs for the individual rate codes in a
risk-sharing managed care environment. In addition, AHCCCSA offers reinsurance
programs to provide Contractor with protection from unusual and unforeseen
costs.
The Offeror must demonstrate that the capitation rates proposed are actuarially
sound. In general terms, this means that the Offeror who is awarded a contract
should be able to keep utilization at
or below its proposed levels and that it will be able to contract for unit costs
that average at or below the amounts shown on its Capitation Rate Calculation
Sheet The Offeror may require assistance from an actuary to develop some of the
fundamental assumptions for meeting the criteria defined above.
To facilitate the preparation of its capitation proposals, AHCCCSA will provide
each offeror with a Data Supplement Book. This book should not be used as the
sole source of information in making decisions concerning the capitation
proposal. Each offeror is solely responsible for research, preparation, and
documentation of its capitation proposal.
Required Submission: Capitation
17. The Offeror must submit its capitation proposal using the AHCCCSA
computer bid disk. Attachment E to this solicitation contains detailed
instructions for using the computer bid disk program.
Offeror must prepare and submit its capitation proposal assuming a $20,000
deductible level for regular reinsurance for all rate codes (except $15,000
deductible for MN/MI) in all counties. AHCCCSA will provide a table of PM/PM
reinsurance adjustments to be made to capitation rates for those contractors
whose actual deductible level exceeds $20,000. (See Section D, Paragraph 39,
Reinsurance.)
Graduate Medical Education (GME) - The Offeror must delete this component from
the inpatient tiers in its capitation proposal; information regarding GME will
be included in the Bidder's Library. See also Section D, Paragraph 64, Pending
Legislative Issues.
48-hour Maternity Stay - The Offeror must assume any additional costs in its
capitation proposal for the 48-hour maternity stay described in Section D,
Paragraph 64, Pending Legislative Issues. No subsequent adjustments will be
made.
Administrative costs - The Offeror's rate proposal will be deemed by AHCCCSA to
include the costs of administrative adjustments required during the term of this
contract, including the possibility of requiring all health plans to use a
standardized format for claims processing.
IV. PROGRAM OPERATIONS
Required Submissions: Programs
(Member Services)
18. Member Handbook (A continuing offeror does not need to submit this if
it is in full compliance with CYE 97 Review Standard MS 5.3.)
19. Description of the Offeror's methods of routine communication with its
members (Maximum: 3 pages)
20. Policies and procedures pertaining to member communication
21. Policies and procedures pertaining to new member enrollment
22. Policies and procedures pertaining to PCP assignment (A continuing
offeror does not have to submit if the 1996 AHCCCS Member Survey had a
95% "easy" response to the question "When you changed a PCP how hard or
easy was it?".)
23. Member complaint process policies and procedures (A continuing offeror
does not have to submit if in full compliance with CYE 97 Review
Standard MS 3.2 and 6.0 and received a 95% "Very good" or "Good" on
overall rating of Member Services on the 1996 AHCCCS Member Survey.)
24. Policies and procedures pertaining to member surveys and survey tools,
if any. (A continuing offeror does not have to submit if in full
compliance with CYE 97 Review Standard MS 4.1.)
(Quality Management/ Utilization Management)
25. Description of the Offeror's medical claims review process (Maximum: 3
pages)
26. Policies and procedures pertaining to concurrent review
27. Policies and procedures pertaining to prior authorization (A continuing
offeror does not have to submit if it is in full compliance with CYE 97
Review Standard MM 1.7.)
28. Policies and procedures pertaining to utilization management (A
continuing offeror does not have to submit if it is in full compliance
with CYE 97 Review Standard MM 1.1, l.2, and 1.6.)
29. Description of utilization management of emergency services (A
continuing offeror does not have to submit if in full compliance with
CYE 97 Review Standard MM 1.5.) (Maximum: 2 pages)
30. Policies and procedures pertaining to case management (A continuing
offeror does not have to submit if in full compliance with CYE 97
Review Standard MM 3.1.)
31. Policies and procedures pertaining to discharge planning
32. Policies and procedures pertaining to credentialing and
re-credentialing, including those for on-call back up physicians for
PCPs
33. Policies and procedures pertaining to peer review
34. Description of member's access to advice in emergent or urgent
situations (Maximum: 2 pages)
35. Examples of medical and case management protocols, if any
36. Description of the Offeror's member health assessment process, if any
(Maximum: 2 pages)
37. Policies and procedures pertaining to member transition
(EPSDT)
38. Policies and procedures pertaining to EPSDT (A continuing offeror does
not have to submit information about immunizations if it is in full
compliance with the CYE 97 Review Standard MM 14.0. A continuing
offeror does not have to submit information about member and provider
EPSDT participation if it is in full compliance with the CYE 97 Review
Standards 13.0, 15.1 and 15.2 and received at least a 95% response of
"Yes" to 1996 AHCCCS Member Survey question #15.)
39. Description of the Offeror's EPSDT activities such as unique programs,
incentives or other activities not covered in its EPSDT policies and
procedures.
40. Description of the Offeror's quality improvement plan as it relates to
EPSDT Participation, Immunization and Dental Performance Measures.
(Maternal Health/ Women's Health)
41. Policies and procedures pertaining to maternal health (A continuing
offeror does not have to submit case management policies and procedures
if in full compliance with the CYE 97 Review Standard MM 3.1.)
42. Description of the Offerer's maternal health program including
information that may not be covered in the policy and procedures.
(Maximum: 3 pages)
43. Policies and procedures pertaining to family planning services,
including the SOBRA Family Planning Extension Program (A continuing
offeror does not have to submit if in full compliance with the CYE 97
Review Standard MM 11.0)
44. Description of the Offerer's quality improvement plan as it relates to
Mammography, Cervical Cancer Screening, and Low Birth Weight
Performance Measures.
(Behavioral Health Service)
45. Policies and procedures pertaining to the delivery of behavioral health
services (A continuing offeror does not have to submit if in full
compliance with the CYE 97 Review Standards MM 16.0, 17.1, 17.3 and
19.0.)
V. ORGANIZATION
Organization refers to the Offeror's ability to perform the administrative tasks
necessary to support the requirements identified throughout this RFP. The
following table identifies the submission requirements for continuing as well as
new offerors:
Required Submissions: Organization
(Organization and Staffing)
46. Job descriptions of key personnel
47. Resumes of key personnel (If a continuing offeror received full
compliance on AM 1.1 in the CYE 97 Review, resumes will not have to be
submitted.)
48. The names of people, along with their positions, who have held key
positions from January 1, 1995 through December 31, 1996.
49. Organizational chart down to the supervisor level.
50. Number of full time employees devoted to AHCCCS by functional area
(functional area defined as: member services, provider services,
medical services, grievance and appeals, finance, claims/prior
authorization, information systems, and quality management).
(Fraud and Abuse)
51. New employee orientation materials. (If a continuing offeror received
full-compliance with the CYE 97 Review Standard AM 2.1, new employee
orientation materials do not have to be submitted.)
52. Policies and procedures pertaining to fraud and abuse. (If a continuing
offeror received full-compliance with the CYE 97 Review Standard AM
2.1, the Fraud and Abuse policies and procedures do not have to be
submitted.)
53. Flow chart and written description of the Offeror's fraud and abuse
process (Maximum: 2 pages)
(Subcontracts)
54. Model PCP subcontracts (If a continuing offeror received full
compliance on FM 6.3 in the CYE 97 review, model PCP subcontracts do
not have to be submitted.)
55. Model hospital subcontracts.
56. All signed hospital subcontracts for Maricopa and Pima counties
57. All signed rural hospital subcontracts, if any
58. Automated data processing subcontract, if any
59. Management services subcontract, if any
60. Third party administrator subcontract, if any
61. A listing of all hospitals the Offeror attempted to contact with,
stating those it negotiated successful contracts with, as well as those
that were not finalized. The reasons for not finalizing contracts
should be submitted.
(Encounters)
62. Policies and procedures pertaining to encounter submission
63. A description of how encounter adjustments are handled, including
cutback days (Maximum: 3 pages)
64. A description of the Offeror's process for ensuring ongoing timely and
complete encounter submission in the event of a major computer system
conversion (Maximum: 2 pages)
65. A description of the Offeror's procedure for reconciling the claims
system with the encounter system (Maximum: 3 pages)
66. A description of the Offeror's provider education program as it relates
to claims and encounter submissions. (Maximum: 2 pages)
67. A description of how the Offeror resolves pended encounters within 100
days (Maximum: 3 pages) (A continuing offeror does not have to submit
if in full compliance with CYE 97 Review Standard FM 3.0)
(Claims and Third Party Liability)
68. Policies and procedures pertaining to claims processing (A continuing
offeror does not have to submit if it is in full-compliance with CYE 97
Review Standard FM 2.1)
69. One-page summary on how the Offeror handles provider claims inquiries
70. Flow chart and written description of the Offeror's claims process.
(Maximum: 3 pages) (A continuing offeror does not have to submit if it
is in full-compliance with CYE 97 Review Standard FM 2.1)
71. One-page description of the Offeror's claims processing capacity
72. October, November, December 1996 month end claims aging (A continuing
offeror does not have to submit if it is in full-compliance with CYE 97
Review Standard FM 2.2)
73. Remittance advices from 5 different providers to include a hospital.
specialist and PCP for December 1996 (A continuing offeror does not
have to submit if it is in full-compliance with CYE 97 Review Standard
FM 2.3)
74. Policies and procedures pertaining to TPL/COB (A continuing offeror
does not have to submit if it is in full-compliance with CYE 97 Review
Standard FM 1.0)
(Financial Standards)
75. Last four unaudited internally prepared quarterly financial statements
with preparation date indicated (A continuing offeror does not have to
submit)
76. Verification of any contributions made to the Offeror to improve its
financial position after its audit (copies of bank statements and
deposit slips, if applicable)
77. A description of the Offeror's corporate cost allocation plan, if
applicable (Maximum: 1 page) (A continuing offeror does not have to
submit if it is in full-compliance with CYE 97 Review Standard FM 6.4)
78. Financial forecasts for the first three years of the contract starting
with September 30, 1998. Include all assumptions used for the
forecasts. Financial forecasts shall include a balance sheet and a
statement of revenues, expenses and changes in equity in ax least the
level of detail specified for annual audited financial statements as
outlined in the Reporting Guide for Acute Care Contractors with the
Arizona Health Care Cost Containment System.
79. Two most recent audited financial statements (A continuing offeror does
not have to submit)
80. Enrollment as of the two most recent audited financial statements, and
also the average enrollment for the year based on the 12-month period
of the offeror's last audit. (A continuing offeror does not have to
submit)
(Liability Management)
81. Policies and procedures pertaining to incurred but not reported claims
(IBNR)
82. Policies and procedures pertaining to reported but unpaid claims (RBUC)
83. Sample of an IBNR calculation using 12-31-95 quarterly financial
statement including all assumptions
84. Sample of an RBUC calculation using 12-31-95 quarterly financial
statement including all assumptions
(Grievance and Appeals)
85. Policies and procedures pertaining to member grievances and provider
grievances. (A continuing offeror does not have to submit policies and
procedures for grievances if it is in full compliance with CYE 97
Review Standard GA 2.3 and GA 2.4.)
86. Policies and procedures pertaining to member appeals and provider
appeals. (A continuing offeror does not have to submit policies and
procedures for appeals if it is in full compliance with CYE 97 Review
Standard GA 2.3 and GA 2.4.)
87. Provider grievance and member grievance (complaint) information logs
from 10/1/95 through 9/30/96. (A continuing offeror does not have to
submit grievance information logs if it is in full compliance with CYE
97 Review Standard GA 5.1)
88. Flowchart and written description of the Offeror's grievance process
(Maximum: 3 pages)
89. Flowchart and written description of the Offeror's appeals process
(Maximum: 3 pages)
90. A summary of the number of provider grievances and the number of member
grievances (complaints) from 10-1-95 through 9-30-96. (A continuing
offeror does not have to submit a grievance summary.)
91. New offerors must submit the name, address and phone number of the
offeror's oversight agency.
2. PROSPECTIVE OFFERORS' INQUIRIES
Any questions related to this solicitation must be directed to Mark Renshaw,
AHCCCSA Contracts and Purchasing. Offerors shall not contact or ask questions of
other AHCCCSA staff unless authorized by the Contracting Officer. Questions
shall be submitted on disk, saved as a text file (.txt), along with a hard copy
printout, prior to the Prospective Offerors Conference (submit by 4:45 p.m. on
Feb. 26. 1997) or at the Prospective Offerors Conference. Offerors are
encouraged to submit inquiries using Word 6.0 if possible. Questions submitted
by the deadline above may be addressed at the Prospective Offerors Conference.
The envelope must be marked "RFP Questions- Acute Care". Questions that cannot
be answered at the Prospective Offerors' Conference will be answered within a
reasonable period of time by letter. Any correspondence pertaining to this RFP
must refer to the appropriate page, section and paragraph numbers.
3. ON SITE REVIEW
All new offerors will receive a standardized on site review that has been
specifically developed to determine that an infrastructure is in place that will
support the provision of services to the AHCCCS population. See Attachment J for
areas to be reviewed. A prospective offeror who does not believe it will meet
the requirements evaluated in the review tool in Attachment J should not submit
a proposal or may contact Mark Renshaw, Contracts and Purchasing, for further
clarification.
4. PROSPECTIVE OFFERORS' CONFERENCES
A New Offerors' Conference will be held on March 4, 1997 from 9 a..m. until
noon, at the 701 E. Jefferson, 3rd Floor Conference Room. The purpose of this
conference will be to orient new offerors to AHCCCS. Continuing offerors are
welcome to attend but the agenda will assume no prior familiarity with the
AHCCCS program. Then from 1 p.m. to 5 p.m. there will be a Prospective Offerors'
conference for all new and continuing offerors. The purpose of this second
conference is to clarify the contents of this solicitation and to avoid any
misunderstandings regarding AHCCCSA requirements. Any doubt as to the contents
and requirements of this solicitation or any apparent omission or discrepancy
should be presented at this conference. AHCCCSA will then determine the action
necessary and issue a written amendment to the solicitation, if appropriate.
5. LATE PROPOSALS
Late proposals will not be considered.
6. WITHDRAWAL OF PROPOSAL
At any time prior to the proposal due date and time, the Offeror (or designated
representative) may withdraw its proposal. Telegraphic or mailgram withdrawals
will not be considered.
7. AMENDMENTS TO RFP
Amendments may be issued subsequent to the issue date of this solicitation.
Receipt of solicitation amendments must be acknowledged by signing and returning
the signature page of the amendment to AHCCCSA.
8. BEST AND FINAL OFFERS
AHCCCSA reserves the right to accept any or all initial offers without further
negotiation and may choose not to request a best and final offer (BFO). Offerors
are therefore advised to submit their most competitive offers at the outset. If
it is considered in the best interest of the State, however, AHCCCSA may issue a
written request to all offerors for a best and final offer in a particular
geographic service area or areas. The purpose of a BFO request is to allow
offerors an opportunity to resubmit bids for rate codes not previously accepted
by AHCCCSA. This request will notify them of the date, time and place for the
submission of their offers. In addition. AHCCCSA will disclose to each offeror
which of its bid rates are acceptable (within or below actuarial rate range) and
which are not acceptable (above the actuarial rate range). All offerors whose
final bid rates fall below the bottom of the actuarial rate range will have
their rates increased to the bottom of that rate range after the final BFO. If
an offeror does not submit a notice of withdrawal or a best and final offer, its
immediate previous offer will be considered its best and final offer.
All BFOs must be submitted on the computer disk provided by AHCCCSA. AHCCCSA
will limit the number of BFO rounds if it is in the best interest of the State.
Offerors will be permitted within the restrictions and limitations defined
below, to adjust upward a capitation rate for a rate code that was previously
accepted to offset the reduction of a capitation rate in another rate code in
the first BFO round only. These restrictions and limitations include, but are
not limited to:
a. An offeror will be allowed to adjust upward a previously accepted rate
code bid only during the first BFO round;
b. The weighted amount of BFO increase cannot exceed the weighted amount
of BFO reduction. AHCCCSA will furnish the Offeror the enrollment
percentages, by rate code, by GSA, to be used in determining the
weighted amount. Should the weighted amount of the adjustment exceed
the weighted amount of the BFO reduction, AHCCCSA shall reject the
first BFO and the adjustment (costing the Offeror the loss of the first
BFO round in that GSA). Since a rate code can only be adjusted during
the first BFO round, the Offeror will lose the opportunity to make an
upward capitation adjustment to previously accepted rate code bids in
that GSA.
For example, assume that MN/MI was the rate code where a BFO was needed
and the offeror reduced this rate by $10. PMPM. Also assume the MN/MI
rate code accounted for 9% of the members in the GSA.
Weighted Average Capitation Reduction - 9% X $10.00 =$.90.
Assume the rate code adjusted upward was TANF and this rate code was
increased by $2.00 PMPM. Also assume this rate code accounted for 50%
of the members in the GSA.
Weighted Average Capitation Increase - 50% X $2.00 = $1.00
Therefore, the BFO would be rejected because the weighted amount of the
BFO adjustment exceeded the weighted amount of the BFO reduction.
c. If an adjustment during the initial BFO round causes the Offeror to
exceed the upper range of any rate code, AHCCCSA will reject the
adjustment and return the (adjusted) rate code to the initial
capitation rate bid by the Offeror. Since a previously accepted rate
code bid can only be adjusted during the first BFO round, the Offeror
will lose the opportunity to make an upward capitation adjustment for
this rate code.
d. AHCCCSA reserves the sole right to accept or reject any adjustment. The
Offeror by submitting an adjustment to a rate code is requesting
approval by AHCCCSA; such approval shall not be automatic. If an
initial bid is below the bottom of a rate range, it cannot be adjusted
downward by the Offeror in a BFO round.
Capitation Rates Offered after the BFOs: As stated above, AHCCCSA may limit the
number of BFO rounds. After the final BFO round is complete, provided it is in
the best interest of the state, AHCCCSA will cease issuing BFO requests. At this
point, should the Offeror have a rate code(s) without an accepted capitation
rate, AHCCCSA shall offer a capitation rate to the Offeror. The capitation rate
offered shall be somewhere in the bottom half of the rate range (specific
placement to be determined by AHCCCSA and its actuaries). Note that all rates
offered in this manner shall be identical for all offerors in the same GSA and
rate code.
9. AWARD OF CONTRACT
AHCCCSA has determined that the provision of covered services to eligible
populations in the Geographic Service Areas as described below will stabilize
risk sharing. The Offeror must therefore bid on at least one entire GSA in order
to be considered for a contract award. If deemed in the best interest of the
State, AHCCCSA may limit the number of GSA's awarded to any one offeror.
Notwithstanding any other provision of this solicitation, AHCCCSA expressly
reserves the right to:
a. Waive any immaterial mistake or informality;
b. Reject any or all proposals or portions thereof; and/or
c. Reissue a Request for Proposals
If two plans or their parents merge after obtaining contract awards, AHCCCS
retains the right to address each merger issue on an individual basis according
to what is deemed in the best interest of the State. AHCCCS is aware that APIPA
and Mercy Care may merge, therefore, we have
notified these plans that we require certification from both plans that those
who work on the APIPA bid and those that work on Mercy Care bid, have not
received, heard or discussed any non-public information about or with the other
in preparing their respective bids. Pending this certification from APIPA and
Mercy Care we shall consider their respective bid proposals.
Effective retroactively to October 1, 1994, Mercy Care Plan is considered to be
an incumbent health plan in Santa Cruz County and APIPA is considered to be an
incumbent health plan in Cochise County.
If there are significant compliance issues with a current plan or a plan's
contract in a particular county has been previously terminated, AHCCCS retains
the right to address each compliance or termination issue on an individual basis
according to what is deemed in the best interest of the State. A new bid
proposal may not be accepted until it has been determined that the reason for
the significant compliance or termination issue has been resolved and there is a
reasonable assurance that it will not recur. Further, points may be deducted
from an offeror's score as described in Section 1 of this contract.
A response to this Request for Proposals is an offer to contract with AHCCCSA
based upon the terms, conditions, scope of work and specifications of the RFP.
Proposals do not become contracts unless and until they are accepted by the
Contracting Officer. A contract is formed when the AHCCCSA Contracting Officer
signs the award page and provides written notice of the award(s) to the
successful offeror(s). For that reason, all of the terms and conditions of the
contract are contained in this solicitation, solicitation amendments and
subsequent contract amendments, if any, signed by the Contracting Officer.
AHCCCSA may also, at its sole option, modify any requirements described herein.
All offerors will be promptly notified of award.
AHCCCSA reserves the right to specify and/or modify the number of contracts to
be awarded in any GSA. AHCCCSA anticipates awarding contracts as follows:
GSA #: County or Counties Number of Contracts
- ------ ------------------ -------------------
1. Yuma Maximum of 2
2. Mohave, LaPaz Maximum of 2
3. Yavapai, Coconino Maximum of 2
4. Pinal, Gila Maximum of 2
5. Pima Maximum of 4
6. Maricopa Maximum of 6
7. Graham, Greenlee Maximum of 2
8. Apache, Navajo Maximum of 2
9. Cochise, Santa Cruz Maximum of 2
An existing contractor in Maricopa or Pima county who is not awarded a new
contract may request to have its enrollment capped and to continue providing
services under the terms and conditions of this new RFP. AHCCCSA may, at its
sole option, want or deny such a request. If AHCCCSA approves such an enrollment
cap, the contractor would continue to serve its existing members but receive no
new ones. The enrollment cap will not be lifted during the term of this or any
subsequent contract period unless one of the following conditions exist:
a. Another health plan is terminated and increased member capacity is
needed, or
b. Legislative action creates a sudden and substantial increase in the
overall AHCCCS population, or
c. Extraordinary and unforeseen circumstances make such an action
necessary and in the best interest of the State.
In the event two or more competing proposals are received, and one of the
proposals is from an incumbent health plan, AHCCCSA may, at its sole option and
in the interest of continuity of care, waive negligible differences in overall
evaluation scores and award the contract to the incumbent health plan.
Finally, in the event of significant non-compliance issues with a contractor in
a particular GSA, AHCCCSA may refer back to the results of the evaluation of
this solicitation and select another contractor for a particular GSA that is
considered to be in the best interest of the State.
10. RFP MILESTONE DATES
The following is the schedule of events regarding the solicitation process:
Activity Date(s)
-------- -------
PMMIS Technical Interface Meeting February 21, 1997
Technical Assistance Questions Due February 26, 1997
Prospective Offerors Conference and March 4, 1997
Technical Assistance Session
RFP Amendment Issued, if necessary March 19, 1997
Proposals Due May 12, 1997 (3 p.m.)
Contracts Awarded on or about June 12, 1997
11. AHCCCSA BIDDER'S LIBRARY
The Bidders Library contains critical reference material on AHCCCS policies and
performance requirements. References are made throughout this solicitation to
material in the Bidder's Library and offerors are responsible for the contents
of such referenced material as if they were printed in full herein. All such
material is incorporated into the contract by reference. The Bidder's Library is
located at 701 E. Jefferson, Phoenix, AZ. Please contact Mark Renshaw at (602)
417-4577 for further information and appointment times.
SECTION I: EVALUATION FACTORS AND SELECTION PROCESS
AHCCCSA has established a scoring methodology which is designed to evaluate
fairly an offeror's ability to provide cost-effective, high-quality contract
services in a managed care setting. The following factors will be evaluated:
1. Provider Network
2. Capitation
3. Program
4. Organization
5. On-site review (for new Offerors only)
It is anticipated that capitation and the network development portion of
provider network will be scored by Geographic Service Area. The remaining
provider network management, organization and program are anticipated to be
scored statewide, not specific to any geographic service area. The scores
received for each of the four components will be weighted separately and
combined to derive a final score for the Offeror, by Geographic Service Area.
Contracts will be awarded to qualified offerors whose proposals are deemed to be
most advantageous to the State in accordance with Section H, Paragraph 9, Award
of Contract.
AHCCCSA will consider the past performance and experience of continuing offerors
as a factor in evaluating their proposals. In certain instances, as described in
Section H, a continuing offeror may be excused from certain submission
requirements. In these instances, a continuing offeror will receive "full
points" for a particular area if AHCCCSA has determined through experience that
the Offeror meets requirements in a particular area. Conversely, AHCCCSA may
deduct points based upon past performance and experience that is not, or was
not, in compliance with AHCCCSA requirements. In the event two or more competing
proposals are received for a particular GSA, and one of the proposals is from an
incumbent health plan, AHCCCSA may, at its sole option and in the interest of
continuity of care, waive negligible differences in overall evaluation scores
and award the contract to the incumbent health plan.
AHCCCSA reserves the right to waive immaterial defects or omissions in this
solicitation or submitted proposals. The Offeror should note that, if
successful, it must meet all AHCCCS requirements, irrespective of what is
requested and evaluated through this solicitation
- --------------------------------------------------------------------------------
All of the components listed below will be evaluated against relevant statutes,
AHCCCSA rules, regulations and policies and the requirements contained in this
RFP. The Offeror's Checklist (Attachment L) contains RFP references for each of
these items:
1. PROVIDER NETWORK
The provider network will be evaluated and scored with reference to the
Offeror's network development and network management. Network development is
defined as the process of developing contractual arrangements with a sufficient
number of providers capable of delivering all covered services to AHCCCS members
in accordance with AHCCCSA standards (e.g.,
appointment times). AHCCCSA will use the Health Plan Provider Affiliation Tape
Submission and/or completed letters of intent with other required materials to
evaluate and score network development. The Offeror's network will be evaluated
by service and by site in each GSA bid by the Offeror. The Offeror should note
that Attachment B of this solicitation identifies minimum-geographic standards
for a provider network.
Network management is defined as the process by which the Offeror certifies,
monitors, evaluates and communicates with its network. AHCCCSA anticipates
evaluating and scoring the Offeror's submitted materials relative to the
following areas:
a. Monitoring and control of network
b. Network communications
c. Network capacity issues and analysis
d. Medical Director oversight
2. CAPITATION
The Offeror shall submit initial capitation bids by rate code grouping within a
geographic service area. These initial bids will be evaluated and scored. The
lowest bid within each geographic service area and rate code grouping will
receive the maximum allowable points. If a bid is below the actuarial rate range
the bid will be evaluated as if it were at the bottom of the actuarial rate
range. No additional points will be given for bids below the actuarial rate
range. Conversely, the highest bid (within or above the actuarial rate range)
will receive the least number of points.
If AHCCCSA requests best and final offers, these will be scored using the same
methodology as was used to score the initial bids. The initial and final bids
will receive equal weighting for scoring. Offerors should note that AHCCCSA may
not offer the opportunity to submit best and final offers.
3. PROGRAM
AHCCCSA will evaluate the Offeror's responsiveness to the requirements of this
solicitation and AHCCCSA policies. In particular, it is anticipated that the
Offeror's proposal regarding the following will be evaluated:
a. Quality Management/Utilization Management
b. Early Periodic Screening, Diagnosis and Treatment (EPSDT)
c. Maternal/Women's Health
d. Member Services
e. Behavioral Health
4. ORGANIZATION
Organization refers to the Offeror's prospective ability to perform the
administrative tasks necessary to support the requirements identified in this
solicitation. It is anticipated that the following areas will be evaluated:
a. Key personnel
b. Claims payment, including third party collections
c. Financial standards, including performance bond
d. Liability management (Incurred But Not Reported claims and Received But
Unpaid Claims)
e. Encounter submission
f. Grievance and appeals
g. Fraud and abuse
h. Model subcontracts
5. NEW OFFEROR REVIEWS
AHCCCSA will conduct New Offeror Reviews prior to award of contracts. These
reviews will be approximately 6 hours in length and will be conducted on-site at
the Offeror's place of business. These reviews are anticipated to take place
between May 15, 1997 and June 6, 1997 and will be scored on a pass/fail basis. A
new offeror must meet substantially all of the requirements noted in the New
Offeror Review Guide (see Attachment J) in order to be further considered for
contract award. The areas anticipated to be reviewed during the on-site review
are as follows:
a. Interviews and review of qualifications of key management staff
b. Claims processing, including a review of remittance advices
c. Review of management information system
d. Review of quality management activities
e. Review of accounting system, including calculations of IBNRs and RBUCs
f. Tour of offices and facilities
New offerors should ensure that key personnel are available during the on-site
review. There will be no follow-up visits. New offerors must have the required
infrastructure in place in order for AHCCCS to conduct its review and be
eligible for further consideration for contract award.
[END OF SECTION I]
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract.
2. RECORDS AND REPORTS
The Subcontractor shall maintain all forms, records, reports and working papers
used in the preparation of reports, files, correspondence, financial statements,
records relating to quality of care, medical records, prescription flies,
statistical information and other records specified by AHCCCSA for purposes of
audit and program management. The Subcontractor shall comply with all
specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect
each service provided and all net costs, direct and indirect, of labor,
materials, equipment, supplies and services, and other costs and expenses of
whatever nature for which payment is made to the Subcontractor. Such material
shall be subject to inspection and copying by the state, AHCCCSA and the U.S.
Department of Health and Human Services during normal business hours at the
place of business of the person or organization maintaining the records.
The Subcontractor agrees to make available at the office of the Subcontractor,
at all times reasonable times, any of its records for inspection, audit or
reproduction, by any authorized representative of the state or federal
governments.
The Subcontractor shall preserve and make available all records for a period of
five years from the date of final payment under this subcontract except as
provided in paragraphs a. and b. below:
a. If this subcontract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for a
period of five years from the date of any such termination.
b. Records which relate to disputes, litigation or the settlement of
claims arising out of the performance of this subcontract, or costs and expenses
of this subcontract to which exception has been taken by the state, shall be
retained by the Subcontractor until such disputes, litigation, claims or
exceptions have been disposed of.
The Subcontractor shall provide all reports requested by AHCCCSA, and all
information from records relating to the performance of the Subcontractor which
AHCCCSA may reasonably
require. The Subcontractor reporting requirements may include, but are not
limited to, timely and detailed utilization statistics, information and reports.
The Subcontractor shall certify to the Contractor that it has not engaged in
conduct prohibited by ss.1128B of the Social Security Act (42 USC 1320a-7b).
3. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Subcontractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS
covered-services. This provision shall not apply to patient contributions to the
cost of services delivered by nursing homes.
4. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Subcontractor under this subcontract may be assigned without
the prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5. APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The Contractor shall
notify AHCCCSA in the event of any proposed amendment or termination during the
term hereof. Any such amendment or termination is subject to the prior approval
of AHCCCSA. Approval of the subcontract may be rescinded by the Director of
AHCCCSA for violation of federal or state laws or rules.
6. WARRANTY OF SERVICES
The Subcontractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
7. SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Contractor and AHCCCSA for
the provision of covered services.
8. AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the Contractor may undertake or award other contracts for
additional or related work to the work performed by the Subcontractor and the
Subcontractor shall fully cooperate with such other contractors, subcontractors
or state employees. The Subcontractor shall not commit or permit any act which
will interfere with the performance of work by any other contractor,
subcontractor or state employee.
9. INDEMNIFICATION BY SUBCONTRACTOR
The Subcontractor agrees to hold harmless the state, all state officers and
employees, AHCCCSA and other appropriate state agencies, and all officers and
employees of AHCCCSA and all AHCCCS eligible persons in the event of nonpayment
to the Subcontractor. The Subcontractor shall further indemnify and hold
harmless the state, AHCCCSA, other appropriate state agencies, AHCCCS
contractors, and their agents, officers and employees against all injuries,
deaths, losses, damages, claims, suits, liabilities, judgments, costs and
expenses which may, in any manner accrue against the State, AHCCCSA or its
agents, officers or employees, or AHCCCS contractors, through the intentional
conduct, negligence or omission of the Subcontractor, its agent, officers or
employees.
10. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Subcontractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
11. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Subcontractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract.
12. SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
13. VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Subcontractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
14. CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, ARS ss.36-107, 36-2903, 41-1959 and 46-135, and AHCCCS and/or ALTCS
Rules.
15. GRIEVANCE PROCEDURES
Any grievances filed by the Subcontractor shall be adjudicated in accordance
with AHCCCS Rules.
16. TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Subcontractor, terminate this subcontract
if it is found, after notice and hearing by the State, that gratuities in the
form of entertainment, gifts, or otherwise were offered or given by the
Subcontractor, or any agent or representative of the Subcontractor, to any
officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to the awarding, amending or the
making of any determinations with respect to the performance of the
Subcontractor; provided, that the existence of the facts upon which the state
makes such findings shall be in issue and may be reviewed in any competent
court. If the subcontract is terminated under this section, unless the
Contractor is a governmental agency, instrumentality or subdivision thereof,
AHCCCSA shall be entitled to a penalty, in addition to any other damages to
which it may be entitled by law, and to exemplary damages in the amount of three
times the cost incurred by the Subcontractor in providing any such gratuities to
any such officer or employee.
17. PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The Contractor and Subcontractor shall develop, maintain and use a system for
Prior Authorization and Utilization Review which is consistent with AHCCCS Rules
and the Contractor's policies.
18. NON-DISCRIMINATION REQUIREMENTS
If applicable, the Subcontractor shall comply with:
a. The Equal Pay Act of 1963, as amended, which prohibits sex
discrimination in the payment of wages to men and women performing
substantially equal work under similar working conditions in the same
establishment.
b. Title VI of the Civil Rights Act of 1964, as amended, which prohibits
the denial of benefits of, or participation in, contract services on
the basis of race, color, or national origin.
c. Title VII of the Civil Rights Act of 1964, as amended which prohibits
private employers, state and local governments, and educational
institutions from discriminating against their employees and job
applicants on the basis of race, religion, color, sex, or national
origin.
d. Title I of the Americans with Disabilities Act of 1990, as amended,
which prohibits private employers and state and local governments from
discriminating against job applicants and employees on the basis of
disability.
e. The Civil Rights Act of 1991, which reverses in whole or in part,
several recent Supreme Court decisions interpreting Title VII.
f. The Age Discrimination in Employment Act (ABS Title 41-1461, et seq.);
which prohibits discrimination based on age.
g. State Executive Order 75-5 and Federal Order 11246 which mandates that
all persons, regardless of race, color, religion, sex, age, national
origin or political affiliation, shall have equal access to employment
opportunities.
h. Section 503 of the Rehabilitation Act of 1973, as amended, which
prohibits discrimination in the employment or advancement of the
employment of qualified persons because of physical or mental handicap.
i. Section 504 of the Rehabilitation Act of 1973, as amended, which
prohibits discrimination on the basis of handicap in delivering
contract services.
19. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Subcontractor's records and the inspection of the
Subcontractor's facilities. If the Subcontractor is an inpatient facility, the
Subcontractor shall file uniform reports and Title XVIII and Title XIX cost
reports with AHCCCSA.
20. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Subcontractor certifies that all
representations set forth herein are true to the best of its knowledge.
21. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Subcontractor certifies that it has not engaged
in any violation of the Medicare Anti-Kickback statute (42 USC ss.1320a-7b) or
the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Subcontractor provides
laboratory testing, it certifies that it has complied with 42 CFR ss.41 1.361
and has sent to AHCCCSA simultaneous copies of the information required by that
rule to be sent to the Health Care Financing Administration.
22. CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
23. ENCOUNTER DATA REQUIREMENT
If the Subcontractor does not bill the Contractor (e.g., Subcontractor is
capitated), the Subcontractor shall submit encounter data to the Contractor in a
form acceptable to AHCCCSA.
24. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. Contractor may not reimburse providers who do
not comply with the above requirements.
25. INSURANCE
[This provision applies only if the Subcontractor provides services directly to
AHCCCS members]
The Subcontractor shall maintain for the duration of this subcontract a policy
or policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance. The Subcontractor agrees that any
insurance protection required by this subcontract or otherwise obtained by the
Subcontractor shall not limit the responsibility of Subcontractor to indemnify,
keep and save harmless and defend the State and AHCCCSA. their agents, officers
and employees as provided herein. Furthermore, the Subcontractor shall be fully
responsible for all tax obligations, Worker's Compensation Insurance, and all
other applicable insurance coverage, for itself and its employees, and AHCCCSA
shall have no responsibility or liability for any such taxes or insurance
coverage.
26. FRAUD AND ABUSE
If the Subcontractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Subcontractor shall report the incident to the
Contractor, who shall proceed in accordance with the AHCCCS Health Plans and
Program Contractors Policy for Prevention, Detection and Reporting of Fraud and
Abuse. Incidents involving potential member eligibility fraud should be reported
to AHCCCSA, Office of Managed Care, Member Fraud Unit. All other incidents of
potential fraud should be reported to AHCCCSA, Office of the Director, Office of
Program Integrity. (See AHCCCS Rule R9-22-511.)
ATTACHMENT B: MINIMUM NETWORK STANDARDS
(By Geographic Service Area)
INSTRUCTIONS
Note: Offerors are permitted to bid only by Geographic Service Area. Please see
Section H, Paragraph 9, Award of Contracts, for further information on bidding
by Geographic Services Area.
Offerors shall have in place an adequate network of providers capable of meeting
contract requirements. The information that follows describes the minimum
network requirements by Geographic Service Area (GSA). The minimum bid is a
single entire GSA, as depicted on the following page.
In some GSA's there are required service sites located outside of the
geographical boundary of a GSA. The reason for this relates to practical access
to care. In certain instances, a member must travel a much greater distance to
receive services within their assigned GSA if the member were not allowed to
receive services in an adjoining GSA or state.
Split zip codes occur in some counties. Split zip codes are those which straddle
two different counties. Enrollment for members residing in these zip codes is
based upon the county and GSA to which the entire zip code has been assigned by
AHCCCS. The Offeror shall be responsible for providing services to members
residing in the entire zip code that is assigned to the GSA for which the
Offeror has agreed to provide services. The split zip codes GSA assignments are
as follows:
ZIP CODE SPLIT BETWEEN COUNTY ASSIGNED ASSIGNED GSA
THESE COUNTIES TO
------------------------------------------------------------------------
85220 Pinal and Maricopa Maricopa 6
85242 Pinal and Maricopa Maricopa 6
85292 Gila and Pinal Gila 4
85342 Yavapai and Maricopa Maricopa 6
85358 Yavapai and Maricopa Maricopa 6
85390 Yavapai and Maricopa Maricopa 6
85643 Graham and Cochise Cochise 9
85645 Pima and Santa Cruz Santa Cruz 9
85943 Apache and Navajo Navajo 8
86336 Coconino and Yavapai Yavapai 3
86351 Coconino and Yavapai Coconino 3
86434 Mohave and Yavapai Yavapai 3
If outpatient specialty services (OB, family planning, and pediatrics) are not
included in the primary care provider contract, at least one subcontract is
required for each of these specialties in the service sites specified. General
surgeons must be available within 50 miles of service sites.
In Tucson (GSA 5) and Metropolitan Phoenix (GSA 6), the Offeror must demonstrate
its ability to provide PCP, dental and pharmacy services so that members don't
need to travel more than 5 miles from their residence. Metropolitan Phoenix is
defined on the Minimum Network Standard page specific to GSA #6.
Offerors bidding in GSA's other than GSA 5 and GSA 6 are encouraged to contract
with the hospitals in their provider network. However, AHCCCSA will not award
additional points in the evaluation process for hospital contracts in rural
areas. At a minimum, the Offeror shall have a physician with admitting and
treatment privileges with each hospital in its network. Offerors bidding in GSA
5 and/or GSA 6 must have at least one hospital contract in each service district
as depicted on the respective maps for GSA 5 and GSA 6. This requirement is part
of the Hospital Reimbursement Pilot Program. described more fully in Section D,
Paragraph 35, Hospital Reimbursement. For offerors' convenience, a list of
Phoenix and Tucson area hospitals are included on the reverse of the Phoenix and
Tucson maps which follow.
Provider categories required at various service delivery sites included in the
Service Area Minimum Network Standards are indicated as follows:
H Hospitals
P Primary Care Providers (physicians, certified nurse
practitioners and physician assistants)
D Dentists
Ph Pharmacies
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 1
COUNTY: YUMA
Hospitals
Yuma
Primary Care Providers
Yuma
Somerton
Welton
Dentists
Yuma
Pharmacies
Yuma
Welton
[MAP OF YUMA]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 2
COUNTIES: LA PAZ AND MOHAVE
Hospitals
Bullhead City
Kingman
Lake Havasu City
Parker
St. George, Utah
Primary Care Providers
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah
Dentists
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah
Pharmacies
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah
[MAP OF LA PAZ AND MOHAVE COUNTIES]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 3
COUNTY: COCONINO AND YAVAPAI
Hospitals
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Winslow
Primary Care Providers
Camp Verde
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payston
Phoenix/Wickenburg
Prescott
Prescott Valley
Sedona
Williams
Winslow
Dentists
Camp Verde
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Prescott Valley
Sedona
Williams
Winslow
Pharmacies
Camp Verde
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payston
Phoenix/Wickenburg
Prescott
Prescott Valley
Sedona
Williams
Winslow
[MAP OF COCONINO AND YAVAPAI COUNTIES]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 4
COUNTIES: GILA AND PINAL
Hospitals
Casa Grande
Claypool
Mesa
Payson
Primary Care Providers
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Kearney
Mammonth/San Manuel/Oracle
Mesa
Payson
Dentists
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Hayden/Winkelman
Kearney
Mammonth/San Manuel/Oracle
Mesa
Payson
Pharmacies
Apache Junction
Casa Grande
Coolidge/Florence
Globe/Miami/Claypool
Hayden/Winkelman
Kearney
Mammonth/San Manuel/Oracle
Mesa
Payson
[MAP OF GILA AND PINAL COUNTIES]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 5
COUNTIES: PIMA
Hospitals
Tucson
Northwest Service Sector - Contract Requirement
Southwest Service Sector - Contract Requirement
Nogales
Physician(s) with admit and treatment - privileges required
Primary Care Providers
Ajo
Catalina
Green Valley/Continental
Marana
Nogales
Oro Valley
Tucson++
Dentists
Ajo
Catalina
Green Valley/Continental
Marana
Nogales
Oro Valley
Tucson++
Pharmacies
Ajo
Catalina
Green Valley/Continental
Nogales
Oro Valley
Tucson++
[MAP OF PIMA COUNTY]
++ Within Tucson, distance standards must be met as specified in
Attachment B.
[MAP OF METROPOLITAN TUCSON - ARTERIAL STREETS]
HOSPITALS IN TUCSON METROPOLITAN AREA (By service district, by zip code)
NORTHWEST DISTRICT
85719 Tucson General Hospital
University Medical Center
85741 Columbia Northwest Hospital
85745 Carondelet St. Mary's Hospital
SOUTHEAST DISTRICT
85711 Carondelet St. Joseph's Hospital
85712 Columbia El Dorado Hospital
Tucson Medical Center
85713 Kino Community Hospital
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 6
COUNTIES: MARICOPA
Hospitals
Metropolitan Phoenix++
Northwest Service Sector - Contract Required
Central Service Sector - Contract Required
Southeast Service Sector - Contract Required
Wickenburg
Physician(s) with admit and treatment - privileges required
Primary Care Providers
Avondale/Goodyear/Litchfield Park/Tolleson
Buckeye
Gila Bend
Metropolitan Phoenix++
Queen Creek
Wickenburg
Dentists
Avondale/Buckeye/Goodyear/Litchfield Park/Tolleson
Metropolitan Phoenix++
Wickenburg
Pharmacies
Avondale/Goodyear/Litchfield Park/Tolleson
Buckeye
Metropolitan Phoenix++
Wickenburg
[MAP OF MARICOPA COUNTY]
++ For purposes of this RFP, Metropolitan Phoenix encompasses the following:
Phoenix, Paradise Valley, Cave Creek/Carefree, Fountain Hills, Scottsdale,
Glendale, Sun City/Sun City West, Tempe, Mesa, Gilbert, Chandler, Apache
Junction, Peoria, El Mirage, Guadalupe, Surprise and Youngtown. Within this
area, distance standards must be met as specified in Attachment B.
[MAP OF METROPOLITAN PHOENIX - ARTERIAL STREETS]
HOSPITALS IN PHOENIX METROPOLITAN AREA (By service district, by zip code)
CENTRAL DISTRICT
85006 Good Samaritan Regional Medical Center
Phoenix Children's Hospital
St. Luke's Medical Center
85007 Phoenix Memorial Hospital
85008 Maricopa Medical Hospital
85013 St. Joseph's Hospital & Medical Center
85015 Community Hospital Medical Center
Phoenix Baptist Hospital & Medical Center
85016 Columbia Medical Center Phoenix
85020 John C. Lincoln Hospital & Health Center
85027 Phoenix General Hospital & Medical Center
NORTHWEST DISTRICT
85031 Maryvale Samaritan Medical Center
85031 Columbia Paradise Valley Hospital
85306 Thunderbird Samaritan Medical Center
85308 Arrowhead Community Hospital & Medical Center
85351 Walter O. Boswell Memorial Hospital
85375 Del E. Webb Memorial Hospital
SOUTHWEST DISTRICT
85201 Mesa General Hospital Medical Center
Mesa Lutheran Hospital
85202 Desert Samaritan Medical Center
85206 Valley Lutheran Hospital
85224 Chandler Regional Hospital
85251 Scottsdale Memorial Hospital - Osborn
85261 Scottsdale Memorial Hospital - North
85281 Tempe St. Luke's Hospital
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 7
COUNTY: GRAHAM AND GREENLEE
Hospitals
Safford
Primary Care Providers
Morenci/Clifton
Safford
Dentists
Morenci/Clifton
Safford
Pharmacies
Morenci/Clifton
Safford
{MAP OF GRAHAM AND GREENLEE COUNTIES]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 8
COUNTY: APACHE AND NAVAJO
Hospitals
Gallup, NM
Showlow
Springerville
Winslow
Primary Care Providers
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
Dentists
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
Pharmacies
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
[MAP OF APACHE AND NAVAJO COUNTIES]
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 9
COUNTY: COCHISE AND SANTA CRUZ
Hospitals
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Wilcox
Primary Care Providers
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Wilcox
Dentists
Benson/Wilcox
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Pharmacies
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Wilcox
[MAP OF COCHISE AND SANTA CRUZ COUNTIES]
ATTACHMENT C: MANAGEMENT SERVICES SUBCONTRACTOR STATEMENT
INSTRUCTIONS: A Management Services Subcontractor is defined as a marketing
organization or any other organization or person agreeing to perform any
administrative function or service for the Contractor specifically related to
securing or fulfilling the Contractor's obligations to AHCCCSA. This includes,
but is not limited to, third-party administrators, firms or persons who manage
operations of the Contractor such as marketing, automatic data processing,
claims processing, quality management, utilization management, prior
authorization and other management functions.
All Management Services Subcontractors are required to have an annual financial
audit. A copy of this audit must be filed with AHCCCSA within 120 days of the
Subcontractor's fiscal year end. Failure to file a copy may result in withdrawal
of AHCCCSA approval.
Attach to this proposal a signed copy of the Management Subcontract for Contract
Year 97 (10/1/96 -9/30/97) in addition to all information requested below. If
the existing subcontract is for multiple terms, attach the original management
subcontract and all amendments. When making attachments to this section, please
refer to the question number and the item heading.
******
MANAGEMENT SERVICES SUBCONTRACTOR STATEMENT
NAME OF BUSINESS_______________________________________________________________
ADDRESS___________________________ CITY_________________ STATE____ ZIP_________
PHONE NO. ________________________
1. TYPE OF BUSINESS (check appropriate box)
[ ] Individual [ ] Partnership [ ] Corporation
[ ] Joint Venture [ ] Government [ ] Other (Describe) ________
If a corporation, indicate type:____________________________________
2. INCORPORATED IN THE STATE OF:_______________________
If incorporated in a state other than Arizona, do you have a certificate to do
business in the State of Arizona? Yes____ No____. If yes, type of certificate
and with what agency or administration is it filed: _________________________
3. WHO IS YOUR STATUTORY AGENT FOR THE STATE OF ARIZONA:
Name________________________________________ Phone______________________
Address____________________________ State:___________ Zip:________________
4. PARENT COMPANY AND EMPLOYER IDENTIFICATION NUMBER
For the purpose of this RFP, a parent company is defined as one which
either owns or controls the activities and basic business policies of the
Management Services Subcontractor. To own another company means the parent
company must own at least a majority (more than 50%) of the voting rights
in the company. To control another company, such ownership is not required;
if such company is able to formulate, determine, or veto business policy
decisions of the Management Services Subcontractor, such other company is
considered the parent company of the Management Services Subcontractor.
Is the Management Services Subcontractor owned or controlled by a parent
company as described above? Yes_____ No_____. If yes, insert in the space
below the name and main office address of the parent company.
Name______________________________________________________________________
Address______________________________________ State ________ Zip__________
5. ORGANIZATION CHART
Attach a copy of your staff functional organizational chart, setting forth
lines of authority, responsibility and communication which will pertain to
this proposal.
6. IF OTHER THAN A GOVERNMENT AGENCY, WHEN WAS YOUR ORGANIZATION FORMED?
____________________________
If your organization is a corporation, attach a list of the names and
addresses of the Board of Directors.
7. LICENSE/CERTIFICATION
Attach a list of all licenses and certifications your organization is
required to maintain. Use a separate sheet of paper using the following format:
SERVICE COMPONENT LICENSE/REQUIREMENT RENEWAL DATE
----------------- ------------------- ------------
If any licenses have been denied, revoked or suspended within the past 10
years, please explain.
8. ADMINISTRATIVE AGENTS
Is your agency acting as the administrative agent for any other agency
organization? Yes___ No___ If yes, describe the relationship in both legal
and functional aspects.
9. CIVIL RIGHTS COMPLIANCE DATA
Has any federal or state agency ever made a finding of noncompliance with
any relevant civil rights requirement with respect to your company? Yes____
No____. If yes, please explain.
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10. PRIOR CONVICTIONS
Are there any felony convictions of any key personnel (i.e., Chief
Executive Officer, Plan Managers, Financial Officers, major stockholders or
those with controlling interest. etc.) within the past 15 years?
Yes _____ No _____. If yes, please explain.
11. DOES YOUR COMPANY HAVE ANY OWNERSHIP OR CONTROL INTEREST OF 5% OR MORE
(i.e., able to formulate, determine, vote or influence business policy
decisions, etc.) in another organization? Yes_______ No_____. If yes, list
each organization's name, address and the percentage of ownership and/or
control.
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
12. DO THOSE WHO OWN OR CONTROL YOUR COMPANY HAVE ANY OWNERSHIP OR CONTROL
INTEREST OF 5% OR MORE (i.e., able to formulate, determine, veto or
influence business policy decisions, etc.) in another organization?
Yes____ No____. If yes, list each organization's name and address, the
percentage of ownership or control, and the names of those with the common
ownership or control interest:
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
13. HAS YOUR COMPANY EVER BEEN SUSPENDED OR EXCLUDED FROM ANY FEDERAL PROGRAM
FOR ANY REASON?
Yes_____ No______. If yes, please attach explanation.
14. SUBCONTRACTOR'S CUSTOMER DESCRIPTION: For each of your principal customers
(i.e. one that generates 5% or more of Subcontractor's gross annual
revenue), please provide the following information:
a. Customer's name and address
b. Customer's percentage of Subcontractor revenue
c. Percent of Subcontractor's time managing customer
d. Customer's principal business
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15. SUBCONTRACTOR'S PERSONNEL EXPERIENCE STATEMENT
Please provide resumes for all key personnel describing professional
experience and education including continuing educational courses taken
during the last three years.
16. SUBCONTRACTOR CONTROLLING INTEREST STATEMENT
Please provide the name and address of any individuals or organizations
with an ownership or controlling interest in the Subcontractor company
(i.e., able to formulate, determine or veto business policy decisions,
etc.). You may include those whose ownership or control interest is less
than 5%.
PERCENT OF
NAME ADDRESS OWNERSHIP OR CONTROL
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
17. SUBCONTRACTOR FINANCIAL STATEMENT
a. Is your accounting system based on a cash or accrual method?
Cash [ ]
Accrual [ ]
Other [ ] (Give a brief explanation.)
b. Does your organization prepare an annual financial statement?
Yes_____ No______. If yes, provide a copy of the latest report.
c. Are interim financial statements prepared? Yes_____ No______. If yes,
how often are they prepared? ___________________
Are footnotes and supplementary schedules an integral part of the
statements?
Yes______ No______.
Provide a copy of the latest statements including all necessary data
to support your answers above.
d. Is your organization audited by an independent accounting firm or
accountant?
Yes_____ No____. If yes, how often are audits conducted?____________.
By whom are they conducted? Provide name, address and telephone number
and attach a copy of the latest audited financial statements.
e. Do you have any uncorrected audit exceptions? Yes_____ No______.
If yes, please explain the action being taken to correct the
exceptions.
C-4
f. Does your organization have an accounting manual? Yes_____ No_____.
If no, please explain if you have proper accounting policies and
procedures, and how you provide for the dissemination of such
accounting policies and procedures within your organization and what
controls exist to ensure the integrity of your financial information.
The Subcontractor agrees to furnish copies of such written accounting
policies and procedures for inspection upon request from AHCCCSA.
g. Are management letters on internal controls issued by the accounting
firm? Yes_____ No_____.
If yes, attach a copy of the management letter from the latest audit.
This must be on the auditor's letterhead and the Subcontractor, by its
submission, certifies the letter is unaltered.
If no, please provide a comprehensive description of internal control
systems. (You are responsible for instituting adequate procedures
against irregularities and improprieties and enforcing adherence to
generally accepted accounting principles.)
h. Does your organization have a formal basis to distribute or allocate
costs reflected in your financial statement? Yes_____ No____. Please
explain principal allocation techniques used or proposed to be used.
Indicate the allocation base used for each type of cost allotment.
i. Indicate the types of liability insurance your organization maintains.
State the amount of coverage and the name and address of the carrier.
j. Please attach a complete analysis of revenues and expenses by business
segment (lines of business) and by geographic area (within Arizona and
outside Arizona) for your company or your company's owners.
k. Are there any suits, judgments., tax deficiencies, or claims pending
against your organization?
Yes_____ No_____.
If yes, briefly describe each item and indicate the dollar amount,
either actual or estimated.
l. In the last 12 months has your firm or organization paid any bonuses,
provided any gifts over a dollar value of $500, or in any other way
provided a financial reward, over and above salary, to any staff
member, board member or other personnel associated with the firm or
organization? Yes_____ No_____. If yes, describe to whom it was given,
the type of reward, its value and source(s) of revenue.
18. SUBCONTRACTOR'S BACKGROUND CHECK INFORMATION
All Management Services Subcontractors must provide sufficient information
concerning key personnel to enable AHCCCSA to conduct background checks.
Please provide a list of all key personnel giving the following information
for each:
a. Name
b. All other names ever used
c. Social Security Account Number
d. Date of Birth
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e. Place of Birth
f. All addresses for the last 10 years
g. Ever suspended from any federal program for any reason? If yes, please
explain.
19. SUBCONTRACTOR RESTRICTION OF COMPETITION STATEMENT
In connection with the Management Services Subcontractor's participation in
this procurement the Management Services Subcontractor (to include its
employees) to the best of its knowledge and belief:
a. has not disclosed and will not knowingly disclose the prices, or any
matter relating to such prices, to any other offeror, subcontractor or
competitor,
b. has not attempted and will not make any attempt to induce any other
person or firm to submit or not to submit a proposal for the purpose
of restricting competition.
---------------------------------------------------------------------
Management Services Subcontractor Signature
---------------------------------------------------------------------
Print Name and Title
The Management Services Subcontractor shall insert in the applicable space
below, if the Management Services Offeror has no parent company, its own
employer's identification number (Federal social security number used on
employer's quarterly federal tax return, U.S. Treasury Department Form
941), or, if the Subcontractor has a parent company, the employer's
identification number of the parent company.
Management Services Subcontractor
Employer Identification No. ____________________________________
Parent Company's
Employer Identification No. ____________________________________
C-6
ATTACHMENT D: SAMPLE LETTER OF INTENT
(No alterations or changes are permitted. Provider must submit a separate letter
of intent for each service site or AHCCCS ID#. This letter is subject to
verification by AHCCCS.)
The provider signing below is willing to enter into contract negotiations with
[Offeror's name] for provision of covered services to AHCCCS members enrolled
with [Offeror's name]. This provider intends to sign a contract with [Offeror's
name] if [Offeror's name] is awarded an AHCCCS contract beginning 10/1/97 in the
provider's service area and an acceptable agreement can be reached between the
provider and [Offeror's name]. Signing this Letter of Intent does not obligate
the provider to sign a contract with [Offeror's name]; however, please do not
sign this Letter of Intent unless you seriously intend to enter into
negotiations with the above mentioned health plan.
The following information is furnished by the provider:
1. AHCCCS IDENTIFICATION NUMBER _____________________________________________
2. PROVIDER'S PRINTED NAME __________________________________________________
3. ADDRESS (where services will be provided)_________________________________
________________________________________________ ZIP CODE ________________
4. COUNTY______________ 5. TELEPHONE_________________ 6. FAX______________
7. CHECK ALL THAT APPLY:
____ A. Primary Care Physician ____ Family Practice Services: ____ EPSDT
____ General Practice ____ OB
____ Pediatrician ____ Family Planning
____ B. Primary Care Nurse Practitioner ____ Family Practice Services: ____ EPSDT
____ General Practice ____ OB
____ Pediatric ____ Family Planning
____C. Primary Care Physician's Assistant ____ Family Practice Services: ____ EPSDT
____ General Practice ____ OB
____ Pediatrician ____ Family Planning
____ D. Physician - Specialist- (Specify) _____________________________________
____ E. Hospital
____ F. Pharmacy
____ G. Laboratory
____ H. Medical Imaging
____ I. Emergency Transportation (Air or Ground)
____ J. Medically Necessary Transportation
____ K. Nursing Facility
____ L. Dentist
____ M. Therapy (Specify Physical Therapy, Occupational Therapy, Speech, Respiratory)
____ N. Behavioral Health Provider (Specify) ______________________________________________
____ O. Podiatrist
____ P. Durable Medical Equipment
____ Q. Home Health Agency
____ R. Home Infusion Provider
____ S. Chiropractor
____ T. Optometrist/Optician
____ U. Other (Please Specify) ____________________________________________________________
NOTICE TO PROVIDERS: This Letter of Intent will be used by Arizona Health Care
Cost Containment System Administration in its bid evaluation and contract award
process. You should only sign this Letter of Intent if you intend to enter into
contract negotiations with (offeror's name) it they receive a contract award. It
you are signing on behalf of a physician, please provide evidence of authority.
8. PROVIDER SIGNATURE _____________________________TITLE_____________________
9. PRINTED NAME OF SIGNER____________________________________________________
10. DATE __________________________________
- --------------------------------------------------------------------------------
Subcontracts 54.
- --------------------------------------------------------------------------------
55.
- --------------------------------------------------------------------------------
56.
- --------------------------------------------------------------------------------
57.
- --------------------------------------------------------------------------------
58.
- --------------------------------------------------------------------------------
59.
- --------------------------------------------------------------------------------
60.
- --------------------------------------------------------------------------------
61.
- --------------------------------------------------------------------------------
Encounters 62.
- --------------------------------------------------------------------------------
63.
- --------------------------------------------------------------------------------
64.
- --------------------------------------------------------------------------------
65.
- --------------------------------------------------------------------------------
66.
- --------------------------------------------------------------------------------
67.
- --------------------------------------------------------------------------------
Claims/Third Party Liability 68.
- --------------------------------------------------------------------------------
69.
- --------------------------------------------------------------------------------
70.
- --------------------------------------------------------------------------------
71.
- --------------------------------------------------------------------------------
72.
- --------------------------------------------------------------------------------
73.
- --------------------------------------------------------------------------------
74.
- --------------------------------------------------------------------------------
Financial Standards 75.
- --------------------------------------------------------------------------------
76.
- --------------------------------------------------------------------------------
77.
- --------------------------------------------------------------------------------
78.
- --------------------------------------------------------------------------------
79.
- --------------------------------------------------------------------------------
80.
- --------------------------------------------------------------------------------
Liability Management 81.
- --------------------------------------------------------------------------------
82.
- --------------------------------------------------------------------------------
83.
- --------------------------------------------------------------------------------
84.
- --------------------------------------------------------------------------------
Grievance and Appeals 85.
- --------------------------------------------------------------------------------
86.
- --------------------------------------------------------------------------------
87.
- --------------------------------------------------------------------------------
88.
- --------------------------------------------------------------------------------
89.
- --------------------------------------------------------------------------------
90.
- --------------------------------------------------------------------------------
91.
- --------------------------------------------------------------------------------
[END OF CHECKLIST]
C-8
Amend 14/97
OFFEROR _________________________________
ATTACHMENT D: NETWORK SUMMARY FORM
Summarize your network by County, by City, by provider type, by specialty and
PCP on this form.
County ____________________ City __________________________
NUMBER OF:
----------
AHCCCS PROVIDER TYPE PROV. TYPE SPECIALTY (SPEC.) SPEC. PCPS
-------------------- ---------- ----------------- ---- ----
NUMBER
----------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
- -------------------------------------------------- -------------------- ------------------------ --------- ---------
PCP TOTAL
PLEASE DUPLICATE THIS FORM IF YOU NEED ADDITIONAL SPACE, AND NUMBER EACH PAGE
SEQUENTIALLY. PLEASE PROVIDE A DESCRIPTION OF ANY CODES USED.
PLEASE NOTE: THE SPECIALTY COLUMN ONLY NEEDS TO BE COMPLETED IF APPLICABLE.
ATTACHMENT E: INSTRUCTIONS FOR PREPARING CAPITATION PROPOSAL
INTRODUCTION:
All capitation proposals must be submitted to AHCCCSA on the AHCCCS Capitation
Rate Calculation Sheet (CRCS) Bid Disk. All best and final offers must also be
submitted on the AHCCCS CRCS Bid Disk. A CRCS must be completed for each rate
code in each Geographic Service Area (GSA) that the Offeror is bidding. The
Offeror must also use the CRCS Bid Disk to print and submit Section B,
Capitation Rates, of the Request for Proposal (RFP).
BID DISK CHANGES FROM CYE 95:
Several modifications have been made to the CRCS Bid Disk since the CYE 95 bid
year. The changes are summarized as follows:
a. The "Prepared by" and "Preparation Date" have been deleted from the bid
disk screens. Now the program will automatically print the current date
when the Offeror prints the reports.
b. MN/MI with Medicare and MN/MI without Medicare will be bid as one rate
code: MN/MI.
c. The TANF (previously AFDC) and CCP rate codes have been combined so
that the Offeror will bid both populations under one rate code. In
addition, the TANF/CCP rate code will be bid on an age/sex basis.
d. Several service lines on the CRCS have been changed. "Hospital
Outpatient" has been changed to "Outpatient Facility". The term
"Surgical Service" has been removed. "Other Professional" has been
added to account for services related to Physician Assistants, Nurse
Midwives, Nurse Practitioners, etc. Finally, the "Family Planning" and
"Mental Health" lines have been removed. These costs should now be
reported as part of the "Other Costs - Miscellaneous" line item.
e. Another change in rates code screens is the addition of the SOBRA
Family Planning screens. Women whose SOBRA eligibility has been
terminated are eligible only for family planning services for a maximum
of 24 months under the SOBRA Family Planning Services Extension
Program. Previously paid on a fee-for-service basis by AHCCCS, these
services will now be paid on a capitated basis and the Offeror is
required to complete a CRCS for these services.
f. Screen 3 of 3 of the SOBRA Supplemental has been modified to add a line
to show the capitation offset to the total cost of services related to
SOBRA births. The program will automatically calculate this line item
by taking 6 months (the average number of months of capitation
typically paid a contractor for a SOBRA women) times the Offeror's bid
per the CRCS for the TANF/CCP 14-44 year-olds (F) rate code.
g. In accordance with Section H, Paragraph 9, Award of Contract, of the
RFP, bid screens are presented by rate code and by Geographic Service
Area, rather than by rate code and by county.
HELP SCREENS:
The CYE 98 CRCS Bid Disk has Help screens available to answer questions every
step of the way. The Offeror can access the Help screens at any time by pressing
the Fl key. In addition, the program contains on-screen instructions for each
screen.
GETTING STARTED:
The CYE 98 CRCS Bid Disk program requires approximately 525K bytes of available
main memory to run properly. Boot your machine to the DOS prompt. Insert the CYE
98 CRCS Bid Disk. Change the default drive to the disk drive containing the CYE
98 CRCS Bid Disk by typing "A:" or "B:" (whichever
drive contains the CYE 98 Bid Disk) and press the [Enter] key. Type "CRCS98" and
press the [Enter] key. This will initiate the program and will bring up the main
menu.
MAIN MENU OPTIONS:
The main menu to the CYE 98 CRCS Bid Disk offers the following seven options:
1. Bidding Input or Edit capitation rate data.
2. Summary Display previously calculated net capitation rates for all
rate codes and all Geographic Service Areas.
3. Print Send detail and/or summary information to the printer.
4. Submit/Copy Copy capitation bids to diskette for submission of data to
AHCCCS.
5. Supplement Browse through sections of RFP directly related to this
bid program.
6. Utilities Set screen colors, change printer destination, bulk erase
data, etc.
7. Exit Leave this program.
FORMAT OF CAPITATION RATE CALCULATION SHEET:
The CRCS for all rate codes consists of three screens requiting data input. For
all rate codes, except SOBRA women and SOBRA Family Planning, screen 1 of 3
contains the following bid elements: 1) Hospital Inpatient, 2) Outpatient
Facility, 3) Emergency Roam, 4) Primary Care, 5) Referral Physician, 6) Other
Professional, and 7) Pharmacy. The Offeror will have to enter: annual
utilization units per 1,000 members, cost per unit, and co-pay amounts (where
applicable) for each of the seven bid elements listed above. The program will
automatically calculate the per member per month (PMPM) amount for each of these
bid elements.
Screen 2 of 3 for all rate codes, except SOBRA women and SOBRA Family Planning,
contains the following bid elements: 1) Lab, X-ray, and Medical Imaging, 2)
Physical Therapy, 3) DME and Oxygen, 4) NP and Home Health Care, 5) Ambulance
and Medically Necessary Transportation, 6) Dental, and 7) Miscellaneous. The
Offeror must enter the PMPM amount for each of these seven bid elements.
Screen 3 of 3 for all rate codes, except SOBRA women and SOBRA Family Planning,
contains the following bid elements: 1) Reinsurance, 2) Third Party Recoveries,
3) Administration Charges, 4) Profit and Contingencies. The Offeror must enter
the PMPM amount for each of these four bid elements. The program will
automatically calculate the Net Capitation Rate based on data entered.
The SOBRA women rate codes are capitated on a monthly basis at the TANF/CCP
capitation rate for the GSA of residence. The SOBRA CRCS to be completed by the
Offeror is for the SOBRA Supplement payment only. The Contractor will be
eligible to receive the SOBRA Supplement payment upon the birth of a child to a
SOBRA eligible women enrolled with the Contractor.
The CRCS for the SOBRA Supplement is comprised of 3 screens requiring data
input. Screen 1 of 3 for the SOBRA Supplement contains the following bid
elements: 1) Hospital Inpatient, 2) Lab and Testing, 3) Transportation, 4)
Pharmacy, 5) OB/GYN, 6) Specialist/Anesthesia, and 7) Other. Elements 1 through
4 require utilization units and unit costs to be entered for a vaginal delivery
and separately for a cesarean delivery. The program computes the amount per
birth automatically for these elements. The Offeror shall enter the per birth
amount directly for bid elements 5 through 7.
Screen 2 of 3 for the SOBRA Supplement contains the following bid elements: 1)
Third Party Recoveries, 2) Administration Charges, 3) Profit and Contingencies.
The Offeror shall enter the per birth amounts for vaginal and cesarean
deliveries for each of these bid elements. The Offeror must enter the percent of
vaginal deliveries expected (must be between 50-100%). The program will
calculate the weighted average SOBRA Supplement bid automatically.
Screen 3 of 3 for the SOBRA Supplement details the calculation for the
Capitation Offset and Net Capitation Rate. The program will calculate both items
automatically.
The CRCS for SOBRA Family Planning is comprised of 3 screens requiring data
input. Screen 1 of 3 contains the following bid elements: 1) Outpatient
Facility, 2) Primary Care, 3) Referral Physician, 4) Other Professional, and 5)
Pharmacy. The Offeror must enter: annual utilization units per 1,000 members,
cost per unit, and co-pay amounts (where applicable) for each of the five bid
elements listed above. The program will automatically calculate the per member
per month (PMPM) amount for each of these bid elements.
Screen 2 of 3 for SOBRA Family Planning, contains the following bid elements: 1)
Lab, X-ray, and Medical Imaging, 2) Medically Necessary Transportation, and 3)
Miscellaneous. The Offeror shall enter the PMPM amount for each of these three
bid elements.
Screen 3 of 3 for SOBRA Family Planning, contains the following bid elements: 1)
Third Party Recoveries, 2) Administration Charges, 3) Profit and Contingencies.
The Offeror must enter the PMPM amount for each of these three bid elements. The
program will automatically calculate the Net Capitation rate based on data
entered.
TECHNICAL NOTES:
The following is a list of miscellaneous technical notes which may be helpful to
the Offeror:
a. Decimal points must be entered manually.
b. Help screens can be accessed at any time by pressing the F1 key.
c. Before saving or copying data to a new disk make sure the new disk is
formatted.
d. Within the CRCS screens, the Page Up key will take you to the previous
screen.
e. Within the CRCS screens, the Page Down key will take you to the next
screen.
f. Use the up and down arrow keys to scroll vertically through the data entry
fields within the CRCS screens.
g. Use Tab and Shift Tab to Scroll horizontally through the data entry fields
within the CRCS screens.
h. Within the CRCS screens the F3 key takes you to the previous rate code far
the GSA.
i. Within the CRCS screens the F4 key takes you to the next rate code far the
GSA.
j. Within the CRCS screens the F7 key takes you to the previous GSA (same rate
code).
k. Within the CRCS screens the F8 key takes you to the next GSA (same rate
code).
l. Within the CRCS screens the F10 key will save the data that has been
entered/edited and return to main CRCS menu.
M The Esc key cancels the function or menu in progress.
n. Calculations are rounded to 2 decimal places whenever a calculated result
produces more than 2 decimal places.
INSTALLING CRCS BID DISK ON A NETWORK OR HARD DRIVE
The CRCS Bid Disk can be copied to a directory on a network or a local PC hard
drive merely by copying all of the files on the disk to a directory. If the
program is installed on a network, care must be taken to allow only one person
at a time to use the program or a loss of bid data could occur. To run the
program on a local PC hard drive, you must first switch over to the drive and
directory where the program is located before running the program for it to run
properly.
LISTING OF FILES INCLUDED ON THE BID DISK:
The following files are included on the CRCS Bid Disk:
CRCS98.EXE The CRCS Bid Program.
R98.DAT Data file containing the section of the RFP that
directly pertains to
this bid disk. H98.DAT Help file used by the bid program.
HP98.DAT Supplementary help file.
DATA98.DAT Data file containing your bids. This file can be
copies to a diskette manually or menu option #4 in
the CRCS Bid Program will copy it for you.
If you have any technical questions relating to the operation or functions of
the CYE 98 CRCS Bid Disk call the AHCCCS/OMC customer technical support desk at
(602) 417-4564.
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the Contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
- ------------------------------------------------------------------------------------------------------------------------
REPORT WHEN DUE SOURCE/REFERENCE AHCCS CONTACT
- ------------------------------------------------------------------------------------------------------------------------
Monthly Financial Report 45 days after the end of Reporting Guide Financial Manager
the month, as applicable
- ------------------------------------------------------------------------------------------------------------------------
Quarterly Financial Report 60 days after the end of Reporting Guide Financial Manager
the each quarter
- ------------------------------------------------------------------------------------------------------------------------
Draft Annual Audit Report 90 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Draft Management Letter 90 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Final Annual Audit Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Final Management Letter 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Accountant's Report on Compliance 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Reconciliation--Annual Audit and 120 days after the end of Reporting Guide Financial Manager
Plan Year-to-Date Financial Report each fiscal year
Information
- ------------------------------------------------------------------------------------------------------------------------
Financial Disclosure Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Annual Analysis of Profitability 120 days after the end of Reporting Guide Financial Manager
by Major Rate Code (by County) each fiscal year
- ------------------------------------------------------------------------------------------------------------------------
Provider Affiliation Tape 10 business days after PMMIS Provider-to-Health Health Plan Operations
the beginning of each Plan magnetic tape Manager
quarter submission and processing
- ------------------------------------------------------------------------------------------------------------------------
18-20 NON-SMI Status Report 15 days after the end of Instructions on form Behavioral Health
each month Manager
- ------------------------------------------------------------------------------------------------------------------------
Encounter Data - Magnetic Tape Monthly, according to Encounter Manual Encounter Administrator
Submission established schedule
- ------------------------------------------------------------------------------------------------------------------------
Corrected Pended Encounter Tape Monthly, according to Encounter Manual Encounter Administrator
established schedule
- ------------------------------------------------------------------------------------------------------------------------
New Day Tape Monthly, according to Encounter Manual Encounter Administrator
established schedule
- ------------------------------------------------------------------------------------------------------------------------
Medical Records for Data Validation 6 weeks after the request RFP, Section C, Paragraph 1 Data Validation Manager
received from AHCCCSA
- ------------------------------------------------------------------------------------------------------------------------
Quarterly Grievance Report 45 days after the end of RFP, Section D, Paragraph 26 Administrative
each quarter Assistant
- ------------------------------------------------------------------------------------------------------------------------
Comprehensive Dental Plan Annually on November (1) RFP, Section D, Paragraph 16 Acute Care Program
Manager
- ------------------------------------------------------------------------------------------------------------------------
EPSDT Progress Report - Quarterly 15 days after the end of AMPM, Chapter 400 Acute Care Program
Update each quarter Manager
- ------------------------------------------------------------------------------------------------------------------------
Quarterly Inpatient Hospital 15 days after the end of State Medicaid Manual and Acute Care Program
Showing each quarter the AMPM, Chapter 900 manager
- ------------------------------------------------------------------------------------------------------------------------
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals.
The algorithm employs a data table and a formula to assign cases (a case may be
a member or a household of members) to contractors using the target percentages
developed. The algorithm data table consists of all the zip codes in the state,
all contractors serving each zip code area, and the target percentages by rate
code within each zip code.
The contractor farthest away from its target percentage within a zip code and
rate code, the largest negative difference, is assigned the next case for that
zip code. The equation used is:
(t/T) - P = d
t = The total members assigned to the zip code per rate code category for the
contractor
T = The total members assigned to the zip code per rate code category, all
contractors combined
P = The target percentage of members for the rate code for the contractor
d = The difference
The algorithm is calculated after each assignment to give a new difference for
each contractor. When more than one contractor has the same difference, and
their differences are greater than all other contractors, the contractor with
the lowest Health Plan I.D. Number will be assigned the case.
The member population assigned by the algorithm includes:
1. MN/MI members that are newly eligible to the AHCCCS program.
2. Members that are categorically eligible (plus EAC and ELIC) that did not
choose a contractor within the prescribed time limits.
3. MN/MI members who have been enrolled with a contractor but have changed zip
codes and the previous contractor is not available in the new zip code.
4. MN/MI members with a break in eligibility of 90 days or greater.
All contractors, within a given geographic service area (GSA) and for each rate
code, will have a placement in the algorithm and will receive members
accordingly. A contractor with a more favorable target percentage in the
algorithm will receive proportionally more members. Conversely, a contractor
with a lower target percentage in the algorithm will receive proportionally
fewer members. The algorithm favors contractors with both lower final bids and
awarded rates. The algorithm also favors those contractors with programs that
score higher based on AHCCCSA's evaluation criteria.
DEVELOPMENT OF THE TARGET PERCENTAGES FOR CATEGORICAL MEMBERS (INCLUDING EAC AND
ELIC)
For the first year of the contract, the algorithm target percentages will be
developed using the methodology described below. However, for subsequent years,
AHCCCS reserves the right to change the algorithm methodology to assure
assignments are made in the best interest of the AHCCCS program and the state.
For the categorical rate codes (plus EAC and ELIC), a contractor's placement in
the algorithm is based upon the following three factors which are weighted
equally (i.e., 33.33%):
1. The final capitation rate bid submitted by the contractor. Final bids that
are below the bottom of the rate range will be assigned to the bottom of
the rate range for development of the target percentages.
2. The contractor's final awarded rate from AHCCCSA.
3. The contractor's score on the Program component of the proposal.
Points will be assigned to each contractor by rate code by GSA. Based on the
rankings of the final bids submitted and the final awarded rates, each
contractor will be assigned a number of points for each of these two components
separately as follows:
TABLE FOR FACTORS #1 AND #2
- -----------------------------------------------------------------------------------------------------------------------
Number of
Awards in Lowest 2nd Lowest 3rd Lowest 4th Lowest 5th Lowest 6th Lowest 7th Lowest 8th Lowest
GSA Rate Rate Rate Rate Rate Rate Rate Rate
- -----------------------------------------------------------------------------------------------------------------------
2 60 40
- -----------------------------------------------------------------------------------------------------------------------
3 44 32 24
- -----------------------------------------------------------------------------------------------------------------------
4 35 28 22 15
- -----------------------------------------------------------------------------------------------------------------------
5 30 25 20 15 10
- -----------------------------------------------------------------------------------------------------------------------
6 26 23 19 15 11 6
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
Contractors that have equal bids in a GSA for the same rate code will be given
an equal percentage of the points for all of the positions combined.
The third component of the calculation, program scores, will be assigned a
number of points based on where the contractor ranks among the scores. The
higher the score, the more points assigned. For this component, points will be
assigned as follows:
TABLE FOR FACTOR #3
- --------------------------------------------------------------------------------------------------------------------------
Number of
Awards in Program 2nd Highest 3rd Highest 4th Highest 5th Highest 6th Highest 7th Highest 8th Highest
GSA Score Score Score Score Score Score Score Score
- --------------------------------------------------------------------------------------------------------------------------
2 60 40
- --------------------------------------------------------------------------------------------------------------------------
3 44 32 24
- --------------------------------------------------------------------------------------------------------------------------
4 35 28 22 15
- --------------------------------------------------------------------------------------------------------------------------
5 30 25 20 15 10
- --------------------------------------------------------------------------------------------------------------------------
6 26 23 19 15 11 6
- --------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------
Contractors that have equal program scores will be given an equal percentage of
the points for all of the positions combined.
The points awarded for the three components will be combined as follows to give
the target percentage for each contractor by GSA by rate code.
Final Bid Points + Awarded Bid Points + Program Score Points = TARGET PERCENTAGE
- ------------------------------------------------------------
300
DEVELOPMENT OF THE TARGET PERCENTAGES FOR NON-CATEGORICAL MEMBERS (MN/MIS)
For the non-categorical rate codes, a contractor's placement in the algorithm is
based upon the final capitation rate awarded by AHCCCSA. The target percentages
will be assigned as follows:
- --------------------------------------------------------------------------------------------------------------------------
Number of Lowest
Awards in Awarded 2nd Lowest 3rd Lowest 4th Lowest 5th Lowest 6th Lowest 7th Lowest 8th Lowest
GSA Rate Rate Rate Rate Rate Rate Rate Rate
- --------------------------------------------------------------------------------------------------------------------------
2 55% 45%
- --------------------------------------------------------------------------------------------------------------------------
3 39% 32% 29%
- --------------------------------------------------------------------------------------------------------------------------
4 30% 26% 24% 20%
- --------------------------------------------------------------------------------------------------------------------------
5 26% 21% 19% 18% 16%
- --------------------------------------------------------------------------------------------------------------------------
6 22% 19% 17% 16% 14% 12%
- --------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------
Contractors that have equal bids in a GSA for the same rate code will be given
an equal percentage of the positions combined.
ATTACHMENT H: GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22-802; and R9-22-804. It shall include the
following provisions:
a. The grievance procedure will be provided to members upon enrollment, to
all subcontractors at time of contract, and to non-contracting providers
within 10 days of the date of receipt of the claim. For non-contracting
providers, the grievance procedure may be mailed with the remittance
advice provided the remittance is sent within 45 days of receipt of
claim.
b. Specific individual(s) are appointed with authority to require corrective
action to administer the grievance policy.
c. A log is maintained for all grievances containing sufficient information
to identify the grievant, date of receipt, nature of the grievance and
the date grievance is resolved.
d. Within five working days of receipt, the grievant is informed by letter
that the grievance has been received. The letter must also be in a second
language when 200 members or 5% of the Contractor's enrolled population,
whichever is greater, is non-English speaking.
e. Each grievance is thoroughly investigated using the applicable statutory,
regulatory and contractual provisions as well as the Contractor's
policies and procedures, ensuring that facts are gathered from all
parties.
f. All documentation received and mailed by Contractor during the grievance
process is dated.
g. All grievances are filed in a secure, designated area and are retained
for five years following the final decision, judicial appeal or close of
a grievance.
h. A copy of the Contractor's final decision will be either hand-delivered
or delivered by certified mail to all parties whose interest has been
adversely affected by the decision. The final decision shall be mailed to
all other parties by regular mail. The date of the final decision shall
be the date of personal delivery or, if mailed, the postmark date of the
mailing. The final decision must include, and describe in detail, the
following:
1. the nature of the grievance
2. the issues involved
3. the reasons supporting the Contractor's decision including
references to applicable statute, rule and procedure
4. the grievant's right to appeal the Contractor's decision to
AHCCCSA by filing the appeal to the Contractor no later than 15
days alter the date of the Contractor's final decision. This must
also be written in a second language, if applicable.
i. If the Contractor's final decision is appealed, all supporting
documentation must be received by AHCCCSA, Office of Grievance and
Appeals no later than five working days from the date the Contractor
receives the appeal or from the date of the oral or written request from
AHCCCSA, Office of Grievance and Appeals.
The appeal file must contain a cover letter that includes:
1. grievant's name
2. grievant's AHCCCS ID number
3. grievant's address
4. phone number (if available)
5. date of receipt of grievance and appeal
6. summary of the Contractor's actions undertaken to resolve the
grievance and basis thereof
j. The following material shall be included in the appeal file:
1. written request of the grievant asking for the appeal
2. copies of the entire file which include the investigations and/or
medical records; and the Contractor's grievance decision
3. other information used by the Contractor to resolve the grievance
and that would be necessary to AHCCCSA to resolve the grievance.
k. The Contractor may attempt to use alternative resolution procedures to
resolve disputes presented to the Contractor verbally or in writing. If
the Contractor elects to use an alternative resolution process, it must
be administered and completed within 30 days from receipt of the dispute.
If the matter is not resolved to the grievant's satisfaction within the
30-day period, the dispute must then be adjudicated using the grievance
standards contained above. However, the Contractor must render the
written grievance decision within a maximum of 45 days from the date of
the initial filing of the grievance or dispute unless a longer period was
agreed to by the parties involved.
l. For all disputes where an alternative resolution is proposed, the
Contractor must inform the grievant of the Contractor's resolution and
ask the grievant if the resolution is acceptable no later than 30 days
from the date that the dispute is initially presented to the Contractor.
If acknowledged as acceptable, the matter may be closed. If the member or
provider states that the resolution is unacceptable, the Contractor must
then treat the dispute as a formal grievance and abide by the standards
contained above.
m. For all disputes where an alternative resolution is proposed, the
Contractor must maintain a separate log, complying with paragraphs c. and
g. above.
HOSPITAL REIMBURSEMENT PILOT PROGRAM - MARICOPA AND PIMA COUNTIES ONLY (SEE
SECTION D, PARAGRAPH 35):
Arbitration may be used in lieu of the grievance and appeal procedure. If
arbitration is used, the hospital contract must identify:
a. The parties agreement on arbitrating claims arising from the contract;
b. Whether arbitration is non-binding or binding;
c. Timeliness of arbitration;
d. What contract provisions may be appealed;
e. What rules will govern arbitrations;
f. The number of arbitrators that will be used;
g. How arbitrators will be selected; and
h. How arbitrators will be compensated.
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed sanctions for noncompliance with encounter
submission requirements. AHCCCSA may also perform special reviews of encounter
data, such as comparing encounter reports to the Contractor's claims files. Any
findings of incomplete or inaccurate encounter data may result in the
imposition of sanctions or requirement of a corrective action plan.
PENDED ENCOUNTER CORRECTIONS
The Contractor must resolve all pended encounters within 100 days of the
original processing data. A sanction of $5.00 each month will be imposed for
each encounter pended for more than 100 days unless the pend is due to AHCCCSA
error. "AHCCCSA error" is defined as a pended encounter which (1) AHCCCSA
acknowledges to be the result of its own error, and (2) requires a change to the
system programming, an update to the database reference table, or further
research by AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA in writing that the resolution of a pended
encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will respond in
writing within 30 days of receipt of such notification. The AHCCCSA response
will report the status of each pending encounter problem or issue in question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor in writing of the
total number of encounters pended more than 100 days and the number of such
encounters not subject to sanction because of AHCCCSA error.
ENCOUNTER VALIDATION STUDIES
Per HCFA requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's submitted encounter data. Any and
all covered services may be validated as part of these studies. Encounter
validation studies will be conducted at least yearly.
The following reflects AHCCCSA's encounter validation study process and sanction
policy as of 10/1/97. AHCCCSA may revise study methodology, timelines, and
sanction amounts based on agency review or as a result of consultations with
HCFA. The Contractor will be notified in writing of any significant change in
study methodology.
AHCCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to
AHCCCSA. In the case of medical records requests, the Contractor's failure to
provide AHCCCSA with the records requested within 90 days may result in a
sanction of $1,000 per missing medical record. If AHCCCSA does not receive a
sufficient number of medical records from the Contractor to select a
statistically valid sample for a study, the Contractor may be sanctioned up to
5% of its annual capitation payment.
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date
that the encounter is received at AHCCCS. All encounters must be
received by AHCCCSA no later than 240 days after the end of the month
in which the service was rendered, or the effective date of enrollment
with the Contractor, whichever is later. For all encounters for which
timeliness is evaluated, a sanction per encounter error extrapolated to
the population of encounters may be assessed if the encounter record is
received by AHCCCSA more than 240 days after the date determined above.
It is anticipated that the sanction amount will be $1.00 per error
extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has
changed, or if HCFA changes sanction requirements. The Contractor will
be notified of the sanction amount in effect for the studies at the
time the studies begin. Timeliness will be evaluated through
retrospective encounter validation studies for contract years through
10/95-9/96, inclusive. Pending HCFA approval, for contract years
10/97-9/98 and after, timeliness will be evaluated concurrently as
encounters are received based on the difference between the receipt
date at AHCCCS and the date of service.
Correctness: A correct encounter contains a complete and accurate
description of AHCCCS covered services provided to a member. A sanction
per encounter error extrapolated to the population of encounters may be
assessed if the encounter is incomplete or incorrectly coded. It is
anticipated that the sanction amount will be $1.00 per error
extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has
changed, or if HCFA changes sanction requirements. The Contractor will
be notified of the sanction amount in effect for the studies at the
time the studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA's pending encounter file or
historical files in lieu of correction of such record. For Study "A"
and for Study "B", a sanction per encounter error extrapolated to the
population of encounters may be assessed for an omission. It is
anticipated that the sanction amount will be $5.00 per error
extrapolated to the population of encounters for Study "A" and $10.00
per error extrapolated to the population of encounters for Study "B";
however, sanction amounts may be adjusted if AHCCCSA determines that
encounter quality has changed, or if HCFA changes sanction
requirements. The Contractor will be notified of the sanction amount in
effect for the studies at the time the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors found by the number of encounters reviewed. A 95% confidence interval
will be used to account
for limitations caused by sampling. The confidence interval shows the range
within which the true error rate is estimated to be. If error rates are based on
a sample, the error rate used for sanction purposes will be the lower limit of
the confidence interval.
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to HCFA, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance pursuant to Article 8 of AHCCCS Rules.
Sanction amounts will be deducted from the Contractor's capitation payment.
ATTACHMENT J: NEW OFFEROR REVIEW GUIDE
This document contains interview guides and worksheets for use in evaluating the
existing infrastructure and potential readiness of new offerors to participate
in the AHCCCS program. There are separate guides and worksheets for each of four
review areas, as well as a final section for recording summary findings. Each
evaluator will complete the readiness review guides and worksheets pertaining to
his/her section of the review and assign a grade (A, B, or C). In assigning the
grade, evaluators will determine whether the organization:
a. Demonstrates full readiness to meet AHCCCS program standards as of the
time of the review (i.e., has in place a core health plan
infrastructure, as well as specific components relevant to a mandatory
Medicaid managed care program); OR
b. Demonstrates the existence of a core health plan infrastructure, as
well as: l) an understanding of what modifications will be required to
modify its system to meet AHCCCS program standards and 2) a reasonable
plan for making such modifications; OR
c. Fails to demonstrate the existence of a core health plan infrastructure
and/or an understanding of what modifications will be required to meet
AHCCCS program standards.
REVIEWER PREPARATION ACTIVITIES: The chart at the back of this section contains
a summary of the interviews to be conducted on-site, as well as the documents to
be examined by reviewers. Prior to the review, the new offeror should be
contacted for purposes of arranging the necessary interviews and confirming
availability of the requested documents. Note that some documents may be
included in offeror proposals. To the extent these are available prior to the
site visit, reviewers will examine them beforehand. Reviewers also will examine
the CYE 98 AHCCCS RFP and the new offeror's full proposal, again assuming it is
available prior to the visit.
POST REVIEW ACTIVITIES: Following the completion of on-site activities,
reviewers should record findings in the summary section of the guide, being
certain to document fully the basis for any "C" grades awarded to a plan. The
individual functional area findings then should be used by the review team's
leader to make a final judgment and recommendation to AHCCCS with respect to the
readiness of the new offeror to meet all program standards at the start of the
next contract cycle, if awarded a contract.
EVALUATION SCOPE SUMMARY BY SECTION
- ----------------------------------------------------------------------------------------------------------------------
SECTION INTERVIEWS DOCUMENT REVIEW
- ----------------------------------------------------------------------------------------------------------------------
Administration and a. Health Plan CEO or Government a. Resumes for Key Staff
Management Programs Director b. Implementation Plan
b. AHCCCS Program Manger (if c. Financial Policies and Procedures
identified) d. Financial Reports
c. Health Plan CFO
- ----------------------------------------------------------------------------------------------------------------------
Member Enrollment and d. Individual to be identified e. Member Enrollment/Services Policies
Services by plan and Procedures
f. Customer Service Representative
Reference Guides
g. New Employee Training Materials
- ----------------------------------------------------------------------------------------------------------------------
Quality Management/Medical e. Medical Director h. Credentialling Policies & Procedures
Management f. Quality Management/Medical i. Medical Management Policies &
Management Director(s) Procedures
j. Quality Management Plan
- ----------------------------------------------------------------------------------------------------------------------
Claims/Encounters g. Claims Director k. Claims Policies and Procedures
Processing/MIS h. MIS Director l. Sampling of Claims/Remittance Advices
- ----------------------------------------------------------------------------------------------------------------------
I. ADMINISTRATION AND MANAGEMENT
INTERVIEW TOPICAL AREAS
1. Experience with Managed Care (Commercial and Medicaid)
2. General Implementation/Readiness Activities
3. Proposed Infrastructure for AHCCCS Program Management
4. Financial Management
DOCUMENT INSPECTION
1. Resumes/Job Descriptions for Key Staff
2. Implementation Plan for AHCCCS Program Management
a. Financial Policies and Procedures
4. Financial Reports
AM1. EXPERIENCE WITH MANAGED CARE
1. Provide an overview of your organization's experience in managing full
risk capitation products.
a. Commercial products outside of Arizona (where operate; years;
number of enrollees)
b. Commercial products within Arizona (where operate; years;
number of enrollees)
c. Medicaid products outside of Arizona (where operate; years;
number of enrollees)
2. What do you see as the key differences between meeting the requirements
of your existing contracts versus what would be required for
demonstrating full compliance with AHCCCS standards?
a. Differentiation between commercial and Medicaid lines of
business (member education/sophistication; EPSDT requirements
for children; maternal health; large disabled population)
b. Differentiation between AHCCCS program and other Medicaid
programs in which offeror currently operates if applicable
(mandatory enrollment; inclusion of SSI beneficiaries; large
rural component; American Indian population)
AM2. GENERAL IMPLEMENTATION/READINESS ACTIVITIES
1. Describe your hiring and intended training activities to prepare for
participation in the AHCCCS program.
a. Key management slots (schedule for hiring)
b. Other staff (how were staffing numbers developed?)
c. Training (what general training will be required for all
employees, regardless of functional area?)
2. Describe the status of network development activities.
a. Primary care (if awarded contract, timetable and plan for
converting LOIs to contracts)
b. Specialists
c. Hospitals
d. Other providers (pharmacies, transportation, behavioral
health, dental)
3. Implementation Plan
a. Describe the status of your formal implementation plan.
b. What did you draw upon in setting timetables and resource
commitments (e.g., experience in other Medicaid programs)?
c. Who is accountable for the plan's timely execution and how
will its execution be monitored by senior management?
d. Have you previously undertaken any expansions similar in scope
to this one? Were they accomplished on-schedule? What were the
major operational issues confronted and how were they
resolved?
AM3. PROPOSED INFRASTRUCTURE FOR AHCCCS PROGRAM MANAGEMENT
1. Where will your administrative offices for the program be located?
a. Functions to be housed in-State (status -- has space been
acquired/leased; if bidding for multiple counties, what
functions will be established within each county and which
will be administered from a central State office?)
b. Functions to be housed out-of-State (how will these be linked
to your in-State operations; is this a model already used by
your organization for other programs?)
AM4. FINANCIAL MANAGEMENT
1. Discuss your financial expectations with respect to the AHCCCS program.
a. Medical expense and administrative expense (how determined).
b. Discuss your experience in other Medicaid programs (if
applicable).
2. Describe the methods used for tracking separate lines of business.
a. Medical expense
b. Corporate overhead (allocation methodology)
3. Describe other components of your financial reporting system.
a. What types of financial management reports do you currently
generate? How often? Who reviews?
b. Describe IBNR/RBUC methodology.
c. What modifications, if any, do you see as necessary for the
AHCCCS program as it relates to financial management?
CHART AM-A: RESUMES/JOB DESCRIPTIONS FOR KEY STAFF
Instructions: Obtain resumes for existing staff and job
descriptions for unfilled positions. Fill-out chart for each
position. If no resume or job description available, note as
such. In all cases, review the resume or job description for
the individual who would be most directly responsible for the
AHCCCS contract (e.g., if the plan has a corporate Member
Services Director but will designate an AHCCCS Member Services
Manager, review the latter).
- -----------------------------------------------------------------------------------------------------------------------------------
RELEVANT MANAGED CARE RELEVANT MEDICAID EDUCATION/TRAINING/
EXPERIENCE (ACTUAL OR EXPERIENCE (ACTUAL OR LICENSE (ACTUAL OR
POSITION REQUIRED) REQUIRED) REQUIRED) COMMENTS
- -----------------------------------------------------------------------------------------------------------------------------------
CEO or AHCCCS Program
Director
- -----------------------------------------------------------------------------------------------------------------------------------
CFO
- -----------------------------------------------------------------------------------------------------------------------------------
Medical Director
- -----------------------------------------------------------------------------------------------------------------------------------
QM/MM Director
- -----------------------------------------------------------------------------------------------------------------------------------
Claims Director
- -----------------------------------------------------------------------------------------------------------------------------------
MIS Director
- -----------------------------------------------------------------------------------------------------------------------------------
Member Svcs Director
- -----------------------------------------------------------------------------------------------------------------------------------
Prov. Svcs. Dir.
- -----------------------------------------------------------------------------------------------------------------------------------
Additional Comments:
CHART AM-B: IMPLEMENTATION PLAN
Instructions: Obtain organization's implementation plan(s) for
preparing to participate in the AHCCCS program. Document
whether the identified major tasks are addressed within each
functional area and, if so, the expected completion date. Note
in comments section whether the workplan appears sufficiently
detailed, whether tasks are ordered appropriately, and whether
the timeline is both realistic and rapid enough to assure
readiness at the start of the next contract cycle. If no plan
exists for a particular functional area, or if all necessary
components already are in place, note this as well.
- --------------------------------------------------------------------------------------------------------------------
TARGET
ADDRESSED? COMPLETION
FUNCTIONAL AREA IMPLEMENTATION ACTIVITY (YES OR NO) DATE COMMENTS
- --------------------------------------------------------------------------------------------------------------------
Administration Hiring Program Director
Obtaining office space, phone system
Enrollment and Member Hiring a Member Services Director
Services Hiring Member Services Staff
Developing AHCCCS-specific policies &
procedures
Developing AHCCCS-specific CSR reference
guides/scripts
Acquiring and installing CSR workstations
to accommodate AHCCCS enrollment
Training Member Services staff (CSRs)
Producing materials for new members
(handbook, other)
- --------------------------------------------------------------------------------------------------------------------
Quality Mgt/Medical Hiring a Medical Director
Mgt. (QM/MM) Hiring a QM/MM Director(s)
Hiring other QM/MM staff
Creating/updating PA policies for AHCCCS
program
Creating/updating concurrent review
policies for AHCCCS
Creating/updating retro review policies for
AHCCCS
- --------------------------------------------------------------------------------------------------------------------
Prov. Contracting and Hiring a Provider Services Director
Services Completing contracting and credentialling
activities
Completing provider training and
orientation of office staff
- --------------------------------------------------------------------------------------------------------------------
Claims/Encounters Hiring a Claims Director (or finalizing
out-sourcing)
Hiring other claims staff to accommodate
volume (Number of staff and position titles
(i.e., Medical Review, Data Entry, etc.))
Updating claims policies and procedures for
AHCCCS
Enhancing processing capacity for AHCCCS
- --------------------------------------------------------------------------------------------------------------------
MIS Hiring an MIS Director (or finalizing
out-sourcing)
Hiring other MIS staff
Enhancing MIS capacity for AHCCCS
- --------------------------------------------------------------------------------------------------------------------
Additional comments:
CHART AM-C: FINANCIAL POLICIES AND PROCEDURES; GENERAL LEDGER
Instructions: Obtain and review financial policies and procedures and
general ledger of accounts. Document the adequacy of each with respect
to health plan management in general, and the AHCCCS program in
particular. Also note any inconsistencies with interview comments.
- ----------------------------------------------------------------------------------------------------------------------
ADEQUACY WITH RESPECT
REVIEW AREA ADEQUACY FOR GENERAL FINANCIAL MANAGEMENT TO THE AHCCCS PROGRAM
- ----------------------------------------------------------------------------------------------------------------------
Medical expense tracking
Administrative cost allocation
IBNR/RBUC methodology
Financial Reports
- ----------------------------------------------------------------------------------------------------------------------
II. MEMBER ENROLLMENT AND SERVICES
INTERVIEW TOPICAL AREAS
1. General Implementation/Readiness Activities
2. Training of Member Services Staff (CSRs)
3. Member Complaints
DOCUMENT INSPECTION
1. Member Enrollment/Services Policies and Procedures
2. CSR Reference Guides
3. New Employee Training Materials
MS1. GENERAL IMPLEMENTATION/READINESS ACTIVITIES
1. Describe your existing Member Services capacity and how it will be
expanded/modified for participation in the AHCCCS program.
a. Existing capacity (staff, workstations)
b. Expansion/modifications intended for AHCCCS (how determined?)
2. Describe how you do the following today (if applicable), your
understanding of AHCCCS requirements in each area, and how your process
will be modified for AHCCCS, if at all.
a. Contacting new members (methods and timeframes)
b. Assigning PCPs (timeframes and criteria)
c. Encouraging initial physician visits; EPSDT screens (for
children)
d. Identifying members with special health care needs (e.g.,
asthma, diabetes, pregnancy etc.) and linking them with
appropriate providers/services
e. Assisting non-English speaking members; visually and hearing
impaired members
f. Handling non-compliant members (missed appointments; high risk
behavior, unnecessary ER utilization)
g. Producing/distributing educational materials to members (what
exists today; reading level; commercial or Medicaid?)
MS2. TRAINING OF MEMBER SERVICES STAFF
1. Describe your current training methods for new Member Services staff
(CSRs) and how this will be modified for AHCCCS, if at all.
a. Current (orientations; training materials; time spent working
with senior CSRs)
b. AHCCCS
MS3. MEMBER COMPLAINTS
1. Describe your current process for receiving and responding to
complaints (if applicable), your understanding of AHCCCS requirements,
and how your process will be modified for AHCCCS, if at all.
a. Current (who handles; logging; tracking; timeframes for
resolution--medical and other)
b. AHCCCS
CHART MS-A: MEMBER ENROLLMENT/SERVICES POLICIES AND PROCEDURES
Instructions: Review policies and procedures for completeness
and consistency with interview comments. Also indicate degree
to which policies conform to AHCCCS standards or will require
revision. If policies/procedures do not exist at all, note
this as well.
- --------------------------------------------------------------------------------------------------------------------
POLICY/PROCEDURE COMPLETENESS/CONSISTENCY CONFORMANCE TO AHCCCS STANDARDS
- --------------------------------------------------------------------------------------------------------------------
Contracting new members
- --------------------------------------------------------------------------------------------------------------------
Assigning PCPs
- --------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------
Handling PCP change requests
- --------------------------------------------------------------------------------------------------------------------
Assisting members to arrange
appointments
- --------------------------------------------------------------------------------------------------------------------
Responding to member complaints
- --------------------------------------------------------------------------------------------------------------------
Additional comments:
CHART MS-B: CSR REFERENCE GUIDES/SCRIPTS
Instructions: Review CSR reference guides and telephone scripts for
completeness and quality. Also indicate degree to which policies
conform to AHCCCS standards or will require revision. If guides/scripts
do not exist at all, note this as well.
- --------------------------------------------------------------------------------------------------------------------
GUIDE/SCRIPT COMPLETENESS/QUALITY CONFORMANCE TO AHCCCS STANDARDS
- --------------------------------------------------------------------------------------------------------------------
Assisting in PCP selection
- --------------------------------------------------------------------------------------------------------------------
Handling PCP change requests
- --------------------------------------------------------------------------------------------------------------------
Assisting members to arrange
appointments
- --------------------------------------------------------------------------------------------------------------------
Addressing other member inquiries
- --------------------------------------------------------------------------------------------------------------------
Additional comments:
MS-C: NEW EMPLOYEE TRAINING MATERIALS
Instructions: Review materials for completeness and consistency with
interview comments. Also indicate degree to which policies conform to
AHCCCS standards or will require revision. If materials do not exist at
all, note this as well.
- --------------------------------------------------------------------------------------------------------------------
TRAINING AREA COMPLETENESS/CONSISTENCY CONFORMANCE TO AHCCCS STANDARDS
- --------------------------------------------------------------------------------------------------------------------
AHCCCS Program or Medicaid Programs
in General
- --------------------------------------------------------------------------------------------------------------------
Assigning PCPs
- --------------------------------------------------------------------------------------------------------------------
Handling PCP change requests
- --------------------------------------------------------------------------------------------------------------------
Assisting members to arrange
appointments
- --------------------------------------------------------------------------------------------------------------------
Responding to member complaints
- --------------------------------------------------------------------------------------------------------------------
III. QUALITY MANAGEMENT/MEDICAL MANAGEMENT (QM/MM)
INTERVIEW TOPICAL AREAS
1. General Implementation/Readiness Activities
2. Understanding of Quality Management/Utilization Management (QM/UM)
DOCUMENT INSPECTION
1. Credentialling Policies
2. Medical Management Policies and Procedures
QM1. GENERAL IMPLEMENTATION/READINESS ACTIVITIES
1. Describe your existing QM/MM structure and how it will be
enhanced/modified for participation in the AHCCCS program.
a. Existing structure/capacity (clinical staff; other)
b. Enhancements/modifications intended for AHCCCS, including
staffing (how determined?)
2. Describe how the following medical management components are currently
addressed (if applicable), your understanding of AHCCCS requirements in
each area, and how these components/policies will be modified for
AHCCCS, if at all.
a. Prior Authorization (what requires authorization; who reviews;
timeframe for reviews: appeal process for denials)
b. Concurrent review (who conducts; how often; protocols followed
for discharge planning)
c. Retrospective medical review (what is reviewed; who performs;
follow-up to identified issues)
d. Pharmacy benefits management (describe)
QM2. UNDERSTANDING OF QM/UM
1. Describe how your QM/UM Plan addresses each of the following today,
your understanding of QM requirements in each area, and how your QM/UM
Plan will be modified to meet QM/AHCCCS standards.
a. Responsible body/parties for oversight of QM/UM Plan (e.g.,
board)
b. Quality Management Committee (composition; responsibilities;
meeting frequency)
c. Medical Director's role in QM/UM Plan development (FTE
commitment; development/review of medical policies and
protocols; involvement in medical management)
d. Addressing member rights and responsibilities, including
protection of confidential information
e. Defining and monitoring standards for service
availability/accessibility (PCP capacity; compliance with
appointment standards; after-hours availability)
f. Medical records standards
g. Monitoring for service over- and under-utilization among
physicians; acting on findings
h. Implementing effective case management and care coordination
systems, including methods for identifying members with
complex/chronic conditions and special health care needs
i. Selecting focused clinical study areas; performing same
j. Ensuring provision of EPSDT screens and immunizations
k. Performing provider credentialling and recredentialling (scope
of what is examined during credentialling; frequency of
recredentialling; oversight of delegated credentialling
activities)
l. Describe how findings of QM/UM Plan and QM/UM Committee will
be reviewed/responded to by Executive Committee (Board, etc.)
CHART QM-A: CREDENTIALLING/RECREDENTIALLING POLICIES AND PROCEDURES
Instructions: Review credentialling policies for completeness and
consistency with interview comments. If policies do not exist at all,
note this as well:
- ----------------------------------------------------------------------------------------------------------------------
POLICIES ADDRESS
CREDENTIALLING AREA YES NO COMMENTS
- ----------------------------------------------------------------------------------------------------------------------
Separate policies for credentialling and recredentialling
- ----------------------------------------------------------------------------------------------------------------------
Practitioner must hold current license and DEA certificate, as applicable
- ----------------------------------------------------------------------------------------------------------------------
Work history and association with hospitals, HMQs, PHPs, and medical groups
examined
- ----------------------------------------------------------------------------------------------------------------------
National Practitioners Data Bank (NPDB) queried
- ----------------------------------------------------------------------------------------------------------------------
Holds current, adequate malpractice coverage
- ----------------------------------------------------------------------------------------------------------------------
Has not had medical staff privileges curtailed/suspended
- ----------------------------------------------------------------------------------------------------------------------
Has not had state license or DEA number revoked
- ----------------------------------------------------------------------------------------------------------------------
Has not been sanctioned by Medicare or Medicaid
- ----------------------------------------------------------------------------------------------------------------------
Applicant must list names and relevant information of providers who will serve
as on-call designees for provider (applies to non-staff group models only)
- ----------------------------------------------------------------------------------------------------------------------
Applicant attests to validity of information provided
- ----------------------------------------------------------------------------------------------------------------------
Site visit is made to practitioner's office
- ----------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------------------------------------------------------------
POLICIES ADDRESS
CREDENTIALLING AREA YES NO COMMENTS
- ----------------------------------------------------------------------------------------------------------------------
RECREDENTIALLING POLICIES AND PROCEDURES
- ----------------------------------------------------------------------------------------------------------------------
Conducted at least every two years
- ----------------------------------------------------------------------------------------------------------------------
NPDB is queried
- ----------------------------------------------------------------------------------------------------------------------
Member complaints reviewed
- ----------------------------------------------------------------------------------------------------------------------
Results of chart audits/quality reviews examined
- ----------------------------------------------------------------------------------------------------------------------
CHART QM-B: MEDICAL MANAGEMENT POLICIES AND PROCEDURES
Instructions: Review policies for completeness and consistency with
interview comments. Also indicate degree to which policies conform to
AHCCCS standards or will require revision. If policies do not exist at
all, note this as well.
- --------------------------------------------------------------------------------------------------------------------
MEDICAL MANAGEMENT AREA COMPLETENESS/CONSISTENCY CONFORMANCE TO AHCCCS STANDARDS
- --------------------------------------------------------------------------------------------------------------------
Prior Authorization
- - services requiring
- - process for requesting
- - after hours process
- - timeliness
- - appeal process
- --------------------------------------------------------------------------------------------------------------------
Concurrent Review
- - staff to perform
- - protocols used
- - frequency
- --------------------------------------------------------------------------------------------------------------------
Retrospective Review
- - cases requiring
- - staff to perform
- - follow-up
- --------------------------------------------------------------------------------------------------------------------
Additional comments:
IV. CLAIMS/INFORMATION SYSTEMS
INTERVIEW TOPICAL AREAS
1. General Implementation/Readiness Activities
DOCUMENT INSPECTION
1. Claims Sampling
2. Claims Policies and Procedures
CL1. GENERAL IMPLEMENTATION/READINESS ACTIVITIES
1. Describe your existing claims processing system and capacity and how it
will be enhanced/modified for participation in the AHCCCS program.
a. Existing structure/capacity (age of system; in-house or
outsourced; staffing; claims volume)
b. Describe claims flow and timeliness of processing for hospital
claims, physician claims, and pharmacy claims
c. How will the claims system interface with the prior
authorization system and concurrent review system to ensure
claims are correctly paid?
d. If claims are processed by a subcontractor, describe any
modifications that will be necessary under the contract
pursuant to participating in the AHCCCS program.
e. If claims are processed by an in-house system, describe any
enhancements/modifications intended for AHCCCS, including
staffing. (How determined?)
f. Do you process encounters, as opposed to claims, as part of
your current operations? How do you produce encounters and how
do you ensure their accuracy? Describe your understanding of
AHCCCS encounter reporting requirements and any
enhancements/modifications that will be necessary to meet
them.
2. Describe your overall existing information system capacity and how it
will be enhanced/modified for participation in the AHCCCS program.
a. Existing structure/capacity (age of system; how supported;
programmer staffing, ability/ experience in reporting HEDIS,
or AEDIS - like indicators/outcome measurements)
b. Enhancements/modifications intended for AHCCCS, including
staffing (how determined?)
CHART CL-A: CLAIMS TESTING
Instructions: Pull a sample of hospital and physician claims, following
the sampling methodology to be supplied under separate cover. Examine
each claim for completeness, clarity of remittance advice (if
applicable), and timeliness of adjudication.
- -----------------------------------------------------------------------------------------------------------------------
CLAIM DATE OF REM. REMITTANCE DATE OF PAYMENT OR
NUMBER/TYPE DATE OF RECEIPT ADVICE ISSUE ADVICE CLEAR? FINAL DENIAL COMMENTS
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
CHART CL-B: CLAIMS POLICIES AND PROCEDURES
Instructions: Review policies and procedures for completeness and
timeliness and consistency with references. Also indicate degree to
which policies conform to AHCCCS standards or will require revision. If
policies/procedures do not exist at all, note this as well.
- --------------------------------------------------------------------------------------------------------------------
CONFORMANCE TO AHCCCS
POLICY/PROCEDURE COMPLETENESS/TIMELINESS STANDARDS
- --------------------------------------------------------------------------------------------------------------------
Receipt and logging-in of claims
- --------------------------------------------------------------------------------------------------------------------
Verification of prior authorization (if applicable)
- --------------------------------------------------------------------------------------------------------------------
Edit/override authority for claims staff
- --------------------------------------------------------------------------------------------------------------------
Claim matched against TPL information
- --------------------------------------------------------------------------------------------------------------------
Remittance Advice information
- --------------------------------------------------------------------------------------------------------------------
Payment/final adjudication timeframes
- --------------------------------------------------------------------------------------------------------------------
V. SUMMARY OF FINDINGS
Instructions: Assign a grade of "A", "B", or "C" for each
review topical area and for each review section overall.
Consider documentation findings as appropriate in grading
related topical areas. Explain in detail the basis for any "C"
findings. Team leader is responsible for assigning total
grade, based on findings for the four review sections.
- ---------------------------------------------------------------------------------------------------------------------
READINESS LEVEL
REVIEW AREA A B C COMMENTS
- ---------------------------------------------------------------------------------------------------------------------
Administration and Management
- ---------------------------------------------------------------------------------------------------------------------
1. Experience
- ---------------------------------------------------------------------------------------------------------------------
2. General Implem./Readiness Activities
- ---------------------------------------------------------------------------------------------------------------------
3. Proposed Infrastructure
- ---------------------------------------------------------------------------------------------------------------------
4. Financial Management
- ---------------------------------------------------------------------------------------------------------------------
Overall Readiness - Admin. & Mgt.
- ---------------------------------------------------------------------------------------------------------------------
Member Enrollment and Services
- ---------------------------------------------------------------------------------------------------------------------
1. General Implem./Readiness Activities
- ---------------------------------------------------------------------------------------------------------------------
2. Training of Member Services Staff
- ---------------------------------------------------------------------------------------------------------------------
3. Member Complaints
- ---------------------------------------------------------------------------------------------------------------------
Overall Readiness - Mbr. Enroll./Svcs.
- ---------------------------------------------------------------------------------------------------------------------
Quality Management and Medical Mgt.
- ---------------------------------------------------------------------------------------------------------------------
1. General Implem./Readiness Activities
- ---------------------------------------------------------------------------------------------------------------------
2. Understanding of QM/UM Plan (AHCCCS)
- ---------------------------------------------------------------------------------------------------------------------
Overall Readiness - QM/MM
- ---------------------------------------------------------------------------------------------------------------------
Claims/Information System
- ---------------------------------------------------------------------------------------------------------------------
1. General Implem./Readiness Activities
- ---------------------------------------------------------------------------------------------------------------------
Overall Readiness - Claims/IS
- ---------------------------------------------------------------------------------------------------------------------
Overall Grade:
- ---------------------------------------------------------------------------------------------------------------------
Additional Comments:
ATTACHMENT K: EPSDT PERIODICITY SCHEDULE
<Table>
<Caption>
- ---------------------------------------------------------------------------------------------------------------------------------
EARLY MIDDLE
PROCEDURES INFANCY CHILDHOOD CHILDHOOD
------------------------------------------------------------------------------------------------------
NEW 2-4 BY 1 2 4 6 9 12 15 18 24 3 4 5 6 8 10
BORN DAY MO MO MO MO MO MO MO MO MO YR YR YR YR YR YR
HISTORY INITIAL/INTERVAL X X X X X X X X X X X X X X X X X
HEIGHT & WEIGHT X X X X X X X X X X X X X X X X X
HEAD CIRCUMFERENCE X X X X X X X X X X X
BLOOD PRESSURE X X X X X X
NUTRITIONAL ASSESSMENT X X X X X X X X X X X X X X X X X
VISION**
HEARING**/SPEECH
DEV./BEHAVIORAL ASSESS. X X X X X X X X X X X X X X X X X
PHYSICAL EXAMINATION X X X X X X X X X X X X X X X X X
IMMUNIZATION X--- ----- -> X X X <- X -> <- X -> <-
TUBERCULIN TEST X X X X X X X X X X
HEMATOCRIT/HEMOGLOBIN <- <- <- <- X
URINALYSIS X
LEAD SCREEN X -> X
ANTICIPATORY GUIDANCE X X X X X X X X X X X X X X X X X
DENTAL REFERRAL**
- ---------------------------------------------------------------------------------------------------------------------------------
- ----------------------------------------------------------------
PROCEDURES ADOLESCENCE
-----------------------------------
12 14 16 18 20+ UP
YR YR YR YR TO 21 YR
-----------------------------------
HISTORY INITIAL/INTERVAL X X X X X
HEIGHT & WEIGHT X X X X X
HEAD CIRCUMFERENCE
BLOOD PRESSURE X X X X X
NUTRITIONAL ASSESSMENT X X X X X
VISION**
HEARING**/SPEECH
DEV./BEHAVIORAL ASSESS. X X X X X
PHYSICAL EXAMINATION X X X X X
IMMUNIZATION X -> ->
TUBERCULIN TEST X X X X X
HEMATOCRIT/HEMOGLOBIN <- X -> -> ->
URINALYSIS <- X -> -> ->
LEAD SCREEN
ANTICIPATORY GUIDANCE X X X X X
DENTAL REFERRAL**
THESE ARE MINIMUM REQUIREMENTS. IF AT ANY TIME OTHER PROCEDURES, TESTS, ETC. ARE
MEDICALLY INDICATED, THE PHYSICIAN IS OBLIGATED TO PERFORM THEM. IF A CHILD
COMES UNDER CARE FOR THE FIRST TIME AT ANY POINT ON THE SCHEDULE, OR IF ANY
ITEMS ARE NOT ACCOMPLISHED AT THE SUGGESTED AGE, THE SCHEDULE SHOULD BE BROUGHT
UP TO DATE AT THE EARLIEST POSSIBLE TIME.
KEY: X = TO BE COMPLETED + = TO BE PERFORMED FOR MEMBERS AT RISK
<- X -> = THE RANGE DURING WHICH A SERVICE MAY BE PROVIDED WITH THE
X INDICATING THE PREFERRED AGE.
** SEE SEPARATE SCHEDULE FOR DETAIL.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
DENTAL PERIODICITY SCHEDULE
MONTHS YEARS
PROCEDURE BIRTH THRU 3 4 5 6 7 8 9 10 11 12 13 14
36 MONTHS
- -----------------------------------------------------------------------------------------------------------------------------------
DENTAL + X X X X X X X X X X X X
REFERRAL
MONTHS YEARS
PROCEDURE BIRTH THRU 15 16 17 18 19 20+ UP
36 MONTHS TO 21
- ---------------------------------------------------------------------------------------
DENTAL + X X X X X X
REFERRAL
REFERRALS FOR ROUTINE DENTAL VISITS SHOULD BEGIN AT AGE 3. EARLIER INITIAL
DENTAL EVALUATIONS MAY BE APPROPRIATE FOR SOME CHILDREN. SUBSEQUENT EXAMINATIONS
AS PRESCRIBED BY DENTIST.
KEY: + = BIRTH TO 36 MONTHS IF INDICATED
X = TO BE COMPLETED
ATTACHMENT L: OFFEROR'S CHECKLIST
INSTRUCTIONS:
a. Offerors must submit all items below, except as noted. In the column
titled "Offeror's Page #", the Offeror must enter the appropriate page
numbers from its proposal where the AHCCCS Evaluation Panel may find
the Offeror's response to that requirement.
b. A continuing offeror must submit all items below unless the specific
submission requirement is waived as described in Section H of this RFP.
If a continuing offeror is claiming full compliance under this
provision, the offeror must enter "PER REVIEW" in the column titled
"Offeror's Page #".
I. GENERAL MATTERS
----------------------------------------------------------------------------------------------
DISCUSSED
IN SECTION/ RFP OFFEROR'S
PARA. #: PAGE #: PAGE #
----------------------------------------------------------------------------------------------
Offeror's signature page (Front page) 1 N/A
----------------------------------------------------------------------------------------------
Offeror's Checklist (this attachment) N/A N/A
----------------------------------------------------------------------------------------------
Certification of Accuracy of Information Provided G.1 63 N/A
----------------------------------------------------------------------------------------------
Certification of Non-Coercion G.2 63 N/A
----------------------------------------------------------------------------------------------
Certification of Compliance/Anti-Kickback/Lab testing G.3 63 N/A
----------------------------------------------------------------------------------------------
Completion of all items in Section G of the RFP G. 63-70
----------------------------------------------------------------------------------------------
- -------------------------------------------------------------------------------------------------------
NOTE: The "Reqmt. #"shown below in Parts II, III, IV and V refers to the
numbered submission requirements outlined in Section H, Paragraph 1, pages 73-78
of this RFP.
II. PROVIDER NETWORK
---------------------------------------------------------------------------------
OFFEROR'S
SUBJECT: REQMT. #: PAGE #:
---------------------------------------------------------------------------------
Network Development 1. (a, b)
---------------------------------------------------------------------------------
2.
---------------------------------------------------------------------------------
3.
---------------------------------------------------------------------------------
Monitoring/Control of Network 4.
---------------------------------------------------------------------------------
5.
---------------------------------------------------------------------------------
6.
---------------------------------------------------------------------------------
Network Communication 7.
---------------------------------------------------------------------------------
8.
---------------------------------------------------------------------------------
9.
---------------------------------------------------------------------------------
10.
---------------------------------------------------------------------------------
11.
---------------------------------------------------------------------------------
Capacity Analysis 12.
---------------------------------------------------------------------------------
13.
---------------------------------------------------------------------------------
14.
---------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1
- -------------------------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
1 YH8-0001-05 October 1, 1997 ACUTE
- -------------------------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- -------------------------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To add conditions to the establishment of the contract.
- -------------------------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
The attached pages describe certain conditions that the above Offeror/Contractor
must agree to in order to establish this contract. By signing, dating and
returning both originals of this amendment, the Offeror/Contractor is agreeing
to be bound by the new conditions contained herein.
NOTE. Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and
Purchasing
701 E. Jefferson
Phoenix, AZ 85034
<Caption>
- -------------------------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT REMAIN UNCHANGED
AND IN FULL EFFECT.
- -------------------------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING OFFICER:
/s/ Pat Levin /s/ Michael Veit
- -------------------------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
Pat Levin Michael Veit
- -------------------------------------------------------------------------------------------------
TITLE: TITLE:
President Contracts & Purchasing Administrator
- -------------------------------------------------------------------------------------------------
DATE: DATE:
June 16, 1997 June 17, 1997
- -------------------------------------------------------------------------------------------------
SPECIAL PROVISIONS (YH8-0001)
HEALTH CHOICE OF ARIZONA
1. MINIMUM NETWORK STANDARDS
Contractor must have made significant progress toward signed
subcontracts with the entire provider network by July 15, 1997, in
order to participate in "Open Enrollment". Contractors must have their
entire provider network contracted, with contracts that meet or exceed
the applicable Geographic Service Area (GSA) Minimum Network Standards,
as outlined in Attachment B of this contract, by August 15, 1997.
Furthermore, the Contractor must have in place a sufficient number of
contracts with providers to ensure that all covered services, as
described in Section D, paragraph 1 (Scope of Services) of this
contract, will be provided in accordance with Section D, paragraph 19
(Appointment Standards) of this contract. Contractor must have a
provider network that will be capable of serving the greater of your
existing membership in a GSA or up to one quarter of the members in
Pima County and one sixth of the members in Maricopa County, based on
May 1997 members (see attached matrix of members to be covered by
Network). Also attached is a matrix showing the contract awards by GSA,
effective October 1, 1997.
Failure to meet this provision may result in contract termination or
the selection of an alternative contractor, financial sanctions, an
enrollment cap, or other penalties in accordance with R9-22-405 and
R9-22-406.
2. COMPLIANCE WITH MARKETING POLICY
Marketing materials can only list contracted providers. If Contractor
is found to be in violation of the AHCCCS Health Plan Marketing Policy,
Contractor may be subject to an enrollment cap in the applicable
GSA(s) affected by the violation.
3. REVISED FINANCIAL FORECASTS
The contractor is required to supply AHCCCS with revised financial
forecasts by 7/15/97 based on awarded rates, excluding prior period
coverage revenues and expenses. On a statewide basis, provide financial
forecasts including income statement and balance sheet for each year of
the next three years. Any losses budgeted will require additional
equity and performance bond coverage.
4. PERFORMANCE BONDS
Contractor must submit a detailed plan to meet the AHCCCS performance
bond requirements to the Office of Managed Care by June 30, 1997. All
performance bond account activity requires the advanced approval of
AHCCCS. The performance bond must be posted within 15 days following
notification by AHCCCSA of the amount required.
5. MINIMUM CAPITALIZATION REQUIREMENTS AND EQUITY PER MEMBER
The capitalization requirement must be met by June 30, 1997. Please
refer to Section D, paragraph 55, of the CYE `98 Contract, for the
minimum capitalization requirements by GSA. Contractor must maintain
unencumbered equity, in the amount of $150 per non-SOBRA Family
Planning Extension Services members enrolled, with no liens or
obligations against it. Failure to meet this standard may result in an
enrollment cap being imposed in any or all contracted GSA's.
6. READINESS ASSESSMENT
As discussed in Section D, paragraph 32 of this contract, AHCCCS may
conduct Operational and Financial Readiness Reviews on all successful
offerors. A contractor will be permitted to commence operations only if
the Readiness Review establishes the ability to comply with contractual
requirements. AHCCCS may enforce provisions of R9-22-405 and R9-22-406
if Contractor does not satisfy Readiness Review requirements.
7. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost
allocation plans must be submitted to the Office of Managed Care for
prior approval. Cost allocation plans must be submitted with the
proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees.charged and/or
corporate allocations made. If the fees or allocations actually paid
out are determined to be unjustified or excessive, amounts may be
subject to repayment to the Contractor, the Contractor may be placed on
monthly financial reporting, and/or financial sanctions may be imposed.
Further, no changes can be made to the management agreements without
AHCCCS' prior approval. Finally, all administrative costs, including
management fees, allocated fees, can not exceed 10% annually.
8. ADDITIONAL FINANCIAL REPORTING
Contractor is a wholly owned subsidiary of OrNda HealthCorp, a Delaware
corporation. Consequently , contractor must submit quarterly unaudited
financial information of the parent or sponsoring organization (balance
sheet and income statement only) within 60 days of quarter end, and
audited financial statements of the parent or sponsoring organization
no later than 120 days after fiscal year end.
9. PRIOR PERIOD COVERAGE RATES
AHCCCS acknowledges that the final offered prior period coverage rates
have not been provided and will provide the Contractor with these rates
as soon as possible.
Members to be Covered by Network by Offerors
Offerors GSA #1 GSA #2 GSA #3 GSA #4 GSA #5 GSA #6 GSA #7 GSA #8 GSA #9
- ---------------------------------------------------------------------------------------------------------------------------
Access Blue Connection 8,100 8,264 7,181 31,055
- ---------------------------------------------------------------------------------------------------------------------------
Arizona Physician IPA 12,459 7,190 9,019 15,521 42,776 2,022 4,927 10,937
- ---------------------------------------------------------------------------------------------------------------------------
CIGNA Community Choice 20,389
- ---------------------------------------------------------------------------------------------------------------------------
Doctor's Health Plan 2,545
- ---------------------------------------------------------------------------------------------------------------------------
Family Health Plan of NEAZ 3,431
- ---------------------------------------------------------------------------------------------------------------------------
Health Choice of Arizona 15,507 31,055
- ---------------------------------------------------------------------------------------------------------------------------
Maricopa Managed Care 31,055
- ---------------------------------------------------------------------------------------------------------------------------
Mercy Care Plan 7,994 15,507 39,126 9,969
- ---------------------------------------------------------------------------------------------------------------------------
Phoenix Health Plan/C.C. 10,841 31,055
- ---------------------------------------------------------------------------------------------------------------------------
Pima Health Plan 11,509
- ---------------------------------------------------------------------------------------------------------------------------
University Physicians 15,507
- ---------------------------------------------------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 2
- -------------------------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
2 YH8-0001-05 October 1, 1997 ACUTE
- -------------------------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- -------------------------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To set prospective and prior period capitation rates.
- -------------------------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
Effective 10/1/97, the Contractor will be paid prospective and prior
period capitation in accordance with the rates shown on the following page.
NOTE. Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and
Purchasing
701 E. Jefferson
Phoenix, AZ 85034
<Caption>
- -------------------------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT REMAIN UNCHANGED
AND IN FULL EFFECT.
- -------------------------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING OFFICER:
/s/ Pat Levin /s/ Michael Veit
- -------------------------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
Pat Levin Michael Veit
- -------------------------------------------------------------------------------------------------
TITLE: TITLE:
President Contracts & Purchasing Administrator
- -------------------------------------------------------------------------------------------------
DATE: DATE:
August 19, 1997 August 25, 1997
- -------------------------------------------------------------------------------------------------
Page 2 of 2
HEALTH CHOICE ARIZONA
The new capitation rates effective 10/1/97 are as follows:
TANF
GEOGRAPHIC TANF 1-13, TANF TANF TANF SSI SSI SOBRA
SERVICE AREA <1, M/F M/F 14-44, F 14-44, M 45+, M/F W/MED W/O MED MN/MI SFP KICK
- ---------------- --------- ------ -------- -------- -------- ------- ------- ------- ----- ---------
GSA #5 (Pima)
Prospective: $ 313.04 $51.96 $ 158.72 $ 72.90 $193.75 $118.52 $292.32 $331.47 $8.82 $4,260.88
PPC: $1,004.80 $31.27 $ 130.31 $ 73.36 $173.48 $ 13.81 $ 60.66 $292.12 N/A N/A
GSA #6 (Maricopa)
Prospective: $ 326.82 $52.73 $ 164.11 $ 74.59 $206.59 $130.77 $291.62 $406.27 $9.22 $4,432.33
PPC: $1,004.80 $31.27 $ 130.11 $ 73.36 $173.48 $ 13.81 $ 60.66 $292.12 N/A N/A
PMPM amounts are based on a $35,000/$15,000 (MN/MI) reinsurance deductible
level. PPC MN/MI rate is a daily rate.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
SOLICITATION AMENDMENT
================================================================================
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
2 YH8-0001 10/1/97 ACUTE
================================================================================
CONTRACTOR'S NAME AND ADDRESS:
Health Choice Arizona, Inc.
1600 W. Broadway, Suit 260
Tempe, Arizona 85282
================================================================================
PURPOSE OF AMENDMENT: To make various changes in solicitation provisions.
================================================================================
THE SOLICITATION REFERENCED ABOVE IS AMENDED AS FOLLOWS:
The following paragraphs have been revised to reflect changes in
capitation, reinsurance, best and final offer procedure, and bid evaluation:
Section D, Paragraph 22, Primary Care Provider Standards
Section D, Paragraph 23, Other Provider Standards
Section D, Paragraph 37, Compensation
Section D, Paragraph 39, Reinsurance
Section H, Paragraph 8, Best and Final Offers
Section 1, Paragraph 2, Capitation
NOTE TO OFFERORS: Please enter name and address above; enter name and title
below; sign below. A copy of this signature page only must be submitted with
your proposal.
================================================================================
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
REMAIN UNCHANGED AND IN FULL EFFECT.
================================================================================
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING
OFFICER:
/s/ Patricia E. Levin /s/ Michael Veit
================================================================================
TYPED NAME: TYPED NAME:
Patricia E. Levin Michael Veit
================================================================================
TITLE: TITLE:
President/CEO Contracts & Purchasing
Administrator
================================================================================
DATE: DATE:
May 12, 1997 May 07, 1997
================================================================================
SECTION D, PROGRAM REQUIREMENT:
22. PRIMARY CARE PROVIDER STANDARDS
"... Contractor policies and procedures shall be subject to approval by AHCCCSA,
Office of Managed Care, and shall be monitored through operational audits...."
23. OTHER PROVIDER STANDARDS
"... Contractor policies shall be subject to approval by AHCCCSA, Office of
Managed Care, and shall be monitored through operational audits
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services. Any
waiver of this requirement by the Contractor must be approved in advance by
AHCCCSA...."
37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, SOBRA supplement, HIV-AIDS supplement,
reinsurance (PPC and prospective), and third party liability, as described and
defined within this contract and appropriate laws, regulations or policies.
Subject to the availability of fluids, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of ARS Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or NACHA transfer
and will provide the Contractor at least 30 days notice prior to the effective
date of any such change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the, electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, any
savings remaining to the Contractor as a result of favorable claims experience
and efficiencies in service delivery at the end of the contract term may be kept
by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in ARS ss.36-2913. An error discovered by the State with or
without an audit in the amount of fees paid to Contractor will be
2
subject to adjustment or repayment by Contractor making a corresponding decrease
in a current Contractor's payment or by making an additional payment by AHCCCSA
to the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
action shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation on newborns of
members who were enrolled at the time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For the first year of the
contract, AHCCCSA will offer a reconciliation process for contractors whose
total PPC cost experience (i.e., for all capitation risk groups) is more than
10% higher than the reimbursement associated with PPC (capitation and
reinsurance). AHCCCSA will reimburse 100% of a Contractor's excess reasonable
costs. AHCCCSA may also require all Contractors to complete a reconciliation
process and recoup from any Contractor, profit amounts in excess of a 10% limit.
AHCCCSA will develop a detailed reconciliation policy which will be distributed
for review and comment at a later date.
PROSPECTIVE CAPITATION: The Contractor will be paid capitation for all
prospective member months, including partial member months. AHCCCSA will make
monthly capitation payments to the Contractor for each member enrolled with the
Contractor on the first of the month as payment in full for any and all covered
services provided to the member, Payment shall be made no later than the fifth
working day of the month for which payment is due. For members enrolled at any
time after the beginning of the month's payment cycle, capitation will be
prorated from the effective date of enrollment through the remainder of the
month of enrollment. These payments will be made by AHCCCS to Contractor on a
weekly basis.
SOBRA SUPPLEMENT: When the Contractor has an enrolled SOBRA woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
SOBRA payment. SOBRA Supplemental payments will not apply to SOBRA women who
deliver in a prior period
3
coverage time period. AHCCCSA reserves the right at any time during the term of
this contract to adjust the amount of this SOBRA payment for women who deliver
at home. The Contractor is responsible for meeting the newborn notification
requirements defined in AHCCCS Rule R9-22-342 before this payment will be made
to the Contractor.
HIV-AIDS SUPPLEMENT: In addition to the capitation payment described above, a
separate and additional payment will be made to the Contractor to help defray
costs for members receiving approved protease inhibitors and associated lab work
related to their treatment for HIV/AIDS. The list of AHCCCSA-approved protease
inhibitors is available in the Bidder's Library.
On a quarterly basis, the Contractor shall submit to AHCCCSA, Office of Managed
Care, an unduplicated monthly count of members, by rate code, who are using
approved protease inhibitors. The report shall be submitted, along with the
quarterly financial reporting package, within 60 days after the end of each
quarter. (A sample of this reporting form may be found in the Bidder's Library.)
The rate of reimbursement for this separate payment will $634.50 per month and
is subject to review during the term of the contract. Payment will be made
quarterly to the Contractor based on the reported eligible members for the
preceding quarter. AHCCCSA will review this HIV/AIDS-related data at least
annually as part of its Operational and Financial Review and reserves the right
to recoup any amounts paid for ineligible members as determined through this
review as well as an associated penalty for incorrect reporting.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503). Per diem rates
paid for nursing facility services, including room and board, provided in lieu
of hospitalization for up to 90 days in any contract year shall be eligible for
reinsurance coverage (see AHCCCS Rule R9-22-203 subsection B for excluded
services). Reinsurance for the Hospital Reimbursement Pilot Program (See Section
D, Paragraph 35, Hospital Reimbursement), will be paid in accordance with AHCCCS
Rule R9-22-503.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's statewide AHCCCS acute care
enrollment as of October 1st each contract year for all rate codes and counties,
as shown in the following table. These deductible levels are subject to change
by AHCCCSA during the term of this contract.
4
REGULAR REINSURANCE:
- -----------------------------------------------------------------------------------
Statewide Plan Enrollment Deductible-MN/MI Deductible - Others Coinsurance %
0 - 19,999 $15,000 $20,000 75%
20,000 - 49,999 $15,000 $35,000 75%
50,000 and over $15,000 $50,000 75%
- -----------------------------------------------------------------------------------
If a Contractor's actual non-MN/MI deductible is $35,000 or $50,000, AHCCCSA
will increase the Contractor's capitation rate awarded by defined amounts for
each capitation risk group. These specific capitation adjustments are available
in the Bidder's Library.
PRIOR PERIOD COVERAGE REINSURANCE: For the first two years of the contract
period, a separate reinsurance deductible and coinsurance percentage will apply
during prior period coverage. All Contractors, regardless of enrollment, will be
subject to a deductible level anticipated to be between $3,000 and $8,000. The
exact deductible level will be specified prior to award of contracts. The
coinsurance percentage for the prior period coverage reinsurance is 100%.
Expenses incurred during prior period coverage will not apply toward the
prospective reinsurance thresholds.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
The Contractor shall be subject to utilization and other reviews by AHCCCSA of
care provided to a member which results in a reinsurance claim as referenced in
R9-22-503 (G.3).
Medical review on prospective and prior period coverage reinsurance cases will
be determined based on statistically valid random sampling . AHCCCSA, Office of
the Medical Director, will generate the sampling and will notify the Contractor
of documentation needed for the retrospective medical review process to occur at
the Contractor's offices. The results of the medical review sampling will be
separately extrapolated to the entire prospective and prior period coverage
reinsurance reimbursement populations of the Contractor. A recoupment of
reinsurance reimbursements made to the Contractor may occur based on the results
of the medical review sampling. AHCCCSA will give the Contractor at least 45
days advance notice of any on-site review. The Contractor shall have all
requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor representative shall be available to the
Review Team at all times during AHCCCSA on-site review activities. While
on-site, the Contractor shall provide the Review Team with work space, access to
a telephone, electrical outlets and privacy for conferences. The Contractor will
be furnished a copy of the Reinsurance Review Report within 60 days of the
onsite review and given an opportunity to comment on any review findings.
5
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia and members who receive covered organ and tissue transplantation
including bone marrow, heart and other organ transplantation. For additional
detail and restrictions see AHCCCS Rule R9-22-202. There is no deductible for
catastrophic reinsurance cases and AHCCCS will reimburse the Contractor at 85%
of the Contractor's covered costs. All catastrophic claims will be subject to
medical review by AHCCCSA.
HEMOPHILIA: When an eligible member is identified as being catastrophically
eligible by AHCCCSA due to a specific diagnosis of hemophilia (ICD9 286.0,
286.1, 286.2 and 286.4), all medically necessary covered services provided
during the contract year shall be eligible for reimbursement at 85% of the
Contract's paid amount. Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDA VP responders
that are dependent on Plasma Factor VIII. The Contractor must promptly notify
AHCCCS Office of the Medical Director Reinsurance Unit after diagnosis.
Catastrophic reinsurance will be paid for a maximum 30-day retroactive period
from the date of notification to AHCCCSA.
TRANSPLANTS: Bone grafts, kidney and cornea transplantation services are not
eligible for catastrophic reinsurance coverage but are eligible under the
regular (non-catastrophic) reinsurance program. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor-paid amount
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library.
Encounter data will not be used to determine catastrophic reinsurance benefits.
However, this does not relieve the Contractor of the responsibility for
submitting encounters for catastrophic reinsurance services. The initial claims
for reimbursement under the catastrophic reinsurance program must be filed no
later than June 30th of the year following the contract year. Catastrophic
reinsurance claims that are submitted within this time limit and are denied or
adjusted, may be corrected until September 30th of the year following the
contract year. All catastrophic reinsurance claims must be submitted in
accordance with the AHCCCS Reinsurance Policy/Procedure Manual.
[FROM SECTION H, INSTRUCTIONS TO OFFERORS]
8. BEST AND FINAL OFFERS
AHCCCSA reserves the right to accept any or all initial offers without further
negotiation and may choose not to request a best and final offer (BFO). Offerors
are therefore advised to submit their most competitive offers at the outset. If
it is considered in the best interest of the State, however, AHCCCSA may issue a
written request to all offerors for a best and final offer in a particular
geographic service area or areas. The purpose of a BFO request is to allow
offerors an opportunity to resubmit bids for rate codes not previously accepted
by AHCCCSA. This request will notify them of the date, time and place for the
submission of their offers. In addition,
6
AHCCCSA will disclose to each offeror which of its bid rates are acceptable
(within or below actuarial rate range), and which are not acceptable (above the
actuarial rate range). All offerors whose final bid rates fall below the bottom
of the actuarial rate range will have their rates increased to the bottom of
that rate range after the final BFO. If an offeror does not submit a notice of
withdrawal or a best and final offer, its immediate previous offer will be
considered its best and final offer.
All BFOs must be submitted on the computer disk provided by AHCCCSA. AHCCCSA
will limit the number of BFO rounds if it is in the best interest of the State.
Offerors will be permitted, within the restrictions and limitations defined
below, to adjust upward a capitation rate for a rate code that was previously
accepted to offset the reduction of a capitation rate in another rate code in
the first BFO round only. These restrictions and limitations include, but are
not limited to:
a. An offeror will be allowed to adjust upward a previously accepted rate
code bid only during the first BFO round;
b. The weighted amount of BFO increase cannot exceed the weighted amount
of BFO reduction. AHCCCSA will furnish the Offeror the enrollment
percentages, by rate code, by GSA, to be used in determining the
weighted amount. Should the weighted amount of the adjustment exceed
the weighted amount of the BFO reduction, AHCCCSA shall reject the
first BFO and the adjustment (costing the Offeror the loss of the first
BFO round in that GSA). Since a rate code can only be adjusted during
the first BFO round, the Offeror will lose the opportunity to make an
upward capitation adjustment to previously accepted rate code bids in
that GSA.
For example, assume that MN/MI was the rate code where a BFO was needed
and the offeror reduced this rate by $10. PMPM. Also assume the MN/MI
rate code accounted for 9% of the members in the GSA.
Weighted Average Capitation Reduction - 9% X $10.00 = $.90
Assume the rate code adjusted upward was TANF and this rate code was
increased by $2.00 PMPM. Also assume this rate code accounted for 50%
of the members in the GSA.
Weighted Average Capitation Increase - 50% X $2.00 =$1.00
Therefore, the BFO would be rejected because the weighted amount of the
BFO adjustment exceeded the weighted amount of the BFO reduction.
c. Contractors will not be allowed to decrease a bid in a BFO round if the
initial bid was below the bottom of the rate range. If such a BFO is
submitted it will be rejected.
d. If an adjustment during the initial BFO round causes the Offeror to
exceed the upper range of any rate code, AHCCCSA will reject the
adjustment and return the (adjusted)
7
rate code to the initial capitation rate bid by the Offeror. Since a
previously accepted rate code bid can only be adjusted during the first
BFO round, the Offeror will lose the opportunity to make an upward
capitation adjustment for this rate code.
e. AHCCCSA reserves the sole right to accept or reject any adjustment. The
Offeror by submitting an adjustment to a rate code is requesting
approval by AHCCCSA; such approval shall not be automatic. If an
initial bid is below the bottom of a rate range, it cannot be adjusted
downward by the Offeror in a BFO round.
Capitation Rates Offered after the BFOs: As stated above AHCCCSA may limit the
number of BFO rounds. After the final BFO round is complete, provided it is in
the best interest of the state, AHCCCSA will cease issuing BFO requests. At this
point, should the Offeror have a rate code(s) without an accepted capitation
rate, AHCCCSA shall offer a capitation rate to the Offeror. The capitation rate
offered shall be somewhere in the bottom half of the rate range (specific
placement to be determined by AHCCCSA and its actuaries). Note that all rates
offered in this manner shall be identical for all offerors in the same GSA and
rate code.
[FROM SECTION I, EVALUATION FACTORS:]
2. CAPITATION
The Offeror shall submit initial capitation bids by rate code grouping within a
geographic service area. These initial bids will be evaluated and scored. The
lowest bid within each geographic service area and rate code grouping will
receive the maximum allowable points. If a bid is below the actuarial rate
range, the bid will be evaluated as if it were at the bottom of the actuarial
rate range. No additional points will be given for bids below the actuarial rate
range. Conversely, the highest bid (within or above the actuarial rate range)
will receive the least number of points.
If AHCCCSA requests best and final offers, these will be scored using the same
methodology as was used to score the initial bids. The initial bid will be
weighted 20% and the final bid will be weighted 80% for scoring. Offerors should
note that AHCCCSA may not offer the opportunity to submit best and final offers.
[END OF AMENDMENT #2]
8
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 1
- -------------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
3 Y -0001-05 October 1, 1997 ACUTE
- -------------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- -------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To set prospective and prior period reinsurance
thresholds.
- -------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
Effective 10/1/97, the Contractor's prior period reinsurance threshold
is $5,000 and its prospective reinsurance threshold is $35,000 ($15,000
MN/MI).
NOTE: Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and
Purchasing
701 E. Jefferson
Phoenix, AZ 85034
- --------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
REMAIN UNCHANGED AND IN FULL EFFECT.
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING
OFFICER:
/s/ Pat Levin /s/ Michael Veit
- --------------------------------------------------------------------------------
TYPED NAME: PAT LEVIN TYPED NAME: MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: PRESIDENT TITLE: CONTRACTS & PURCHASING
ADMINISTRATOR
- --------------------------------------------------------------------------------
DATE: DATE:
10/28/97 Oct 31, 1997
- --------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 1
- --------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
4 YH8-0001-05 March 1, 1998 ACUTE
- --------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- --------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To re-number GSA's.
- --------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
The Geographical Service Areas are re-numbered as follows:
ORIGINAL DESIGNATION: NEW DESIGNATION:
GSA 1 (Yuma) GSA 2 (Yuma)
GSA 2 (La Paz/Mohave) GSA 4 (La Paz/Mohave)
GSA 3 (Coconino/Yavapai) GSA 6 (Coconino/Yavapai)
GSA 4 (Gila/Pinal) GSA 8 (Gila/Pinal)
GSA 5 (Pima) GSA 10 (Pima)
GSA 6 (Maricopa) GSA 12 (Maricopa)
GSA 7 (Graham/Greenlee) GSA 14 (Graham/Greenlee)
GSA 8 (Navajo/Apache) GSA 16 (Navajo/Apache)
GSA 9 (Cochise/Santa Cruz) GSA 18 (Cochise/Santa Cruz)
NOTE: Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and
Purchasing
701 E. Jefferson
Phoenix, AZ 85034
- --------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
REMAIN UNCHANGED AND IN FULL EFFECT.
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING
OFFICER:
/s/ Pat Levin /s/ Michael Veit
- --------------------------------------------------------------------------------
TYPED NAME: PAT LEVIN TYPED NAME: MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: PRESIDENT TITLE: CONTRACTS & PURCHASING
ADMINISTRATOR
- --------------------------------------------------------------------------------
DATE: DATE:
4/10/98 April 15, 1998
- --------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 2
- --------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
5 YH8-0001-05 October 1, 1998 ACUTE
- --------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- --------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To set prospective and prior period capitation rates.
- --------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
Effective 10/1/98, the Contractor will be paid prospective and prior
period capitation in accordance with the rates shown on the following page.
NOTE: Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and
Purchasing
701 E. Jefferson
Phoenix, AZ 85034
- --------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
REMAIN UNCHANGED AND IN FULL EFFECT.
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING
OFFICER:
/s/ Pat Levin /s/ Michael Veit
- --------------------------------------------------------------------------------
TYPED NAME: PAT LEVIN TYPED NAME: MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: PRESIDENT TITLE: CONTRACTS & PURCHASING
ADMINISTRATOR
- --------------------------------------------------------------------------------
DATE: DATE:
9/15/98 Sep 18 1998
- --------------------------------------------------------------------------------
HEALTH CHOICE ARIZONA
The new capitation rates effective 10/1/98 are as follows:
- -----------------------------------------------------------------------------------------------------------------------------------
TANF TANF TANF TANF TANF SSI SSI SOBRA
GEOGRAPHIC SERVICE AREA <1, M/F 1-13, M/F 14-44, F 14-44, M 45+, M/F W/MED W/O MED MN/MI SFP KICK
- -----------------------------------------------------------------------------------------------------------------------------------
GSA #10 (PIMA):
Prospective: $ 296.62 $57.49 $158.66 $81.00 $198.67 $128.45 $317.16 $370.10 $18.84 $4,033.39
PPC: $1164.82 $32.70 $136.50 $76.91 $180.25 $ 14.50 $ 61.79 $306.73 N/A N/A
Kids Care: $270.86 $70.17 $135.29 $80.71
GSA #12 (MARICOPA):
Prospective: $ 312.65 $59.07 $165.41 $83.47 $211.79 $141.79 $314.96 $454.70 $19.68 $4,188.89
PPC: $1164.82 $32.70 $136.50 $76.91 $180.25 $ 14.50 $ 61.79 $306.73 N/A N/A
Kids Care: $ 281.83 $72.23 $140.17 $81.01
PMPM amounts are based on a $35,000/$15,000 (MN/MI) reinsurance deductible
level. PPC MN/MI rate is a daily rate.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
- -------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
6 YH8-0001-05 October 1, 1998 OMC
- -------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, CEO
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282
- -------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To extend the term of the contract for one year and to
amend Sections C, D, and E and Attachments F and I.
- -------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
The contract term is hereby extended for the period 10/1/98 - 9/30/99
in accordance with Section D, Paragraph 50.
The contract is hereby amended in accordance with Section E, Paragraph
30. Section C, Definitions, and Section D, Contract Requirements, are
hereby replaced in their entirety by the attached pages 3-56 Each new
page is shown with the footer "Acute Care Renewal, Revised 10/1/98" in
the lower right-hand corner. Page 57 contains changes to Section E,
Contract Clauses. Pages 58-62 contain complete revisions of Attachment
F, Periodic Report Requirements, and Attachment I, Encounter Submission
Requirements.
Immediately following this signature page is a 5-page summary of the
changes effective with this renewal amendment. Items in the summary
preceded by "Clarification only" are clarifications of already existing
requirements. Shaded areas indicate changes made since the first
Summary was distributed to the health plans in Flagstaff on July 29,
1998.
By signing this contract amendment, the Contractor is (1) agreeing to
perform for an additional year according to the terms of the contract
as amended, and (2) agreeing to the new and changed requirements
contained herein.
In addition to the text changes to Sections C, D and E and Attachments
F and I contained herein, Attachment B (Minimum Network Requirements)
is changed to delete the requirement for a pharmacy in Catalina and
Wellton.
- --------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
REMAIN UNCHANGED AND IN FULL EFFECT. (AS AMENDED)
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED SIGNATURE OF AHCCCSA CONTRACTING
REPRESENTATIVE: OFFICER:
/S/ PAT LEVIN /S/ MICHAEL VEIT
- --------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
PAT LEVIN MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: TITLE:
CHIEF EXECUTIVE OFFICER CONTRACTS AND PURCHASING ADMINISTRATOR
- --------------------------------------------------------------------------------
DATE: DATE:
8/27/98 OCTOBER 13, 1998
- --------------------------------------------------------------------------------
UPDATED SUMMARY OF CHANGES - ACUTE CARE CYE 99
This summary is provided as a convenience to the Contractor and is not to be
construed as superseding or limiting the revised text which follows. It is
believed to be an accurate and complete summary of changes which take effect
10/1/98; however, any conflict between the summary and the text will be resolved
in favor of the text.
All text revisions summarized below are considered either an actual change to
contract requirements or merely a clarification of existing requirements. The
latter are clearly identified throughout the summary. Finally, numerous
punctuation, grammar and style changes have been made throughout the revised
text which have no effect on the contract requirements and which may not be
otherwise identified.
Shaded areas below indicate changes made since the first Summary was distributed
to the health plans in Flagstaff on July 29, 1998.
- -----------------------------------------------------------------------------------------------------------------------
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- -----------------------------------------------------------------------------------------------------------------------
N/A [Throughout the document] References to the Arizona Administrative Code provisions N/A
pertaining to the new KidsCare program (Title XXI) have
been added as appropriate throughout the document.
- -----------------------------------------------------------------------------------------------------------------------
N/A [Throughout the document] The term "categorical", referring to eligibility for N/A
AHCCSA benefits throughout federal programs, has been
replaced by "Title XIX", "Title XXI", and/or
"state-only" eligibility, as appropriate.
- -----------------------------------------------------------------------------------------------------------------------
N/A [Throughout the document] Test that refers to the initial proposal or negotiation N/A
processes now shows as deleted text.
- -----------------------------------------------------------------------------------------------------------------------
N/A [Throughout the document] Since acronym "EPSDT" refers to a specific federally-defined N/A
group of services and protocols, this reference has
been replaced where KidsCare eligibility and services,
which are more limited, would make use of the term
"EPSDT" inaccurate.
- -----------------------------------------------------------------------------------------------------------------------
C Section C, Definitions Seven new definitions have been added. 3-8
- -----------------------------------------------------------------------------------------------------------------------
" CLARIFICATION ONLY: "SOBRA" definition changed to clarify 7
that AHCCSA provides only Medicaid services to pregnant
women.
- -----------------------------------------------------------------------------------------------------------------------
" Definitions of "clean claim" and "tribal facility" added. 3,8
- -----------------------------------------------------------------------------------------------------------------------
D.1 Scope of Services CLARIFICATION ONLY: ALL treatment options are to be 10
discussed with the member, even if needed services are not
covered by the Contractor.
- -----------------------------------------------------------------------------------------------------------------------
D.1 " The Contractor is responsible for knowing and implementing 10
all requirements of the Balanced Budget Act of 1997, even
if not stated in this document.(*)
- -----------------------------------------------------------------------------------------------------------------------
D.1 " The Contractor is responsible for providing services, as 10
defined and limited throughout this document, to KidsCare
members.
- -----------------------------------------------------------------------------------------------------------------------
i
<Caption>
- ----------------------------------------------------------------------------------------------------------------------
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- ----------------------------------------------------------------------------------------------------------------------
D.1 " "12-month period of enrollment" changed to "contract year" 10
for all KidsCare references.
- ----------------------------------------------------------------------------------------------------------------------
D.1 " Licensed midwives and home deliveries are NOT covered for 10, 18
KidsCare members and kidney-pancreas transplants are
covered ONLY for KidsCare members.
- ----------------------------------------------------------------------------------------------------------------------
D.1. "Behavioral Health" CLARIFICATION ONLY: For state-only members, AHCCCSA will 11
pay for only the first three days of emergency service.
The Contractor may continue to provide services as needed
but must seek additional reimbursement elsewhere.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Chiropractic Services" Description of chiropractic services added. 11
- ----------------------------------------------------------------------------------------------------------------------
D.1 "EPSDT" Distinctions made between services under Title XIX and 11
Title XXI.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Emergency Services" Emergency services are covered without prior authorization 12
for up to 72 hours.(*)
- ----------------------------------------------------------------------------------------------------------------------
D.1 " "Prudent layperson" standard added, as well as the 12
coordination of post-stabilization care.(*)
- ----------------------------------------------------------------------------------------------------------------------
D.1 " Liability for payment of certain emergency services for 12
Native Americans is changed.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Family Planning" Contractor must notify AHCCCSA when a SOBRA woman is 12
sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program.
Notification may be made at the time the newborn is
reported or after the sterilization procedure is
completed.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Hospice" Hospice services are added for members under age 21. 13
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Maternity" Home delivery and licensed midwives are not covered under 14
KidsCare.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Maternity" A normal newborn may be granted an extended stay in the 14
hospital when the mother's stay is extended.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Nursing Facility" CLARIFICATION ONLY: Christian Science sanatoria are 14
covered under the nursing facility requirement.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Prescription Medications" OTC medication may be prescribed when it is determined to 14
be a lower-cost alternative to prescription medication.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Transplantations" Kidney-pancreas transplants are covered only for KidsCare 15
members.
- ----------------------------------------------------------------------------------------------------------------------
D.1 "Transportation" KidsCare members are not entitled to non-emergency 15
transportation except for transfers between facilities.
- ----------------------------------------------------------------------------------------------------------------------
D.2 Behavioral Health Services The Contractor must provide behavioral health screenings 16
for Title XIX and KidsCare members under age 21.
- ----------------------------------------------------------------------------------------------------------------------
ii
<Caption>
- -----------------------------------------------------------------------------------------------------------------------
Para # PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- -----------------------------------------------------------------------------------------------------------------------
D.2 " CLARIFICATION ONLY: Details added on the Contractor's 16
responsibilities for referring members to ADHS and/or
the RBHA for behavioral health services.
- -----------------------------------------------------------------------------------------------------------------------
D.2 "Service Plan" CLARIFICATION ONLY: Services shall be initiated within 16
30 days of the initial screening, not necessarily
completed within that time.
- -----------------------------------------------------------------------------------------------------------------------
D.2 "Provider Network" CLARIFICATION ONLY: The Contractor would subcontract for 17
behavioral health services directly with a RBHA, not with
ADHS.
- -----------------------------------------------------------------------------------------------------------------------
D.2 "Title XXI Members" Covered behavioral health services for KidsCare members are 17-18
detailed.
- -----------------------------------------------------------------------------------------------------------------------
D.2 " "Psychotropic medication adjustment and monitoring" divided 18
into "Psychotropic Medication" and Psychotropic medication
adjustment and monitoring."
- -----------------------------------------------------------------------------------------------------------------------
D.2 " "Basic and intensive" added to Partial Care 18
- -----------------------------------------------------------------------------------------------------------------------
D.2 " "Case management" added. 18
- -----------------------------------------------------------------------------------------------------------------------
D.2 " CLARIFICATION ONLY: KidsCare members are entitled to a 18
total of 30 outpatient visits per contract year.
- -----------------------------------------------------------------------------------------------------------------------
D.2 " Screening services do not count toward the 30-visit maximum. 18
- -----------------------------------------------------------------------------------------------------------------------
D.2 " Group therapy and group counseling count as one-half an 18
outpatient visit.
- -----------------------------------------------------------------------------------------------------------------------
D.2 " Bed hold days are not covered under KidsCare. 18
- -----------------------------------------------------------------------------------------------------------------------
D.2 "State-Only Members" CLARIFICATION ONLY: Reimbursement for state-only 18
emergency behavioral health service limited to three
days per episode.
- -----------------------------------------------------------------------------------------------------------------------
D.4 Vaccine for Children Program CLARIFICATION ONLY: Vaccines for AHCCCSA members under 18
age 19 are provided by the federal government at no
cost to any immunization provider who is registered
with ADHS/VFC. The Contractor must not use AHCCCSA
funds to purchase such vaccines.
- -----------------------------------------------------------------------------------------------------------------------
D.5 Denials or Reductions of Services Notification requirements mandated by Perry v. Kelly have 19
been incorporated into the Arizona Administration Code and
are referenced here.
- -----------------------------------------------------------------------------------------------------------------------
D.6 Enrollment and Disenrollment List of groups for whom the Department of Economic Security 19
determined eligibility is updated.
- -----------------------------------------------------------------------------------------------------------------------
D.6 "Health Plan Choice" All members (except MN/MI) now receive a list of 19
available health plans during the application process. Plan
selection and effective dates of enrollment are described.
- -----------------------------------------------------------------------------------------------------------------------
D.6 "Newborns" Effective date of enrollment for newborns is detailed. 20-21
AHCCCSA can now receive newborn notifications 24-hours
per day, 7 days per week.
- -----------------------------------------------------------------------------------------------------------------------
iii
<Caption>
- -----------------------------------------------------------------------------------------------------------------------
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
D.6 "Enrollment Guarantees" Enrollment guarantee for KidsCare is 12 months. Title 21
XIX remains at 5 months. Guarantee applies only one
time per eligibility category (i.e. KidsCare, Title
XIX, EAC).
- -----------------------------------------------------------------------------------------------------------------------
D.6 "Native Americans" PL 93-638 tribal entities are added as a health plan choice 21
for Native Americans. Other details on health plan choice
for Native Americans added.
- -----------------------------------------------------------------------------------------------------------------------
D.8 Member Information The reading grade level and evaluation methodology used to 22
determine the reading level should be included with all
informational materials submitted to AHCCCSA.
- -----------------------------------------------------------------------------------------------------------------------
D.8 " Several new requirements to the Member Handbook have been 22-24
added, including what to do if the member is billed for
a covered service, descriptions of behavioral health
and dental services, reminder not to discard the ID
card, notification rights, fraud and abuse
responsibilities, member's right to receive certain
types of information from the Contractor, right to
non-discriminatory treatment, grievance period changed
from 35 to 60 days.
- -----------------------------------------------------------------------------------------------------------------------
D.11 Annual Enrollment Choice Open enrollment now occurs on each member's anniversary 24-24
date, rather than once per year for everyone in August.
- -----------------------------------------------------------------------------------------------------------------------
D.13 Staff Requirements The Contractor shall not employ or contract with anyone 26
that has been debarred or prohibited from public
procurement activity.(*)
- -----------------------------------------------------------------------------------------------------------------------
D.13 " CLARIFICATION ONLY: The Behavioral Health Coordinator must 26
devote sufficient time to ensure AHCCCSA requirements are
met.
- -----------------------------------------------------------------------------------------------------------------------
D.16 Performance Measures Performance measures apply to all AHCCCSA members, whether 28
they are Title XIX, KidsCare or State-only members.
- -----------------------------------------------------------------------------------------------------------------------
D.16 " New performance measures have been added, including 28-30
well-child visits for children under 15 months
old, well-child visits for children 3, 4, 5 and 6 years
old, PCP visits for members under 21.
- -----------------------------------------------------------------------------------------------------------------------
D.18 Physician Incentives Details on submission to AHCCCSA of physician incentive 30
proposals have been added.
- -----------------------------------------------------------------------------------------------------------------------
D.19 Appointment Standards Maximum time for routine dental appointments has been 31
changed from 30 days to 45 days from date of request.
- -----------------------------------------------------------------------------------------------------------------------
D.23 Other Provided Standards CLARIFICATION ONLY: The Contractor's oversight of its 34
provided network must include provision and accessibility
of services to members with limited proficiency in English.
- -----------------------------------------------------------------------------------------------------------------------
iv
<Caption>
- -----------------------------------------------------------------------------------------------------------------------
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- -----------------------------------------------------------------------------------------------------------------------
D.24 Network Development Maximum travel distance requirement (PCP and pharmacy) 34
for Contractor's members has been changed from "all
members" to "95% of its members" to allow for the
practicalities of provider locations.
- -----------------------------------------------------------------------------------------------------------------------
D.24 " Reference to new hospital subcontracting requirements added. 34
- -----------------------------------------------------------------------------------------------------------------------
D.24 " In subcontracting and subcontractor reimbursement, the 34
Contractor shall not discriminate against providers based
on their type of licensure or certification.(*)
- -----------------------------------------------------------------------------------------------------------------------
D.24 " CLARIFICATION ONLY: Clarification added regarding Balanced 34
Budget Act requirements on subcontractor participation
and reimbursement. (See immediately above.)(*)
- -----------------------------------------------------------------------------------------------------------------------
D.25 Network Management CLARIFICATION ONLY: The Contractor must have policies and 35
procedures related to the grievance process that ensure the
member's care is not compromised during the grievance
process.
- -----------------------------------------------------------------------------------------------------------------------
D.26 Federally Qualified Health New process for reasonable cost reimbursement has been 35
Centers (FQHC) added.
- -----------------------------------------------------------------------------------------------------------------------
D.34 Claims Payment System 90% of all clean claims must be paid within 30 days and 99% 39
must be paid within 90 days.(*)
- -----------------------------------------------------------------------------------------------------------------------
D.35 Hospital Subcontracting and References to AHCCCSA tiered per-diem rates must be deleted 40
Reimbursement from all hospital subcontracts.
- -----------------------------------------------------------------------------------------------------------------------
D.35 Hospital subcontracting and The Contractor must obtain hospital subcontracts in all 40
Reimbursement rural GSAs in which it is contracted with AHCCCSA. For
non-emergency patient-days, the Contractor must ensure
that 85% of its members use contracted hospitals.
AHCCCSA may require a contract at a particular hospital
if inpatient days become significant. The Contractor
must obtain at least one subcontract with a tertiary
care facility in one of the urban GSAs.
- -----------------------------------------------------------------------------------------------------------------------
D.37 Compensation Process for reconciliation of Prior Period Costs has been 41
modified.
- -----------------------------------------------------------------------------------------------------------------------
D.37 " KidsCare capitation rates to be set by AHCCCSA and will be 42
reviewed after first year of program.
- -----------------------------------------------------------------------------------------------------------------------
D.37 " AHCCCSA policy on HIV/AIDS supplemental payment and 42
review is now available through AHCCCSA, Office of
Managed Care.
- -----------------------------------------------------------------------------------------------------------------------
D.39 Reinsurance Modifications to reinsurance policy have been added. 43
- -----------------------------------------------------------------------------------------------------------------------
D.39 " Catastrophic reinsurance is available for members with 43
Gaucher's Disease
- -----------------------------------------------------------------------------------------------------------------------
D.39 " The Contractor must notify AHCCCSA within 30 days of (a) 43
initial diagnosis, (b) enrollment with the Contractor, and
(c) the beginning of each contract year.
- -----------------------------------------------------------------------------------------------------------------------
v
<Caption>
- ------------------------------------------------------------------------------------------------------------------------
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION; Pg. #
- ------------------------------------------------------------------------------------------------------------------------
D.39 " The Contractor must notify AHCCCSA when a member is referred 44
to transplant facility for an AHCCCSA-covered organ transplant.
- ------------------------------------------------------------------------------------------------------------------------
D.40 COB/TPL Special Treatment Trusts added to list of types of TPL 46
cases for which the Contractor shall not seek reimbursement.
- ------------------------------------------------------------------------------------------------------------------------
D.40 " Contractor is now responsible for payment of lien filing 47
fees in TPL recoveries.
- ------------------------------------------------------------------------------------------------------------------------
D.40 " Contractor must report potential health insurance coverage 46
to AHCCCSA for determination of KidsCare eligibility.
Contractor must follow same cost avoidance and postpayment
recovery for KidsCare as for Title XIX and main separate
reporting system for each.
- ------------------------------------------------------------------------------------------------------------------------
D.41 Medicare Services and Cost CLARIFICATION ONLY: For details on cost-sharing
Sharing responsibilities, refer to the AHCCCSA Medicare Cost
Sharing Policy.
- ------------------------------------------------------------------------------------------------------------------------
D.47 Data Exchange Requirement Contractor must begin appropriate planning for year 2000 51
compliance.
- ------------------------------------------------------------------------------------------------------------------------
D.56 Performance Bond Amt. of Contractor may not change terms of performance bond without 56
D.57 Performance Bond prior AHCCCSA approval.
- ------------------------------------------------------------------------------------------------------------------------
D.58 Financial Viability Criteria In calculating equity per member, the amount of the 57
on-balance sheet performance bond is deducted from total
equity.
- ------------------------------------------------------------------------------------------------------------------------
D.60 Sanctions CLARIFICATION ONLY: Sanctions may be imposed for failure 57
to meet encounter submission standards.
- ------------------------------------------------------------------------------------------------------------------------
D.60 Sanctions Sanction money collected by AHCCCSA may be redistributed 58
among acute health plans based on certain criteria.
- ------------------------------------------------------------------------------------------------------------------------
D.64 KidsCare Arizona has adopted a state version of the State Children's 58
Health Insurance Program, a federal health program.
- ------------------------------------------------------------------------------------------------------------------------
D.64 " CLARIFICATION ONLY: Details added on service providers 58
under KidsCare.
- ------------------------------------------------------------------------------------------------------------------------
D.64 " Title XXI Parent/Guardian Health Insurance Guidelines will 58
be available in the Bidder's Library.
- ------------------------------------------------------------------------------------------------------------------------
E.17 Suspension or Debarment Contractor may not employ or contract with any person or 60
entity who has been debarred or excluded from federal
procurement activity.(*)
- ------------------------------------------------------------------------------------------------------------------------
E.19 Termination for Default If Contractor requests a hearing prior to termination for 60
default, AHCCCSA must appoint temporary management.(*)
- ------------------------------------------------------------------------------------------------------------------------
Att. F Periodic Report Requirements One new report and several changes in reporting 61
requirements.
- ------------------------------------------------------------------------------------------------------------------------
vi
<Caption>
Para #: PARAGRAPH TITLE: SUMMARY OF CHANGE OR CLARIFICATION: Pg. #
- ---------------------------------------------------------------------------------------------------------------------
Att. I Encounter Requirements Contractor must not delete pended encounters to avoid 63
sanctions for failure to correct.
- ---------------------------------------------------------------------------------------------------------------------
(*) New requirement mandated by the Balanced Budget Amendment of 1997
vii
SECTION C: DEFINITIONS
AAC See "Arizona Administrative Code".
AGENT Any person who has been delegated the authority to
obligate or act on behalf of a provider.
AID TO FAMILIES WITH A federal assistance program under Title IV-A of the
DEPENDENT CHILDREN Social Security Act. Replaced by the Temporary
(AFDC) Assistance to Needy Families (TANF) program.
AHCCCS Arizona Health Care Cost Containment System as
defined by ARS 36-2901.
ARCCCSA Arizona Health Care Cost Containment System
Administration.
AHCCCS BENEFITS See "COVERED SERVICES."
AHCCCS MEMBER See "MEMBER."
ALTCS The Arizona Long Term Care System (ALTCS), a program
under AHCCCSA that delivers long term, acute and
behavioral health care services to members, as
authorized by ARS ss. 36-2931 et seq.
AMBULATORY CARE Preventive, diagnostic and treatment services
provided on an outpatient basis by physicians, nurse
practitioners, physician assistants and other primary
care providers.
AMPM The AHCCCS Medical Policy Manual.
ARIZONA ADMINISTRATIVE State regulations established pursuant to relevant
CODE (AAC) statutes. For purposes of this solicitation, the
relevant sections of the AAC are referred to
throughout this document as "AHCCCS Rules".
ARS Arizona Revised Statutes.
AT RISK Refers to the period of tune that a member is
enrolled with a contractor during which time the
Contractor is responsible to provide AHCCCS covered
services under capitation.
BIDDERS LIBRARY As referred to in this RFP, a repository of manuals,
statutes, rules and other reference material located
at the AHCCCS office in Phoenix.
1
BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
CAPITATION A method by which a contractor is paid to deliver
covered services for the duration of a contract to
members based on a fixed rate per member
notwithstanding (a) the actual number of members who
receive care from the contractor, and (b) the amount
of health care services provided to any member; a
cost containment alternative to fee-for-service
payments.
CATEGORICALLY A member who is eligible for Medicaid.
ELIGIBLE MEMBER
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider or from a
third party; does not include claims under
investigation for fraud or abuse or claims under
review for medical necessity.
COMPETITIVE BID PROCESS A state procurement system used to select
contractors to provide covered services on a
geographic basis.
CONTINUING OFFEROR An AHCCCS contractor during CYE 97 that submits a
proposal pursuant to this solicitation.
CONTRACT SERVICES See "COVERED SERVICES".
CONTRACT YEAR (CY) Corresponds to federal fiscal year (Oct. 1 through
Sept. 30). For example, Contract Year 98 is 10/1/97 -
9/30/98.
CONTRACTOR A person, organization or entity agreeing through a
direct contracting relationship with AHCCCSA to
provide the goods and services specified by this
contract in conformance with the stated contract
requirements, AHCCCS statute and rules and federal
law and regulations.
CONVICTED A judgment of conviction has been entered by a
federal, state or local court, regardless of whether
an appeal from that judgment is pending.
CO-PAYMENT An amount which the member pays directly to a
contractor or provider at the time covered services
are rendered.
COUNTY CONTRIBUTION Amount of hinds contributed to the AHCCCSA fund by
each Arizona county based on funding formulas
established by law.
2
COVERED SERVICES Health care services to be delivered by a contractor
which are so designated in Section D of this contract
and also AHCCCS Rules R9-22-202 et seq. and R9-31-201
et seq.
CRS Children's Rehabilitative Services (See Section D,
Paragraph 1, Covered Services).
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified.
DHS Arizona Department of Health Services.
DIRECTOR The Director of AHCCCSA.
DISCLOSING PARTY An AHCCCS provider or a fiscal agent.
DME Durable Medical Equipment; sturdy, long-lasting items
and appliances that can withstand repeated use, are
designed to serve a medical purpose, and are not
generally useful to a person in the absence of a
medical condition, illness or injury.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
DUAL ELIGIBLE QUALIFIED A person who is entitled to Medicare Part A insurance
MEDICARE BENEFICIARY and who meets certain income, resource and residency
requirements of the Qualified Medicare Beneficiary
program, and is categorically eligible for full
AHCCCS benefits.
EAC Eligible Assistance Child as defined in ARS
36-2905.03(B); an AHCCCS state program for children
under age 14 receiving food stamps.
ELIC Eligible Low-Income Child as defined in ABS
36-2905.05(C) and (D); an AHCCCS state program for
children under age 14 whose household income exceeds
the income limit for the MN/MI program but is less
than 100% of the federal poverty level.
ELIGIBLE PERSON A person who meets all eligibility requirements for
the AHCCCS acute care program but who has not yet
been enrolled with an AHCCCS acute care contractor.
3
ELIGIBILITY DETERMINATION A process of determining, through a written
application, including required documentation,
whether an applicant meets the qualifications for
Title XIX, Title XXI and/or state-only eligibility.
EMERGENCY MEDICAL A medical condition manifesting itself by acute
CONDITION symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical
attention could reasonably be expected to result in:
a) placing the patient's health in serious jeopardy;
b) serious impairment to bodily functions; or c)
serious dysfunction of any bodily organ or part.
EMERGENCY MEDICAL Medical services provided for an emergency medical
SERVICE condition and resulting in an unscheduled or
unplanned visit, admission or other medical service
to assess, relieve and/or treat the emergent
condition.
ENCOUNTER An encounter is a record of a medically related
service rendered by a provider or providers
registered with AHCCCSA to a member who is enrolled
with a contractor on the date of service. It includes
all services for which the contractor incurred any
financial liability.
ENROLLMENT The process by which a person who has been determined
eligible becomes a member with a contractor subject
to the Limitations specified in AHCCCS Rule
R9-22-333, R9-31-301 and R9-31-306
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; these services provide comprehensive
health care, as defined in Rule R9-22-213 and
R9-31-213, through primary prevention, early
intervention, diagnosis and medically necessary
treatment of physical and behavioral health problems
for AHCCCS members under 21 years of age.
FEE-FOR-SERVICE (FFS) A method of payment to registered providers on an
amount-per service basis.
FEDERALLY QUALIFIED An entity which meets the requirements and receives a
HEALTH CENTER (FQHC) grant and funding pursuant to Section 330 of the
Public Health Service Act. An FQHC includes an
outpatient health program or facility operated by a
tribe or tribal organization under the Indian
Self-Determination Act (PL 93-638) or an urban Indian
organization receiving funds under Title V of the
Indian Health Care Improvement Act.
4
FFP Federal financial participation (FFP) refers to the
federal matching rate that the federal government
makes to the Title XIX and Title XXI program portions
of AHCCCS.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1
through September 30; State fiscal year; July 1
through June 30.
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered and who makes
referrals as necessary and monitors the member's
treatment.
GEOGRAPHIC SERVICE AREA A specific county or defined grouping of counties
(GSA) that are available for contract award. An offeror may
bid on any or all GSAs. See Section H, Paragraph 9,
Award of Contract.
GROUP OF PROVIDERS Two or more health care professionals who practice
their profession at a common location (whether or not
they share facilities, supporting staff, or
equipment).
HCFA Health Care Financing Administration, an organization
within the Department of Health and Human Services, a
federal agency with oversight responsibility for
Title XVIII (Medicare), Title XIX (Medicaid), and
Title XXI (CHIPS).
HEALTH MAINTENANCE Various forms of plan organization, including staff
ORGANIZATION (HMO) and group models, that meet the HMO licensing
requirements of the federal and/or state government
and offer a full array of health care services to
members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported claims which is the
liability for services rendered for which claims have
not been received.
IHS Indian Health Service (IHS) is a division of the U.S.
Public Health Service. It administers a system of
hospitals and health centers providing health
services to Native Americans and Native Alaskans.
LIEN A legal claim filed with the County Recorder's office
in which a member resides and in the county an injury
was sustained for the purpose of ensuring that AHCCCS
receives reimbursement for medical services paid. The
lien is attached to any settlement the member may
receive as a result of an injury.
5
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by means
of arrangements with selected providers to furnish
comprehensive services to members; explicit criteria
for the selection of health care providers;
significant financial incentives for members to use
providers and procedures associated with the plan;
and formal programs for quality assurance and
utilization review.
MANAGING EMPLOYEE A general manager, business manager, administrator,
director, or other individual who exercises
operational or managerial control over, or who
directly or indirectly conducts the day-to-day
operation of, an institution, organization or agency.
MANAGEMENT SERVICES A person or organization who agrees to perform any
SUBCONTRACTOR administrative function or service for the Contractor
specifically related to securing or fulfilling the
Contractor's obligations to AHCCCSA under the terms
of the contract.
MATERIAL OMISSION A fact, data or other information excluded from a
report, contract, etc. which could lead to erroneous
conclusions following reasonable review of such
report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended, which provides
federal matching funds for a state-operated medical
assistance program for specified populations.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEMBER For this solicitation, a person eligible for AHCCCS
who is enrolled with a Contractor. Medically Needy/
Medically Indigent; state program for individuals not
eligible for Medicaid but who meet the eligibility
requirements for the state program.
MN/MI Medically Needy/Medically Indigent; state program for
individuals not eligible for Medicaid but who meet
the eligibility requirements for the state program.
NEW OFFEROR The organization, entity or person which submits a
proposal in response to this solicitation and which
has not been an AHCCCS contractor during CYE 97.
6
NON-CONTRACTING PROVIDER A provider who has a contract or subcontract within
the AHCCCS system and renders covered services to an
eligible person or member to whom such provider bears
no contractual obligation.
OFFEROR The organization, entity or person which submits a
proposal in response to the AHCCCS Request for
Proposal. An offeror who is awarded a contract
becomes a Contractor.
PERFORMANCE MEASURES A set of standardized indicators designed to assist
AHCCCS in evaluating, comparing and improving the
performance of its contractors. Specific descriptions
of health services measurement goals are found in
Section D, Paragraph 16, Performance Measures.
PMMIS Pre-paid Medicaid Management Information System.
PRIMARY CARE PROVIDER An individual responsible for the management of the
(PCP) member's health care that includes a physician who is
generally a family practitioner, general
practitioner, pediatrician, general internist,
obstetrician, gynecologist, certified nurse
practitioner or, under the supervision of a
physician, a physician's assistant. The PCP must be
an individual, not a group or association of persons,
such as a clinic.
PRIOR PERIOD The period of time preceding the actual notification
to a health plan of a member's enrollment during
which the health plan is retroactively liable for
payment of all covered services received by the
member. It is generally the period from the first day
of the month of application up to the day of the
health plan's receipt of notification of the member's
enrollment. Prior period coverage also includes
updated eligibility that covers a retroactive time
period when the member was not previously enrolled
with AHCCCS. Prior period coverage does not apply to
Title XXI members and does not include prior quarter
coverage (see below).
PRIOR QUARTER The three-month period immediately preceding the
month in which the member applies for Title XIX
benefits. If it is determined that the member would
have been eligible had the member applied in the
month in which services were provided, AHCCCSA may
pay for Title XIX services on a fee-for-service
basis. The Contractor is not liable for the prior
quarter period.
PROVIDER A person or entity who contracts with AHCCCSA or
subcontracts with an AHCCCS health plan to provide
AHCCCS covered services to members.
7
QUALIFIED MEDICARE A Medicare cost-sharing program established by the
BENEFICIARY (QMB) Medicare Catastrophic Coverage Act of 1988 in which
Medicaid pays the Medicare premiums, coinsurance and
deductibles for Medicare recipients meeting specific
eligibility requirements.
RATE CODE Eligibility classification for capitation payment
purposes.
REINSURANCE A risk-sharing program provided by AHCCCSA to
contractors for the reimbursement of certain contract
service costs incurred by a member beyond a certain
monetary threshold.
RELATED PARTY A party that has, or may have, the ability to control
or significantly influence a contractor, or a party
that is, or may be, controlled or significantly
influenced by a contractor. "Related parties"
include, but are not limited to, agents, managing
employees, persons with an ownership or controlling
interest in the disclosing entity, and their
immediate families, subcontractors, wholly-owned
subsidiaries or suppliers, parent companies, sister
companies, holding companies, and other entities
controlled or managed by any such entities or
persons.
RFP Request For Proposal document prepared by AHCCCSA
which describes the services required and which
instructs prospective offerors how to prepare a
response (proposal).
SCOPE OF SERVICES See "COVERED SERVICES".
SERIOUSLY MENTALLY ILL An adult whose emotional or behavioral functioning is
(SMI) so impaired as to interfere with his (or her)
capacity to remain in the community without
supportive treatment or services of a long-term or
indefinite duration. The mental disability is severe
and persistent and may result in a long-term
limitation of his capacities for primary activities
of daily living, interpersonal relationships,
home-making, self-care, employment or recreation.
SOBRA Refers to a federal law (Sixth Omnibus Budget and
Reconciliation Act) passed in 1986 and subsequently
amended, which establishes eligibility for pregnant
women and children based on a percentage of the
federal poverty level (FPL). Currently, AHCCCS
provides Medicaid services to pregnant women and
infants up to age one with income up to 140% of FPL,
children from 1 through 5 years with income up to
133% of FPL and children born on or after October 1,
1983 with income up to 100% of FPL.
8
STATE The State of Arizona.
STATE-ONLY MEMBER A member who is not eligible for Medicaid but
is eligible for one of the state-funded eligibility
categories which include Medically Needy/Medically
Indigent (MN/MI), Eligible Assistance Children (EAC),
Eligible Low Income Children (ELIC), and SSI-related
non-qualified aliens.
STATE PLAN The written agreement between the State and HCFA
which describes how the AHCCCS program meets HCFA
requirements for participation in the Medicaid
program.
SUBCONTRACT An agreement entered into by Contractor with a
provider of health care services who agrees to
furnish covered services to members, or with a
marketing organization, or with any other
organization or person who agrees to perform any
administrative function or service for Contractor
specifically related to fulfilling Contractor's
obligations to AHCCCSA under the terms of this
contract.
SUBCONTRACTOR (I) A person, agency or organization to which a
contractor has contracted or delegated some of its
management functions or responsibilities to provide
covered services to its members; or (2) A person,
agency or organization with which a fiscal agent has
entered into a contract, agreement, purchase order or
lease (or leases of real property) to obtain space,
supplies, equipment or services provided under the
AHCCCS agreement.
SUPPLEMENTAL SECURITY A federal assistance program under Title XVI of the
INCOME (SSI) Social Security Act.
TEFRA RISK HMO A Health Maintenance Organization or Comprehensive
Medical Plan which provides Medicare services to
Medicare beneficiaries pursuant to a Medicare risk
contract with HCFA under ss. 1876 of the Social
Security Act.
9
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS applicant
or member. Filing of liens is a method of securing
reimbursement from third parties.
THIRD PARTY LIABILITY The resources available from a person or entity that
is, or may be, by agreement, circumstance or
otherwise. liable to pay all or part of the medical
expenses incurred by an AHCCCS applicant or eligible
person.
TITLE XIX MEMBER Member eligible for Medicaid under Title XIX of the
Social Security Act including Temporary Assistance to
Needy Families (TANF), Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI) or SSI-related groups.
TITLE XXI MEMBER Member eligible for acute care services under Title
XXI of the Social Security Act, referred to in
federal legislation as the "Children's Health
Insurance Program" (CHIP). The Arizona version of
CHIP is referred to as "KidsCare."
TRIBAL FACILITY A facility that is operated by an Indian tribe and
that is authorized to provide services pursuant to
Public Law 93-638, as amended.
YEAR See "Contract Year".
[END OF DEFINITIONS]
10
SECTION D: PROGRAM REQUIREMENTS
Table of Contents
1. Scope of Services............................................... 10
2. Behavioral Health Services...................................... 16
3. AHCCCS Medical Policy Manual.................................... 18
4. Vaccine for Children Program.................................... 19
5. Denials or Reductions of Services............................... 19
6. Enrollment And Disenrollment.................................... 19
7. Mainstreaming of AHCCCS Members................................. 21
8. Member Information.............................................. 22
9. Member Surveys.................................................. 24
10. Marketing Plans................................................. 24
11. Annual Enrollment Choice........................................ 24
12. Transition of Members........................................... 24
13. Staff Requirements and Support Services......................... 25
14. Written Policies, Procedures and Job Descriptions............... 27
15. Advance Directives.............................................. 27
16. Performance Measures............................................ 27
17. Quality Management and Utilization Management (QM/UM)........... 29
18. Physician Incentives............................................ 30
19. Appointment Standards........................................... 30
20. Referral Procedures and Standards............................... 31
21. Provider Manual................................................. 31
22. Primary Care Provider Standards................................. 32
23. Other Provider Standards........................................ 33
24. Network Development............................................. 34
25. Network Management.............................................. 34
26. Federally Qualified Health Centers (FQHC)....................... 35
27. Provider Registration........................................... 36
28. Provider Affiliation Tape....................................... 36
29. Periodic Report Requirements.................................... 36
30. Dissemination of Information.................................... 37
31. Requests for Information........................................ 37
32. Operational and Financial Readiness Reviews..................... 37
33. Operational and Financial Reviews............................... 37
34. Claims Payment System........................................... 38
35. Hospital Subcontracting and Reimbursement....................... 38
36. Nursing Facility Reimbursement.................................. 39
37. Compensation.................................................... 39
38. Capitation Adjustments.......................................... 41
39. Reinsurance..................................................... 42
40. Coordination of Benefits/Third Party Liability.................. 44
41. Medicare Services and Cost Sharing.............................. 45
42. Copayments...................................................... 46
43 Records Retention............................................... 46
44. Medical Records................................................. 46
45. Advances, Distributions, Loans and Investments.................. 47
46. Accumulated Fund Deficit........................................ 47
47. Data Exchange Requirement....................................... 47
48. Encounter Data Reporting........................................ 48
49. Monthly Roster Reconciliation................................... 49
50. Term Of Contract and Option To Renew............................ 49
11
51. Subcontracts.................................................... 50
52. Specialty Contracts............................................. 51
53. Management Services Subcontractors.............................. 51
54. Management Services Subcontractor Audits........................ 52
55. Minimum Capitalization Requirements............................. 52
56. Performance Bond or Bond Substitute............................. 52
57. Amount of Performance Bond...................................... 53
58. Financial Viability Criteria/Performance Measures............... 53
59. Merger, Reorganization and Change of Ownership.................. 54
60. Sanctions....................................................... 54
61. Auto-Assignment Algorithm....................................... 55
62. Grievance Process and Standards................................. 55
63. Quarterly Grievance Report...................................... 55
64. KidsCare........................................................ 55
65. Pending Legislative Issues...................................... 56
12
SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22-202 et seq., the AHCCCS Medical Policy
Manual, the AHCCCS Behavioral Health Policy Manual, and the document entitled
"AHCCCS Health Plan Performance Indicators", all of which are incorporated
herein by reference and may be found in the Bidder's Library. The covered
services are briefly described below. Covered services must be medically
necessary and provided by, or coordinated with, a primary care provider, except
for behavioral health and children's preventive dental services. Services must
be rendered by providers that are appropriately licensed, operating within their
scope of practice, and registered as an AHCCCS provider. The Contractor shall
provide the same standard of care for all members regardless of the member
eligibility category.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options even if needed services are not
covered by the Contractor.
BALANCED BUDGET ACT OF 1997: This revision of the AHCCCS acute care contract is
believed to contain all of the new requirements mandated by the federal Balanced
Budget Act of 1997. The Contractor, however, shall be held liable for all
mandated requirements whether or not they appear in this renewal amendment.
KIDSCARE COVERED SERVICES: KidsCare members are eligible for the same services
covered for members under the Title XIX and state-only programs, with the
following differences, exclusions and/or limitations:
a. Non-emergency transportation is not covered.
b. Chiropractic services are not covered.
c. Vision services are limited to one eye examination per contract year
and one pair of glasses or contacts every contract year.
d. EPSDT services are limited to those services specified in this
contract.
e. Behavioral health services are limited to 30 inpatient days and 30
outpatient visits per contract year. (See details under Section D
Paragraph 2, Behavioral Health Services.)
f. Licensed midwives and home deliveries are not covered.
g. Kidney-pancreas transplants are covered for Title XXI members only.
For further details regarding the KidsCare program, see Section D, Paragraph 64,
KidsCare, and the AHCCCS Medical Policy Manual (AMPM).
13
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a free-standing surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 21 including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through other than medical or surgical means
(i.e. hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D), Paragraph 2, Behavioral Health Services. For state-only
members (MN/MI, EAC, ELIC) reimbursement for behavioral health services will not
exceed the first three days per episode of emergency/ crisis stabilization, not
to exceed 12 days per contract year. See also the AMPM and the AHCCCS Behavioral
Health Policy Manual for details on covered behavioral health services.
CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for CRS-covered conditions
is administered by the Arizona Department of Health Services (ADHS) for children
who meet CRS eligibility criteria. The Contractor is responsible for referring
children to the CRS program who are potentially eligible for these services.
Eligibility criteria and the referral process are described in the CRS Policy
and Procedures Manual available in the Bidder's Library. The Contractor is also
responsible for providing primary medical care, including emergency services and
initial care of newborn infants, for members who are also CRS eligible, and to
require the member's Primary Care Provider (PCP) to coordinate their care with
the CRS program. All services provided must be included in the member's medical
record maintained by the PCP.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
Title XIX members under age 21 when prescribed by the member's PCP and approved
by the Contractor in order to ameliorate the member's medical condition.
Chiropractic services shall also be covered, subject to limitations specified in
CFR 410.22, for dually qualified Medicare beneficiaries if prescribed by the
member's PCP and approved by the Contractor.
DENTAL: The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services; dental
screening and preventive services in accordance with the AHCCCS periodicity
schedule; therapeutic dental services; dentures; and pre-transplantation dental
services. The Contractor shall monitor compliance with the EPSDT periodicity
schedule for dental screening services and ensure that dental service reports
are included in the member's medical record maintained by the PCP. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 16, Performance Measures. The Contractor shall
ensure that members are notified when dental screenings are due if the member
has not been scheduled for a visit. If no response is received, a second notice
must be sent. Members under the age of 21 may request dental services without
referral from their PCP and may choose a dental provider from the Contractor's
provider network. Members 21 years of age and older are eligible for emergency
dental services, medically necessary dentures and pre-transplantation dental
services only. Dental standards may
14
be found in the AMPM which is incorporated herein by reference and which may be
found in the Bidder's Library.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment for members
under age 21. The Contractor shall ensure that these members receive required
health screenings, including developmental/behavioral health, in compliance with
the AHCCCS periodicity schedule (included herein as Attachment K) and to submit
to the AHCCCS Office of the Medical Director/Acute Care Unit, all EPSDT reports
as required by AHCCCS medical policy. For Title XIX members under age 21,
chiropractic services shall be covered. The Contractor is required to meet
specific participation/utilization rates for members as described in Section D,
Paragraph 16, Performance Measures. Because the behavioral health benefit for
Title XIX and Title XXI members age 0-17 is provided through the ADHS/RBHA
system, the Contractor shall ensure the initiation and coordination of the
referral of these members to the RBHA. Referrals for behavioral health services
for Title XIX 18-, 19- and 20-year olds and Title XXI 18-year-old non-SMIs
shall be the responsibility of the Contractor's Behavioral Health Coordinator.
Title XXI members are not entitled to the all-encompassing EPSDT service package
required for Title XIX children. Title XXI children are entitled only to the
EPSDT and other covered services specified in this document and the Title XXI
State Plan.
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-days-a-week basis, for the sudden onset of a medically
emergent condition as defined by AHCCCS Rule R9-22-101 and R9-31-101.
Emergency medical services are covered without prior authorization. The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged
to contract with or employ the services of non-emergency facilities
(e.g. urgent care centers) to address member non-emergency care issues
occurring after regular office hours or on weekends. The Contractor
shall be responsible for educating members and providers regarding
appropriate utilization of emergency room services. The Contractor
shall monitor emergency services utilization (by both provider and
member) and shall have guidelines for implementing corrective action
for inappropriate utilization. For utilization review, the test for
appropriateness of the request for emergency services shall be whether
a prudent layperson, similarly situated, would have requested such
services. For purposes of this contract, a "prudent layperson" is
defined as a person without medical training who exercises those
qualities of attention, knowledge, intelligence and judgment which
15
society requires of its members for the protection of their own
interest and the interests of others. The phrase does not apply to a
person's ability to reason, but rather the prudence with which he acts
under a given set of circumstances.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
e. The Contractor shall comply with established guidelines regarding the
coordination of post-stabilization care.
EYE EXAMINATIONS/ OPTOMETRY: The Contractor shall provide all medically
necessary emergency eye care, vision examinations, prescriptive lenses, and
treatments for conditions of the eye for all members under the age of 21, with
the exception of KidsCare members. See limitations for KidsCare members
described at the beginning of this section, titled "KidsCare Covered Services."
For members who are 21 years of age and older, the Contractor shall provide
emergency care for eye conditions which meet the definition of an emergency
medical condition, cataract removal, and/or medically necessary vision
examinations and prescriptive lenses if required following cataract removal and
other eye conditions as specified in the AMPM.
FAMILY PLANNING: The Contractor shall provide family planning services for all
members who choose to delay or prevent pregnancy, including medical, surgical,
pharmacological and laboratory services, as well as contraceptive devices,
information and counseling necessary to allow the members to make informed
decisions regarding family planning methods. If the Contractor does not provide
family planning services, it must contract for these services through another
health care delivery system which allows members freedom of choice in selecting
a provider. A prospective offeror may discuss arrangements for family planning
services only with other prospective offerors during the RFP process for the
purpose of making arrangements for the provision of family planning services.
The Contractor shall provide services to members enrolled in the Family Planning
Services Extension Program, a program that provides only family planning
services for a maximum of 24 months to women whose SOBRA eligibility has
terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification may be made at the time
the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually-transmitted diseases, tuberculosis and
HIV/AIDS; mammograms and prostate screenings; physical examinations and
diagnostic work-ups; and immunizations. Assessment and screening services for
members under age 21 are based on the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: The Contractor shall provide these services when members require
part-time or intermittent care but do not require hospital care under the daily
direction of a physician to
16
prevent re-hospitalization or institutionalization and may include skilled
nursing, therapies, supplies and home health aide services.
HOSPICE: These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/ crisis stabilization. If the
member's medical condition requires isolation, private inpatient accommodations
are covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the above
services which may be provided on an outpatient or ambulatory basis (i.e.
laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if determined
reasonable and necessary to decide whether the member should be admitted for
inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
oral polio vaccine, measles, mumps, rubella vaccine (MMR), H. influenza, type B
(HIB), hepatitis B (Hep B), combined 3-antigen rate (4 DPT, 3 OPV, 1 MMR) and
varicella vaccine. The Contractor is required to meet specific immunization
rates for members under the age of 21 which are described in Section D,
Paragraph 16, Performance Measures.
INDIAN HEALTH SERVICE: Effective October 1,1998, the Contractor shall not
reimburse IHS or a tribal facility for Title XIX, Title XXI or state-only
covered services, including emergency services, provided in the IHS facility or
tribal facility to Native American members enrolled with the Contractor. Subject
to approval from HCFA, AHCCCSA will allow IHS or the tribal facility to submit
Title XIX claims for such services directly to AHCCCSA. Details of the claims
and payment process will be determined after HCFA approval. At its option, the
Contractor may choose to subcontract with and pay an IHS facility or tribal
facility for covered services provided to members.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending physician
or dentist, and provided by a CLIA (Clinical Laboratory Improvement Act)
approved hospital, clinic, physician office or other health care facility
laboratory.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants or
17
nurse practitioners certified in midwifery. Members may select or be assigned to
a PCP specializing in obstetrics. Circumcisions are covered if performed during
the newborn's hospital stay after birth, or on an outpatient basis within one
month of the infant's hospital discharge. Title XIX and state-only members
anticipated to have a low-risk delivery may elect to receive labor and delivery
services in their home from their maternity provider if this setting is included
in allowable settings for the Contractor, and the Contractor has providers in
its network that offer home labor and delivery services. Title XIX and
state-only members anticipated to have a low-risk prenatal course and delivery
may elect to receive maternity services of prenatal care, labor and delivery and
postpartum care provided by licensed midwives if they are in the Contractor's
provider network. All licensed midwife labor and delivery services must be
provided in the member's home since licensed midwives do not have admitting
privileges in hospitals or AHCCCS registered free-standing birthing centers.
Members receiving maternity services from a licensed midwife must also be
assigned to a PCP for other health care and medical services. Home delivery and
licensed midwives are not covered for Title XXI members.
The Contractor shall allow women and their newborns to receive up to 48 hours of
inpatient hospital care after a routine vaginal delivery and up to 96 hours of
inpatient care after a cesarean delivery. The attending health care provider, in
consultation with the mother, may discharge the mother or newborn prior to the
48-hour minimum length of stay. A normal newborn may be granted an extended stay
in the hospital of birth when the mother's continued stay in the hospital is
beyond the 48 or 96 hour stay.
MEDICALLY-NECESSARY ABORTIONS: These services are covered when the pregnancy
would endanger the life of the mother if the fetus were to be carried to term
and, for Title XIX and Title XXI members, if the pregnancy is the result of rape
or incest. Providers must document and submit to the Contractor a Certificate of
Medical Necessity for Pregnancy Termination and prior authorization is required.
If the procedure is performed on an emergency basis, documentation must be
submitted to the Contractor within two working days. Additional documentation,
outlined in the AMPM, is required for members under 18 years of age who seek
medically necessary abortion due to rape or incest.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHODIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP, other
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide nursing facility services,
including Christian Science sanatoria, for members who require short-term
convalescent care not to exceed 90 days per contract year. Services must be
provided in a dually-certified Medicare/Medicaid facility which includes in the
per-diem rate: nursing services, basic patient care equipment and sickroom
supplies, dietary services, administrative physician visits, non-customized DME,
necessary maintenance rehabilitation therapies, over-the-counter medications,
social, recreational and spiritual activities, and administrative, operational
medical direction services. The Contractor
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shall continue medically necessary nursing facility services for any member who
has not been determined ALTCS eligible but is currently residing in a nursing
facility and is eligible for services provided under this contract. If the
member becomes ALTCS eligible and is enrolled with an ALTCS Program Contractor
before the end of the maximum 90 days of nursing facility coverage, the
Contractor is only responsible for nursing facility coverage during the time the
member is enrolled with the Contractor.
NUTRITION: The Contractor shall provide nutritional assessment and nutritional
supplements including oral supplements for EPSDT members when medically
necessary. Total parenteral nutrition (TPN) is covered for all members when it
is the sole source of nutrition due to severe pathology of the alimentary tract.
TPN may also be used to supplement nutrition for EPSDT members when medically
necessary but need not be the member's sole source of nutrition.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS AND PHARMACY: Medications ordered by a PCP, attending
physician or dentist and dispensed under the direction of a licensed pharmacist
are covered subject to limitations related to prescription supply amounts,
Contractor formularies and prior authorization requirements, as well as
restrictions for immunosuppressant drugs addressed in AHCCCS medical policies
for transplantations. Over-the-counter medication may be prescribed when it is
determined to be a lower-cost alternative to prescription medication.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gate-keeper
and coordinator in referring the member for specialty medical services,
behavioral health and dental services. The PCP is responsible for maintaining
the member's primary medical record which contains documentation of all health
risk assessments and health care services, including those provided by the PCP
and through referral.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those 21 and over, physical therapy for
all members and occupational and speech therapies for members under the
19
age of 21 are covered on both an inpatient and outpatient basis if not used as a
maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient basis
when prescribed by the member's PCP or attending physician and is necessary to
restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services include bone marrow, heart, lung, heart-lung, kidney, liver, and cornea
transplantations (all with related immunosuppressant medications), and are
covered within limitations defined in the AMPM for members diagnosed with
specified medical conditions. Kidney-pancreas transplants are covered for Title
XXI members only. Such limitations include whether the stage of the disease is
such that the transplant can affect the outcome; the member has no other
conditions which substantially reduce the potential for successful
transplantation; and whether the member will be able to comply with necessary
and required regimens of treatment. Bone grafts are also covered under this
service. Services include: pre-transplant inpatient or outpatient evaluation;
donor search; organ/tissue harvesting or procurement; preparation and
transplantation services; and convalescent care. In addition, if a member
receives a transplant covered by a source other than AHCCCS, medically necessary
non-experimental services are provided within limitations after the discharge
from the acute care hospitalization for the transplantation. AHCCCS has
contracted with transplantation providers for the Contractor's use or the
Contractor may select its own transplantation provider. However, the quality of
services must be equal to or exceed those from the AHCCCS provider and the rate
paid can not exceed the AHCCCS provider's negotiated rate. Transplantations for
the MN/MI population are subject to available funding.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. In an emergency, the member shall be taken to the
nearest appropriate emergency facility. Non-emergency transportation shall be
provided for Title XIX and state-only members who are unable to provide their
own transportation for medically necessary services. Title XXI members are not
eligible for non-emergency transportation services except for transfers between
facilities.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine services necessary to alleviate or stabilize the
emergent condition. The provider must notify the Contractor within 12 hours of
the member's registration with the facility for emergency services. Supporting
documentation for services rendered must be provided when reporting or billing a
service. Triage/screening services must be reasonable, cost effective and meet
the criteria for severity of illness and intensity of service.
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2. BEHAVIORAL HEALTH SERVICES
The Contractor must provide developmental/behavioral health screenings as part
of the EPSDT program for Title XIX and Title XXI members under 21 years of age.
The Contractor is responsible for the provision of Title XIX covered behavioral
health services to members as described below:
TITLE XIX MEMBERS (TANF, SSI, SOBRA):
UNDER AGE 18; AGE 21 AND OVER; SMI: On and after the effective date of
enrollment, the Contractor is responsible for up to the first three days of
emergency behavioral health services provided to Title XIX members not enrolled
with ADHS. The Contractor shall immediately refer members receiving emergency
behavioral health services to the RBHA when it is determined that the member may
be eligible for ADHS enrollment. The Contractor is also responsible for
referring Title XIX eligible, children age 0-17, adults age 21 and older, and
SMI members age 18 and older to the Regional Behavioral Health Authorities
(RBHAs) for the provision of Title XIX covered behavioral health services. (The
RBHAs may, in turn, contract with local providers.) The Contractor is
responsible for ensuring that a medical record is established by the PCP when
information is received about an assigned member even if the PCP has not yet
seen the assigned member. The Contractor shall also communicate information
pertaining to ADHS enrolled members to the ADHS RBHAs including, but not limited
to, current diagnosis, medication, pertinent laboratory results, last PCP visit,
and last hospitalization. For prior period coverage, the Contractor is
responsible for payment of all claims for medically necessary covered behavioral
health services to eligible persons not enrolled with ADHS.
NON-SMI, AGE 18, 19 AND 20: The Contractor is responsible for providing Title
XIX covered behavioral health services to Title XIX eligible non-SMI members age
18, 19 and 20 in accordance with AHCCCS Rule R9-22-1204 and the AHCCCS
Behavioral Health Policy Manual Covered services include: inpatient hospital,
inpatient psychiatric facility for individuals under the age of 21, individual
therapy and counseling, group and/or family therapy and counseling, psychotropic
medication adjustment and monitoring, partial care, emergency crisis services,
behavior management, psychosocial rehabilitation, screening, evaluation and
diagnosis, case management, psychotropic medications, and medically necessary
transportation.
REFERRALS: Title XIX-eligible members age 18, 19 and 20 may be referred
directly for the provision of behavioral health services by the PCP,
family members, self-referrals, schools, other service providers, and
members of the community and State agencies as well as the Contractor's
staff. The Contractor is responsible for identifying 18, 19 and 20 year
old members who may meet the ADHS definition for Serious Mental Illness
(SMI) and to refer these members to the RBHA for evaluation. The
Contractor shall be responsible for all costs associated with
conducting SMI evaluations in cases where a Title XIX 18, 19 or 20 year
old member is determined by the R.BHA or their subcontractor not to
meet the ADHS definition for SMI.
SERVICE PLAN: The Contractor is responsible for developing a Service
Plan for each Title XIX eligible non-SMI member age 18, 19 and 20
requiring behavioral health services.
21
Service Plans shall be developed within two weeks of assessment and
services shall be authorized and initiated within 30 days from
completion of the screening. The Service Plan is to be included as part
of the member's medical record.
CASE MANAGEMENT, CASE COORDINATION: The Contractor is responsible for
providing case management services, when medically necessary. Case
management services may vary in scope and frequency, depending on the
eligible person's intensity of need. Case management services consist
of a set of services and activities through which appropriate and
cost-effective Title XIX covered services are identified, planned,
coordinated, obtained, monitored and continuously evaluated. Case
coordination is provided to Title XIX non-SMI members age 18, 19 and 20
who are in need of behavioral health services but who do not require
case management services which are more intensive. Case coordination is
limited to Service Plan development, identification of service
providers, monitoring, updates and follow-up, when necessary.
QUALITY MANAGEMENT/UTILIZATION MANAGEMENT (QM/UM) REQUIREMENTS:
Quality management QM/UM for behavioral health services must be
integrated into the Contractor's QM/UM plans and must meet the QM/UM
requirements established by AHCCCSA.
PROVIDER NETWORK: The Contractor is responsible for contracting with
behavioral health providers who meet ADHS licensure and/or
certification standards and who are registered as a behavioral health
provider with AHCCCSA. The Contractor may, at its option, contract with
RBHAs for the provision of behavioral health services. The Contractor
must ensure that a sufficient number of qualified behavioral health
providers are in their provider network and that providers comply with
subcontracting, appointment standards and other provider related
requirements in this document.
NOTIFICATION REQUIREMENTS: The Contractor is responsible for notifying
AHCCCSA monthly of 18-, 19- and 20-year-old Title XIX, non-SMI members
referred and receiving behavioral health services. The information is
to be submitted to the AHCCCS Office of Managed Care using the
reporting format developed by AHCCCSA and available in the Bidder's
Library.
TITLE XXI (KIDSCARE) MEMBERS
On and after the effective date of enrollment, the Contractor is responsible for
up to the first three days of emergency behavioral health services provided to
Title XXI members not enrolled with ADHS. The Contractor shall immediately refer
members receiving emergency behavioral health services to the RBHA when it is
determined that the member may be eligible for ADHS enrollment. The Contractor
is also responsible for referring Title XXI eligible children age 0-17 (SMI and
non-SMI) and 18-year-old SMI members to the Regional Behavioral Health
Authorities (RBHAs) for the provision of Title XXI covered behavioral health
services. (The RBHAs may, in turn, contract with local providers.) The
Contractor is responsible for ensuring that a medical record is established by
the PCP when information is received about an assigned member even if the PCP
has not yet seen the assigned member. The Contractor shall also
22
communicate information pertaining to ADHS enrolled members to the ADHS RBHAs
including, but not limited to, current diagnosis, medication, pertinent
laboratory results, last PCP visit, and last hospitalization.
The Contractor is responsible for providing Title XXI covered behavioral health
services to 18-year-old non-SMI members. Covered services include:
a. Inpatient hospital
b. Inpatient psychiatric facility for persons under 21 years of age
c. Individual therapy and counseling
d. Group and/or family therapy and counseling
e. Psychotropic medication
f. Psychotropic medication adjustment and monitoring
g. Partial care, basic and intensive
h. Emergency crisis services
t. Behavior management
j. Psychosocial rehabilitation
k. Evaluation and diagnosis
l. Laboratory and radiology services for psychotropic medication
regulation and diagnosis
m. Emergency transportation
n. Case management
Title XXI covered services are subject to the following limitations per contract
year. The Contractor shall ensure that services provided to Title XXI members
under this contract are monitored and counted against the applicable annual
limitations below:
a. Inpatient behavioral health services provided in an inpatient hospital
or inpatient psychiatric facility for persons under 21 years of age are
limited to 30 days per contract year. Inpatient substance abuse
services when combined with inpatient behavioral health services shall
not exceed 30 days per contract year.
b. If basic or intensive partial care is provided, each half-day of
partial care shall equal one-fourth of an inpatient day and each full
day of partial care shall equal one-half of an inpatient day.
c. The following outpatient behavioral health services are limited to a
total of 30 visits per contract year: behavior management, emergency
crisis services, evaluation and diagnosis, group and/or family therapy
and counseling, individual therapy and counseling and psychosocial
rehabilitation.
d. If group therapy and counseling is provided, the benefit shall count as
one-half an outpatient visit.
e. Screening services which are used to determine the need for further
evaluation, diagnosis and treatment are not counted toward the 30-visit
limitation.
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f. The following outpatient services are to be provided as medically
necessary with no annual service limitation: Emergency transportation,
case management, psychotropic medication, psychotropic medication
monitoring, and laboratory and radiology services for psychotropic
medication regulation and diagnosis.
g. Bed hold days are not covered under the Title XXI program.
STATE-ONLY MEMBERS (MN/MI, EAC, ELIC):
For state-only members (MN/MI, EAC, ELIC) reimbursement for behavioral health
services will not exceed the first three days per episode of emergency/crisis
stabilization, not to exceed 12 days per contract year. This limitation of the
Contractor's financial liability is the same regardless of whether the member is
enrolled with a RBHA.
3. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. AHCCCSA will provide three copies of the AMPM to the Contractor
(for use by the CEO, Medical Director and Quality Management staff). Updates to
medical policies will be distributed quarterly. The Contractor is responsible
for maintaining the AMPM with these updates and for complying with the
requirements set forth therein.
4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program the federal and state governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. Therefore, the Contractor shall not utilize AHCCCS
funding to purchase vaccines for members under the age of 19. Any provider
licensed by the State to administer immunizations may register with ADHS as a
"VFC provider" and receive free vaccines. The Contractor shall comply with all
VFC requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When a covered service is denied, reduced, suspended or terminated, the
Contractor shall comply with the notice and continuation of benefits
requirements specified in 42 CFR 431.200 et seq., AAC R9-22, Article 13
outlining members' rights and responsibilities, and AHCCCS policy.
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
24
Social Security Administration (SSA) SSA determines eligibility for the
Supplementary Security Income (SSI) cash
program. SSI Cash recipients are
automatically eligible for AHCCCS
coverage.
Department of Economic Security (DES) DES determines eligibility for the
Temporary Assistance to Needy Families
(TANF) program (formerly Aid to Families
with Dependent Children), 1931 Group
Medical Assistance Only (MAO) groups,
SOBRA women and children, the Eligible
Assistance Children state program (EAC),
the Adoption Subsidy Program, Title IV-E
foster care children, and the Federal
Emergency Services program (FES) related
to the TANF, 1931 Group, or SOBRA
programs.
AHCCCSA AHCCCSA determines eligibility for the
SSI/MAO groups, including the FES
program related to the SSI-Cash program
(aged, disabled, blind), the Arizona
Long-Term Care System (ALTCS), the
Qualified Medicare Beneficiary program,
and the Title XXI program.
Arizona's 15 Counties Each county determines eligibility for
the Medically Needy/Medically Indigent
(MN/MI), Eligible Low Income Children
(ELIC), and the State Emergency Services
state programs.
AHCCCS acute care members are enrolled with contractors in accordance with the
rules set forth in R9-22-333, R9-22-334, R9-22-335, R9-22-337, R9-22-339,
R9-22-340, R9-22-342 and R9-22-707.
HEALTH PLAN CHOICE
All members except for those eligible under the MN/MI program have a choice of
available health plans. A listing of the available health plans and their
telephone numbers will be given to each member applicant during the application
process for AHCCCS benefits. Also included are instructions to member applicants
to call the health plans directly with specific questions concerning the health
plan. If there is only one health plan available for the member applicant's
Geographical Service Area, no choice is offered. Members who do not choose prior
to AHCCCSA's being notified of their eligibility are automatically assigned to a
health plan based on family continuity or the auto-assignment algorithm.
25
Title XXI members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. When a member is transferred from
Title XIX to Title XXI and has not made a health plan choice for Title XXI, the
member will remain with the Title XIX health plan and a choice notice will be
sent to the member. The member may then change plans no later than 16 days from
the date the choice notice is sent.
AHCCCSA assigns MN/MI members to an available health plan based on family
continuity or through AHCCCSA's auto-assignment algorithm. These members do not
get a choice of available contractors until their annual enrollment choice
period.
Exceptions to the above enrollment policies for Title XIX and state-only members
include: Previously eligible and enrolled members who have been disenrolled for
less than 90 days will be automatically enrolled with the same contractor if
that contractor is still available. Also, women whose SOBRA eligibility has
terminated and have become enrolled in the Family Planning Services Extension
Program will automatically remain assigned to the same health plan. The Family
Planning Services Extension Program provides a maximum of 24 months of family
planning services.
The effective date of enrollment for a new Title XIX or state-only member with
the Contractor will generally be the day prior to the date the Contractor
receives notification from AHCCCSA via the daily roster. However, the Contractor
is responsible for payment of medically necessary covered services retroactive
to the member's beginning date of eligibility, excluding any prior quarter
coverage period.
The effective date of enrollment for a Title XXI member will be the first day of
the month following notification to the health plan. If a Title XXI member is
determined eligible by the 25th of the month, the member will be enrolled with
the health plan as of the 1st of the following month. If the member is
determined eligible AFTER the 25th of the month, the member will be enrolled
with the health plan as of the 1st of the second following month.
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for Title XIX and
state-only members. For Title XIX members, prior period coverage starts from the
first day of the month of application, or first eligible month. The Contractor
is responsible for payment of all claims for medically necessary covered
services provided to Title XIX members during prior period coverage. For
state-only members (MN/MI, ELIC) prior period coverage is generally limited to
the two days prior to the date of AHCCCSA being notified of eligibility.
However, prior period coverage could include additional days prior to the date
of enrollment. The Contractor is responsible for payment of all claims for
medically necessary covered services provided on an emergency basis to
state-only members pursuant to ARS ss.36-2908 for the first two days of the
prior period coverage. Any additional prior period coverage for state-only
members will include all claims for medically necessary covered services. This
may include services provided prior to 10/1/97. (See Section D, Paragraph 37,
Compensation, for a description of the Contractor's reimbursement from AHCCCSA
for this eligibility time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers, including Title XXI mothers,
who were enrolled at the time of the child's birth and whose newborn
notification was received by
26
AHCCCSA will be enrolled with the mother's health plan. The Contractor is
responsible for notifying AHCCCSA of a child's birth to an enrolled member.
Capitation to the Contractor will begin on the date notification is received by
AHCCCSA (except for cases of births during prior period coverage). The effective
date of AHCCCS eligibility will be the newborn's date of birth, and the
Contractor is responsible for all covered services to the newborn whether or
tint AHCCCSA has received notification of the child's birth. Note that AHCCCSA
is currently available to receive notification calls 24 hours a day, 7 days a
week. Title XIX and Title XXI eligible mothers of newborns are sent a letter
advising them of their right to choose a different contractor for their child;
otherwise the child will remain with the mother's contractor. Newborns of MN/MI
mothers are enrolled with the mother's contractor for a minimum of 30 days up to
a maximum of 60 days. Newborns of FES mothers are auto-assigned to a health plan
and mothers of these newborns are sent a letter advising them of their right to
choose a different health plan for their child. AHCCCS Rules R9-22-342,
R9-22-707, R9-31-303 and R9-31-306 contain additional information concerning
newborn enrollment and payment.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, or as an Eligible Assistance Child (EAC), the member is guaranteed a
minimum of five full months of continuous enrollment. Upon initial capitated
enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of
12 full months of continuous enrollment. Enrollment guarantees do not apply to
Native Americans who choose to obtain their covered services through Indian
Health Services (IHS) on a fee-for-service basis or children enrolled with
Department of Economic Security/Comprehensive Medical and Dental Program. The
enrollment guarantee applies a maximum of one time per member per eligibility
category for Title XIX, Title XXI and EAC members. If a member changes from one
contractor to another within the enrollment guarantee period, the remainder of
the guarantee period applies to the new contractor. The enrollment guarantee may
not be granted or may be terminated if the member is incarcerated or, if a minor
child, is adopted. AHCCCS Rule R9-22-337 and R9-31-307 describe other reasons
for which the enrollment guarantee may not apply.
NATIVE AMERICANS: Native Americans eligible under any coverage group other than
MN/MI, on or off-reservation, have a choice of Indian Health Services (IHS) or
any available contractor. If choice is not available or made within the
specified time limit, Native American Title XIX and state-only members living
on-reservation will be assigned to IHS and Native American Title XIX and
state-only members living off-reservation will be assigned to an available
contractor using AHCCCSA's family continuity policy and auto-assignment
algorithm. Native Americans may change from IHS or a PL 93-638 tribal entity to
a contractor or from a contractor to IHS or a PL 93-638 tribal entity at any
time. Native American Title XXI members must make a choice prior to being
determined eligible.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, or physical or
27
mental handicap, except where medically indicated. Examples of prohibited
practices include, but are not limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way m his or her enjoyment of any advantage or privilege enjoyed by
others receiving any covered service.
d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. Information shall be submitted on
disk, saved as a text file (.txt) along with a hard copy printout. The reading
level and name of the evaluation methodology used should be included.
Information shall be provided in English and a second language when 200 members
or 5% of the Contractor's enrolled population, whichever is greater, are
non-English speaking. (AHCCCSA will advise the Contractor when and if this
requirement applies.) When there are program or service site changes
notification will be provided to the affected members at least 14 days before
implementation. The Contractor shall review and update the Member Handbook at
least once a year. The Handbook must be submitted to AHCCCSA Office of Managed
Care for approval by Sept. 1 of each contract year, or within four weeks of
receiving the annual renewal amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
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I. A MEMBER HANDBOOK which, at a minimum, shall include:
a. A table of contents
b. A general description of how managed care works, particularly in
regards to member responsibilities, appropriate utilization of services
and the PCP's role as gatekeeper of services
c. A description of all available covered services and an explanation of
any service limitations or exclusions from coverage and a notice
stating that the Contractor will be liable only for those services
authorized by the Contractor. The description should include a brief
explanation of the Contractor's approval and denial process.
d. Information on what to do when family size changes
e. How to obtain a PCP
f. How to change PCPs
g. How to make, change and cancel appointments with a PCP or dentist
h. List of applicable copayments (including a statement that care will not
be denied due to lack of copayment). The member handbook must clearly
state that members cannot be billed for covered services (other than
applicable copayments), what to do if they are billed, and under what
circumstances a member may be billed for non-covered services. Dual
eligibility (i.e. Medicare and Medicaid); services received in and out
of the Contractor's network; copayments. See Section D, Paragraph 41,
Medicare Services and Cost Sharing.
j. The process of referral to specialists and other providers, including
access to behavioral health services provided by the ADHS RBHA system
for members under age 18, 21 and older, and SMI members of any age.
k. How to contact Member Services and a description of its function
1. What to do in case of an emergency and instructions for receiving
advice on getting care in case of an emergency. In a life-threatening
situation, the member handbook should instruct members to use the
emergency medical services (EMS) available and/or activate EMS by
dialing 9-1-1. Handbook should contain information on proper emergency
service utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. Screenings include a comprehensive history and
developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing,
laboratory tests, dental screening and immunizations.
o. Maternity and family planning services
p. Description of covered behavioral health services and how to access
them
q. Description of all covered dental services for members under 21 and how
to access these services
r. Out of county/out of state moves
s. Grievance procedures, including a clear explanation of the member's
right to file a grievance and to appeal any decision that affects the
member's receipt of covered services.
t. Contributions the member can make towards his/her own health, member
responsibilities, appropriate and inappropriate behavior, and any other
information deemed essential by the Contractor or AHCCCS. This shall
include a statement that the member is responsible for protecting his
or her ID card and that misuse of the card, including loaning, selling
or
29
giving it to others could result in loss of the member's eligibility
and/or legal action. A sentence shall be included that stresses the
importance of members keeping, not discarding, the swipe ID card.
u. How to access after-hours care (urgent care).
v. Advance directives for adults
w. Use of other sources of insurance. See Section D, Paragraph 40,
Coordination of Benefits.
x. The last revision date
y. Member's notification rights and responsibilities under AAC R9-22,
Article 13 and AHCCCS policy
z. A description of Fraud and Abuse including instructions on how to
report suspected fraud or abuse. This shall include a statement that
misuse of a member's identification card, including loaning, selling or
giving it to others could result in loss of the member's eligibility
and/or legal action against the member
aa. A statement that informs the member of their right to request
information on whether or not the health plan has Physician Incentive
Plans (PIP) that affect the use of referral services, the right to know
the types of compensation arrangements the plan uses, the right to know
whether stop-loss insurance is required and the right to a summary of
member survey results. (in accordance with PIP regulation).
bb. Member's right to be treated fairly regardless of race, religion, sex,
age or ability to pay.
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type-style and size which can easily be read by members with
varying degrees of visual impairment. At a minimum, the member handbook shall
also contain the following language regarding questions, problems and grievances
(Ref. AHCCCS Rule R9-22-518 and R9-31-518):
Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call _______ and ask to talk
to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 60 days after the date of the
action, decision, or incident.
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
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II. A LIST OF THE NAMES, TELEPHONE NUMBERS AND SERVICE SITE ADDRESSES OF
PCPS available for selection by the member and a description of the
selection process. Upon request by the member, the Contractor must make
information available regarding provider qualifications.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs; communication
between members and the Contractor, and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in this survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, the Contractor shall perform its own annual general
or focused member survey. All such contractor surveys must be approved in
advance by AHCCCSA.
10. MARKETING PLANS
The Contractor shall submit all proposed marketing plans and materials to
AHCCCSA for prior approval in accordance with the AHCCCS Health Plan Marketing
Policy, a copy of which is available in the Bidder's Library. The Contractor
must have signed contracts with hospitals (in Maricopa and Pima counties), PCPs,
specialists and pharmacies in order for them to be included in marketing
materials.
11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment on a limited basis as
deemed necessary. During AEC, members may change contractors subject to the
availability of other contractors within their Geographic Service Area. Members
are mailed a printed enrollment form and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if the Contractor's contract is renewed and the member
continues to live in the Contractor's service area. The Contractor shall comply
with the Office of Managed Care Member Transition for Annual Enrollment Choice
and Other Plan Changes policy.
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12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM standards for member transitions
between health plans or GSAs, to or from an ALTCS program contractor, IHS, a PL
93-638 tribal entity, or a Title XXI direct service provider and upon
termination or expiration of a contract. The Contractor shall develop and
implement policies and procedures which comply with AHCCCS medical policy to
address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as behavioral health,
dialysis, home health, chemotherapy and/or radiation therapy or who are
hospitalized at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services.
The Contractor shall comply with the AHCCCS Behavioral Health Policy Manual for
transition of members in need of behavioral health services to be provided
through the ADHS RBHA system.
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
1) A monthly claims aging report by provider/creditor including
IBNR amounts;
32
2) A monthly summary of cash disbursements;
3) Copies of all bank statements received by the Contractor.
Such reports shall be due on the fifth day of each succeeding month for
the prior month.
d. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
e. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
f. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
HOSPITAL REIMBURSEMENT PILOT PROGRAM - MARICOPA AND PIMA COUNTIES ONLY: Members
transferred from non-contracting hospitals shall be done in accordance with the
AHCCCS Medical Policy pertaining to member transfers.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff are required.
a. A full-time ADMINISTRATOR who is available at all times to fulfill the
responsibilities of the position and to oversee the entire operation of
the health plan.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A full-time CHIEF FINANCIAL OFFICER who is available at all times to
fulfill the responsibilities of the position and to oversee the budget
and accounting systems implemented by the Contractor.
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20-306.B. The
Behavioral Health Coordinator shall devote sufficient time to ensure
that the Contractor's behavioral health program is implemented per
AHCCCSA requirements.
33
g. PRIOR AUTHORIZATION STAFF to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A CLAIMS ADMINISTRATOR and CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
l. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE COORDINATOR who will manage and adjudicate member and
provider grievances.
n. CLERICAL AND SUPPORT STAFF to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCSA, Office of Managed Care, in writing within
seven days of staffing changes in the following key positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/EPSDT Coordinator Quality Management Utilization Management Coordinator
Grievance Coordinator Behavioral Health Coordinator
The Contractor shall ensure that all staff have appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
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15. ADVANCE DIRECTIVES
The Contractor shall specify in the contract or agreement with each hospital,
nursing facility, provider of home health care, hospice or personal care
services that the provider must comply with federal and State law regarding
advance directives for adult members. At a minimum, the providers (hospitals,
nursing facilities, home health care, hospice and personal services) shall:
a. Maintain written policies for adult members receiving care through
their organization regarding the member's right to make decisions about
medical care, including the right to accept or refuse medical care and
the right to execute an advance directive. The information must contain
an explanation of any conscientious objection the provider may have in
carrying out the advance directive. (The Contractor is not prohibited
from making such objection when made pursuant to ARS 36-3205 (C.1)
b. Provide written information to adult members regarding an individual's
rights under State law to make decisions regarding medical care and the
provider's written policies concerning advance directives.
c. Require documentation in the member's medical record as to whether the
adult member has executed an advance directive.
d. Not condition the provision of care or discriminate against a member
because of his or her decision to execute or not execute an advance
directive.
e. Provide education for staff on issues concerning advance directives.
f. Ensure compliance with requirements of federal and State law regarding
advance directives.
The Contractor shall also maintain policies and procedures on advance directives
with respect to all adult members. These policies and procedures must contain
the same information described immediately above.
16. PERFORMANCE MEASURES
All performance measures described below apply to Title XIX, state-only, and
Title XXI member populations.
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program to at least 80% of all enrolled
members under age 21 during CYE 99. "Participation" is defined as at least one
initial and periodic screening or one preventive or treatment visit. AHCCCSA
will measure participation levels through encounter data and will not use
information from prior period coverage (see Paragraph D.6, Prior Period
Coverage) in evaluating the Contractor's performance.
If the Contractor has not achieved at least the statewide average
participation/utilization rates for EPSDT services by the end of the contract
year, as indicated through notification from AHCCCSA, the Contractor shall
submit a corrective action plan to AHCCCSA. The plan shall be submitted within
30 days of the Contractor's receipt of participation/utilization rate
35
notification from AHCCCSA. In addition, AHCCCSA may conduct one or more
follow-up on-site reviews to verify compliance with the corrective action plan.
If the Contractor's rate is higher than the statewide average for EPSDT
participation, but lower than 80%, AHCCCSA may require the Contractor to submit
a corrective action plan within specified time lines.
EPSDT IMMUNIZATIONS: The Contractor shall ensure members under age 21 receive
age-appropriate immunizations as specified in the AMPM. The AHCCCSA long range
goal is to reach or exceed the Healthy People Year 2000 goal of 90%
immunization for two year old members. During CYE 99, the Contractor shall meet
or exceed the following:
Percentage of Number of
Immunization Members Immunized Doses
Diphtheria, Tetanus, Pertussis vaccine (DPT) 80% 4
Oral Polio Vaccine 85% 3
Measles, Mumps, Rubella Vaccine (MMR) 90% 1
H. Influenza, Type B (HIB) 90% 1
Hepatitis B (Hep B) 85% 3
Combined 3-Antigen Rate (4DPT, 3 OPV, 1MMR) 80% N/A
Combined All Antigens 70% N/A
Varicella Vaccine N/A N/A
The Contractor shall conduct an annual immunization audit based on random
sampling to assess and verify the immunization status of two year old members.
AHCCCSA will provide the Contractor, within two weeks after the end of the
contract year, the selected sample, specifications for conducting the audit, the
AHCCCSA reporting requirements, and technical assistance. The Contractor shall
identify the children's PCP, conduct the assessment, and report to AHCCCSA in
the required format all immunization rates for the sampled two-year-old children
no later than December 15 after the end of the contract year. If medical records
are missing for more than 5% of the sample group, the Contractor is subject to
sanctions by AHCCCSA. Health Services Advisory Group (HSAG) will conduct a study
to validate the Contractor's reported rates.
AHCCCSA will provide the statewide average immunization rates to the Contractor.
If the Contractor has not achieved at least these statewide averages by the end
of the contract year, the Contractor shall submit a corrective action plan to
AHCCCSA. The plan shall be submitted within 60 days of the Contractor's receipt
of utilization rate notification from AHCCCSA. In addition, AHCCCSA may conduct
one or more follow-up on-site reviews to verify compliance with the corrective
action plan.
If the Contractor's immunization rates are higher than the statewide average for
immunizations, but lower than the stated goals set forth in this contract,
AHCCCSA may require the Contractor to submit a corrective action plan within
specified time lines.
36
PERFORMANCE INDICATORS: The AHCCCS goal for quality of care is to meet or exceed
the Healthy People Year 2000 national goals. For CYE 99, the Contractor shall
comply with AHCCCS quality management requirements to improve performance of at
least the following established performance indicators: low birth weight;
mammography screening; and cervical cancer screening.
If the Contractor has not achieved at least the statewide average for each
performance indicator by the end of the contract year, it shall submit to
AHCCCS, Office of the Medical Director, Acute Care Unit, a quality improvement
plan. The plan shall be submitted within 60 days after the Contractor's receipt
of performance measurement notification from AHCCCSA.
A quality improvement plan may be required for each performance indicator in
which the Contractor's performance rate is above the statewide average for all
contractors but below the midpoint between the statewide average and the
best-performing health plan.
EPSDT/DENTAL SERVICES: The Contractor shall take affirmative steps to increase
utilization of dental services for members under age 21. At least 50% of all
enrolled members under age 21 shall have at least one dental visit during CYE
99. AHCCCSA will monitor utilization through reported encounter data.
If the Contractor has not achieved at least the statewide average rate for
utilization of dental services by the end of the contract year, as indicated
through notification from AHCCCSA, the Contractor shall submit a corrective
action plan to AHCCCSA. The plan shall be submitted within 30 days of the
Contractor's receipt of utilization rate notification from AHCCCSA. In addition,
AHCCCSA may conduct one or more follow-up on-site reviews to verify compliance
with the corrective action plan. If the Contractor's rate is higher than the
statewide average for EPSDT dental services, but lower than 50%, AHCCCSA may
require the Contractor to submit a corrective action plan within specified time
lines.
WELL-CHILD VISITS FOR CHILDREN UNDER THE AGE OF 15 MONTHS: The Contractor shall
ensure that members under the age of 15 months receive all recommended
Well-Child visits as specified in the AMPM. During CYE 99, the Contractor shall
ensure that a minimum of 60% of its members receive all recommended Well-Child
visits. If the Contractor has not achieved at the least the statewide average
rate of utilization by the end of the contract year as indicated through
notification from AHCCCSA, the Contractor shall submit a corrective action plan
to AHCCCSA, Office of the Medical Director within 30 days of receipt of the
notification. If the Contractor rate's is higher than the statewide average but
lower than 60%, AHCCCSA may require the Contractor to submit a corrective action
plan within a specified time limit.
WELL CHILD VISITS FOR CHILDREN 3,4,5 AND 6 YEARS OF AGE: The Contractor shall
ensure that children 3,4,5 and 6 years of age receive all recommended Well-Child
visits as specified in the AMPM. During CYE 99, the Contractor shall ensure that
a minimum of 60% of its members receive at least one Well-Child visit during the
contract year. If the Contractor has not achieved at least the state-wide
average rate for utilization by the end of the contract year as indicated
through notification from AHCCCSA, the Contractor shall submit a corrective
action plan to AHCCCSA, Office of the Medical Director within 30 days of receipt
of the notification. If the
37
Contractor rate's is higher than the statewide average for this indicator but
lower than 60%, AHCCCSA may require the Contractor to submit a corrective action
plan within a specified time limit.
PRIMARY CARE PROVIDER VISITS: The Contractor shall ensure that members under age
21 have access to primary care provider (PCP) services. During CYE 99, the
Contractor shall ensure that a minimum of 70% of members under age of 21 visit
their PCP at least once during the contract year. If the Contractor has not
achieved at the least the statewide average rate for utilization by the end of
the contract year as indicated through notification from AHCCCSA, the Contractor
shall submit a corrective action plan to AHCCCSA, Office of the Medical Director
within 30 days of receipt of the notification. If the Contractor's rate is
higher than the statewide average but lower than 70%, AHCCCSA may require the
Contractor to submit a corrective action plan within a specified time limit.
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
The Contractor shall provide to members quality medical care as described in the
AMPM, Chapter 900, regardless of payer source or eligibility category. The
Contractor shall institute processes to assess, plan, implement and evaluate
quality improvement activities. The Contractor shall conduct two clinical
studies each contract year as required in Chapter 900 of the AMPM AHCCCSA will
determine the subject matter and study methodology for one of the annual studies
and the Contractor shall submit to AHCCCSA by November 15 of each contract year
its proposed subject matter and methodology for the other. The results of the
studies shall be submitted to AHCCCS, Office of the Medical Director, within 90
days after the end of each contract year.
The Contractor must maintain a written QM/UM plan which details plans for
compliance with the AMPM. The Contractor shall incorporate in its QM/UM plan an
action plan for improving the performance rates for those indicators with
established baselines.
18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. In order to
obtain approval, the following must be submitted to the Office of Managed Care
45 days prior to the implementation of the contract:
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1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the substantial
financial risk definition.
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or HCFA.
Please refer to the "Physician Incentive Guidelines" in the Bidder's Library for
details on providing required disclosures.
19. APPOINTMENT STANDARDS
For purposes of this section, "urgent" is defined as an acute but not
necessarily severe disorder which, if not attended to, could endanger the
patient's health. The Contractor shall have procedures in place that ensure the
following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within two days of request
c. Routine care PCP appointments - within 21 days of request
For specialty referrals, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within 3 days of referral
c. Routine care appointments - within 30 days of referral
For dental appointments, the Contractor shall be able to provide:
a. emergency appointments - within 24 hours of request
b. urgent appointments - within 3 days of request
c. routine care appointments - within 45 days of request
For maternity care, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within 3 days of request
d. High risk pregnancies - within 3 days of identification of high risk by
the Contractor or maternity care provider, or immediately if an
emergency exists
For behavioral health services to members 18-20 years of age, non-seriously
mentally ill, the Contractor shall be able to provide appointments as follows:
a. Emergency screening and evaluation - within 24 hours of referral or
request for services
b. Routine Behavioral health screening - within seven days of referral
c. Routine Non-emergency appointments - within 30 days of referral or
behavioral health screening
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If a member needs medically-necessary transportation, the Contractor shall
require its transportation provider to schedule the transportation so that the
member arrives no sooner than one hour before the appointment; does not have to
wait more than one hour after making the call to be picked up; nor have to wait
for more than one hour after conclusion of the appointment for transportation
home.
The Contractor shall monitor the adequacy of its appointment processes and
reduce the unnecessary use of alternative methods such as emergency room visits.
The Contractor shall monitor and ensure that a member's waiting time for a
scheduled appointment at the PCP's or specialist's office is no more than 45
minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network about appointment time requirements. The Contractor must assign
a specific staff member or unit within its organization to monitor compliance
with appointment standards and shall require a corrective action plan when
appointment standards are not met.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists to include, as a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of the
provider
c. Overview of the Contractor's Provider Service department and function
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d. Listing and description of covered and non-covered services,
requirements and limitations
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing,
laboratory tests, dental screenings and immunizations
g. Dental services
h. Maternity/Family Planning services
i. Listing of behavioral health services
j. The Contractor's policy regarding PCP assignments
k. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS RBHA system for members
under age 18, 21 and older, and SMI members of any age
l. Grievance and appeal rights
m. Billing and encounter submission information
- indicate which form, UB92, HCFA 1500, or Form C is to be used
for services
- indicate which fields are required for a claim to be
considered acceptable by the Contractor. A completed sample of
each form shall be included
n. Contractor's written policies and procedures which affect the
provider(s) and/or the provider network
o. Claims re-submission policy and procedure
p. Reimbursement, including reimbursement for dual eligibles (i.e.
Medicare and Medicaid) or members with other insurance
q. Explanation of remittance advice
r. Prior authorization requirement
s. Claims medical review
t. Concurrent review
u. Fraud and Abuse
v. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
w. AHCCCS appointment standards
22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics or pediatrics; certified nurse practitioners or certified nurse
midwifes; or physician's assistants.
At a minimum, the Contractor's number of full-time equivalent PCPs to enrolled
members shall not exceed a ratio of 1:1800 for adults and 1:1200 for children
who are 12 or younger. If the PCP contracts with more than one AHCCCS health
plan, the ratio shall be adjusted by the Contractor to ensure the total number
of AHCCCS members does not exceed the above ratio. The Contractor should
consider the PCP's total patient panel size (i.e. AHCCCS and non-AHCCCS
41
patients) when assessing the PCP's ability to meet AHCCCS' appointment and other
standards. In addition, AHCCCS members shall not comprise the majority of the
PCP's panel of patients. The Contractor shall also reduce the number of members
assigned to its network PCPs as necessary to meet the appointment standards
specified in Section D, Paragraph 19, Appointment Standards. Any variation to
the above standards must be submitted to AHCCCSA, Office of the Medical Director
for prior approval. PCPs with assigned members diagnosed with AIDS or as
HIV-positive shall meet criteria and standards set forth in AHCCCS Medical
Policy and AHCCCS AIDS Advisory Committee Guidelines.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions who are age 12 and younger to Board-certified
pediatricians.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP assignment, should the member desire to do so. The
Contractor shall confirm any PCP change in writing to the member. Members may
make both their initial PCP selection and any subsequent PCP changes either
verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of Managed Care, and shall be monitored through operational
audits. PCPs and specialists who provide inpatient services to the Contractor's
members shall have admitting and treatment privileges in a minimum of one
general acute care hospital that is located within the Contractor's service
area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
42
a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet
the medical needs of its members.
b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English.
Contractor policies shall be subject to approval by AHCCCSA, Office of Managed
Care, and shall be monitored through operational audits.
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services. Any
waiver of this requirement by the Contractor must be approved in
advance by AHCCCSA.
b. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies of test
results if applicable, treatment services provided and the resulting
outcome for each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians and certified nurse practitioners and certified nurse midwives who
include such services within their practice.
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24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient professional and
paramedical personnel for the provision of covered services, including emergency
medical care on a 24-hour-a-day, 7-days-a-week basis. The proposed network shall
be sufficient to provide covered services within designated time and distance
limits. For Maricopa and Pima Counties only, this includes a network such that
95% of its members residing within the boundary area of metropolitan Phoenix and
Tucson do not have to travel more than 5 miles to see a PCP or pharmacy. 95% of
its members residing outside the boundary area must not have to travel more than
10 miles to see such providers. See Attachment B, Minimum Network Requirements,
for details on network requirements by Geographic Service Area. Also see Section
D, Paragraph 35, Hospital Subcontracting and Reimbursement, for details on
changes in hospital subcontracting effective October 1, 1998.
Under the Balanced Budget Act of 1997, the Contractor shall not discriminate
with respect to participation in the AHCCCS program, reimbursement or
indemnification against any provider based solely on the provider's type of
licensure or certification. This provision, however, does not prohibit the
Contractor from limiting provider participation to the extent necessary to meet
the needs of the Contractor's members. This provision also does not interfere
with measures established by the Contractor to control costs consistent with its
responsibilities under this contract.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertain to all
service specifications described in the AMPM, Chapters 300, 600 and 900. In
addition, the Contractor shall have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements
b. Monitor and control network compliance with policies and rules of
AHCCCSA and the Contractor, including compliance with all policies and
procedures related to the grievance process and ensuring the member's
care is not compromised during the grievance process.
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area
e. Monitor network capacity to ensure that there are sufficient providers
to handle the volume of members
f. Ensure service accessibility, including monitoring appointment
procedures standards, appointment waiting times, and service provision
standards
44
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract. The
Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun, for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates in OBRA 89 and OBRA 90. This
legislation gives FQHCs the option to require state Medicaid programs to
reimburse the FQHC at 100% of reasonable costs for the services delivered.
AHCCCSA and its contractors are required to comply with this legislation. The
following payment methodology for reasonable cost reimbursement was implemented
effective October 1, 1997.
If the FQHC elects reasonable cost reimbursement, the FQHC will receive a
quarterly payment per member per month from AHCCCSA. The initial capitation
amount will be $1.75 PMPM statewide. In accordance with the Balanced Budget Act
of 1997, this additional reimbursement will be phased out over a five-year
period beginning in contract year ending 2000:
CONTRACT YEAR PHASE-OUT PERCENTAGE PMPM AMOUNT
1997 through 1999 No phase-out $ 1.75
2000 95% $ 1.66
2001 90% $ 1.58
2002 85% $ 1.49
2003 70% $ 1.23
2004 100% $ 0.00
Contractors are required to submit member month information for Title XIX
members for each FQHC on a quarterly basis to AHCCCS Office of Managed Care.
Contractors should refer to the Office of Managed Care's policy on FQHC
reimbursement for further guidance. The following FQHCs are currently recognized
by HCFA:
45
Clinica Adelante, Inc.
El Rio Health Center
Lake Powell Medical Center
Mariposa Community Health Center, Inc.
Mountain Park Health Center
Sun Life Family Health Center
United Community Health Center, Inc.
Sunset Community Health Center (formerly Valley Health Center, Inc.)
Inter-Tribal Health Care Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
Chiricahua Community Health Centers, Inc.
Marana Health Center
North Country Community Health Center
Any other clinics that subsequently become FQHCs will be subject to the
reimbursement methodology described above upon electing reasonable cost
reimbursement from AHCCCSA.
27. PROVIDER REGISTRATION
The Contractor shall ensure that each of its subcontractors register with
AHCCCSA as an approved service provider and receive an AHCCCS Provider ID
Number. A Provider Participation Agreement must be signed with each provider who
does not already have a current AHCCCS ID number. The original shall be
forwarded to AHCCCSA. This provider registration process must be completed in
order for the Contractor to report services a subcontractor renders to enrolled
members and for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TAPE
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Tape User Manual on October 15, January 15, April 15, and
July 15 of each contract year. The Manual may be found in the Bidder's Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its HCFA grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on or
before scheduled due dates.
46
b. Accuracy: Reports or other required data shall be prepared in strict
conformity with appropriate authoritative sources and/or AHCCCS defined
standards.
c. Completeness: All required information shall be fully disclosed in a
manner that is both responsive and pertinent to report intent with no
material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA, or the federal government, to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials which are produced by the Contractor and
refer to covered services shall state that such services are funded under
contract with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business for the initial contract year beginning 10/1/97.
The purpose of Readiness Reviews is to assess new contractors' readiness and
ability to provide contract services to members at the start of the contract
year. A new contractor will be permitted to commence operations only if the
Readiness Review factors are met to AHCCCSA's satisfaction.
47
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with HCFA requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The Contractor shall comply
with all other medical audit provisions as required by AHCCCS Rule R9-22-521 and
R9-31-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel as identified in advance shall be
available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
work space, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the Contractor has obtained accreditation from NCQA or
any other nationally recognized accrediting body. The Contractor must submit the
entire NCQA report to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in implementing recommendations and
achieving program compliance. Follow-up reviews may be conducted at any time
after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost-avoiding and paying claims in accordance with AHCCCS Rule
R9-22-705, a copy of which may be found in the Bidder's Library. In the absence
of a subcontract provision to the contrary,
48
claims submission deadlines shall be calculated from the date of service or the
effective date of enrollment, whichever is later. Remittance advices
accompanying the Contractor's payments to providers must contain, at a minimum,
adequate descriptions of all denials and adjustments, the reasons for such
denials and adjustments, the amount billed, the amount paid, and grievance
rights. The Contractor's claims payment system, as well as its prior
authorization and concurrent review process, must minimize the likelihood of
having to recoup already-paid claims. Any recoupment in excess of $50,000 per
provider within a contract year must be approved in advance by AHCCCSA, Office
of Managed Care.
In accordance with the Balanced Budget Act of 1997, the Contractor shall ensure
that 90% of all clean claims are paid within 30 days of receipt of the clean
claim and 99% are paid within 90 days of receipt of the clean claim.
During the term of this contact, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout All formats are subject to changes initiated by the
Kennedy-Kassebaum legislation. Reasonable implementation timeframes will be
negotiated with each plan.
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
Hospital subcontracts negotiated and/or renewed after October 1, 1998 shall not
contain any references to the AHCCCS tiered per-diem hospital rates.
MARICOPA AND PIMA COUNTIES ONLY: The Arizona Laws of 1996 Chapter 288 Section 20
sets forth the Hospital Reimbursement Pilot Program (Pilot), which is effective
from October 1, 1997, through September 30, 2000. The Pilot as defined by AHCCCS
Rule R9-22-718 requires hospital subcontracts to be negotiated between health
plans in Maricopa and Pima counties and hospitals to establish reimbursement
levels, terms and conditions. Subcontracts shall be negotiated by the Contractor
and hospitals to cover operational concerns, such as timeliness of claims
submission and payment, payment of discounts or penalties, legal resolution,
which may, as an option, include establishing arbitration procedures. These
negotiated subcontracts shall remain under close scrutiny by AHCCCSA to insure
availability of quality services within specific service districts, equity of
related party interests, reasonableness of rates, and only marketing of
contracted organizations. The general provisions of this program encompass acute
care hospital services and outpatient hospital services that result in an
admission. The Contractor shall submit all hospital subcontracts and any
amendments to AHCCCSA, Office of Managed Care, for prior approval. For
non-emergency patient-days, the Contractor shall ensure that at least 85% of its
members use contracted hospitals. AHCCCSA reserves the right to subsequently
adjust the 85% standard. Further, if in AHCCCSA's judgment the number of
emergency days at a particular non-contracted hospital becomes significant,
AHCCCSA may require a subcontract at that hospital. Hospitals and health
plans/program contractors outside of Maricopa and Pima
49
counties are not included in this Pilot. Offerors should refer to the
"Hospital Reimbursement Pilot Program Packet" for additional information and
requirements.
ALL GSA'S EXCEPT MARICOPA AND PIMA: The Contractor shall reimburse hospitals for
member care in accordance with AHCCCS Rule R9-22-705. The Contractor is
encouraged to obtain contracts with hospitals in all other GSA's and must submit
copies of these contracts to AHCCCSA, Office of Managed Care, at least seven
days prior to the effective dates thereof.
FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor fails to identify lack of medical necessity
through concurrent review and/or prepayment medical review, lack of medical
necessity identified during postpayment medical review shall not constitute a
basis for recoupment by the Contractor. See also Section D, Paragraph 34, Claims
Payment System. For a more complete description of the guidelines for hospital
reimbursement, please consult the Bidder's Library for applicable statutes and
rules.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment The Contractor is responsible
for payment of services while the member is enrolled with the Contractor. The
Contractor is not responsible for the full 90 days of nursing facility coverage
if ALTCS enrollment occurs before the 90 days has ended.
37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, SOBRA supplement, HIV-AIDS supplement,
reinsurance (PPC and prospective), and third party liability, as described and
defined within this contract and appropriate laws, regulations or policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contact provided that the
Contractor's performance is in compliance with the terms and conditions of this
contact Payment must comply with requirements of ABS Title 36. AHCCCSA reserves
the option to
[INTENTIONALLY LEFT BLANK]
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make payments to the Contractor by wire or NACHA transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, any
savings remaining to the Contractor as a result of favorable claims experience
and efficiencies in service delivery at the end of the contract term may be kept
by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in ARS ss.36-2913. An error discovered by the State with or
without an audit in the amount of fees paid to Contractor will be subject to
adjustment or repayment by Contractor making a corresponding decrease in a
current Contractor's payment or by making an additional payment by AHCCCSA to
the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation for newborns of
members who were enrolled at the time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE `98 and CYE `99, AHCCCSA
will offer a reconciliation process for contractors whose total PPC medical cost
experience (excluding administrative and non-operating expenses) is more than
10% higher than the reimbursement associated with PPC (PPC reinsurance and
"retro" portion of PPC capitation excluding administrative add-on). AHCCCSA will
reimburse 100% of a Contractor's excess reasonable costs. AHCCCSA may also
require Contractors to provide documentation to support an audit of the PPC
medical expenses and a reconciliation to audited medical expenses. AHCCCS may
recoup from any Contractor, profit amounts in excess of a 10% limit. Refer to
the Office of Managed Care's PPC Reconciliation Policy for further details of
the reconciliation process.
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PROSPECTIVE CAPITATION: The Contractor will be paid capitation for all
prospective member months, including partial member months. AHCCCSA will make
monthly capitation payments to the Contractor for each member enrolled with the
Contractor on the first of the month as payment in full for any and all covered
services provided to the member. Payment shall be made no later than the fifth
working day of the month for which payment is due. For members enrolled at any
time after the beginning of the month's payment cycle, capitation will be
prorated from the effective date of enrollment through the remainder of the
month of enrollment. These payments will be made by AHCCCS to Contractor on a
weekly basis.
KIDSCARE CAPITATION: The Contractor will be paid capitation for KidsCare members
in the same manner as prospective capitation (see above). KidsCare capitation
rates will be set by AHCCCSA in conjunction with an independent actuary.
Following CYE 99, AHCCCSA will review the assumptions made in setting the
capitation rates and may, at its option, reconcile and/or adjust the rates.
SOBRA SUPPLEMENT: When the Contractor has an enrolled SOBRA woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
SOBRA payment. SOBRA Supplemental payments will not apply to SOBRA women who
deliver in a prior period coverage time period. AHCCCSA reserves the right at
any time during the term of this contract to adjust the amount of this SOBRA
payment for women who deliver at home. The Contractor is responsible for meeting
the newborn notification requirements defined in AHCCCS Rule R9-22-342,
R9-3l-309 and R9-31-707 before this payment will be made to the Contractor.
HIV-AIDS SUPPLEMENT: In addition to the capitation payment described above, a
separate and additional payment will be made to the Contractor to help defray
costs for members receiving approved protease inhibitors and associated lab work
related to their treatment for HIV/AIDS. The list of AHCCCSA-approved protease
inhibitors is available in the Bidder's Library.
On a quarterly basis, the Contractor shall submit to AHCCCSA, Office of Managed
Care, an unduplicated monthly count of members, by rate code, who are using
approved protease inhibitors. The report shall be submitted, along with the
quarterly financial reporting package, within 60 days after the end of each
quarter.
The rate of reimbursement for this separate payment will $634.50 per month and
is subject to review during the term of the contract. Payment will be made
quarterly to the Contractor based on the reported members for the preceding
quarter. AHCCCSA will review this HIV/AIDS-related data at least annually as
part of its Operational and Financial Review and reserves the right to recoup
any amounts paid for ineligible members as determined through this review as
well as an associated penalty for incorrect reporting.
Refer to the Office of Managed Care's HIV/AIDS supplemental payment and review
policies for further details and requirements.
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38. CAPITATION ADJUSTMENTS
Except for changes made specifically in accordance with this contract, the rates
set forth in Section B shall not be subject to re-negotiation or modification
during the contract period. AHCCCSA may, at its option, review the effect of a
program change and determine if a capitation adjustment is needed. In these
instances the adjustment will be prospective with assumptions discussed with the
Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable;
AHCCCSA will not unreasonably withhold such a review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits)
c. duplicate capitation to the same contractor
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503 and R9-31-503). Per
diem rates paid for nursing facility services, including room and board,
provided in lieu of hospitalization for up to 90 days in any contract year shall
be eligible for reinsurance coverage Refer to the AHCCCS Reinsurance Claims
Processing Manual for further details on the Reinsurance Program. Reinsurance
for the Hospital Reimbursement Pilot Program (See Section D, Paragraph 35,
Hospital Reimbursement), will be paid in accordance with AHCCCS Rule R9-22-503
and R9-31-503.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's statewide AHCCCS acute care
enrollment (not including SOBRA Family Planning Extension services as of October
1st each contract year for all rate codes and counties, as shown in the
following table. These deductible levels are subject to change by AHCCCSA during
the term of this contract.
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PROSPECTIVE REINSURANCE PPC REINSURANCE
- --------------------------------------------------------------------------------------------------------------
STATEWIDE PLAN MNMI NON MNMI ALL RATE
ENROLLMENT DEDUCTIBLE DEDUCTIBLE COINSURANCE CODES COINSURANCE
0-19,999 $15,000 $20,000 75% $5,000 100%
20,000-49,999 $15,000 $35,000 75% $5,000 100%
50,000 and over $15,000 $50,000 75% $5,000 100%
- --------------------------------------------------------------------------------------------------------------
A Contractor whose enrollment qualifies for the $35,000 or $50,000 non-MN/MI
deductible level may, prior to the start of the contract period, elect one of
the lower deductible levels indicated in the above table. Contractors may not
elect to increase their deductible level. If a Contractor's actual non-MN/MI
deductible is $35,000 or $50,000, AHCCCSA will increase the Contractor's
capitation rate awarded by defined amounts for each capitation risk group. These
specific capitation adjustments are available from the Office of Managed Care.
PRIOR PERIOD COVERAGE REINSURANCE: For CYE 98 and CYE 99, a separate reinsurance
deductible and coinsurance percentage will apply during prior period coverage.
As noted in the table above, all Contractors, regardless of enrollment, will be
subject to a $5,000 deductible level. The coinsurance percentage for the prior
period coverage reinsurance is 100%. Expenses incurred during prior period
coverage will not apply toward the prospective reinsurance thresholds.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
Effective October 1, 1998, when a member changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs incurred for that
member will follow the member to the receiving health plan. Therefore, all
submitted encounters from the health plan the member is leaving (for dates of
service within the current contract year) will be applied toward the receiving
health plan's deductible level. For further details regarding this policy and
other reinsurance policies refer to the AHCCCS Reinsurance Claims Processing
Manual.
Medical review on prospective and prior period coverage reinsurance cases will
be determined based on statistically valid random sampling. AHCCCSA, Office of
the Medical Director, will generate the sampling and will notify the Contractor
of documentation needed for the retrospective medical review process to occur at
the Contractor's offices. Reinsurance consideration will be given to inpatient
facility contracts, and hearing decisions rendered by the Office of Grievance
and Appeals. Pre-hearing and/or hearing penalties discoverable during the review
process will not be reimbursed under reinsurance. A recoupment of reinsurance
reimbursements made to the Contractor will occur based on the results of the
medical review sampling. The results of the medical review sampling will be
separately extrapolated to the entire prospective and prior period coverage
reinsurance reimbursement populations in the review time frame for the
Contractor. AHCCCSA will give the Contractor at least 45 days advance notice of
any on-site review. The Contractor shall have all requested medical records
on-site. Any
54
documents not requested in advance by AHCCCSA shall be made available upon
request of the Review Team during the course of the review. The Contractor
representative shall be available to the Review Team at all times during AHCCCSA
on-site review activities. While on-site, the Contractor shall provide the
Review Team with work space, access to a telephone, electrical outlets and
privacy for conferences. The Contractor will be furnished a copy of the
Reinsurance Review Report within 60 days of the onsite review and given an
opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia, von Willebrand's Disease, and Gaucher's Disease. This program
also covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver and other
organ transplantation. For additional detail and restrictions refer to the
AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All catastrophic claims are
subject to medical review by AHCCCSA.
The Contractor shall notify AHCCCSA, Office of the Medical Director, Reinsurance
Unit, of cases identified for catastrophic reinsurance coverage within 30 days
of (a) initial diagnosis, (b) enrollment with the Contractor, and (c) the
beginning of each contract year. Catastrophic reinsurance will be paid for a
maximum 30-day retroactive period from the date of notification to AHCCCSA.
HEMOPHILIA: When a member is identified as being catastrophically eligible by
AHCCCSA due to the specific diagnosis of hemophilia (ICD9 codes 286.0, 286.1,
286.2), all medically necessary covered services provided during the contract
year shall be eligible for reimbursement at 85% of the Contractor's paid amount.
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII. The Contractor must promptly notify AHCCCS
Office of the Medical Director Reinsurance Unit after diagnosis. All medically
necessary covered services provided during the contract year shall be eligible
for reimbursement at 85% of the Contractor's paid amount.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy. Refer to the AMPM for additional details and restrictions.
All medically necessary covered services provided during the contract year shall
be eligible for reimbursement at 85% of the Contractor's paid amount.
TRANSPLANTS: Bone grafts, kidney and cornea transplantation services are not
eligible for catastrophic reinsurance coverage but are eligible under the
regular (non-catastrophic) reinsurance program. Refer to the AMPM, Chapter 300
for covered services for organ and tissue transplants. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor's paid
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amount, whichever is lower. The AHCCCS contracted transplantation rates may be
found in the Bidder's Library. When a member is referred to a transplant
facility for an AHCCCS-covered organ transplant, the Contractor shall notify
AHCCCSA, Office of the Medical Director.
Encounter data will not be used to determine catastrophic reinsurance benefits.
However, this does not relieve the Contractor of the responsibility for
submitting encounters for catastrophic reinsurance services. The initial claims
for reimbursement under the catastrophic reinsurance program must be filed no
later than June 30th of the year following the contract year. Catastrophic
reinsurance claims that are submitted within this time limit and are denied or
adjusted, may be corrected until September 30th of the year following the
contract year. All catastrophic reinsurance claims must be submitted in
accordance with the AHCCCS Reinsurance Claims Processing Manual.
40. COORDINATION OF BENEFITS/ THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. See Section D, Paragraph 41, Medicare
Services and Cost Sharing.
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for coinsurance and deductibles is limited
to what the Contractor would have paid for the entire service pursuant to a
written contract with the provider or the AHCCCS fee-for-service rate, less any
amount paid by the third party. (The Contractor must decide whether it is more
cost-effective to provide the service within its network or pay coinsurance and
deductibles for a service outside its network. For continuity of care, the
Contractor may also choose to provide the service within its network.) If the
Contractor refers the member for services to a third-party insurer (other than
Medicare), and the insurer requires payment in advance of all copayments,
coinsurance and deductibles, the Contractor must make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
pre-natal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment
56
with the third-party payer. The Contractor shall also provide medically
necessary transportation so the member can receive third-party benefits.
Further, if a service is medically necessary, the Contractor shall ensure that
its cost avoidance efforts do not prevent a member from receiving such service
and that the member shall not be required to pay any coinsurance or deductibles
for use of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA's authorized representative:
Uninsured/ underinsured motorist insurance Adoption recovery
First and third-party liability insurance Worker's Compensation
Tortfeasors Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-1002 and R9-31-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related costs. AHCCCSA's
authorized representative is also responsible for negotiating and acting in the
best interest of all parties to obtain a reasonable settlement in joint cases
and may compromise a settlement in order to maximize overall reimbursement, net
of legal and other costs. For total plan cases involving only payments from the
Contractor, the Contractor is responsible for performing all research,
investigation, the filing of liens and payment of lien filing fees and other
related costs.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING: The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. The Contractor shall notify AHCCCSA's authorized
representative within five working days of the identification of a third-party
liability case with known reinsurance (often referred to as joint liability
cases). The Contractor shall communicate any known change in health insurance
information, including Medicare, to AHCCCS Administration, Division of Member
Services, not later than 10 days
57
from the date of discovery using the AHCCCS Third-Party Coverage Form found in
the Bidder's Library.
Approximately every four months, AHCCCSA will provide the Contractor with a
complete file of all third-party coverage information (other than Medicare) for
the purpose of updating the Contractor's files. The Contractor shall notify
AHCCCSA of any known changes in coverage within deadlines and in a format
prescribed by AHCCCSA.
TITLE XXI (KIDSCARE): Eligibility for KidsCare benefits requires that the
applicant/member not be enrolled with or entitled to any other health insurance
benefits. If the Contractor becomes aware of any such potential coverage, the
Contractor shall notify AHCCCSA immediately. The Contractor shall follow the
same cost avoidance and postpayment recovery practices for the KidsCare
population as it does for the Title XIX population, and shall maintain a
reporting system which allows Title XIX and KidsCare information to be reported
separately.
41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligible". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
sharing responsibilities that apply to dual eligible members based on a variety
of factors. The Contractor is responsible for adhering to the cost sharing
responsibilities presented in the AHCCCS Medicare Cost Sharing policy. Effective
10/1/97, the Contractor shall have no cost sharing obligation if the Medicare
payment exceeds what the Contractor would have paid for the same service of a
non-Medicare member.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-71l and R9-31-7ll.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or federal government.
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The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
a. If this contract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available
for a period of five years from the date of any such termination.
b. Records which relate to grievances, disputes, litigation or the
settlement of claims arising out of the performance of this contract,
or costs and expenses of this contract to which exception has been
taken by AHCCCSA, shall be retained by the Contractor for a period of
five years after the date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request.
The Contractor is responsible for ensuring that a medical record is established
when information is received about a member. If the PCP has not yet seen the
member, such information may be kept temporarily in an appropriately labeled
file, in lieu of actually establishing a medical record, but must be associated
with the member's medical record as soon as one is established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
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Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (ARS ss.36-6641)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSAs as a result of an accumulated deficit, even if unaudited.
47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
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The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in. the
submitted input data. Neither the State of Arizona nor AHCCCSA shall be
responsible for any incorrect or delayed payment to the Contractor's AHCCCS
services providers (subcontractors) resulting from such error, omission,
deletion, or erroneous input data caused by the Contractor in the submission of
AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
ELECTRONIC DATA INTERCHANGE (EDI): In addition to the requirements outlined in
Section D, Paragraph 34, Claims Payment System, the Contractor will be required
to comply with all EDI standards which result from the Kennedy-Kassebaum
legislation. This law requires the Department of Health and Human Services to
provide national electronic submission standards for health care data and may
include compliance with National Provider Identifier requirements. The Secretary
has 18 months to develop these standards. As the standards are finalized,
AHCCCSA will phase in the implementation. Electronic standards which may be
implemented include, but are not limited to, encounters, enrollment and
capitation payments.
YEAR 2000 COMPLIANCE: The Contractor shall undertake all appropriate technical
planning measures to ensure timely compliance with all Year 2000 automated data
processing requirements.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance measures. The
Contractor shall submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability,
61
including services provided during prior period coverage. This requirement is a
condition of the HCFA grant award.
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA-supplied formats. Formatting and specific
requirements for encounter data are described in the AHCCCS Encounter Reporting
User Manual and the AHCCCS Technical Interface Guidelines, copies of which may
be found in the Bidder's Library. The Encounter Submission Requirements are
included herein as Attachment I.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data which the Contractor shall
use to update its member records. The daily roster which is run prior to the
monthly roster is referred to as the "last daily" and will contain all rate code
changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next mouth. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/97 through 9/30/98. In addition,
AHCCCSA reserves the sole option to extend the term of the contract, not to
exceed a total contracting period of five years. The terms and conditions of any
such contract extension shall remain the same as the original contract, as
amended. Any contract extension, however, shall not affect the maximum
contracting period of five years. All contract extensions shall be through
contract amendment. If, in conjunction with a contract extension, AHCCCSA elects
to increase the capitation rate for any rate code category, such increase will
not exceed the inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA but not in another. In addition, if the
Contractor has bad significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
AHCCCSA may require a contractor to renew all GSAs, or may terminate remaining
GSAs if the Contractor does not agree to renew all GSAs.
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When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses to sign the extension amendment If the Contractor provides such
notification, AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW - If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 120 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See policy on claims processing by
subcontracted providers in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
See also Section D, Paragraph 35, Hospital Reimbursement, regarding required
submission of hospital subcontracts.
The Contractor shall maintain a fully executed original of all subcontracts
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is voidable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of federal and State laws,
regulations and policies.
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The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the
contract year refuses to enter into a written agreement with the
Contractor, the Contractor shall submit documentation of such refusal
to AHCCCS Office of Managed Care within seven days of its final attempt
to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor. See Section D,
Paragraph 35, Hospital Subcontracting and Reimbursement
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and
for which compensation will be paid.
e. The term of the subcontract including beginning and ending dates,
methods of extension, termination and re-negotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and
other third-party liability coverage and to seek such Medicare or
third-party liability payment before submitting claims to the
Contractor/ Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality
assurance programs and comply with the utilization control and review
procedures specified in 42 CFR Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in
ownership of a subcontractor that is related to or affiliated with the
Contractor shall require a contract amendment and prior approval of
AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population.
l. A provision that the subcontractor shall be fully responsible for all
tax obligations, Worker's Compensation Insurance, and all other
applicable insurance coverage obligations which arise under this
subcontract, for itself and its employees, and that
64
AHCCCSA shall have no responsibility or liability for any such taxes or
insurance coverage.
m. A provision that the subcontractor must obtain any necessary
authorization from the Contractor or AHCCCSA for services provided to
eligible and/or enrolled members.
n. A provision that the subcontractor must comply with encounter reporting
and claims submission requirements as described in the subcontract.
52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over and supersede existing and future subcontracts for services
that are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement for
transplant surgery exceed that payable under the relevant AHCCCSA specialty
contract.
During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
AHCCCSA shall provide at least 60 days advance written notice to the Contractor
prior to the implementation of any specialty contract.
53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement AHCCCSA reserves the right to perform
a thorough review of actual management fees charged and/or corporate allocations
made. If the fees or allocations actually paid out are determined to be
unjustified or excessive, amounts may be subject to repayment to the Contractor,
the Contractor may be placed on monthly financial reporting, and/or financial
sanctions may be imposed.
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are
65
less than $50,000, AHCCCSA will waive the requirement for an audit of that
consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award. Minimum capitalization requirements by GSA are as follows:
----------------------------------------------------------------------
GEOGRAPHIC SERVICE AREA CAPITALIZATION REQUIREMENT
GSA #2 Yuma $ 1,400,000
GSA #4 Mohave, La Paz 1,150,000
GSA #6 Yavapai, Coconino 1,250,000
GSA #8 Pinal, Gila 1,450,000
GSA #10 Pima 1,250,000
GSA #12 Maricopa 2,500,000
GSA #14 Graham, Greenlee 350,000
GSA #16 Apache, Navajo 650,000
GSA #18 Cochise, Santa Cruz 1,450,000
----------------------------------------------------------------------
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSAs, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSAs awarded. This requirement is in addition to the
Performance Bond requirements defined in Paragraphs 56 and 57 below and must be
met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above). Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash
66
deposit ("Performance Bond") to AHCCCSA for as long as the Contractor has
AHCCCS-related liabilities of $50,000 or more outstanding, or 15 months
following the effective date of this contract, whichever is later, to guarantee:
(1) payment of the Contractor's obligations to providers, non-contracting
providers, and non-providers; and (2) performance by the Contractor of its
obligations under this contract. The Performance Bond shall be in a form
acceptable to AHCCCSA as described in the AHCCCS Performance Bond policy
available in the Office of Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers
and nonproviders by reason of a breach of the Contractor's obligations
under this contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses
incurred by reason of a breach of the Contractor's obligations under
this contract, including, but not limited to, expenses incurred after
termination of this contract for reasons other than the convenience of
the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above. The Contractor may not change
the amount, duration or scope of the performance bond without prior written
approval from AHCCCSA, Office of Managed Care.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October, 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement must be satisfied by the Contractor not
later than 15 days after notification by AHCCCSA of the amount required.
Thereafter, AHCCCSA shall evaluate the enrollment statistics of the Contractor
on a monthly basis. If there is an increase in capitation payment that exceeds
10% of the performance bond amount, AHCCCSA may require an increase in the
amount of the Performance Bond. The Contractor shall have 15 days following
notification by AHCCCSA to increase the amount of the Performance Bond. The
Performance Bond amount that must be
67
maintained after the contract term shall be sufficient to cover all outstanding
liabilities and will be determined by AHCCCSA. The Contractor may not change the
amount of the performance bond without prior written approval from AHCCCSA,
Office of Managed Care.
58. FINANCIAL VIABILITY CRITERIA/ PERFORMANCE MEASURES
AHCCCSA has established the following financial viability criteria/performance
goals:
CURRENT RATIO Current assets divided by current
liabilities. "Current assets"
includes any long-term investments
that can be converted to cash within
24 hours without significant penalty
(i.e., greater than 20%).
STANDARD: AT LEAST 1.00
EQUITY PER MEMBER Equity, less on-balance sheet
performance bond, divided by the
number of non-SOBRA Family Planning
Extension Services members enrolled
at the end of the period.
STANDARD: AT LEAST $150
(Failure to meet this standard may
result in an enrollment cap being
imposed in any or all contracted
GSAs.)
MEDICAL EXPENSE RATIO Total medical expenses (net of
reinsurance, TPL, HIV/AIDS
Supplement) divided by total
capitation + SOBRA
STANDARD: 85-90%
ADMINISTRATIVE COST PERCENTAGE Total administrative expenses
(excluding income taxes), divided
by total capitation + SOBRA +
TPL + reinsurance + HIV/AIDS
Supplement.
STANDARD: NO MORE THAN 10%
RECEIVED BUT UNPAID CLAIMS Received but unpaid claims
(DAYS OUTSTANDING) divided by the average daily
medical expenses for the period,
net of sub-capitation expense
STANDARD: NO MORE THAN 30 DAYS
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor must submit a detailed merger, reorganization and/or
transition plan to AHCCCSA Contracting Office for AHCCCSA review. The purpose of
the plan review is to ensure uninterrupted services to members, evaluate the new
entity's ability to support the provider network, ensure that services to
members are not diminished and that major components of the organization and
68
AHCCCS programs are not adversely affected by such merger, reorganization or
change in ownership.
60. SANCTIONS
AHCCCSA may suspend, deny, refuse to renew, or terminate this contract or any
related subcontracts in accordance with AHCCCS Rules R9-22-405 and R9-31-405 and
the terms of this contract and applicable law and regulations. AHCCCSA may, in
addition to these remedies, impose monetary sanctions if the Contractor violates
any provision stated in law or this contract in accordance with AHCCCS Rules
R9-22-406 and R9-31-406 and the provisions of this contract, applicable law and
regulations. Written notice will be provided to the Contractor specifying the
sanction to be imposed, the grounds for such sanction and either the length of
suspension or the amount of capitation prepayment to be withheld. The Contractor
may appeal the decision to impose a sanction in accordance with AHCCCS Rule
R9-22-804.
In addition to the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS financial viability standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
e. Failure to meet AHCCCS encounter standards
CURE NOTICE PROCESS - Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
REDISTRIBUTION OF SANCTION DOLLARS: Monetary sanctions held by AHCCCSA may be
redistributed to participating acute care contractors based on criteria
described in the "AHCCCSA Special Performance Awards Policy", a copy of which
may be found in the Bidder's Library.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right, are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals. The algorithm favors those
contractors with lower capitation rates. For further details on the AHCCCS
Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any
69
time during the term of the contract and frequently does so in response to
contractor-specific issues of non-compliance (e.g. imposition of an enrollment
cap). The Contractor should consider this in preparing its response to this RFP.
AHCCCSA is not obligated to adjust for any financial impacts this may have on
the Contractor.
62. GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22-802; R9-31-802; R9-22-804 and R9-31-803.
The grievance process may not be delegated or subcontracted outside of the
health plan. Refer to Attachment H for a complete description of grievance
process requirements.
63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Grievance and Appeals, using the Quarterly Grievance Report Format on file in
the Bidder's Library. The Quarterly Grievance Report must be received by the
AHCCCSA, Office of Grievance and Appeals, no later than 45 days from the end of
the quarter.
64. KIDSCARE
In May, 1998, the Arizona legislature approved Senate Bill 1008 authorizing the
implementation of a Title XXI Children's Health Insurance Program, now referred
to in Arizona as "KidsCare". KidsCare provides health care coverage statewide to
eligible children 18 and younger and will be provided through the existing
AHCCCS health plans, state employee HMOs that elect to participate, and tribal
facilities or Indian Health Service for Native Americans who elect to receive
services through them. Services will also be directly provided by participating
community health clinics and hospitals which predominantly serve low income
children.
The KidsCare service package will generally include all services provided to
state employees by the least expensive commercial HMO. Those services,
limitations and exclusions are described in Section D, Paragraph 1, Scope of
Services. Capitation rates payable to the Contractor for KidsCare members (age
18 and younger) will be set by AHCCCSA in conjunction with an independent
actuary.
TITLE XXI PARENT/GUARDIAN HEALTH INSURANCE COVERAGE: Title XXI legislation, ARS
ss.36.2984, mandates that the Contractor offer health insurance coverage to the
parent(s) or legal guardian(s) of a child who is eligible for Title XXI. The
Contractor shall establish rates for this coverage which must be approved by
AHCCCSA, Office of Managed Care, prior to implementation. Title XXI funds or any
other federal or state funds shall not be used to subsidize family coverage. The
full cost of the premium shall be paid by the parent or legal guardian who
elects this coverage. The Contractor may include provisions for pre-existing
conditions and any other medical underwriting considerations that are necessary
to protect it from adverse risk. For further
70
information, refer to the Title XXI Parent/Guardian Health Insurance Coverage
Guidelines on file in the Bidder's Library.
65. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that could have an impact on services provided by the
Contractor on or after October 1, 1998. The following is a brief description of
the issues that AHCCCS is aware of at the time of the issuance of this renewal
amendment:
ELIGIBILITY BASED ON 100% OF THE FEDERAL POVERTY LEVEL (FPL): Through a
successful initiative effort, eligibility for AHCCCS has been expanded to allow
persons with income up to 100% of the FPL to become eligible for the Medicaid
program. Legislative action will be required to implement this new eligibility
guideline and HCFA must approve the expansion. If HCFA approval is granted,
there will be a significant number of new persons who will be eligible for the
program and enrolled with the health plans at some future date.
[END OF SECTION D]
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SECTION E: CONTRACT CLAUSES
[Only two paragraphs from Section E have been revised. They are shown below with
changes indicated:]
17. SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from federal procurement activity.
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
19. TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
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ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
REPORT WHEN DUE SOURCE/REFERENCE AHCCCS CONTACT:
- ---------------------------------------------------------------------------------------------------------------------
Monthly Financial Report 45 days after the end of Reporting Guide Financial Manager
the month, as applicable
Quarterly Financial Report 60 days after the end of each Reporting Guide Financial Manager
quarter
FQHC Supplemental Payment 60 days after the end of each Reporting Guide Financial Manager
quarter
HIV\AIDS Approved Protease 60 days after the end of each Reporting Guide Financial Manager
Inhibitor Reimbursement quarter
Draft Annual Audit 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Draft Management Letter 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Final Annual Audit Report 120 days after the end of each Reporting Guide Financial Manager
fiscal year
Final Management Letter 120 days after the end of each Reporting Guide Financial Manager
fiscal year
Accountant's Report on 120 days after the end of each Reporting Guide Financial Manager
Compliance fiscal year
Reconciliation - Annual 120 days after the end of each Reporting Guide Financial Manager
Audit and Plan fiscal year
Year-to-Date Financial
Report Information
Financial Disclosure Report 120 days after the end of each Reporting Guide Financial Manager
fiscal year
Annual Analysis of 120 days after the end of each Reporting Guide Financial Manager
Profitability by Major fiscal year
Rate Code (by County)
Provider Affiliation Tape 10 business days after the PMMIS Provider-to-Health Health Plan Operations
beginning of each quarter Plan magnetic tape Manager
submission and processing
Monthly Title XIX and 30 days after the end of each Instructions on form Behavioral Health
Title XXI Behavioral month Manager
Health Activity Report
Encounter Data - Magnetic Monthly, according to Encounter Manual Encounter Administrator
Tape Submission established schedule
Corrected Pended Encounter Monthly, according to Encounter Manual Encounter Administrator
Tape established schedule
____ Day Tape Monthly, according to Encounter Manual Encounter Administrator
established schedule
Medical Records for 6 weeks after the request RFP, Section C, Data Validation
Data Validation received from AHCCCSA 90 days Paragraph 1 Manager
to submit the requested data
to AHCCCSA
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REPORT WHEN DUE SOURCE/REFERENCE AHCCCS CONTACT:
- ---------------------------------------------------------------------------------------------------------------------
Quarterly Grievance Report 45 days after the end of each RFP, Section D, Paragraph Administrative Assistant
quarter 26
Comprehensive Dental Plan Annually on November 1 RFP, Section D, Paragraph Acute Care Program
16 Manager
EPSDT Progress Report - 15 days after the end of each AMPM, Chapter 400 Acute Care Program
Quarterly Update quarter Manager
Quarterly Inpatient 15 days after the end of each State Medicaid Manual Acute Care Program
Hospital Showing quarter and the AMPM, Chapter 400 Manager
Quality Annually on November 15th AMPM, Chapter 400 Acute Care Program
Management/Utilization Manager
Management Plan Evaluation
and Revision
AIDS/HIV Reports 90 days after the end of each AMPM, Chapter 400 Acute Care Program
contract year Manager
Acute Pharmacy Report 90 days within 90 days of the AMPM, Chapter 400 Acute Care Program
end of each quarter Manager
Monthly Pregnancy End of the month following the AMPM, Chapter 400 Acute Care Program
Termination Report pregnancy termination Manager
Maternity Care Plan Annually on November 1st AMPM, Chapter 400 Acute Care Program
Manager
Clinical Study Proposal Annually on November 15th AMPM, Chapter 400 Acute Care Program
Manager
Clinical Study Results Annually within 90 days AMPM, Chapter 400 Acute Care Program
following the end of each Manager
contract year
Provider Fraud/Abuse Report Immediately following discovery AHCCCS Internal Office of Managed Care:
Audit/Program Member Fraud
Investigation Policy for Investigations Unit
Prevention, Detection and
Reporting of Fraud and
Abuse
Eligible Person Immediately following discovery AHCCCS Internal Office of Managed Care:
Fraud/Abuse Report Audit/Program Member Fraud
Investigation Policy for Investigations Unit
Prevention, Detection and
Reporting of Fraud and
Abuse
74
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed sanctions for noncompliance with encounter
submission requirements. AHCCCSA may also perform special reviews of encounter
data, such as comparing encounter reports to the Contractor's claims files. Any
findings of incomplete or inaccurate encounter data may result in the imposition
of sanctions or requirement of a corrective action plan.
Pended Encounter Corrections
The Contractor must resolve all pended encounters within 100 days of the
original processing data. A sanction of $5.00 each month will be imposed for
each encounter pended for more than 100 days unless the pend is due to AHCCCSA
error. "AHCCCSA error" is defined as a pended encounter which (1) AHCCCSA
acknowledges to be the result of its own error, and (2) requires a change to the
system programming, an update to the database reference table, or further
research by AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA in writing that the resolution of a pended
encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will respond in
writing within 30 days of receipt of such notification. The AHCCCSA response
will report the status of each pending encounter problem or issue in question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor in writing of the
total number of encounters pended more than 100 days and the number of such
encounters not subject to sanction because of AHCCCSA error.
Pended encounters shall not be deleted by the Contractor as a means of avoiding
sanctions for failure to correct encounters within 100 days. The Contractor
shall document deleted encounters and shall maintain a record of the deleted
CRNs with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCSA for review.
Encounter Validation Studies
Per HCFA requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's submitted encounter data. Any and
all covered services may be validated as part of these studies. Encounter
validation studies will be conducted at least yearly.
75
The following reflects AHCCCSA's encounter validation study process and sanction
policy as of 10/1/97. AHCCCSA may revise study methodology, timelines, and
sanction amounts based on agency review or as a result of consultations with
HCFA. The Contractor will be notified in writing of any significant change in
study methodology.
AHCCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to AHCCCSA. In the case of medical records
requests, the Contractor's failure to provide AHCCCSA with the records requested
within 90 days may result in a sanction of $1,000 per missing medical record. If
AHCCCSA does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor
may be sanctioned up to 5% of its annual capitation payment.
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date
that the encounter is received at AHCCCS. All encounters must be
received by AHCCCSA no later than 240 days after the end of the month
in which the service was rendered, or the effective date of enrollment
with the Contractor, whichever is later. For all encounters for which
timeliness is evaluated, a sanction per encounter error extrapolated to
the population of encounters may be assessed if the encounter record is
received by AHCCCSA more than 240 days after the date determined above.
It is anticipated that the sanction amount will be $1.00 per error
extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has
changed, or if HCFA changes sanction requirements. The Contractor will
be notified of the sanction amount in effect for the studies at the
time the studies begin.
Correctness: A correct encounter contains a complete and accurate
description of AHCCCS covered services provided to a member. A sanction
per encounter error extrapolated to the population of encounters may be
assessed if the encounter is incomplete or incorrectly coded. It is
anticipated that the sanction amount will be $1.00 per error
extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has
changed, or if HCFA changes sanction requirements. The Contractor will
be notified of the sanction amount in effect for the studies at the
time the studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA's pending encounter file or
historical files in lieu of correction of such record. For Study "A"
and for Study "B", a sanction per encounter error extrapolated to the
population of encounters may be assessed for an
76
omission. It is anticipated that the sanction amount will be $5.00 per
error extrapolated to the population of encounters for Study "A" and
$10.00 per error extrapolated to the population of encounters for Study
"B"; however, sanction amounts may be adjusted if AHCCCSA determines
that encounter quality has changed, or if HCFA changes sanction
requirements. The Contractor will be notified of the sanction amount in
effect for the studies at the time the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors found by the number of encounters reviewed. A 95% confidence interval
will be used to account for limitations caused by sampling. The confidence
interval shows the range within which the true error rate is estimated to be. If
error rates are based on a sample, the error rate used for sanction purposes
will be the lower limit of the confidence interval.
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to HCFA, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance pursuant to Article 8 of AHCCCS Rules.
Sanction amounts will be deducted from the Contractor's capitation payment.
77
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
Page 1 of 2
- -------------------------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
7 YH8-0001-05 January 1, 1999 ACUTE
- -------------------------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
Pat Levin, President
Health Choice Arizona
1600 W. Broadway, Ste 260
Tempe, AZ 85282-1502
- -------------------------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: To adjust capitation rates effective Jan. 1, 1999.
- -------------------------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
Effective January 1, 1999, compensation for TANF <1 year olds, TANF 14-44 Females, and SOBRA
Supplemental payments will be paid in accordance with the rates shown on the following page.
NOTE. Please sign, date and return both originals to: Mark Renshaw
AHCCCS Contracts and Purchasing
701 E. Jefferson
Phoenix, AZ 85034
- -------------------------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT REMAIN UNCHANGED
AND IN FULL EFFECT.
- -------------------------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING OFFICER:
/s/ Pat Levin /s/ Michael Veit
- -------------------------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
PAT LEVIN MICHAEL VEIT
- -------------------------------------------------------------------------------------------------
TITLE: TITLE:
PRESIDENT CONTRACTS & PURCHASING
ADMINISTRATOR
- -------------------------------------------------------------------------------------------------
DATE: 1/4/99 DATE: JAN 11 1999
- -------------------------------------------------------------------------------------------------
Page 2 of 2
HEALTH CHOICE ARIZONA
The new capitation rates effective 1/1/99 are as follows:
TANF TANF SOBRA
GEOGRAPHIC SERVICE AREA <1, M/F 14-44,F KICK
- ----------------------- ------- ------- ---------
GSA #10 (Pima):
Prospective: $309.00 $161.86 $4,237.07
GSA #12 (Maricopa):
Prospective: $325.07 $169.26 $4,434.78
PMPM amounts are based on a $35,000/$15,000 (MN/MI) reinsurance deductible level
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT MODIFICATION
Page 1 of 2
1. AMENDMENT NO.: 2. CONTRACT NO.: 3. EFFECTIVE DATE OF MODIFICATION: 4. PROGRAM:
- ----------------- ---------------- ---------------------------------- -----------
08 YH8-0001-05 Upon last signature below OMC
- -----------------------------------------------------------------------------------------
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
Health Choice AZ
1600 W. Broadway Suite 260
TEMPE AZ 85282-1502
- --------------------------------------------------------------------------------
6. PURPOSE: To revise the method of compensation related to reconciliation
of PPC Costs to Reimbursement, and to revise the PMPM Prior Period
capitation.
- --------------------------------------------------------------------------------
7. The above referenced contract is hereby modified as follows:
A. In Section D on page 40 of the October 1, 1998 revision of the contract
the paragraph entitled "Reconciliation of PPC Costs to Reimbursement"
is changed as follows:
Continued on next page.
NOTE: Please sign, date and return both originals to: Doug Peeples
AHCCCS Contracts and
Purchasing
701 E. Jefferson,
Phoenix, AZ 85034
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN
FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.
- --------------------------------------------------------------------------------
9. NAME OF CONTRACTOR PROVIDER: 10. ARIZONA HEALTH CARE COST
CONTAINMENT SYSTEM
Health Choice AZ
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
/s/ Pat Levin /s/ Michael Veit
- ----------------------------------- -----------------------------------
TYPED NAME: PAT LEVIN TYPED NAME: MICHAEL VEIT
----------------------- ---------------------
TITLE: PRESIDENT TITLE: CONTRACTS AND PURCHASING
-------------------------- ADMINISTRATOR
-------------------------
DATE 5/14/99 DATE: MAY 03, 1999
----------------------------- --------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT MODIFICATION
Page 2 of 2
1. AMENDMENT NO.:08 2. CONTRACT NO.: YH8-000l-05
Replace with:
For CYE `98 and CYE `99, AHCCCSA will offer a reconciliation process
for contractors whose total PPC medical cost experience (excluding
administrative and non-operating expenses) is more than 10% higher than
the reimbursement associated with PPC in two areas: the "retro" portion
of the capitation rate for all rate categories, and the prospective
three-day notification period for MNMI recipients only. Expenses for
the retro period only will be net of reinsurance.
AHCCCSA will reimburse 100% of a Contractor's excess reasonable costs
as determined by reported encounters. AHCCCS may recoup from any.
Contractor, profit amounts in excess of a 10% limit. Refer to the
Office of Managed Care's PPC Reconciliation Policy for further
details of the reconciliation process. AHCCCSA reserves the right to
extend the reconciliation process into future contract years. AHCCCSA
also reserves the right to adjust the risk-sharing arrangements in
future years.
B. Effective 10/1/98 the Contractor will be paid prospective and prior
period capitation in accordance with the rates shown in the following
table:
Maricopa $11,892.16
Pima $16,841.57
Santa Cruz $14,686.07
Yavapai $16,841.57
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
===================================================================================================================================
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
09 YH8-0001-05 OCTOBER 1, 1999 OMC
===================================================================================================================================
CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE AZ
1600 W. BROADWAY SUITE 260
TEMPE AZ 85282-1502
===================================================================================================================================
PURPOSE OF AMENDMENT: To extend the term of the contract for one year and to amend Sections C, D and Attachments B, F and H.
===================================================================================================================================
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. EXTENSION OF CONTRACT: In accordance with Section D, Paragraph
50, Term of Contract and Option to Renew, this contract is
extended for the period 10/1/99 - 9/30/00. The Contractor's
response affirming or declining the extension must be received by
AHCCCSA no later than 3:00 PM MST, September 17, 1999.
B. CONTRACT RESTATEMENT: This amendment consists of a complete
restatement of Sections B, C, D and Attachments B, F, and H. No
changes were made to Section E and Attachment A, which are
provided for your information.
C. By signing this contract amendment, the Contractor is (1)
agreeing to perform for an additional year according to the terms
of the contract as amended, and (2) agreeing to the new and
changed requirements contained herein.
NOTE: Please sign, date both and return one to: Doug Peeples, MD 5700
AHCCCS Contracts and Purchasing
701 E Jefferson Street
Phoenix AZ 85034
===================================================================================================================================
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN
UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
===================================================================================================================================
Signature of Health Choice AZ Authorized Representative: Signature of AHCCCSA Contracting Officer:
/s/ Pat Levin /s/ Michael Veit
===================================================================================================================================
Typed Name: PAT LEVIN Typed Name: MICHAEL VEIT
===================================================================================================================================
Title: PRESIDENT Title: CONTRACTS & PURCHASING
ADMINISTRATOR
===================================================================================================================================
Date: DATE:
9/24/99 AUGUST 25, 1999
===================================================================================================================================
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
===================================================================================================================================
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
10 YH8-0001-05 OCTOBER 1, 1999 OMC
===================================================================================================================================
CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE AZ
1600 W. BROADWAY SUITE 260
TEMPE AZ 85282-1136
===================================================================================================================================
PURPOSE OF AMENDMENT: To adjust capitation rates effective October 1, 1999.
===================================================================================================================================
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
CAPITATION RATES: The Contractor shall provide services as described in this
contract. In consideration for these services, the Contractor will be paid as
shown below for the term October 1, 1999 through September 3, 2000 (CYR 00).
CAPITATION RATES
(Per member per month)
See attached table for the Contractor's rates
NOTE: Please sign, date both and return one to: Doug Peeples, MD 5700
AHCCCS Contracts and Purchasing
701 E Jefferson Street
Phoenix AZ 85034
===================================================================================================================================
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN
UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
===================================================================================================================================
Signature of Health Choice AZ Authorized Representative: Signature of AHCCCSA Contracting Officer:
/s/ Pat Levin /s/ Michael Veit
===================================================================================================================================
Typed Name: PAT LEVIN Typed Name: MICHAEL VEIT
===================================================================================================================================
Title: PRESIDENT Title: CONTRACTS & PURCHASING
ADMINISTRATOR
===================================================================================================================================
Date: 9/8/99 Date: SEPTEMBER 1, 1999
===================================================================================================================================
HEALTH CHOICE ARIZONA
The new capitation rates effective 10/1/99 are as follows:
TANF TANF TANF TANF TANF SSI SSI
GEOGRAPHIC SERVICE AREA <1, M/F 1-13, /F 14-44, F 14-44, M 45+, M/F W/MED W/O MED
- ----------------------- -------- -------- -------- -------- -------- -------- --------
GSA #10 (Pima):
Prospective: $ 309.42 $ 62.36 $ 108.53 $ 88.76 $ 209.96 $ 139.08 $ 328.27
PPC: $1164.82 $ 32.70 $ 136.50 $ 76.91 $ 180.25 $ 14.50 $ 61.79
Kids Care: $ 270.86 $ 70.17 $ 135.29 $ 80.71 N/A N/A N/A
GSA #12 (Maricopa:)
Prospective: $ 325.49 $ 64.40 $ 98.84 $ 91.64 $ 223.13 $ 153.93 $ 324.90
PPC: $1164.82 $ 32.70 $ 136.50 $ 76.91 $ 180.25 $ 14.50 $ 61.79
Kids Care: $ 281.83 $ 72.23 $ 140.17 $ 81.01 N/A N/A N/A
DELIVERY
MN/MI SFP KICK
-------- -------- ---------
GSA #10 (Pima):
Prospective: $ 419.84 $ 18.84 $4,929.51
PPC: $ 581.32 N/A N/A
Kids Care: N/A N/A $4,929.51
GSA #12 (Maricopa:)
Prospective: $ 516.44 $ 19.68 $5,241.86
PPC: $ 410.48 N/A N/A
Kids Care: N/A N/A $5,241.81
PMPM amounts are based on a $35,000/$15,000 (MN/MI) reinsurance deductible
level. PPC MN/MI rate is a daily rate.
ADDITIONAL REIMBURSEMENT
For the contract term October 1, 1999 through September 30, 2000, the
Contractor will be paid an HIV/AIDS supplemental payment of $634.50 PMPM for
members receiving approved protease inhibitors and associated lab work related
to their treatment for HIV/AIDS.
SECTION B - CAPITATION RATES
The Contractor shall provide services as described in this contract. In
consideration for these services, the Contractor will be paid as shown below
for the term October 1, 1999 through September 30, 2000 (CYE 00).
CAPITATION RATES
(per member per month)
Capitation rates specific to contractor
SECTION C: DEFINITIONS
ADHS Arizona Department of Health Services.
AGENT Any person who has been delegated the authority to
obligate or act on behalf of another person or
entity.
AHCCCS Arizona Health Care Cost Containment System as
defined by ARS ss.36-2901, et seq.
AHCCCS BENEFITS See "COVERED SERVICES".
AHCCCS MEMBER See "MEMBER".
AHCCCSA Arizona Health Care Cost Containment System
Administration.
ALTCS The Arizona Long Term Care System (ALTCS), a
program under AHCCCSA that delivers long term,
acute, behavioral health and case management
services to members, as authorized by ARS ss.
36-2931 et seq.
AMBULATORY Preventive, diagnostic and treatment services
CARE provided on an outpatient basis by physicians,
nurse practitioners, physician assistants and other
health care providers.
AMPM AHCCCS Medical Policy Manual.
ARIZONA State regulations established pursuant to relevant
ADMINISTRATIVE statutes. For purposes of this solicitation, the
CODE (AAC) relevant sections of the AAC referred to throughout
this document as "AHCCCS Rules".
ARS Arizona Revised Statutes.
AT RISK Refers to the period of time that a member is
enrolled with a contractor during which time the
Contractor is responsible to provide AHCCCS covered
services under capitation.
BIDDERS A repository of manuals, statutes, rules
LIBRARY and other reference material located at the AHCCCS
office in Phoenix.
BOARD An individual who has successfully completed all
CERTIFIED prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
CAPITATION Payment to contractor by AHCCCSA as authorized
under ARS ss.36-2942 and ss.36-2931 of a fixed
monthly payment per person in advance for which the
contractor provides a full range of covered
services.
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider of service
or from a third party; but does not include claims
under investigation for fraud or abuse or claims
under review for medical necessity.
COMPETITIVE A state procurement system used to select
BID PROCESS contractors to provide covered services on a
geographic basis.
CONTINUING An AHCCCS contractor during CYE 97 that submits a
OFFEROR proposal pursuant to this solicitation.
CONTRACT See "COVERED SERVICES".
SERVICES
CONTRACT YEAR Corresponds to federal fiscal year (Oct. 1 through
(CY) Sept. 30). For example, Contract Year 99 is 10/1/98
- 9/30/99.
Acute Care Renewal
Revised 10/1/99
3
CONTRACTOR A person, organization or entity agreeing through a
direct contracting relationship with AHCCCSA to
provide the goods and services specified by this
contract in conformance with the stated contract
requirements, AHCCCS statute and rules and federal
law and regulations.
CONVICTED A judgment of conviction has been entered by a
federal, state or local court, regardless of
whether an appeal from that judgment is pending.
CO-PAYMENT A monetary amount specified by the Director that
the member pays directly to a contractor or
provider at the time covered services are rendered.
COUNTY Amount of funds contributed to the AHCCCSA fund by
CONTRIBUTION each Arizona county based on funding formulas
established by law.
COVERED Health care services to be delivered by a
SERVICES contractor which are designated in Section D of
this contract and also AHCCCS Rules R9-22-202 et
seq. and R9-3 1-201 et seq.
CRS Children's Rehabilitative Services.
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified.
DIRECTOR The Director of AHCCCSA.
DISCLOSING An AHCCCS provider or a fiscal agent.
ENTITY
DME Durable Medical Equipment, which is an item, or
appliance that can withstand repeated use, is
designated to serve a medical purpose, and is not
generally useful to a person in the absence of a
medical condition, illness or injury.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
EAC Eligible Assistance Child as defined in ARS ss.
36-2905.03(B); an AHCCCS state program for children
under age 14 receiving food stamps.
ELIC Eligible Low-Income Child as defined in ARS ss.
36-2905.05(C) and (D); an AHCCCS state program for
children under age 14 whose household income
exceeds the income limit for the MN/MI program but
is less than 100% of the federal poverty level.
ELIGIBILITY A process of determining, through a written
DETERMINATION application, including required documentation,
whether an applicant meets the qualifications for
Title XIX, Title XXI and/or state-only eligibility.
ELIGIBLE A person who meets all eligibility
PERSON requirements for the AHCCCS acute care program but
who has not yet been enrolled with an AHCCCS acute
care contractor.
EMERGENCY A medical condition manifesting itself by acute
MEDICAL symptoms of sufficient severity (including severe
CONDITION pain) such that a prudent layperson, who possesses
an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in: a) placing the patient's
health in serious jeopardy; b) serious impairment
to bodily functions; or c) serious dysfunction of
any bodily organ or part. (42 USC 13960-2)
EMERGENCY Services provided after the sudden onset of a
MEDICAL medical condition manifesting itself by acute
SERVICE symptoms of sufficient severity (including severe
pain) that the absence of immediate medical
attention could reasonably be expected to result in:
a) placing the patient's health in serious jeopardy;
b) serious impairment to bodily functions; or c)
serious dysfunction of any bodily organ or part.
Acute Care Renewal
Revised 10/1/99
4
ENCOUNTER A record of a medically related service rendered by
a provider or providers registered with AHCCCSA to a
member who is enrolled with a contractor on the date
of service. It includes all services for which the
contractor incurred any financial liability.
ENROLLMENT The process by which an eligible person becomes a
member of a contractor's health plan.
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; services for persons under 21 years of
age as described in AHCCCS rules R9-22, Article 2.
FAMILY PLANNING
SERVICES A program that provides family planning services
EXTENSION only for a maximum of 24 months to women whose
PROGRAM SOBRA eligibility has terminated.
FEDERALLY An entity which meets the requirements and receives
QUALIFIED a grant and funding pursuant to Section 330 of
HEALTH CENTER the Public Health Service Act. An FQHC includes
(FQHC) an outpatient health program or facility operated
by a tribe or tribal organization under the Indian
Self-Determination Act (PL 93-638) or an urban
Indian organization receiving funds under Title V
of the Indian Health Care Improvement Act.
FEE-FOR- A method of payment to registered providers on an
SERVICE (FFS) amount-per service basis.
FFP Federal financial participation (FFP) refers to the
contribution that the federal government makes to
the Title XIX and Title XXI program portions of
AHCCCS as defined in 42 CFR 400.203.
FISCAL YEAR The budget year - Federal Fiscal Year: October 1
(FY) through September 30; State fiscal year: July 1
through June 30.
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered and who makes
referrals as necessary and monitors the member's
treatment.
GEOGRAPHIC A specific county or defined grouping of counties
SERVICE designated by the Administration within which a
AREA (GSA) contractor of record provides, directly or through
subcontract, covered health care to members enrolled
with that contractor of record
GROUP OF Two or more health care professionals who practice
PROVIDERS their profession at a common location (whether or
not they share facilities, supporting staff, or
equipment).
HCFA Health Care Financing Administration, an
organization within the Department of Health and
Human Services, which administers the Medicare and
Medicaid, programs.
HEALTH Various forms of plan organization, including staff
MAINTENANCE and group models, that meet the HMO licensing
ORGANIZATION requirements of the federal and/or state government
(HMO) and offer a full array of health care services to
members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported claims which is the
liability for services rendered for which claims
have not been received.
IHS Indian Health Service.
LIEN A legal claim filed with the County Recorder's
office in which a member resides and in the county
an injury was sustained for the purpose of ensuring
that AHCCCS receives reimbursement for medical
services paid. The lien is attached to any
settlement the member may receive as a result of an
injury.
Acute Care Renewal
Revised 10/1/99
5
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by
means of arrangements with selected providers to
furnish comprehensive services to members;
establish explicit criteria for the selection of
health care providers; have significant financial
incentives for members to use providers and
procedures associated with the plan; and have
formal programs for quality assurance and
utilization review.
MANAGEMENT A person or organization that agrees to perform any
SERVICES administrative function or service for the Contractor
SUBCONTRACTOR specifically related to securing or fulfilling the
Contractor's obligations to AHCCCSA under the terms
of the contract.
MANAGING A general manager, business manager, administrator,
EMPLOYEE director, or other individual who exercises
operational or managerial control over, or who
directly or indirectly conducts the day-to-day
operation of, an institution, organization or
agency.
MATERIAL A fact, data or other information excluded
OMISSION from a report, contract, etc. the absence of which
could lead to erroneous conclusions following
reasonable review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended, which provides
federal matching funds for a medical assistance
program for recipients.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEMBER For this document, a person eligible for AHCCCS who
is enrolled with a Contractor.
MN/MI Medically Needy/Medically Indigent; state program
for individuals not eligible for Medicaid but who
meet the eligibility requirements for the state
program.
NEW OFFEROR The organization, entity or person which submits
a proposal in response to this solicitation
and which has not been an AHCCCS contractor during
CYE 97.
NON- A person who provides services as prescribed in ARS
CONTRACTING ss.36-2939 and who does not have a subcontract
PROVIDER with an AHCCCS contractor.
OFFEROR A person or other entity that submits a proposal to
the Administration in response to an REP.
PERFORMANCE MEASURES A set of standardized indicators designed to assist
AHCCCS in evaluating, comparing and improving the
performance of its contractors. Specific
descriptions of health services measurement goals
are found in Section D, Paragraph 16, Performance
Measures.
PMMIS Pre-paid Medical Management Information System.
PRIMARY CARE An individual who meets the requirements of
PROVIDER (PCP) ARS ss.36-2901, and who is responsible for (PCP) the
management of a member's health care. A PCP may be
a physician defined as a person licensed as
allopathic or osteopathic physician according to
ARS Title 32, Chapter 13 or Chapter 17 or a
practitioner defined as a physician assistant
licensed under ARS Title 32, Chapter 25, or a
certified nurse practitioner licensed under ARS
Title 32, Chapter 15.
PRIOR PERIOD The period of time preceding the actual notification
to a health plan of a member's enrollment during
which the health plan is retroactively liable for
payment of all covered services received by the
member. It is generally the period from the first
day of the month of application, or first eligible
month, up to the day of the health plan's receipt
of notification of the member's enrollment Prior
period coverage also includes updated eligibility
that covers a retroactive time period when the
member was not previously enrolled with AHCCCS.
Prior period coverage does not apply to Title XXI
members and does not include prior quarter coverage
(see below).
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PRIOR QUARTER The three-month period immediately proceeding the
month in which the member applies for Title XIX
benefits. If it is determined that the member would
have been eligible had the member applied in the
month in which services were provided, AHCCCSA may
pay for unpaid Title XIX services on a
fee-for-service basis. The Contractor is not liable
for the prior quarter period.
PROVIDER Any person who contracts with the Administration for
the provision of hospitalization and medical care
to members according to the provisions ARS ss.
36-2901 or any subcontractor of provider delivering
services pursuant to ARS ss.36-2901.
QUALIFIED A person, eligible under ARS ss.36-2971(4), who is
MEDICARE entitled to Medicare Part A insurance, meets
BENEFICIARY certain income, resource and residency requirements
(QMB) of the Qualified Medicare Beneficiary program. A
QMB who is also categorically eligible for Medicaid
is commonly referred to as a dual eligible.
RATE CODE Eligibility classification for capitation payment
purposes.
REGIONAL An organization under contract with ADHS to
BEHAVIORAL administer covered behavioral health services in a
HEALTH geographically specific area of the state. Tribal
AUTHORITY governments, through an agreement with ADHS, may
(RBHA) operate a tribal regional behavioral health
authority (TRBHA) for the provision of behavioral
health services to Native American members living
on-reservation.
REINSURANCE A risk-sharing program provided by the
Administration to contractors for the reimbursement
of certain contract service costs incurred by a
member beyond a certain monetary threshold.
RELATED PARTY A party that has, or may have, the ability to
control or significantly influence a contractor, or
a party that is, or may be, controlled or
significantly influenced by a contractor. "Related
parties" include, but are not limited to, agents,
managing employees, persons with an ownership or
controlling interest in the disclosing entity, and
their immediate families, subcontractors,
wholly-owned subsidiaries or suppliers, parent
companies, sister companies, holding companies, and
other entities controlled or managed by any such
entities or persons.
RFP Request For Proposals which is a document prepared
by AHCCCSA which describes the services required and
which instructs prospective offerors how to prepare
a response (proposal).
SCOPE OF See "COVERED SERVICES".
SERVICES
SOBRA Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act, 1986, amended by the Medicare
Catastrophic Coverage Act of 1988, 42 U.S.C.
1396a(a)(10)(A)(ii)(IX), July 1, 1988.
STATE The State of Arizona.
STATE PLAN The written agreements between the State and HCFA
which describes how the AHCCCS program meets HCFA
requirements for participation in the Medicaid
program and the Children's Health Insurance
Program.
STATE-ONLY A member who is not eligible for Title XIX or XXI
MEMBER but is eligible for one of the state-funded
eligibility categories which include Medically
Needy/Medically Indigent (MN/MI), Eligible
Assistance Children (EAC), Eligible Low Income
Children (ELIC), and SSI-related non-qualified
aliens.
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SUBCONTRACT Agreement entered into by Contractor with a provider
of health care services who agrees to furnish
covered services to members, or with a marketing
organization, or with any other organization or
person who agrees to perform any administrative
function or service for Contractor specifically
related to fulfilling Contractor's obligations to
AHCCCSA under the terms of this contract.
SUBCONTRACTOR (1) A person, agency or organization to that a
contractor has contracted with or delegated some of
its management functions or responsibilities to
provide covered services to its members; or (2) A
person, agency or organization that a fiscal agent
has entered into a contract, agreement, purchase
order or lease (or leases of real property) to
obtain space, supplies, equipment or services
provided under the AHCCCS agreement.
SUPPLEMENTAL Federal cash assistance program under Title XVI of
SECURITY the Social Security Act.
INCOME (SSI)
TEFRA RISK A Health Maintenance Organization or Comprehensive
HMO Medical Plan, which provides Medicare, services to
Medicare beneficiaries pursuant to a Medicare risk
contract with HCFA under ss.1876 of the Social
Security Act.
TEMPORARY A federal cash assistance program under Title IV-A
ASSISTANCE TO of the Social Security Act. It replaced Aid To
NEEDY FAMILIES Families With Dependent Children (AFDC)
(TANF)
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS
applicant or member.
THIRD PARTY The resources available from a person or entity
LIABILITY that is, or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the medical
expenses incurred by an AHCCCS applicant or member.
TITLE XIX Member eligible for Medicaid under Title XIX of the
MEMBER Social Security Act including those eligible under
1931 provisions of the Social Security Act
(previously AFDC), Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI) or SSI-related groups.
TITLE XXI Member eligible for acute care services under Title
MEMBER XXI of the Social Security Act, referred to in
federal legislation as the "Children's Health
Insurance Program" (CHIP). The Arizona version of
CHIP is referred to as "KidsCare."
TRIBAL A facility that is operated by an Indian tribe and
FACILITY that is authorized to provide services pursuant to
Public Law 93-638, as amended.
YEAR See "Contract Year".
[END OF DEFINITIONS]
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SECTION D: PROGRAM REQUIREMENTS
TABLE OF CONTENTS
1. SCOPE OF SERVICES.............................................................................. 10
2. BEHAVIORAL HEALTH SERVICES..................................................................... 16
3. AHCCCS MEDICAL POLICY MANUAL................................................................... 18
4. VACCINE FOR CHILDREN PROGRAM................................................................... 18
5. DENIALS OR REDUCTIONS OF SERVICES.............................................................. 18
6. ENROLLMENT AND DISENROLLMENT................................................................... 18
7. MAINSTREAMING OF AHCCCS MEMBERS................................................................ 20
8. MEMBER INFORMATION............................................................................. 21
9. MEMBER SURVEYS................................................................................. 23
10. MARKETING PLANS................................................................................ 23
11. ANNUAL ENROLLMENT CHOICE....................................................................... 23
12. TRANSITION OF MEMBERS.......................................................................... 24
13. STAFF REQUIREMENTS AND SUPPORT SERVICES........................................................ 25
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS.............................................. 26
15. ADVANCE DIRECTIVES............................................................................. 26
16. PERFORMANCE MEASUREMENT........................................................................ 27
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM).......................................... 29
18. PHYSICIAN INCENTIVES........................................................................... 29
19. APPOINTMENT STANDARDS.......................................................................... 29
20. REFERRAL PROCEDURES AND STANDARDS.............................................................. 30
21. PROVIDER MANUAL................................................................................ 31
22. PRIMARY CARE PROVIDER STANDARDS................................................................ 32
23. OTHER PROVIDER STANDARDS....................................................................... 32
24. NETWORK DEVELOPMENT............................................................................ 33
25. NETWORK MANAGEMENT............................................................................. 34
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)...................................................... 34
27. PROVIDER REGISTRATION.......................................................................... 35
28. PROVIDER AFFILIATION TAPE...................................................................... 35
29. PERIODIC REPORT REQUIREMENTS................................................................... 35
30. DISSEMINATION OF INFORMATION................................................................... 36
31. REQUESTS FOR INFORMATION....................................................................... 36
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS.................................................... 36
33. OPERATIONAL AND FINANCIAL REVIEWS.............................................................. 36
34. CLAIMS PAYMENT SYSTEM.......................................................................... 37
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT...................................................... 37
36. NURSING FACILITY REIMBURSEMENT................................................................. 38
37. COMPENSATION................................................................................... 39
38. CAPITATION ADJUSTMENTS......................................................................... 40
39. REINSURANCE.................................................................................... 41
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY................................................. 43
41. MEDICARE SERVICES AND COST SHARING............................................................. 45
42. COPAYMENTS..................................................................................... 45
43. RECORDS RETENTION.............................................................................. 45
44. MEDICAL RECORDS................................................................................ 45
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS................................................. 46
46. ACCUMULATED FUND DEFICIT....................................................................... 46
47. DATA EXCHANGE REQUIREMENT...................................................................... 46
48. ENCOUNTER DATA REPORTING....................................................................... 47
49. MONTHLY ROSTER RECONCILIATION.................................................................. 48
50. TERM OF CONTRACT AND OPTION TO RENEW........................................................... 48
51. SUBCONTRACTS................................................................................... 49
52. SPECIALTY CONTRACTS............................................................................ 50
53. MANAGEMENT SERVICES SUBCONTRACTORS............................................................. 50
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS....................................................... 51
55. MINIMUM CAPITALIZATION REQUIREMENTS............................................................ 51
56. PERFORMANCE BOND OR BOND SUBSTITUTE............................................................ 51
57. AMOUNT OF PERFORMANCE BOND..................................................................... 52
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES.............................................. 52
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP................................................. 53
60. SANCTIONS...................................................................................... 53
61. AUTO-ASSIGNMENT ALGORITHM...................................................................... 54
62. GRIEVANCE PROCESS AND STANDARDS................................................................ 54
63. QUARTERLY GRIEVANCE REPORT..................................................................... 54
64. KIDSCARE....................................................................................... 54
65. PENDING LEGISLATIVE ISSUES..................................................................... 55
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SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22-202 et seq., the AHCCCS Medical
Policy Manual (AMPM), and the document entitled "AHCCCS Health Plan Performance
Indicators", all of which are incorporated herein by reference and may be found
in the Bidder's Library. The covered services are briefly described below.
Covered services must be medically necessary and provided by, or coordinated
with, a primary care provider, except for behavioral health and children's
preventive dental services. Services must be rendered by providers that are
appropriately licensed or certified, operating within their scope of practice,
and registered as an AHCCCS provider. The Contractor shall provide the same
standard of care for all members regardless of the member's eligibility
category.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options even if needed services are not
covered by the Contractor.
BALANCED BUDGET ACT OF 1997: This version of the AHCCCS acute care contract is
believed to contain all of the requirements mandated by the federal Balanced
Budget Act of 1997. The Contractor, however, shall be held liable for all
mandated requirements whether or not they appear in this renewal amendment.
KIDSCARE COVERED SERVICES: KidsCare members are eligible for the same services
covered for members under the Title XIX and state-only programs, with the
following differences, exclusions and/or limitations:
a. Non-emergency transportation is not covered.
b. Chiropractic services are not covered.
c. Vision services are limited to one eye examination per contract year
and one pair of glasses or contacts every contract year.
d. EPSDT services are limited to those services specified in this
contract.
e. Behavioral health services are limited to 30 inpatient days and 30
outpatient visits per contract year. (See details under Section D
Paragraph 2, Behavioral Health Services.)
f. Licensed midwives and home deliveries are not covered.
For further details regarding the KidsCare program, see Section D, Paragraph
64, KidsCare, and the AHCCCS Medical Policy Manual (AMPM).
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a free-standing surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 21 including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through other than medical or surgical means
(i.e. hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2, Behavioral Health Services.
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CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for children with
CRS-covered conditions is administered by the Arizona Department of Health
Services (ADHS) for children who meet CRS eligibility criteria. The Contractor
shall refer children to the CRS program who are potentially eligible for
services related to CRS covered conditions. Eligibility criteria and the
referral process are described in the CRS Policy and Procedures Manual
available in the Bidder's Library.
The Contractor is responsible for providing primary medical care and emergency
services not covered by CRS. The Contractor is also responsible for initial
care of newborn members, who are CRS eligible. The Contractor must require the
member's Primary Care Provider (PCP) to coordinate their care with the CRS
program. All services provided must be included in the member's medical record
maintained by the PCP.
A member with private insurance is not required to utilize CRS. If the member
uses their private insurance network for a CRS covered condition, and the
member is not enrolled with CRS, the Contractor is responsible for all
applicable deductibles and copays.
The Contractor remains ultimately responsible for the provision of all covered
services to its members. Therefore, if the Contractor becomes aware that CRS
has failed to meet the established appointment standards, the Contractor shall
provide the services.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
Title XIX members under age 21 when prescribed by the member's PCP and approved
by the Contractor in order to ameliorate the member's medical condition.
Chiropractic services shall also be covered, subject to limitations specified
in CFR 410.22, for dually qualified Medicare beneficiaries if prescribed by the
member's PCP and approved by the Contractor.
DENTAL: The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services; dental
screening and preventive services in accordance with the AHCCCS periodicity
schedule; therapeutic dental services; dentures; and pre-transplantation dental
services. The Contractor shall monitor compliance with the EPSDT periodicity
schedule for dental screening services and ensure that dental service reports
are included in the member's medical record maintained by the PCP. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 16, Performance Measures. The Contractor
shall ensure that members are notified when dental screenings are due if the
member has not been scheduled for a visit. If no dental screening is received
by the member, a second notice must be sent. Members under the age of 21 may
request dental services without referral and may choose a dental provider from
the Contractor's provider network. Members 21 years of age and older are
eligible for emergency dental services, medically necessary dentures and
pre-transplantation dental services only. Dental standards may be found in the
AMPM which is incorporated herein by reference and which may be found in the
Bidder's Library.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment for members
under age 21. The Contractor shall ensure that these members receive required
health screenings, including developmental/behavioral health, in compliance
with the AHCCCS periodicity schedule (Exhibit 430-1 in the AMPM) and to submit
to the AHCCCS Office of the Medical Director/Acute Care Unit, all EPSDT reports
as required by AHCCCS medical policy. The Contractor is required to meet
specific participation/utilization rates for members as described in Section D,
Paragraph 16, Performance Measures. Because the behavioral health benefit for
Title XIX and Title XXI is provided through the ADHS/RBHA system, the
Contractor shall ensure the initiation and coordination of the referral of
these
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members to the RBHA and shall follow up with the RBHA to monitor whether
members have received behavioral health services. Title XXI members are not
entitled to the all-encompassing EPSDT service package required for Title XIX
children. Title XXI children are entitled only to the EPSDT and other covered
services specified in this document, the AMPM and the Title XXI State Plan.
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically
emergent condition as defined by AHCCCS Rule R9-22-101 and R9-31-101.
Emergency medical services are covered without prior authorization. The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged to
contract with or employ the services of non-emergency facilities (e.g.
urgent care centers) to address member non-emergency care issues
occurring after regular office hours or on weekends. The Contractor
shall be responsible for educating members and providers regarding
appropriate utilization of emergency room services including behavioral
health emergencies. The Contractor shall monitor emergency services
utilization (by both provider and member) and shall have guidelines for
implementing corrective action for inappropriate utilization. For
utilization review, the test for appropriateness of the request for
emergency services shall be whether a prudent layperson, similarly
situated, would have requested such services. For purposes of this
contract, a "prudent layperson" is defined as a person without medical
training who exercises those qualities of attention, knowledge,
intelligence and judgment which society requires of its members for the
protection of their own interest and the interests of others. The phrase
does not apply to a person's ability to reason, but rather the prudence
with which he acts under a given set of circumstances.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
e. The Contractor shall comply with established guidelines regarding the
coordination of post-stabilization care.
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically
necessary emergency eye care, vision examinations, prescriptive lenses, and
treatments for conditions of the eye for all members under the age of 21, with
the exception of KidsCare members. See limitations for KidsCare members
described at the beginning of this section, titled "KidsCare Covered Services."
For members who are 21 years of age and older, the Contractor shall provide
emergency care for eye conditions which meet the definition of an emergency
medical condition, cataract removal, and/or medically necessary vision
examinations and prescriptive lenses if required following cataract removal and
other eye conditions as specified in the AMPM.
FAMILY PLANNING: The Contractor shall provide family planning services for all
members who choose to delay or prevent pregnancy. These include medical,
surgical, pharmacological and laboratory services, as well as contraceptive
devices. Information and counseling necessary to allow the members to make
informed decisions regarding family planning methods shall also be included. If
the Contractor does not provide family planning services, it must contract for
these services through another health care delivery system, which allows
members freedom of choice in selecting a provider. A prospective offeror may
discuss arrangements for family planning services only with other prospective
offerors during the RFP process for the purpose of making arrangements for the
provision of family planning services.
The Contractor shall provide services to members enrolled in the Family
Planning Services Extension Program; a program that provides only family
planning services for a maximum of 24 months to women whose SOBRA eligibility
has terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification may be made at the
time the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension,
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elevated cholesterol, colon cancer, sexually transmitted diseases, tuberculosis
and HIV/AIDS; nutritional assessment in cases when the member has a chronic
debilitating disease affected by nutritional needs; mammograms and prostate
screenings; physical examinations and diagnostic work-ups; and immunizations.
Required assessment and screening services for members under age 21 are
included in the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: The Contractor shall provide part-time or intermittent care for
members who do not require hospital care. This service is provided under the
direction of a physician to prevent re-hospitalization or institutionalization
and may include nursing, therapies, supplies and home health aide services.
HOSPICE: These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis stabilization. If the
member's medical condition requires isolation; private inpatient accommodations
are covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the
above services, which may be provided on an outpatient or ambulatory basis
(i.e., laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if
determined reasonable and necessary to decide whether the member should be
admitted for inpatient care. Observation services include the use of a bed and
periodic monitoring by hospital nursing staff and/or other staff to evaluate,
stabilize or treat medical conditions of a significant degree of instability
and/or disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
oral/inactivated polio vaccine (OPV/IPV), measles, mumps, rubella vaccine
(MMR), H. influenza, type B (HIB), hepatitis B (Hep B), and varicella vaccine.
The Contractor is required to meet specific immunization rates for members
under the age of 21, which are described in Section D, Paragraph 16,
Performance Measures.
INDIAN HEALTH SERVICES (IHS): The Contractor may choose to subcontract with and
pay an IHS or tribal facility for covered services provided to members.
Effective October 1, 1999, the Contractor is responsible for reimbursement to
IHS or tribal facilities for emergency services provided to state-only and
Title XXI Native American members enrolled with the Contractor. The Contractor
has no responsibility for non-emergency services to state-only and Title XXI
Native American members unless the Contractor refers or prior authorizes the
service. Effective October 1, 1998, AHCCCSA will reimburse claims for services
that are medically necessary and eligible for 100% Federal reimbursement,
provided to Title XIX members in an IHS or tribal facility.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending
physician or dentist, and provided by a CLIA (Clinical Laboratory Improvement
Act) approved free standing laboratory or hospital laboratory, clinic,
physician office or other health care facility laboratory.
Upon written request, a Contractor may obtain laboratory test data on members
from a laboratory or hospital based laboratory subject to the requirements
specified in ARS ss.36-2903 R. The data shall be used exclusively for quality
improvement activities and health care outcome studies required and/or approved
by the Administration.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members.
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Services may be provided by physicians, physician assistants or nurse
practitioners certified in midwifery. Members may select or be assigned to a
PCP specializing in obstetrics. Circumcisions are covered if performed during
the newborn's hospital stay after birth, or on an outpatient basis within one
month of the infant's hospital discharge. Title XIX and state-only members
anticipated to have a low-risk delivery may elect to receive labor and delivery
services in their home from their maternity provider if this setting is
included in allowable settings for the Contractor, and the Contractor has
providers in its network that offer home labor and delivery services. Title XIX
and state-only members anticipated to have a low-risk prenatal course and
delivery may elect to receive maternity services of prenatal care, labor and
delivery and postpartum care provided by licensed midwives if they are in the
Contractor's provider network. All licensed midwife labor and delivery services
must be provided in the member's home since licensed midwives do not have
admitting privileges in hospitals or AHCCCS registered free-standing birthing
centers. Members receiving maternity services from a licensed midwife must also
be assigned to a PCP for other health care and medical services. Home delivery
and licensed midwives are not covered for Title XXI members.
The Contractor shall allow women and their newborns to receive up to 48 hours
of inpatient hospital care after a routine vaginal delivery and up to 96 hours
of inpatient care after a cesarean delivery. The attending health care
provider, in consultation with the mother, may discharge the mother or newborn
prior to the 48-hour minimum length of stay. A normal newborn may be granted an
extended stay in the hospital of birth when the mother's continued stay in the
hospital is beyond the 48 or 96 hour stay.
MEDICALLY-NECESSARY ABORTIONS: This service is covered for a member if the
member suffers from a physical disorder, physical injury, or physical illness
including a life endangering physical condition caused by or rising from the
pregnancy itself, that would, as certified by a physician, place the member in
danger of death unless an abortion is performed. The service is also covered
for Title XIX and Title XXI members if the pregnancy is caused by rape or
incest. Providers must document and submit to the Contractor a Certificate of
Medical Necessity for Pregnancy Termination and prior authorization is
required. If the procedure is performed on an emergency basis, documentation
must be submitted to the Contractor within two working days. Additional
documentation, outlined in the AMPM, is required for members under 18 years of
age or are considered an incapacitated adult who seek a medically necessary
abortion due to rape or incest.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP,
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide nursing facility services,
including religious nonmedical health care institutions, for members who
require short-term convalescent care not to exceed 90 days per contract year.
In lieu of a nursing facility, the member may be placed in an alternative
living facility or receive home and community based services (HCBS) as defined
in R9-28, Article 1 that meet the provider standards described in R9-28,
Article 5.
Nursing facility services must be provided in a dually-certified
Medicare/Medicaid facility which includes in the per-diem rate: nursing
services, basic patient care equipment and sickroom supplies, dietary services,
administrative physician visits, non-customized DME, necessary maintenance
rehabilitation therapies, over-the-counter medications, social, recreational
and spiritual activities, and administrative, operational medical direction
services. The Contractor shall provide medically necessary nursing facility
services for any member who has a pending ALTCS application, who is currently
residing in a nursing facility and is eligible for services provided under this
contract. If the member becomes ALTCS eligible and is enrolled with an ALTCS
Program Contractor before the end of the maximum 90 days of nursing facility
coverage, the Contractor is only responsible for nursing facility coverage
during the time the member is enrolled with the Contractor. Nursing facility
services covered by a third party insurer (including Medicare) while the member
is enrolled
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14
with the Contractor shall be applied to the 90 day limitation. See Paragraph
36, Nursing Facility Reimbursement, for further details.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application and to prepare for potential fee-for-service coverage if the stay
goes beyond the 90-day maximum.
NUTRITION: Nutritional feeding through a non-oral method such as TPN or tube
feeding is covered for all members when it is the sole source of nutrition due
to severe pathology of the alimentary tract. Nutritional feeding may also be
used to supplement nutrition for members under age 21 when medically necessary
but need not be the member's sole source of nutrition. Medically necessary oral
nutritional supplements are covered only for members under the age 21 and only
when AHCCCS criteria are met. In addition, the Contractor shall provide
nutritional assessments as a part of EPSDT screening for all children. See the
AMPM for details.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS AND PHARMACY: Medications ordered by a PCP, attending
physician or dentist and dispensed under the direction of a licensed pharmacist
are covered subject to limitations related to prescription supply amounts,
Contractor formularies and prior authorization requirements, as well as
restrictions for immunosuppressant drugs addressed in AHCCCS medical policies
for transplantations. Over-the-counter medication may be prescribed when it is
determined to be a lower-cost alternative to prescription medication.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member for specialty medical services,
behavioral health and dental services. The PCP is responsible for maintaining
the member's primary medical record which contains documentation of all health
risk assessments and health care services of which they are aware whether or
not they were provided by the PCP.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those members who are 21 and over;
physical therapy for all members and occupational and speech therapies for
members under the age of 21 are covered on both an inpatient and outpatient
basis if not used as a maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient
basis when prescribed by the member's PCP or attending physician and is
necessary to restore, maintain or improve respiratory functioning.
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TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services are covered within limitations defined in the AMPM for members
diagnosed with specified medical conditions. Such limitations include whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions which substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service. Services include pre-transplant inpatient or outpatient
evaluation; donor search; organ/tissue harvesting or procurement; preparation
and transplantation services; and convalescent care. In addition, if a member
receives a transplant covered by a source other than AHCCCS, medically necessary
non-experimental services are provided within limitations after the discharge
from the acute care hospitalization for the transplantation. AHCCCS has
contracted with transplantation providers for the Contractor's use or the
Contractor may select its own transplantation provider. However, the quality of
services must be equal to or exceed those of the AHCCCS provider and the rate
paid can not exceed the AHCCCS provider's negotiated rate. Transplantations for
the MN/MI population are subject to available funding.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided for
Title XIX and state-only members who are unable to provide their own
transportation for medically necessary services. Title XXI members are not
eligible for non-emergency transportation services except for transfers between
facilities.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine services necessary to alleviate or stabilize the
emergent condition. The provider must notify the Contractor within 12 hours of
the member's registration with the facility for emergency services. Supporting
documentation for services rendered must be provided when reporting or billing a
service. Triage/screening services must be reasonable, cost effective and meet
the criteria for severity of illness and intensity of service.
2. BEHAVIORAL HEALTH SERVICES
Title XIX (1931 group, SSI, SOBRA) and Title XXI (KidsCare) members are eligible
for comprehensive behavioral health services. The behavioral health benefit for
these members is provided through the ADHS-Regional Behavioral Health Authority
(RBHA) system. The Contractor shall be responsible for member education
regarding these benefits; provision of limited emergency inpatient services; and
screening and referral to the RBHA system of members identified as requiring
behavioral health services.
MEMBER EDUCATION: The Contractor shall be responsible for educating members in
the member handbook and other printed documents about covered behavioral health
services and where and how to access services. Covered services for Title XIX
and Title XXI are similar with the exception that non-emergency transportation
is not covered for Title XXI members. For Title XXI members inpatient services
and specified outpatient services are limited to 30 days/30 visits per contract
year. Covered services include:
a. Inpatient services (Title XXI limited to 30 days per contract
year)
b. Individual, group and family therapy and counseling (limited
for Title XXI)
c. Psychotropic medication
d. Psychotropic medication adjustment and monitoring
e. Partial care, basic and intensive (limited for Title XXI)
f. Emergency crisis services
g. Behavior management (limited for Title XXI)
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h. Psychosocial rehabilitation (limited for Title XXI)
i. Evaluation, screening and diagnosis (limited for Title XXI)
j. Laboratory and radiology services for psychotropic medication
regulation and diagnosis
k. Emergency and medically necessary transportation (Title XXI
members limited to emergency transportation only)
l. Case management services
REFERRALS: As specified in Section D, Paragraph 1, the Contractor must provide
developmental behavioral health screenings in compliance with the AHCCCS
periodicity schedule. The Contractor shall ensure the initiation and
coordination of behavioral health referrals of these members to the RBHA when
determined necessary through the screening process.
The Contractor is responsible for referring other Title XIX and Title XXI
members identified as needing behavioral health treatment services to the RBHA
for evaluation and provision of covered services. Members may also access the
RBHA system for evaluation by self-referral or be referred by schools, State
agencies or other service providers. The Contractor is responsible for providing
transportation to Title XIX members first RBHA evaluation appointments if
members are unable to provide their own transportation.
EMERGENCY SERVICES: For Title XIX and Title XXI members not enrolled with ADHS,
the Contractor is responsible for up to three days of inpatient emergency
behavioral health services not to exceed 12 days per contract year.
For state-only members (MN/MI, EAC, ELIC): The Contractor is responsible for up
to three days of inpatient emergency behavioral health services not to exceed 12
days per contract year. For members who become eligible during an emergency
episode, the three (3) days of coverage for this hospital benefit are the first
three (3) days of eligibility. This limitation of the Contractor's financial
liability is the same regardless of whether the member is enrolled with a RBHA.
COORDINATION OF CARE: The Contractor is responsible for ensuring that a medical
record is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has not yet
seen the assigned member. The Contractor shall also respond to RBHA/provider
information requests pertaining to ADHS enrolled members including, but not
limited to, current diagnosis, medication, pertinent laboratory results, last
PCP visit, and last hospitalization. For prior period coverage, the Contractor
is responsible for payment of all claims for medically necessary covered
behavioral health services to members not enrolled with ADHS.
MEDICATION MANAGEMENT SERVICES: The Contractor shall allow PCPs to provide
medication management services (prescriptions, medication monitoring visits,
laboratory and other diagnostic tests necessary for diagnosis and treatment of
behavioral disorders) to members with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder. The Contractor shall make available,
on the Contractor's formulary, medications for the treatment of these disorders.
The Contractor shall ensure that training and education is available to PCPs
regarding behavioral health referral and consultation procedures. The Contractor
shall establish policies and procedures for referral and consultation and shall
include them in their provider manual. Also, Contractors shall inform PCPs about
the availability of training and education through the Regional Behavioral
Health Authorities regarding the diagnosis and treatment of behavioral health
disorders.
The Contractor shall ensure that its quality management and peer review programs
incorporate monitoring of the PCP's management of behavioral health disorders.
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3. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. The Contractor is responsible for complying with the requirements
set forth within. The AMPM with search capability and linkages to AHCCCS rules,
Statutes and other resources is available to all interested parties through the
AHCCCS Home Page on the Internet (WWW.AHCCCS.STATE.AZ.US). A Contractor may also
request up to three copies (for use by the CEO, Medical Director and Quality
Management staff) in addition to Internet availability. AMPM updates will be
available through the Internet immediately upon adoption by AHCCCSA. Hard copy
updates will only be distributed quarterly. Contractors using one or more hard
copies of the AMPM are responsible for maintaining such copies current with
these updates.
4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program, the federal and state governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. Therefore, the Contractor shall not utilize AHCCCS
funding to purchase vaccines for members under the age of 19. Any provider,
licensed by the State to administer immunizations, may register with ADHS as a
"VFC provider" and receive free vaccines. The Contractor shall comply with all
VFC requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When a covered service is denied, reduced, suspended or terminated, the
Contractor shall comply with the notice, appeal and continuation of benefits
requirements specified in 42 CFR 431.200 et seq., AAC R9-22, Article 13
outlining members' rights and responsibilities, and AHCCCS policy.
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
Social Security Administration (SSA) SSA determines eligibility for the Supplementary
Security Income (SSI) cash program. SSI Cash recipients
are automatically eligible for AHCCCS coverage.
Department of Economic Security (DES) DES determines eligibility for the Temporary Assistance to
Needy Families (TANF) program (formerly Aid to Families
with Dependent Children), 1931 Group Medical Assistance
Only (MAO) groups, SOBRA women and children, the Eligible
Assistance Children state program (EAC), the Adoption
Subsidy Program, Title IV-E foster care children, and the
Federal Emergency Services program (FES) related to the
TANF, 1931 Group, or SOBRA programs.
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AHCCCSA AHCCCSA determines eligibility for the SSI/MAO groups,
including the FES program related to the SSI-Cash program
(aged, disabled, blind), the Arizona Long-Term Care System
(ALTCS), the Qualified Medicare Beneficiary program and
other Medicare cost sharing programs, and the Title XXI
program.
Arizona's 15 Counties Each county determines eligibility for the Medically
Needy/Medically Indigent (MN/MI), Eligible Low Income
Children (ELIC), and the State Emergency Services state
programs.
AHCCCS acute care members are enrolled with contractors in accordance with the
rules set forth in R9. Article 17.
HEALTH PLAN CHOICE
Acute members, except for those eligible under the MN/MI program have a choice
of available health plans. A listing of the available health plans and their
telephone numbers will be given to each applicant during the application process
for AHCCCS benefits. Also included are instructions to applicants to call the
health plans directly with specific questions concerning the health plan. If
there is only one health plan available for the applicant's Geographical Service
Area, no choice is offered. Members who do not choose prior to AHCCCSA's being
notified of their eligibility are automatically assigned to a health plan based
on family continuity or the auto-assignment algorithm.
Title XXI members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. When a member is transferred from
Title XIX to Title XXI and has not made a health plan choice for Title XXI, the
member will remain with the Title XIX health plan and a choice notice will be
sent to the member. The member may then change plans no later than 16 days from
the date the choice notice is sent.
AHCCCSA assigns MN/MI members to an available health plan, based on family
continuity or through AHCCCSA's auto-assignment algorithm. These members do not
get a choice of available contractors until their annual enrollment choice
period.
Exceptions to the above enrollment policies for Title XIX and state-only members
include: previously enrolled members who have been disenrolled for less than 90
days will be automatically enrolled with the same contractor, if that contractor
is still available. Also, women whose SOBRA eligibility have terminated and have
become enrolled in the Family Planning Services Extension Program will
automatically remain assigned to the same health plan. The Family Planning
Services Extension Program provides a maximum of 24 months of family planning
services.
The effective date of enrollment for a new Title XIX or state-only member with
the Contractor will generally be the day prior to the date the Contractor
receives notification from AHCCCSA via the daily roster. However, the Contractor
is responsible for payment of medically necessary covered services retroactive
to the member's beginning date of eligibility, excluding any prior quarter
coverage period.
The effective date of enrollment for a Title XXI member will be the first day of
the month following notification to the health plan. If a Title XXI member is
determined eligible by the 25th of the month, the member will be enrolled with
the health plan as of the 1st of the following month. If the member is
determined eligible AFTER the 25th of the month, the member will be enrolled
with the health plan as of the 1st of the second following month.
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for Title XIX and
state-only members. For Title XIX members, prior period coverage starts from the
first day of the month of application, or first eligible month. The Contractor
is responsible for payment of all claims for medically necessary covered
services
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provided to Title XIX members during prior period coverage. For state-only EAC
members, prior period coverage does not apply. For state-only MN/MI and ELIC
members prior period coverage is generally limited to the two days prior to the
date of AHCCCSA being notified of eligibility. However, prior period coverage
could include additional days prior to the date of enrollment. The Contractor is
responsible for payment of all claims for medically necessary covered services
provided on an emergency basis to state-only members pursuant to ARS ss.36-2908
and ARS ss.36-2909 for the first two days of the prior period coverage. Any
additional prior period coverage for state-only members will include all claims
for medically necessary covered services. This may include services provided
prior to the contract year. (See Section D, Paragraph 37, Compensation, for a
description of the Contractor's reimbursement from AHCCCSA for this eligibility
time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers, including Title XXI mothers,
who were enrolled at the time of the child's birth and whose newborn
notification was received by AHCCCSA will be enrolled with the mother's health
plan. The Contractor is responsible for notifying AHCCCSA of a child's birth to
an enrolled member. Capitation to the Contractor will begin on the date
notification is received by AHCCCSA (except for cases of births during prior
period coverage). The effective date of AHCCCS eligibility will be the newborn's
date of birth, and the Contractor is responsible for all covered services to the
newborn whether or not AHCCCSA has received notification of the child's birth.
Note that AHCCCSA is currently available to receive notification calls 24 hours
a day, 7 days a week. Title XIX and Title XXI eligible mothers of newborns are
sent a letter advising them of their right to choose a different contractor for
their child; otherwise the child will remain with the mother's contractor.
Newborns of MN/MI mothers are enrolled with the mother's contractor for a
minimum of 30 days up to a maximum of 60 days. Newborns of FES mothers are
auto-assigned to a health plan and mothers of these newborns are sent a letter
advising them of their right to choose a different health plan for their child.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, or as an Eligible Assistance Child (EAC), the member is guaranteed a
minimum of five full months of continuous enrollment. Upon initial capitated
enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of
12 full months of continuous enrollment. Enrollment guarantees do not apply to
Native Americans who choose to obtain their covered services through Indian
Health Services (IHS) on a fee-for-service basis or children enrolled with
Department of Economic Security/Comprehensive Medical and Dental Program. The
enrollment guarantee applies a maximum of one time per member per eligibility
category for Title XIX, Title XXI and EAC members. If a member changes from one
contractor to another within the enrollment guarantee period, the remainder of
the guarantee period applies to the new contractor. The enrollment guarantee may
not be granted or may be terminated if the member is incarcerated or, if a minor
child is adopted. AHCCCS Rule R9-22, Article 17 and R9-31, Article 3 describes
other reasons for which the enrollment guarantee may not apply.
NATIVE AMERICANS: Native Americans eligible under any coverage group other than
MN/MI, on or off-reservation, have a choice to receive services from Indian
Health Service (IHS), a PL 93-638 tribal facility or any available contractor.
If choice is not available or made within the specified time limit, Native
American Title XIX and state-only members living on-reservation will be assigned
to IHS and Native American Title XIX and state-only members living
off-reservation will be assigned to an available contractor using AHCCCSA's
family continuity policy and auto-assignment algorithm. Native Americans may
change from IHS to a contractor or from a contractor to IHS at any time. Native
American Title XXI members must make a choice prior to being determined
eligible.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, or physical or mental handicap, except where
medically indicated. Examples of prohibited practices include, but are not
limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
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b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. The reading level and name of the
evaluation methodology used should be included when 200 members or 5% of the
Contractor's enrolled population, whichever is greater, speak a 2nd language,
the Contractor shall provide member information in that 2nd language. The
Contractor shall comply whenever it is aware that a population meets this
standard. When there are program or service site changes notification will be
provided to the affected members at least 14 days before implementation. The
Contractor shall review and update the Member Handbook at least once a year. The
Handbook must be submitted to AHCCCSA Office of Managed Care for approval by
Sept. 1 of each contract year, or within four weeks of receiving the annual
renewal amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A MEMBER HANDBOOK which, at a minimum, shall include the following
items that are also listed in the Office of Managed Care, Operations
Policy #404, Member Information Policy:
a. A table of contents
b. A general description of how managed care works, particularly
in regards to member responsibilities, appropriate utilization
of services and the PCP's role as gatekeeper of services
c. A description of all available covered services and an
explanation of any service limitations or exclusions from
coverage and a notice stating that the Contractor will be
liable only for those services authorized by the Contractor.
The description should include a brief explanation of the
Contractor's approval and denial process.
d. Information on what to do when family size changes
e. How to obtain a PCP
f. How to change PCPs
g. How to make, change and cancel appointments with a PCP or
dentist
h. List of applicable copayments (including a statement that care
will not be denied due to lack of copayment). The member
handbook must clearly state that members cannot be billed for
covered services (other than applicable copayments), what to
do if they are billed, and under what circumstances a member
may be billed for non-covered services.
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i. Dual eligibility (i.e. Medicare and Medicaid); services
received in and out of the Contractor's network; copayments.
See Section D, Paragraph 41, Medicare Services and Cost
Sharing.
j. The process of referral to specialists and other providers,
including access to behavioral health services provided by the
ADHS RBHA system.
k. How to contact Member Services and a description of its
function
l. What to do in case of an emergency and instructions for
receiving advice on getting care in case of an emergency. In a
life-threatening situation, the member handbook should
instruct members to use the emergency medical services (EMS)
available and/or activate EMS by dialing 9-1-1. Handbook
should contain information on proper emergency service
utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. Screenings include a comprehensive history and
developmental/behavioral health screening, comprehensive
unclothed physical examination, appropriate vision testing,
hearing testing, laboratory tests, dental screening and
immunizations.
o. Maternity and family planning services
p. Description of covered behavioral health services and how to
access them
q. Description of all covered dental services for members under
21 and how to access these services
r. Out of county/out of state moves
s. Grievance procedures, including a clear explanation of the
member's right to file a grievance and to appeal any decision
that affects the member's receipt of covered services.
t. Contributions the member can make towards his/her own health,
member responsibilities, appropriate and inappropriate
behavior, and any other information deemed essential by the
Contractor or AHCCCS. This shall include a statement that the
member is responsible for protecting his or her ID card and
that misuse of the card, including loaning, selling or giving
it to others could result in loss of the member's eligibility
and/or legal action. A sentence shall be included that
stresses the importance of members keeping, not discarding,
the swipe ID card.
u. How to access after-hours care (urgent care).
v. Advance directives for adults
w. Use of other sources of insurance. See Section D, Paragraph
40, Coordination of Benefits.
x. The last revision date
y. Member's notification rights and responsibilities under AAC
R9-22, Article 13 and AHCCCS policy
z. A description of Fraud and Abuse including instructions on how
to report suspected fraud or abuse. This shall include a
statement that misuse of a member's identification card,
including loaning, selling or giving it to others could result
in loss of the member's eligibility and/or legal action
against the member
aa. A statement that informs the member of their right to request
information on whether or not the health plan has Physician
Incentive Plans (PIP) that affect the use of referral
services, the right to know the types of compensation
arrangements the plan uses, the right to know whether
stop-loss insurance is required and the right to a summary of
member survey results. (in accordance with PIP regulation).
bb. Member's right to be treated fairly regardless of race,
religion, sex, age or ability to pay.
cc. Instructions for obtaining culturally competent materials,
including translated member materials.
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type style and size which can easily be read by members with
varying degrees of visual impairment. At a minimum, the member handbook shall
also contain the following language regarding questions, problems and grievances
(Ref. AHCCCS Rule R9-22-518 and R9-31-518):
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Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call ________ and ask to talk
to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 60 days after the date of the
action, decision, or incident
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
II. A LIST OF THE NAMES, TELEPHONE NUMBERS AND SERVICE SITE ADDRESSES OF
PCPS available for selection by the member and a description of the
selection process. Upon request by the member, the Contractor must make
information available regarding provider qualifications.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs; communication
between members and the Contractor, and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in each survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, the Contractor shall perform its own annual general
or focused member survey. All such contractor surveys must be approved in
advance by AHCCCSA.
10. MARKETING PLANS
The Contractor shall submit all proposed marketing plans and materials to
AHCCCSA for prior approval in accordance with the AHCCCS Health Plan Marketing
Policy, a copy of which is available in the Bidder's Library. The Contractor
must have signed contracts with hospitals (in Maricopa and Pima counties), PCPs,
specialists and pharmacies in order for them to be included in marketing
materials.
11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment on a limited basis as
deemed necessary. During AEC, members may change contractors subject to the
availability of other contractors within their Geographic Service Area. Members
are mailed a printed enrollment form and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process. If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if the Contractor's contract is renewed and the member
continues to live in the Contractor's service area. The Contractor shall comply
with the Office of Managed Care Member Transition for Annual Enrollment Choice
and Other Plan Changes policy.
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12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM standards for member transitions
between health plans or GSAs, to or from an ALTCS program contractor, IHS, a PL
93-638 tribal entity, or a Title XXI direct service provider and upon
termination or expiration of a contract. The Contractor shall develop and
implement policies and procedures, which comply with AHCCCS medical policy to
address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy or who are hospitalized
at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services.
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
1) A monthly claims aging report by provider/creditor including IBNR
amounts;
2) A monthly summary of cash disbursements;
3) Copies of all bank statements received by the Contractor.
Such reports shall be due on the fifth day of each succeeding
month for the prior month.
d. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
e. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
f. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
Members transferred from non-contracting hospitals in order to comply with the
Hospital Reimbursement Pilot Program in Maricopa and Pima Counties shall be
transferred in accordance with the AHCCCS Medical Policy.
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Behavioral Health Transition: The Contractor shall fully cooperate with changes
mandated in Laws of 1999, Chapter 313 regarding the transition of Title XIX
non-SMI 18, 19 and 20 year old members and 18 year old Title XXI members to the
ADHS/RBHA system. The Contractor shall cooperate with ADHS, its subcontractors
and their providers in transitioning members' care. To ensure continuity of care
and avoid disruption of medically necessary services, the Contractor shall
adhere to the transition plan developed by AHCCCS.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff is required.
a. A full-time ADMINISTRATOR who is available at all times to fulfill the
responsibilities of the position and to oversee the entire operation of
the health plan.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all-major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A full-time CHIEF FINANCIAL OFFICER who is available at all times to
fulfill the responsibilities of the position and to oversee the budget
and accounting systems implemented by the Contractor.
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20. The Behavioral
Health Coordinator shall devote sufficient time to ensure that the
Contractor's behavioral health referral and coordination activities are
implemented per AHCCCSA requirements.
g. PRIOR AUTHORIZATION STAFF to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems, and to meet the Contractor's standards for telephone
abandonment rates and telephone hold times.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A CLAIMS ADMINISTRATOR AND CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
l. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE COORDINATOR who will manage and adjudicate member and
provider grievances.
n. CLERICAL AND SUPPORT STAFFS to ensure appropriate functioning of the
Contractor's operation.
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The Contractor shall inform AHCCCSA, Office of Managed Care, in writing and
provide a resume within seven days of staffing changes in the following key
positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/EPSDT Coordinator Quality Management/Utilization Management
Grievance Coordinator Coordinator
Behavioral Health Coordinator
The Contractor shall ensure that all staff has appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
15. ADVANCE DIRECTIVES
The Contractor shall maintain policies and procedures addressing advanced
directives for adult members that specify:
a. Each contract or agreement with a hospital, nursing facility, home
health agency, hospice or organization responsible for providing
personal care must comply with federal and State law regarding advance
directives for adult members. Requirements include:
(1) Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the
right to accept or refuse medical care, and the right to
execute an advance directive. If the agency/organization has a
conscientious objection to carrying out an advance directive,
it must be explained in policies. (A health care provider is
not prohibited from making such objection when made pursuant
to ARS ss.36-3205.C.1.)
(2) Provide written information to adult members regarding each
individual's rights under State law to make decisions
regarding medical care, and the health care provider's written
policies concerning advance directives (including any
conscientious objections).
(3) Documenting in the member's medical record whether or not the
adult member has been provided the information and whether an
advance directive has been executed.
(4) Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and
not making it a condition for the provision of care.
(5) Providing education to staff on issues concerning advance
directives including notification of direct care providers of
services, such as home health care and personal care, of any
advanced directives executed by members to whom they are
assigned to provide services.
b. Contractors shall encourage subcontracted PCPs to comply with the
requirements of subparagraph a. (2) through (5) above. Contractors
shall also encourage health care providers specified in subparagraph a.
to
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provide a copy of the member's executed advanced directive, or
documentation of refusal, to the member's PCP for inclusion in the
member's medical record.
16. PERFORMANCE MEASUREMENT
All performance measures described below apply to Title XIX, Title XXI, and
state-only member populations.
Contractors shall strive to meet the AHCCCS stated performance measure goals.
However, it is equally important that Contractors continually improve their
performance measure outcomes from year to year. Improvement in performance is to
be measured by a reduction in the health plan's adverse outcomes. AHCCCS
requires the Contractor to achieve a reduction of ten percent or more from the
previous year's adverse outcomes. The Contractor's performance will also be
evaluated against the adjusted AHCCCS statewide average performance level,
excluding the effect of the Contractor's data.
AHCCCS will require the Contractor to have a quality improvement plan in place
when:
a) the Contractor has not achieved the AHCCCS statewide performance level
for any measure but has shown significant improvement, or
b) the Contractor's rate has declined but is at or above the AHCCCS
statewide performance level for any measure.
The Contractor will be required to submit a corrective action plan and may be
subject to sanctions if:
a) the Contractor has not achieved the AHCCCS statewide performance level
for any measure and has failed to show adequate improvement, or
b) if the Contractor's rate has declined and fallen below the AHCCCS
statewide performance level for any measure.
Corrective action plans must be received by the Office of the Medical Director
within 30 days of receipt of notification from AHCCCS. AHCCCS may conduct one or
more follow-up on-site reviews to verify compliance with a corrective action
plan.
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program to at least 80% of all enrolled
members under age 21 during CYE 2000. The participant rate is the number of
children receiving at least one medical screen compared to the number of
children expected to receive at least one medical screen. The number of children
expected to receive at least one medical screen is based on the federal
periodicity schedule and the average period of eligibility.
AHCCCSA will measure participation levels through encounter data and will not
use information from prior period coverage (see Paragraph D.6, Prior Period
Coverage) in evaluating the Contractor's performance.
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EPSDT IMMUNIZATIONS: The Contractor shall ensure members under age 21 receive
age-appropriate immunizations as specified in the AMPM. During CYE 2000, the
Contractor shall meet or exceed the following:
Immunization Percentage of Numbers of Doses
Members
Immunized
Diphtheria, Tetanus, Pertussis vaccine (DPT) 82% 4
Oral/Inactivated Polio Vaccine 87% 3
Measles, Mumps, Rubella Vaccine (MMR) 90% 1
H. Influenza, Type B (HIB) 90% 1
Hepatitis B (Hep B) 87% 3
Combined 3-Antigen Rate (4 DPT, 3 OPV, 1 MMR) 82% 8
Combined All Antigen 73% 11
Varicella Vaccine 50% 1
The Contractor shall conduct an annual immunization audit based on random
sampling to assess and verify the immunization status of two-year-old members.
AHCCCSA will provide the Contractor, within two weeks after the end of the
contract year, the selected sample, specifications for conducting the audit, the
AHCCCSA reporting requirements, and technical assistance. The Contractor shall
identify each child's PCP, conduct the assessment, and report to AHCCCSA in the
required format all immunization data for the sampled two-year-old children no
later than December 15 after the end of the contract year. If medical records
are missing for more than 5% of the sample group, the Contractor is subject to
sanctions by AHCCCSA. The External Quality Review Contractor will conduct a
study to validate the Contractor's reported rates.
PERFORMANCE INDICATORS: For CYE 2000, the Contractor shall comply with AHCCCS
quality management requirements to improve performance for all AHCCCS
established performance indicators. Complete descriptions of these indicators
can be found in the document Health Plan Performance Indicators, User and
Technical Specifications. AHCCCS has established goals for the following
indicators: annual dental visits; well-child visits in the first 15 months of
life; and well-child visits in the 3rd, 4th, 5th and 6th years of life.
ANNUAL DENTAL VISITS: The Contractor shall take affirmative steps to increase
utilization of dental services for members under age 21. At least 55% of all
enrolled members between the ages of 3 to 21 shall have at least one dental
visit during CYE 2000. AHCCCSA will monitor utilization through reported
encounter data.
WELL CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE: The Contractor shall ensure
that members under the age of 15 months receive all recommended well-child
visits as specified in the AMPM. During CYE 2000, the Contractor shall ensure
that a minimum of 64% of its members receive all recommended well-child visits.
WELL-CHILD VISITS IN THE 3RD, 4TH, 5TH AND 6TH YEARS OF LIFE: The Contractor
shall ensure that members 3, 4, 5 and 6 years of age receive all recommended
well-child visits as specified in the AMPM. During CYE 2000, the Contractor
shall ensure that a minimum of 64% of its members receive at least one
well-child visit during the contract year.
CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS: The Contractor shall ensure
that members under age 21 have access to primary care provider (PCP) services.
During CYE 2000, the Contractor shall ensure that a minimum of 70% of members
under age 21 visit their PCP at least once during the contract year.
ACCESS TO CARE: AHCCCSA will measure access to care through four new measures:
Provider Turnover, Board Certified/Residence Completed, Provider Compensation
and Availability of Languages. Baselines for these measures will be established
at the beginning of CYE 2000.
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17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
The Contractor shall provide to members quality medical care as described in the
AMPM, Chapter 900, regardless of payer source or eligibility category. The
Contractor shall institute processes to assess, plan, implement and evaluate
quality improvement activities. The Contractor shall conduct two clinical
studies each contract year as required in Chapter 900 of the AMPM. AHCCCSA will
determine the subject matter and study methodology for one of the annual studies
and the Contractor shall submit to AHCCCSA by November 15 of each contract year
its proposed subject matter and methodology for the other. The results of the
studies shall be submitted to AHCCCS, Office of the Medical Director, within 180
days after the end of each contract year.
The Contractor must maintain a written QM/UM plan, which details plans for
compliance with the AMPM. The Contractor shall incorporate in its QM/UM plan an
action plan for improving the performance rates for those indicators with
established baselines.
18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. In order to
obtain approval, the following must be submitted to the Office of Managed Care
45 days prior to the implementation of the contract:
1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the
substantial financial risk definition.
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or HCFA.
Please refer to the "Physician Incentive Guidelines" in the Bidder's Library for
details on providing required disclosures.
19. APPOINTMENT STANDARDS
For purposes of this section, "urgent" is defined as an acute but not
necessarily severe disorder, which, if not attended to, could endanger the
patient's health. The Contractor shall have procedures in place that ensure the
following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within two days of request
c. Routine care PCP appointments - within 21 days of request
For specialty referrals, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within 3 days of referral
c. Routine care appointments - within 30 days of referral
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For dental appointments, the Contractor shall be able to provide:
a. emergency appointments - within 24 hours of request
b. urgent appointments - within 3 days of request
c. routine care appointments - within 45 days of request
For maternity care, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within 3 days of request
d. High risk pregnancies - within 3 days of identification of
high risk by the Contractor or
maternity care provider, or immediately
if an emergency exists
If a member needs medically-necessary transportation, the Contractor shall
require its transportation provider to schedule the transportation so that the
member arrives no sooner than one hour before the appointment; does not have to
wait more than one hour after making the call to be picked up; nor have to wait
for more than one hour after conclusion of the appointment for transportation
home.
The Contractor shall actively monitor the adequacy of its appointment processes
and reduce the unnecessary use of alternative methods such as emergency room
visits. The Contractor shall monitor and ensure that a member's waiting time for
a scheduled appointment at the PCP's or specialist's office is no more than 45
minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network about appointment time requirements. The Contractor must assign
a specific staff member or unit within its organization to monitor compliance
with appointment standards and shall require a corrective action plan when
appointment standards are not met.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists to include, at a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
The Contractor shall comply with all applicable physician referral requirements
and conditions defined in Sections 1903(s) and 1877 of the Social Security Act.
Upon finalization of the regulations, the Contractor shall comply with all
applicable physician referral requirements and conditions defined in 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician's
family has a financial relationship. Designated health services include:
Clinical laboratory services
Physical therapy services
Occupational therapy services
Radiology services
Radiation therapy services and supplies
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Durable medical equipment and supplies
Parenteral and enteral nutrients, equipment and supplies
Prosthetics, orthotics and prosthetic devices and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of
the provider
c. Overview of the Contractor's Provider Service department and
function
d. Listing and description of covered and non-covered services,
requirements and limitations including behavioral health
services
e. Emergency room utilization (appropriate and non-appropriate
use of the emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive
unclothed physical examination, appropriate vision testing,
hearing testing, laboratory tests, dental screenings and
immunizations
g. Dental services
h. Maternity/Family Planning services
i. The Contractor's policy regarding PCP assignments
j. Referrals to specialists and other providers, including access
to behavioral health services provided by the ADHS/RBHA
system.
k. Grievance and appeal rights
l. Billing and encounter submission information
- indicate which form UB92, HCFA 1500, or Form C is to
be used for services
- indicate which fields are required for a claim to be
considered acceptable by the Contractor. A completed
sample of each form shall be included
m. Contractor's written policies and procedures which affect the
provider(s) and/or the provider network
n. Claims re-submission policy and procedure
o. Reimbursement, including reimbursement for dual eligibles
(i.e. Medicare and Medicaid) or members with other insurance
p. Explanation of remittance advice
q. Prior authorization requirement
r. Claims medical review
s. Concurrent review
t. Fraud and Abuse
u. Formularies (with updates and changes provided in advance to
providers, including pharmacies)
v. AHCCCS appointment standards
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22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics, gynecology, or pediatrics; certified nurse practitioners or
certified nurse midwifes; or physician's assistants.
At a minimum, the Contractor's number of full-time equivalent PCPs to enrolled
members shall not exceed a ratio of 1:1800 for adults and 1:1200 for children
who are 12 or younger. If the PCP contracts with more than one AHCCCS health
plan, the ratio shall be adjusted by the Contractor to ensure the total number
of AHCCCS members does not exceed the above ratio. The Contractor should
consider the PCP's total patient panel size (i.e., AHCCCS and non-AHCCCS
patients) when assessing the PCP's ability to meet AHCCCS' appointment and other
standards. In addition, AHCCCS members shall not comprise the majority of the
PCP's panel of patients. The Contractor shall also reduce the number of members
assigned to its network PCPs as necessary to meet the appointment standards
specified in Section D, Paragraph 19, Appointment Standards. Any variation to
the above standards must be submitted to AHCCCSA, Office of the Medical Director
for prior approval. PCPs with assigned members diagnosed with AIDS or as
HIV-positive shall meet criteria and standards set forth in AHCCCS Medical
Policy and AHCCCS AIDS Advisory Committee Guidelines.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions who are age 12 and younger to Board-certified
pediatricians.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP assignment, should the member desire to do so. The
Contractor shall confirm any PCP change in writing to the member. Members may
make both their initial PCP selection and any subsequent PCP changes either
verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of Managed Care, and shall be monitored through operational
audits. PCPs and specialists who provide inpatient services to the Contractor's
members shall have admitting and treatment privileges in a minimum of one
general acute care hospital that is located within the Contractor's service
area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet
the medical needs of its members.
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b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English.
Contractor policies shall be subject to approval by AIICCCSA, Office of Managed
Care, and shall be monitored through operational audits.
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services, except
that women shall have direct access to GYN providers without a referral
for preventive and routine services. Any waiver of this requirement by
the Contractor must be approved in advance by AHCCCSA.
b. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies of test
results if applicable, treatment services provided and the resulting
outcome for each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians and certified nurse practitioners and certified nurse midwives who
include such services within their practice.
24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient professional and
paramedical personnel for the provision of covered services, including emergency
medical care on a 24-hour-a-day, 7-days-a-week basis. The proposed network shall
be sufficient to provide covered services within designated time and distance
limits. For Maricopa and Pima Counties only, this includes a network such that
95% of its members residing within the boundary area of metropolitan Phoenix and
Tucson do not have to travel more than 5 miles to see a PCP or pharmacy. 95% of
its members residing outside the boundary area must not have to travel more than
10 miles to see such providers. See Attachment B, Minimum Network Requirements,
for details on network requirements by Geographic Service Area. Also see Section
D, Paragraph 35, Hospital Subcontracting and Reimbursement, for details on
changes in hospital subcontracting effective October 1, 1998.
Under the Balanced Budget Act of 1997, the Contractor shall not discriminate
with respect to participation in the AHCCCS program, reimbursement or
indemnification against any provider based solely on the provider's type of
licensure or certification. This provision, however, does not prohibit the
Contractor from limiting provider
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participation to the extent necessary to meet the needs of the Contractor's
members. This provision also does not interfere with measures established by the
Contractor to control costs consistent with its responsibilities under this
contract.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertains to all
service specifications described in the Chapters 300, 600 and 900. In addition,
the Contractor shall have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements
b. Monitor and control network compliance with policies and rules of
AHCCCSA and the Contractor, including compliance with all policies and
procedures related to the grievance process and ensuring the member's
care is not compromised during the grievance process.
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area
e. Monitor network capacity to ensure that there are sufficient providers
to handle the volume of members
f. Ensure service accessibility, including monitoring appointment
procedures standards, appointment waiting times, and service provision
standards
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one,
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract. The
Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun, for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates in OBRA 89 and OBRA 90. This
legislation gives FQHCs the option to require state Medicaid programs to
reimburse the FQHC at 100% of reasonable costs for the services delivered to
Title XIX members. AHCCCSA and its contractors are required to comply with this
legislation. The following payment methodology for reasonable cost reimbursement
was implemented effective October 1, 1997.
If the FQHC elects reasonable cost reimbursement, the FQHC will receive a
quarterly payment per Title XIX member per month from AHCCCSA. The initial
capitation amount will be $1.75 PMPM statewide. In accordance with the Balanced
Budget Act of 1997, this additional reimbursement will be phased out over a
five-year period beginning in contract year ending 2000:
CONTRACT YEAR PHASE-OUT PERCENTAGE PMPM AMOUNT
1997 through 1999 No phase-out $ 1.75
2000 95% $ 1.66
2001 90% $ 1.58
2002 85% $ 1.49
2003 70% $ 1.23
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2004 100% $ 0.00
Contractors are required to submit member month information for Title XIX
members for each FQHC on a quarterly basis to AHCCCS Office of Managed Care.
AHCCCSA will perform periodic audits of the member month information submitted.
Contractors should refer to the Office of Managed Care's policy on FQHC
reimbursement for further guidance. The following FQHCs are currently recognized
by HCFA:
Clinica Adelante, Inc.
El Rio Health Center
Lake Powell Medical Center
Mariposa Community Health Center, Inc.
Mountain Park Health Center
Sun Life Family Health Center
United Community Health Center, Inc.
Sunset Community Health Center (formerly Valley Health Center, Inc.)
Inter-Tribal Health Care Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
Chiricahua Community Health Centers, Inc.
Marana Health Center
North Country Community Health Center
Any other clinics that subsequently become FQHCs will be subject to the
reimbursement methodology described above upon electing reasonable cost
reimbursement from AHCCCSA.
27. PROVIDER REGISTRATION
The Contractor shall ensure that all of its subcontractors register with AHCCCSA
as an approved service provider and receive an AHCCCS Provider ID Number. A
Provider Participation Agreement must be signed with each provider who does not
already have a current AHCCCS ID number. The original shall be forwarded to
AHCCCSA. This provider registration process must be completed in order for the
Contractor to report services a subcontractor renders to enrolled members and
for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TAPE
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Tape User Manual on October 15, January 15, April 15, and
July 15 of each contract year. The Manual may be found in the Bidder's Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its HCFA grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on
or before scheduled due dates.
b. Accuracy: Reports or other required data shall be prepared in
strict conformity with appropriate authoritative
sources and/or AHCCCS defined standards.
c. Completeness: All required information shall be fully disclosed
in a manner that is both responsive and pertinent
to report intent with no material omissions.
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AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time dining the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA, or the federal government, to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials which are produced by the Contractor and
refer to covered services shall state that such services are funded under
contract with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business for the initial contract year beginning 10/1/97.
The purpose of Readiness Reviews is to assess new contractors' readiness and
ability to provide contract services to members at the start of the contract
year. A new contractor will be permitted to commence operations only if the
Readiness Review factors are met to AHCCCSA's satisfaction.
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with HCFA requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The Contractor shall comply
with all other medical audit provisions as required by AHCCCS Rule R9-22-52l and
R9-31-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AMCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel as identified in advance shall be
available to the Review Team at all times during AHCCCSA on-site review
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activities. While on-site, the Contractor shall provide the Review Team with
workspace, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the Contractor has obtained accreditation from NCQA or
any other nationally recognized accrediting body. The Contractor must submit the
entire NCQA report to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in implementing recommendations and
achieving program compliance. Follow-up reviews may be conducted at any time
after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost avoiding and paying claims in accordance with AHCCCS Rule
R9-22-705, a copy of which may be found in the Bidder's Library. In the absence
of a subcontract provision to the contrary, claims submission deadlines shall be
calculated from the date of service or the effective date of enrollment,
whichever is later. Remittance advices accompanying the Contractor's payments to
providers must contain, at a minimum, adequate descriptions of all denials and
adjustments, the reasons for such denials and adjustments, the amount billed,
the amount paid, and grievance rights. The Contractor's claims payment system,
as well as its prior authorization and concurrent review process, must minimize
the likelihood of having to recoup already-paid claims. Any recoupment in excess
of $50,000 per provider within a contract year must be approved in advance by
AHCCCSA, Office of Managed Care.
In accordance with the Balanced Budget Act of 1997, the Contractor shall ensure
that 90% of all clean claims are paid within 30 days of receipt of the clean
claim and 99% are paid within 90 days of receipt of the clean claim.
During the term of this contract, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout. All formats are subject to changes initiated by the
Kennedy-Kassebaum legislation. Reasonable implementation timeframes will be
negotiated with each plan.
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
MARICOPA AND PIMA COUNTIES ONLY: Laws of 1996 Chapter 288 Section 20 authorizes
the Hospital Reimbursement Pilot Program (Pilot), which is effective from
October 1, 1997, through September 30, 2000. The Pilot as defined by AHCCCS Rule
R9-22-718 requires hospital subcontracts to be negotiated between health plans
in Maricopa and Pima counties and hospitals to establish reimbursement levels,
terms and conditions. Subcontracts shall be negotiated by the Contractor and
hospitals to cover operational concerns, such as timeliness of claims submission
and payment, payment of discounts or penalties, legal resolution, which may, as
an option, include establishing arbitration procedures. These negotiated
subcontracts shall remain under close scrutiny by AHCCCSA to insure availability
of quality services within specific service districts, equity of related party
interests, reasonableness of rates, and only marketing of contracted
organizations. The general provisions of this program encompass acute care
hospital services and outpatient
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hospital services that result in an admission. The Contractor shall submit all
hospital subcontracts and any amendments to AHCCCSA, Office of Managed Care, for
prior approval. For non-emergency patient-days, the Contractor shall ensure that
at least 85% of its members use contracted hospitals. AHCCCSA reserves the right
to subsequently adjust the 85% standard. Further, if in AHCCCSA's judgment the
number of emergency days at a particular non-contracted hospital becomes
significant, AHCCCSA may require a subcontract at that hospital. Hospitals and
health plans/program contractors outside of Maricopa and Pima counties are not
included in this Pilot. Offerors should refer to the "Hospital Reimbursement
Pilot Program Packet" for additional information and requirements.
ALL GSA'S EXCEPT MARICOPA AND PIMA: The Contractor shall reimburse hospitals for
member care in accordance with AHCCCS Rule R9-22-705. The Contractor is
encouraged to obtain contracts with hospitals in all other GSA's and must submit
copies of these contracts to AHCCCSA, Office of Managed Care, at least seven
days prior to the effective dates thereof.
FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment If the Contractor fails to identify lack of medical necessity through
concurrent review and/or prepayment medical review, lack of medical necessity
identified during postpayment medical review shall not constitute a basis for
recoupment by the Contractor. See also Section D, Paragraph 34, Claims Payment
System. For a more complete description of the guidelines for hospital
reimbursement, please consult the Bidder's Library for applicable statutes and
rules.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment. The Contractor is
responsible for payment of services while the member is enrolled with the
Contractor. The Contractor is not responsible for the full 90 days of nursing
facility coverage if ALTCS enrollment occurs before the 90 days has ended.
The Contractor shall provide medically necessary nursing facility services for
any member who has a pending ALTCS application, who is currently residing in a
nursing facility and is eligible for services provided under this contract. If
the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days of nursing facility coverage,
the Contractor is only responsible for nursing facility coverage during the time
the member is enrolled with the Contractor. Nursing facility services covered by
a third party insurer (including Medicare) while the member is enrolled with the
Contractor shall be applied to the 90 day limitation.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application process and to prepare for potential fee-for-service coverage if the
stay goes beyond the 90-day maximum.
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37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, SOBRA supplement, HIV-AIDS supplement,
reinsurance (PPC and prospective), and third party liability, as described and
defined within this contract and appropriate laws, regulations or policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of ARS Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, any
savings remaining to the Contractor as a result of favorable claims experience
and efficiencies in service delivery at the end of the contract term may be kept
by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in ARS ss.36-2913. An error discovered by the State with or
without an audit in the amount of fees paid to Contractor will be subject to
adjustment or repayment by Contractor making a corresponding decrease in a
current Contractor's payment or by making an additional payment by AHCCCSA to
the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation for newborns of
members who were enrolled at the time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE `98 and CYE `99, AHCCCSA
will offer a reconciliation process for contractors whose total PPC medical cost
experience (excluding administrative and non-operating expenses) is more than
10% higher than the reimbursement associated with PPC in two areas: the "retro"
portion of the capitation rate for all rate categories, and the prospective
three-day notification period for MNMI recipients only. Expenses for the retro
period only will be net of reinsurance.
AHCCCSA will reimburse 100% of a Contractor's excess reasonable costs in excess
of a 10% limit as determined by reported encounters. AHCCCS will recoup profit
amounts in excess of a 10% limit.
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For contract years beginning with CYE `00, a full reconciliation to 0% profit or
loss will be done by AHCCCSA for the same eligibility time periods and risk
groups noted above. AHCCCSA will reimburse the health plans 100% of any excess
reasonable costs as determined by reported encounters, and all profits will be
recouped. Refer to the Office of Managed Care's PPC Reconciliation Policy for
further details of the reconciliation process.
KIDSCARE CAPITATION: The Contractor will be paid capitation for KidsCare members
in the same manner as prospective capitation (see above). KidsCare capitation
rates will be set by AHCCCSA in conjunction with an independent actuary.
Following CYE 99, AHCCCSA will review the assumptions made in setting the
capitation rates and may, at its option, reconcile and/or adjust the rates.
DELIVERY SUPPLEMENT: When the Contractor has an enrolled woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
supplemental payment. Supplemental payments will not apply to women who deliver
in a prior period coverage time period. AHCCCSA reserves the right at any time
during the term of this contract to adjust the amount of this payment for women
who deliver at home.
HIV-AIDS SUPPLEMENT: In addition to the capitation payment described above, a
separate and additional payment will be made to the Contractor to help defray
costs for members receiving approved protease inhibitors and associated lab work
related to their treatment for HIV/AIDS. The list of AHCCCSA-approved protease
inhibitors is available in the Bidder's Library.
On a quarterly basis, the Contractor shall submit to AHCCCSA, Office of Managed
Care, an unduplicated monthly count of members, by rate code, who are using
approved protease inhibitors. The report shall be submitted, along with the
quarterly financial reporting package, within 60 days after the end of each
quarter.
The rate of reimbursement for this separate per member per month payment is
specified in Section B and is subject to review during the term of the contract.
Payment will be made quarterly to the Contractor based on the reported members
for the preceding quarter. AHCCCSA will review this HIV/AIDS-related data at
least annually as part of its Operational and Financial Review and reserves the
right to recoup any amounts paid for ineligible members as determined through
this review as well as an associated penalty for incorrect reporting.
Refer to the Office of Managed Care's HIV/AIDS supplemental payment and review
policies for further details and requirements.
INCENTIVE FUND: AHCCCSA may retain a specified percentage of capitation
reimbursement in order to distribute to Contractors based on their performance
measure outcomes. AHCCCSA will notify Contractors 60 days prior to a new
contract year if this methodology will be implemented and will provide details
of the reimbursement methodology at that time. See Paragraph 16, Performance
Measurement for more details on the performance goals.
38. CAPITATION ADJUSTMENTS
Except for changes made specifically in accordance with this contract, the rates
set forth in Section B shall not be subject to re-negotiation or modification
during the contract period. AHCCCSA may, at its option, review the effect of a
program change and determine if a capitation adjustment is needed. In these
instances the adjustment will be prospective with assumptions discussed with the
Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable;
AHCCCSA will not unreasonably withhold such a review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
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a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits from the date
of incarceration)
c. duplicate capitation to the same contractor
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503 and R9-31-503). Per
diem rates paid for nursing facility services, including room and board,
provided in lieu of hospitalization for up to 90 days in any contract year shall
be eligible for reinsurance coverage. Refer to the AHCCCS Reinsurance Claims
Processing Manual for further details on the Reinsurance Program. Reinsurance
for the Hospital Reimbursement Pilot Program (See Section D, Paragraph 35,
Hospital Reimbursement), will be paid in accordance with AHCCCS Rule R9-22-503
and R9-31-503.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's statewide AHCCCS acute care
enrollment (not including SOBRA Family Planning Extension services) as of
October 1st each contract year for all rate codes and counties, as shown in the
following table. These deductible levels are subject to change by AHCCCSA during
the term of this contract.
PROSPECTIVE REINSURANCE PPC REINSURANCE
- ---------------------------------------------------------------------------------------------------------------
STATEWIDE PLAN MNMI NON-MNMI COINSURANCE ALL RATE CODES COINSURANCE
ENROLLMENT DEDUCTIBLE DEDUCTIBLE
- ---------------------------------------------------------------------------------------------------------------
0-19,999 $15,000 $20,000 75% $5,000 100%
- ---------------------------------------------------------------------------------------------------------------
20,000-49,999 $15,000 $35,000 75% $5,000 100%
- ---------------------------------------------------------------------------------------------------------------
50,000 and over $15,000 $50,000 75% $5,000 100%
- ---------------------------------------------------------------------------------------------------------------
A Contractor whose enrollment qualifies for the $35,000 or $50,000 non-MN/MI
deductible level may, prior to the start of the contract period, elect one of
the lower deductible levels indicated in the above table. Contractors may not
elect to increase their deductible level. If a Contractor's actual non-MN/MI
deductible is $35,000 or $50,000, AHCCCSA will increase the Contractor's
capitation rate awarded by defined amounts for each capitation risk group. These
specific capitation adjustments are available from the Office of Managed Care.
PRIOR PERIOD COVERAGE REINSURANCE: A separate reinsurance deductible and
coinsurance percentage will apply during prior period coverage. As noted in the
table above, all Contractors, regardless of enrollment, will be subject to a
$5,000 deductible level. The coinsurance percentage for the prior period
coverage reinsurance is 100%. Expenses incurred during prior period coverage
will not apply toward the prospective reinsurance thresholds.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
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Effective October 1, 1998, when a member changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs incurred for that
member will follow the member to the receiving health plan. Therefore, all
submitted encounters from the health plan the member is leaving (for dates of
service within the current contract year) will be applied toward the receiving
health plan's deductible level. For further details regarding this policy and
other reinsurance policies refer to the AHCCCS Reinsurance Claims Processing
Manual.
Medical review on prospective and prior period coverage reinsurance cases will
be determined based on statistically valid retrospective random sampling.
AHCCCSA, Office of the Medical Director, will generate the sampling and will
notify the Contractor of documentation needed for the retrospective medical
review process to occur at the Contractor's offices. Reinsurance consideration
will be given to inpatient facility contracts, and hearing decisions rendered by
the Office of Legal Assistance. Pre-hearing and/or hearing penalties
discoverable during the review process will not be reimbursed under reinsurance.
A recoupment of reinsurance reimbursements made to the Contractor will occur
based on the results of the medical review sampling. The results of the medical
review sampling will be separately extrapolated to the entire prospective and
prior period coverage reinsurance reimbursement populations in the review time
frame for the Contractor. AHCCCSA will give the Contractor at least 45 days
advance notice of any on-site review. The Contractor shall have all requested
medical records on-site. Any documents not requested in advance by AHCCCSA shall
be made available upon request of the Review Team during the course of the
review. The Contractor representative shall be available to the Review Team at
all times during AHCCCSA on-site review activities. While on-site, the
Contractor shall provide the Review Team with workspace, access to a telephone,
electrical outlets and privacy for conferences. The Contractor will be furnished
a copy of the Reinsurance Review Report within 60 days of the onsite review and
given an opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia, von Willebrand's Disease, and Gaucher's Disease. This program
also covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver, kidney,
and other organ transplantation. For additional detail and restrictions refer to
the AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All catastrophic claims are
subject to medical review by AHCCCSA.
The Contractor shall notify AHCCCSA, Office of the Medical Director, Reinsurance
Unit, of cases identified for catastrophic non-transplant reinsurance coverage
within 30 days of (a) initial diagnosis, (b) enrollment with the Contractor, and
(c) the beginning of each contract year. Catastrophic reinsurance will be paid
for a maximum 30-day retroactive period from the date of notification to
AHCCCSA.
HEMOPHILIA: When a member is identified as being catastrophically eligible by
AHCCCSA due to the specific diagnosis of hemophilia (ICD9 codes 286.0, 286.1,
286.2), all medically necessary covered services provided during the contract
year shall be eligible for reimbursement at 85% of the Contractor's paid amount.
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII. The Contractor must promptly notify AHCCCS
Office of the Medical Director Reinsurance Unit after diagnosis. All medically
necessary covered services provided during the contract year shall be eligible
for reimbursement at 85% of the Contractor's paid amount.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy. All medically necessary covered services provided during
the contract year shall be eligible for reimbursement at 85% of the Contractor's
paid amount.
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TRANSPLANTS: Bone grafts and cornea transplantation services are not eligible
for catastrophic reinsurance coverage but are eligible under the regular
(non-catastrophic) reinsurance program. Refer to the AMPM, Chapter 300 for
covered services for organ and tissue transplants. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor's paid amount,
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library. When a member is referred to a transplant facility for an
AHCCCS-covered organ transplant, the Contractor shall notify AHCCCSA, Office of
the Medical Director.
Encounter data will not be used to determine catastrophic reinsurance benefits
for transplants. However, this does not relieve the Contractor of the
responsibility for submitting encounters for all catastrophic reinsurance
services.
All reinsurance claims must be submitted in accordance with R9-22-703 and the
AHCCCS Reinsurance Claims Processing Manual.
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. See Section D, Paragraph 41, Medicare
Services and Cost Sharing.
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for coinsurance and deductibles is limited
to what the Contractor would have paid for the entire service pursuant to a
written contract with the provider or the AHCCCS fee-for-service rate, less any
amount paid by the third party. (The Contractor must decide whether it is more
cost-effective to provide the service within its network or pay coinsurance and
deductibles for a service outside its network. For continuity of care, the
Contractor may also choose to provide the service within its network.) If the
Contractor refers the member for services to a third-party insurer (other than
Medicare), and the insurer requires payment in advance of all copayments,
coinsurance and deductibles, the Contractor must make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
pre-natal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost-avoid. The
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Contractor shall identify all potentially liable third parties and pursue
reimbursement from them except in the circumstances below. The Contractor shall
not pursue reimbursement in the following circumstances unless the case has been
referred to the Contractor by AHCCCSA or AHCCCSA's authorized representative:
Uninsured/underinsured motorist insurance Adoption recovery
First-and third-party liability insurance Worker's Compensation
Tortfeasors Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22- 1002 and R9-31-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related costs. AHCCCSA's
authorized representative is also responsible for negotiating and acting in the
best interest of all parties to obtain a reasonable settlement in joint cases
and may compromise a settlement in order to maximize overall reimbursement, net
of legal and other costs. For total plan cases involving only payments from the
Contractor, the Contractor is responsible for performing all research,
investigation, the filing of liens and payment of lien filing fees and other
related costs. The Contractor shall use the cover sheet as prescribed by AHCCCS
when filing liens.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING: The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. In addition, upon AHCCCS's request, the Contractor shall
provide an electronic extract of the Casualty cases, including open and closed
cases. Data elements include, but are not limited to: the member's first and
last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount;
and case status. The AHCCCSA TPL Section shall provide the format and reporting
schedule for this information to the Contractor. The Contractor shall notify
AHCCCSA's authorized representative within five working days of the
identification of a third-party liability case with known reinsurance (often
referred to as joint liability cases). The Contractor shall communicate any
known change in health insurance information, including Medicare, to AHCCCS
Administration, Division of Member Services, not later than 10 days from the
date of discovery using the AHCCCS Third-Party Coverage Form found in the
Bidder's Library.
AHCCCSA will provide the Contractor, on an agreed upon schedule, with a complete
file of all third-party coverage information (other than Medicare) for the
purpose of updating the Contractor's files. The Contractor shall notify AHCCCSA
of any known changes in coverage within deadlines and in a format prescribed by
AHCCCSA.
TITLE XXI (KIDSCARE): Eligibility for KidsCare benefits requires that the
applicant/member not be enrolled with or entitled to any other health insurance
benefits. If the Contractor becomes aware of any such potential coverage, the
Contractor shall notify AHCCCSA immediately. The Contractor shall follow the
same cost avoidance and postpayment recovery practices for the KidsCare
population as it does for the Title XIX population, and shall maintain a
reporting system which allows Title XIX and KidsCare information to be reported
separately.
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41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligible". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
sharing responsibilities that apply to dual eligible members based on a variety
of factors. The Contractor is responsible for adhering to the cost sharing
responsibilities presented in the AHCCCS Medicare Cost Sharing policy. Effective
10/1/97, the Contractor shall have no cost sharing obligation if the Medicare
payment exceeds what the Contractor would have paid for the same service of a
non-Medicare member.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-711 and R9-31-711. In accordance with the
requirements mandated by the Balance Budget Act of 1997, the Contractor may not
collect copayments for family planning services.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or federal government.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
a. If this contract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available
for a period of five years from the date of any such termination.
b. Records which relate to grievances, disputes, litigation or the
settlement of claims arising out of the performance of this contract,
or costs and expenses of this contract to which exception has been
taken by AHCCCSA, shall be retained by the Contractor for a period of
five years after the date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request.
The Contractor is responsible for ensuring that a medical record is established
when information is received about a member. If the PCP has not yet seen the
member, such information may be kept temporarily in an appropriately labeled
file, in lieu of actually establishing a medical record, but must be associated
with the member's medical record as soon as one is established.
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The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (ARS ss.36-664I)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSAs as a result of an accumulated deficit, even if unaudited.
47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
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The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCSA shall be responsible for
any incorrect or delayed payment to the Contractor's AHCCCS services providers
(subcontractors) resulting from such error, omission, deletion, or erroneous
input data caused by the Contractor in the submission of AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
ELECTRONIC DATA INTERCHANGE (EDI): IN addition to the requirements outlined in
Section D, Paragraph 34, Claims Payment System, the Contractor will be required
to comply with all EDI standards which result from the Kennedy-Kassebaum
legislation. This law requires the Department of Health and Human Services to
provide national electronic submission standards for health care data and may
include compliance with National Provider Identifier requirements. The Secretary
has 18 months to develop these standards. As the standards are finalized,
AHCCCSA will phase in the implementation. For encounter data transmissions, it
is anticipated that AHCCCS will make these standards available by March 1, 2000.
Effective October 1, 2000, the electronic standards will be required for
encounters. Electronic standards which may be implemented include, but are not
limited to, encounters, enrollment and capitation payments.
YEAR 2000 COMPLIANCE: The Contractor shall undertake all appropriate planning
measures to ensure timely compliance with all Year 2000 requirements. In
addition, the Contractor shall develop contingency plans addressing alternative
processes to ensure that operations continue in the event that systems fail.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance measures. The
Contractor shall submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability, including services provided
during prior period coverage. This requirement is a condition of the HCFA grant
award.
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AMCCCSA-supplied formats. Formatting and specific
requirements for encounter data are described in the
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AHCCCS Encounter Reporting User Manual and the AHCCCS Technical Interface
Guidelines, copies of which may be found in the Bidder's Library. The Encounter
Submission Requirements are included herein as Attachment I.
An Encounter Submission Tracking Report must be maintained and made available to
AHCCCSA upon request. The Tracking Report's purpose is to link each claim to an
adjudicated or pended encounter returned to the Contractor. Further information
regarding the Encounter Submission Tracking Report may be found in The Encounter
User's Manual.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data, which the Contractor
shall use to update its member records. The daily roster which is run prior to
the monthly roster is referred to as the "last daily" and will contain all rate
code changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next month. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/97 through 9/30/98. In addition,
AHCCCSA reserves the sole option to extend the term of the contract, not to
exceed a total contracting period of five years. The terms and conditions of any
such contract extension shall remain the same as the original contract, as
amended. Any contract extension, however, shall not affect the maximum
contracting period of five years. All contract extensions shall be through
contract amendment. If, in conjunction with a contract extension, AHCCCSA elects
to increase the capitation rate for any rate code category, such increase will
not exceed the inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
AHCCCSA may require a contractor to renew all GSAs, or may terminate remaining
GSAs if the Contractor does not agree to renew all GSAS.
When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses to sign the extension amendment. If the Contractor provides such
notification, AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 120 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
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51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See policy on claims processing by
subcontracted providers in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
See also Section D, Paragraph 35, Hospital Reimbursement, regarding required
submission of hospital subcontracts.
The Contractor shall maintain a fully executed original of all subcontracts,
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is voidable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of federal and State laws,
regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the
contract year refuses to enter into a written agreement with the
Contractor, the Contractor shall submit documentation of such refusal
to AHCCCS Office of Managed Care within seven days of its final attempt
to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor. See Section D,
Paragraph 35, Hospital Subcontracting and Reimbursement
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and
for which compensation will be paid.
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e. The term of the subcontract including beginning and ending dates,
methods of extension, termination and re-negotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and
other third-party liability coverage and to seek such Medicare or third
party liability payment before submitting claims to the
Contractor/Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality
assurance programs and comply with the utilization control and review
procedures specified in 42 CFR Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in
ownership of a subcontractor that is related to or affiliated with the
Contractor shall require a contract amendment and prior approval of
AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population.
l. A provision that the subcontractor shall be fully responsible for all
tax obligations, Worker's Compensation Insurance, and all other
applicable insurance coverage obligations which arise under this
subcontract, for itself and its employees, and that AHCCSA shall have
no responsibility or liability for any such taxes or insurance
coverage.
m. A provision that the subcontractor must obtain any necessary
authorization from the Contractor or AHCCCSA for services provided to
eligible and/or enrolled members.
n. A provision that the subcontractor must comply with encounter reporting
and claims submission requirements as described in the subcontract.
52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over and supersede existing and future subcontracts for services
that are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement for
transplant surgery exceed that payable under the relevant AHCCCSA specialty
contract.
During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts. AHCCCSA shall provide at
least 60 days advance written notice to the Contractor prior to the
implementation of any specialty contract.
53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees charged and/or corporate
allocations made. If the fees or allocations actually paid out are determined to
be unjustified or excessive, amounts may be subject to repayment to the
Contractor, the Contractor may be placed on monthly financial reporting, and/or
financial sanctions may be imposed.
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54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are less than $50,000, AHCCCSA will waive the requirement for an audit of that
consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award.
Minimum capitalization requirements by GSA are as follows:
- -------------------------------------------------------------------------
Geographic Service Area Capitalization Requirement
GSA #2 Yuma $ 1,400,000
GSA #4 Mohave, La Paz 1,150,000
GSA #6 Yavapai, Coconino 1,250,000
GSA #8 Pinal, Gila 1,450,000
GSA #10 Pima 1,250,000
GSA #12 Maricopa 2,500,000
GSA #14 Graham, Greenlee 350,000
GSA #16 Apache, Navajo 650,000
GSA #18 Cochise, Santa Cruz 1,450,000
- -------------------------------------------------------------------------
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSAs, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSAs awarded. This requirement is in addition to the
Performance Bond requirements defined in Paragraphs 56 and 57 below and must be
met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above). Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the
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Contractor's obligations to providers, non-contracting providers, and
non-providers; and (2) performance by the Contractor of its obligations under
this contract. The Performance Bond shall be in a form acceptable to AHCCCSA as
described in the AHCCCS Performance Bond policy available in the Office of
Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers
and nonproviders by reason of a breach of the Contractor's obligations
under this contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses
incurred by reason of a breach of the Contractor's obligations under
this contract, including, but not limited to, expenses incurred after
termination of this contract for reasons other than the convenience of
the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above. The Contractor may not change
the amount, duration or scope of the performance bond without prior written
approval from AHCCCSA, Office of Managed Care.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement must be satisfied by the Contractor not
later than 15 days after notification by AHCCCSA of the amount required.
Thereafter, AHCCCSA shall evaluate the enrollment statistics of the Contractor
on a monthly basis. If there is an increase in capitation payment that exceeds
10% of the performance bond amount, AHCCCSA may require an increase in the
amount of the Performance Bond. The Contractor shall have 15 days following
notification by AHCCCSA to increase the amount of the Performance Bond. The
Performance Bond amount that must be maintained after the contract term shall be
sufficient to cover all outstanding liabilities and will be determined by
AHCCCSA. The Contractor may not change the amount of the performance bond
without prior written approval from AHCCCSA, Office of Managed Care.
58. FINANCIAL VIABILITY CRITERIA/ PERFORMANCE MEASURES
AHCCCSA has established the following financial viability criteria/performance
goals:
CURRENT RATIO Current assets divided by current
liabilities. "Current assets" includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%).
STANDARD: AT LEAST 1.00
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EQUITY PER MEMBER Equity, less on-balance sheet performance
bond, divided by the number of non-SOBRA
Family Planning Extension Services members
enrolled at the end of the period.
STANDARD: AT LEAST $150
(Failure to meet this standard may result in
an enrollment cap being imposed in any or all
contracted GSA.)
MEDICAL EXPENSE RATIO Total medical expenses (net of reinsurance,
TPL, HIV/AIDS Supplement) divided by total
capitation + SOBRA.
STANDARD: AT LEAST 85%
ADMINISTRATIVE COST Total administrative expenses (excluding
PERCENTAGE: income taxes), divided by total capitation +
SOBRA + TPL + reinsurance + HIV/AIDS
Supplement
STANDARD: NO MORE THAN 10%
RECEIVED BUT UNPAID Received but unpaid claims divided by the
CLAIMS (DAYS average daily medical expenses for the
OUTSTANDING) period, net of sub-capitation expense
STANDARD: NO MORE THAN 30 DAYS
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor must submit a detailed merger, reorganization and/or
transition plan to AHCCCSA Contracting Office for AHCCCSA review. The purpose of
the plan review is to ensure uninterrupted services to members, evaluate the new
entity's ability to support the provider network, ensure that services to
members are not diminished and that major components of the organization and
AHCCCS programs are not adversely affected by such merger, reorganization or
change in ownership.
60. SANCTIONS
AHCCCSA may suspend, deny, refuse to renew, or terminate this contract or any
related subcontracts in accordance with AHCCCS Rules R9-22-405 and R9-31-405 and
the terms of this contract and applicable federal or State law and regulations.
AHCCCSA may, in addition to these remedies, impose monetary sanctions if the
Contractor violates any provision stated in law or this contract in accordance
with AHCCCS Rules R9-22-406 and R9-31-406 and the provisions of this contract,
applicable federal or State law and regulations. Written notice will be provided
to the Contractor specifying the sanction to be imposed, the grounds for such
sanction and either the length of suspension or the amount of capitation
prepayment to be withheld. The Contractor may appeal the decision to impose a
sanction in accordance with AHCCCS Rule R9-22-804.
In addition to the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS financial viability standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
e. Failure to meet AHCCCS encounter standards
CURE NOTICE PROCESS: Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the
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period of time during which the Contractor must bring its performance back into
compliance with contract requirements. If, at the end of the specified time
period, the Contractor has complied with the cure notice requirements, AHCCCSA
will take no further action. If, however, the Contractor has not complied with
the cure notice requirements, AHCCCSA will proceed with the imposition of
sanctions.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right, are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals. The algorithm favors those
contractors with lower capitation rates. For further details on the AHCCCS
Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any time during the term of the contract and frequently does so in
response to contractor-specific issues of non-compliance (e.g. imposition of an
enrollment cap). The Contractor should consider this in preparing its response
to this RFP. AHCCCSA is not obligated to adjust for any financial impacts this
may have on the Contractor.
62. GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers, which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22-802; R9-31-802; R9-22-804 and R9-31-803.
The grievance process may not be delegated or subcontracted outside of the
health plan. Refer to Attachment H for a complete description of grievance
process requirements.
63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Legal Assistance, using the Quarterly Grievance Report Format on file in the
Bidder's Library. The Quarterly Grievance Report must be received by the
AHCCCSA, Office of Legal Assistance, no later than 45 days from the end of the
quarter.
64. KIDSCARE
On November 1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance
Program, referred to as "KidsCare". KidsCare provides health care coverage
statewide to eligible children 18 and younger and is provided through the
existing AHCCCS health plans, state employee HMOs that elect to participate, and
tribal facilities or Indian Health Service for Native Americans who elect to
receive services through them. Services will also be directly provided by
participating community health clinics and hospitals which predominantly serve
low income children.
The KidsCare service package is established by the legislature and approved by
HCFA through the State Plan. Services, limitations and exclusions are described
in Section D, Paragraph 1, Scope of Services. Capitation rates payable to the
Contractor for KidsCare members (age 18 and younger) will be set by AHCCCSA in
conjunction with an independent actuary.
Effective October 1,1999, KidsCare members in families with gross household
income over 150% and up to 200% of the federal poverty limit shall pay a premium
to AHCCCSA. The premium amount shall be based on the number of members in the
household and the gross family income in accordance with 9A.A.A.C., Article 14.
TITLE XXI PARENT/GUARDIAN HEALTH INSURANCE COVERAGE: ARS ss.36.2984 mandates
that the Contractor offer health insurance coverage to the parent(s) or legal
guardian(s) of a child who is eligible for Title XXI. The Contractor shall
establish rates for this coverage which must be approved by AHCCCSA, Office of
Managed
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Care, prior to implementation. Title XXI funds or any other federal or state
funds shall not be used to subsidize family coverage. The full cost of the
premium shall be paid by the parent or legal guardian who elects this coverage.
The Contractor may include provisions for pre-existing conditions and any other
medical underwriting considerations that are necessary to protect it from
adverse risk. For further information, refer to the Title XXI Parent/Guardian
Health Insurance Coverage Guidelines on file in the Bidder's Library.
65. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that could have an impact on services provided by the
Contractor on or after October 1, 1998. The following is a brief description of
the issues that AHCCCS is aware of at the time of the issuance of this renewal
amendment:
ELIGIBILITY BASED ON 100% OF THE FEDERAL POVERTY LEVEL (FPL): Through a
successful initiative effort, eligibility for AHCCCS has been expanded to allow
persons with income up to 100% of the FPL to become eligible for the Medicaid
program. Legislative action will be required to implement this new eligibility
guideline and HCFA must approve the expansion. If HCFA approval is granted,
there will be a significant number of new persons who will be eligible for the
program and enrolled with the health plans at some future date.
[END OF SECTION D]
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SECTION E: CONTRACT CLAUSES
Table of Contents
1 APPLICABLE LAW.....................................................................................57
2 AUTHORITY..........................................................................................57
3 ORDER OF PRECEDENCE................................................................................57
4 CONTRACT INTERPRETATION AND AMENDMENT..............................................................57
5 SEVERABILITY.......................................................................................57
6 RELATIONSHIP OF PARTIES............................................................................57
7 ASSIGNMENT AND DELEGATION..........................................................................58
8 GENERAL INDEMNIFICATION............................................................................58
9 INDEMNIFICATION -- PATENT AND COPYRIGHT............................................................58
10 COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS.............................................58
11 ADVERTISING AND PROMOTION OF CONTRACT..............................................................58
12 PROPERTY OF THE STATE..............................................................................58
13 THIRD PARTY ANTITRUST VIOLATIONS...................................................................58
14 RIGHT TO ASSURANCE.................................................................................58
15 TERMINATION FOR CONFLICT OF INTEREST...............................................................59
16 GRATUITIES.........................................................................................59
17 SUSPENSION OR DEBARMENT............................................................................59
18 TERMINATION FOR CONVENIENCE........................................................................59
19 TERMINATION FOR DEFAULT............................................................................60
20 TERMINATION - AVAILABILITY OF FUNDS................................................................60
21 RIGHT OF OFFSET....................................................................................60
22 NON-EXCLUSIVE REMEDIES.............................................................................60
23 NON-DISCRIMINATION.................................................................................60
24 EFFECTIVE DATE.....................................................................................60
25 INSURANCE..........................................................................................61
26 DISPUTES...........................................................................................61
27 RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS........................................................61
28 INCORPORATION BY REFERENCE.........................................................................62
29 COVENANT AGAINST CONTINGENT FEES...................................................................62
30 CHANGES............................................................................................62
31 TYPE OF CONTRACT...................................................................................62
32 AMERICANS WITH DISABILITIES ACT....................................................................62
33 WARRANTY OF SERVICES...............................................................................62
34 NO GUARANTEED QUANTITIES...........................................................................62
35 CONFLICT OF INTEREST ..............................................................................63
36 DISCLOSURE OF CONFIDENTIAL INFORMATION.............................................................63
37 COOPERATION WITH OTHER CONTRACTORS.................................................................63
38 ASSIGNMENT OF CONTRACT AND BANKRUPTCY..............................................................63
39 OWNERSHIP OF INFORMATION AND DATA..................................................................63
40 AHCCCSA RIGHT TO OPERATE CONTRACTOR................................................................64
41 AUDITS AND INSPECTIONS.............................................................................64
42 FRAUD AND ABUSE....................................................................................64
43 LOBBYING...........................................................................................64
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SECTION E: CONTRACT CLAUSES
1. APPLICABLE LAW
Arizona Law - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.
Implied Contract Terms - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.
2. AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3. ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable federal regulations; the terms of the HCFA 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4. CONTRACT INTERPRETATION AND AMENDMENT
No Parol Evidence - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
No Waiver - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.
Written Contract Amendments - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5. SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract which may remain in effect without the invalid
provision or application.
6. RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
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7. ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8. GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to injury, disease, or
death of persons or damage to or loss of property resulting from or in
connection with the negligent performance of this contract by the Contractor,
its agents, employees, and subcontractors or anyone for whom the Contractor may
be responsible. The obligations, indemnities and liabilities assumed by the
Contractor under this paragraph shall not extend to any liability caused by the
negligence of the State or its employees. The Contractor's liability shall not
be limited by any provisions or limits of insurance set forth in this contract.
The State shall reasonably notify the Contractor of any claim for which it may
be liable under this paragraph.
9. INDEMNIFICATION - PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The materials and services supplied under this contract shall comply with all
applicable federal, state and local laws, and the Contractor shall maintain all
applicable licenses and permits.
11. ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12. PROPERTY OF THE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
13. THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14. RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified
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mail, return receipt required. Failure by the Contractor to provide written
assurance within the number of days specified in the demand may, at the State's
option, be the basis for terminating the contract.
15. TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
16. GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCSA, in addition to any other rights or
remedies, shall be entitled to recover exemplary damages in the amount of three
times the value of the gratuity offered by the Contractor.
17. SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from federal procurement activity.
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18. TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19. TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as
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required by AHCCCSA to comply with the terms of the contract. If the Contractor
is providing services under more than one contract with AHCCCSA, AHCCCSA may
deem unsatisfactory performance under one contract to be cause to require the
Contractor to provide assurance of performance under any and all other
contracts. In such situations, AHCCCSA reserves the right to seek remedies under
both actual and anticipatory breaches of contract if adequate assurance of
performance is not received. The Contracting Officer shall mail written notice
of the termination and the reason(s) for it to the Contractor by certified mail,
return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
20. TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
21. RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
22. NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23. NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 75-5, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable federal and state laws, rules and regulations, including
the Americans with Disabilities Act. The Contractor shall take positive action
to ensure that applicants for employment, employees, and persons to whom it
provides service are not discriminated against due to race, creed, color,
religion, sex, national origin or disability.
24. EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
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25. INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000
for each occurrence for bodily injury and property damage to others as
a result of accidents on the premises of or as the result of operations
of the Contractor.
b. Commercial Automobile Liability: Provides coverage of at least
$1,000,000 for each occurrence for bodily injury and property damage to
others resulting from accidents caused by vehicles operated by the
Contractor.
c. Workers Compensation: Provides coverage to employees of the Contractor
for injuries sustained in the course of their employment. Coverage must
meet the obligations imposed by federal and state statutes and must
also include Employer's Liability minimum coverage of $100,000.
Evidence of qualified self-insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance
of a professional act of service.
The above coverages may be evidenced by either one of the following:
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the
form. The Contractor's agent or broker must fill in the pertinent
policy information and ensure the required special conditions are
included in the Contractor's policy.
b. The Accord form: This standard insurance industry certificate of
insurance does not contain the pre-printed special conditions required
by this contract. These conditions must be entered on the certificate
by the agent or broker and read as follows:
The State of Arizona and Arizona Health Care Cost Containment
System are hereby added as additional insureds. Coverages
afforded under this Certificate shall be primary and any
insurance carried by the State or any of its agencies, boards,
departments or commissions shall be in excess of that provided
by the insured Contractor. No policy shall expire, be canceled
or materially changed without 30 days written notice to the
State. This Certificate is not valid unless countersigned by
an authorized representative of the insurance company.
26. DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with AHCCCS Rule R9-28-804(C).
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
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27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor which is related to the performance
of this contract, in accordance with ARS ss.41-2547.
28. INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
29. COVENANT AGAINST CONTINGENT FEE
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30. CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section E, Paragraph 26, Disputes,
and be administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31. TYPE OF CONTRACT
Firm Fixed-Price
32. AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Doug Peeples at (602) 417-4538.
33. WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's expense, require prompt correction of any services failing to meet
the Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
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34. NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35. CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose any situation which may present a conflict of interest. If
the Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.
36. DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCSA.
37. COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39. OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by Contractor pursuant to this contract, shall be deemed to
be owned by AHCCCSA. The federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, or otherwise use
and to authorize others to use for federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software
which is provided at established catalog or market prices and sold or leased to
the general public shall not be subject to the ownership or licensing provisions
of this section.
Data, information and reports collected or prepared by Contractor in the course
of performing its duties and obligations under this contract shall be deemed to
be owned by AHCCCSA. The ownership provision is in consideration of Contractor's
use of public funds in collecting or preparing such data, information and
reports. These items shall not be used by Contractor for any independent project
of Contractor or publicized by Contractor without the prior written permission
of AHCCCSA. Subject to applicable state and federal laws and regulations,
AHCCCSA shall have full and complete rights to
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reproduce, duplicate, disclose and otherwise use all such information. At the
termination of the contract, Contractor shall make available all such data to
AHCCCSA within 30 days following termination of the contract or such longer
period as approved by AHCCCSA, Office of the Director. For purposes of this
subsection, the term "data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by Contractor in the course of performance of this
contract, the federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or federal
government purposes. Contractor shall additionally be subject to the applicable
provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, Contractor's performance is in material breach
of the contract or Contractor is insolvent, AHCCCSA may directly operate
Contractor to assure delivery of care to members enrolled with Contractor until
cure by Contractor of its breach, by demonstrated financial solvency or until
the successful transition of those members to other contractors.
41. AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and -521 and AHCCCS policies and procedures relating to the
audit of Contractor's records and the inspection of Contractor's facilities.
Contractor shall fully cooperate with AHCCCSA staff and allow them reasonable
access to Contractor's staff, subcontractors, members, and records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
AHCCCSA and the federal government may evaluate through on-site inspection or
other means, the quality, appropriateness and timeliness of services performed
under this contract.
42. FRAUD AND ABUSE
It shall be the responsibility of the Contractor to report all cases of
suspected fraud and abuse by subcontractors, members or employees. The
Contractor shall provide written notification of all such incidents to AHCCCSA.
The Contractor shall comply with the AHCCCS Health Plans and Program Contractors
Policy for Prevention, Detection and Reporting of Fraud and Abuse which is
available in the Bidder's Library and incorporated herein by reference.
As stated in ARS ss.13-2310, incorporated herein by reference, any person who
knowingly obtains any benefit by means of false or fraudulent pretenses,
representations, promises or material omissions is guilty of a class 2 felony.
43. LOBBYING
No funds paid to the Contractor by AHCCCSA, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any federal or
State contract, the making of any federal or State grant, the making of any
federal or State loan, the entering into of any
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cooperative agreement, and the extension, continuation, renewal, amendment or
modification of any federal or State contract, grant, loan, or cooperative
agreement. The Contractor shall disclose if any funds other than those paid to
the Contractor by AHCCCSA have been used or will be used to influence the
persons and entities indicated above and will assist AHCCCSA in making such
disclosures to HCFA.
[END OF SECTION E]
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ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract]
1. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract.
2. RECORDS AND REPORTS
The Subcontractor shall maintain all forms, records, reports and working papers
used in the preparation of reports, files, correspondence, financial statements,
records relating to quality of care, medical records, prescription files,
statistical information and other records specified by AHCCCSA for purposes of
audit and program management. The Subcontractor shall comply with all
specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect
each service provided and all net costs, direct and indirect, of labor,
materials, equipment, supplies and services, and other costs and expenses of
whatever nature for which payment is made to the Subcontractor. Such material
shall be subject to inspection and copying by the state, AHCCCSA and the U.S.
Department of Health and Human Services during normal business hours at the
place of business of the person or organization maintaining the records.
The Subcontractor agrees to make available at the office of the Subcontractor,
at all times reasonable times, any of its records for inspection, audit or
reproduction, by any authorized representative of the state or federal
governments.
The Subcontractor shall preserve and make available all records for a period of
five years from the date of final payment under this subcontract except as
provided in paragraphs a. and b. below:
a. If this subcontract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for a
period of five years from the date of any such termination.
b. Records which relate to disputes, litigation or the settlement of
claims arising out of the performance of this subcontract, or costs and expenses
of this subcontract to which exception has been taken by the state, shall be
retained by the Subcontractor until such disputes, litigation, claims or
exceptions have been disposed of.
The Subcontractor shall provide all reports requested by AHCCCSA, and all
information from records relating to the performance of the Subcontractor which
AHCCCSA may reasonably require. The Subcontractor reporting requirements may
include, but are not limited to, timely and detailed utilization statistics,
information and reports.
The Subcontractor shall certify to the Program Contractor that it has not
engaged in conduct prohibited by ss. 1128B of the Social Security Act (42 USC
1320a-7b).
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3. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Subcontractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered
services. This provision shall not apply to patient contributions to the cost of
services delivered by nursing homes.
4. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Subcontractor under this subcontract may be assigned without
the prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5. APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The Program Contractor
shall notify AHCCCSA in the event of any proposed amendment or termination
during the term hereof. Any such amendment or termination is subject to the
prior approval of AHCCCSA. Approval of the subcontract may be rescinded by the
Director of AHCCCSA for violation of federal or state laws or rules.
6. WARRANTY OF SERVICES
The Subcontractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
7. SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Program Contractor and
AHCCCSA for the provision of covered services.
8. AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the Program Contractor may undertake or award other contracts for
additional or related work to the work performed by the Subcontractor and the
Subcontractor shall fully cooperate with such other contractors, subcontractors
or state employees. The Subcontractor shall not commit or permit any act which
will interfere with the performance of work by any other contractor,
subcontractor or state employee.
9. INDEMNIFICATION BY SUBCONTRACTOR
The Subcontractor agrees to hold harmless the state, all state officers and
employees, AHCCCSA and other appropriate state agencies, and all officers and
employees of AHCCCSA and all AHCCCS eligible persons in the event of nonpayment
to the Subcontractor. The Subcontractor shall further indemnify and hold
harmless the state, AHCCCSA, other appropriate state agencies, AHCCCS
contractors, and their agents, officers and employees against all injuries,
deaths, losses, damages, claims, suits, liabilities, judgments, costs and
expenses which may, in any manner, accrue against the State, AHCCCSA or its
A-2
agents, officers or employees, or AHCCCS contractors, through the intentional
conduct, negligence or omission of the Subcontractor, its agent, officers or
employees.
10. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Subcontractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
11. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Subcontractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract.
12. SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
13. VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Subcontractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
14. CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, ARS ss.36-107, 36-2903, 41-1959 and 46-135, and AHCCCS and/or ALTCS
Rules.
15. GRIEVANCE PROCEDURES
Any grievances filed by the Subcontractor shall be adjudicated in accordance
with AHCCCS Rules.
16. TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Subcontractor, terminate this subcontract
if it is found, after notice and hearing by the State, that gratuities in the
form of entertainment, gifts, or otherwise were offered or given by the
Subcontractor, or any agent or representative of the Subcontractor, to any
officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to the awarding, amending or the
making of any determinations with respect to the performance of the
Subcontractor; provided, that the existence of the facts upon which the state
makes such findings shall be in issue and may be reviewed in any competent
court. If the subcontract is terminated under this section, unless the Program
Contractor is a governmental agency, instrumentality or subdivision thereof,
AHCCCSA shall be entitled to a penalty, in addition to any other damages to
which it may be entitled by
A-3
law, and to exemplary damages in the amount of three times the cost incurred by
the Subcontractor in providing any such gratuities to any such officer or
employee.
17. PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The Program Contractor and Subcontractor shall develop, maintain and use a
system for Prior Authorization and Utilization Review which is consistent with
AHCCCS Rules and the Program Contractor's policies.
18. NON-DISCRIMINATION REQUIREMENTS
If applicable, the Subcontractor shall comply with:
a. The Equal Pay Act of 1963, as amended, which prohibits sex
discrimination in the payment of wages to men and women performing
substantially equal work under similar working conditions in the same
establishment.
b. Title VI of the Civil Rights Act of 1964, as amended, which prohibits
the denial of benefits of, or participation in, contract services on
the basis of race, color, or national origin.
c. Title VII of the Civil Rights Act of 1964, as amended which prohibits
private employees, state and local governments, and educational
institutions from discriminating against their employees and job
applicants on the basis of race, religion, color, sex, or national
origin.
d. Title I of the Americans with Disabilities Act of 1990, as amended,
which prohibits private employers and state and local governments from
discriminating against job applicants and employees on the basis of
disability.
e. The Civil Rights Act of 1991, which reverses in whole or in part,
several recent Supreme Court decisions interpreting Title VII.
f. The Age Discrimination in Employment Act (ARS Title 41-1461, et seq.);
which prohibits discrimination based on age.
g. State Executive Order 75-5 and Federal Order 11246 which mandates that
all persons, regardless of race, color, religion, sex, age, national
origin or political affiliation, shall have equal access to employment
opportunities.
h. Section 503 of the Rehabilitation Act of 1973, as amended, which
prohibits discrimination in the employment or advancement of the
employment of qualified persons because of physical or mental handicap.
i. Section 504 of the Rehabilitation Act of 1973, as amended, which
prohibits discrimination on the basis of handicap in delivering
contract services.
A-4
19. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Subcontractor's records and the inspection of the
Subcontractor's facilities. If the Subcontractor is an inpatient facility, the
Subcontractor shall file uniform reports and Title XVIII and Title XIX cost
reports with AHCCCSA.
20. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Subcontractor certifies that all
representations set forth herein are true to the best of its knowledge.
21. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Subcontractor certifies that it has not engaged
in any violation of the Medicare Anti-Kickback statute (42 USC ss.1320a-7b) or
the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Subcontractor provides
laboratory testing, it certifies that it has complied with 42 CFR ss.411.361 and
has sent to AHCCCSA simultaneous copies of the information required by that rule
to be sent to the Health Care Financing Administration.
22. CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
23. ENCOUNTER DATA REQUIREMENT
If the Subcontractor does not bill the Program Contractor (e.g., Subcontractor
is capitated), the Subcontractor shall submit encounter data to the Program
Contractor in a form acceptable to AHCCCSA.
24. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. Program Contractor may not reimburse
providers who do not comply with the above requirements.
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25. INSURANCE
[This provision applies only if the Subcontractor provides services directly to
AHCCCS members]
The Subcontractor shall maintain for the duration of this subcontract a policy
or policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance. The Subcontractor agrees that any
insurance protection required by this subcontract, or otherwise obtained by the
Subcontractor, shall not limit the responsibility of Subcontractor to indemnify,
keep and save harmless and defend the State and AHCCCSA, their agents, officers
and employees as provided herein. Furthermore, the Subcontractor shall be fully
responsible for all tax obligations, Worker's Compensation Insurance, and all
other applicable insurance coverage, for itself and its employees, and AHCCCSA
shall have no responsibility or liability for any such taxes or insurance
coverage.
26. FRAUD AND ABUSE
If the Subcontractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Subcontractor shall report the incident to the
Program Contractor, who shall proceed in accordance with the AHCCCS Health Plans
and Program Contractors Policy for Prevention, Detection and Reporting of Fraud
and Abuse. Incidents involving potential member eligibility fraud should be
reported to AHCCCSA, Office of Managed Care, Member Fraud Unit. All other
incidents of potential fraud should be reported to AHCCCSA, Office of the
Director, Office of Program Integrity. (See AHCCCS Rule R9-22-511.)
A-6
ATTACHMENT B: MINIMUM NETWORK STANDARDS
(By Geographic Service Area)
INSTRUCTIONS:
Note: Offerors are permitted to bid only by Geographic Service Area. Please
see Section H, Paragraph 9, Award of Contracts, for further information on
bidding by Geographic Service Area.
Offerors shall have in place an adequate network of providers capable of meeting
contract requirements. The information that follows describes the minimum
network requirements by Geographic Service Area (GSA). The minimum bid is a
single entire GSA, as depicted on the following page.
In some GSA's there are required service sites located outside of the
geographical boundary of a GSA. The reason for this relates to practical access
to care. In certain instances, a member must travel a much greater distance to
receive services within their assigned GSA if the member were not allowed to
receive services in an adjoining GSA or state.
Split zip codes occur in some counties. Split zip codes are those which straddle
two different counties. Enrollment for members residing in these zip codes is
based upon the county and GSA to which the entire zip code has been assigned by
AHCCCS. The Offeror shall be responsible for providing services to members
residing in the entire zip code that is assigned to the GSA for which the
Offeror has agreed to provide services. The split zip codes GSA assignments are
as follows:
ZIP CODE SPLIT BETWEEN COUNTY ASSIGNED
THESE COUNTIES ASSIGNED TO GSA
--------------------------------------------------------------------
85220 Pinal and Maricopa Maricopa 12
85242 Pinal and Maricopa Maricopa 12
85292 Gila and Pinal Gila 8
85342 Yavapai and Maricopa Maricopa 12
85358 Yavapai and Maricopa Maricopa 12
85390 Yavapai and Maricopa Maricopa 12
85643 Graham and Cochise Cochise 18
85645 Pima and Santa Cruz Santa Cruz 18
85943 Apache and Navajo Navajo 16
86336 Coconino and Yavapai Yavapai 6
86351 Coconino and Yavapai Coconino 6
86434 Mohave and Yavapai Yavapai 6
Acute Care Renewal
Revised 10/1/99
If outpatient specialty services (OB, family planning, and pediatrics) are not
included in the primary care provider contract, at least one subcontract is
required for each of these specialties in the service sites specified. General
surgeons must be available within 50 miles of service sites.
In Tucson (GSA 10) and Metropolitan Phoenix (GSA 12), the Offeror must
demonstrate its ability to provide PCP, dental and pharmacy services so that
members don't need to travel more than 5 miles from their residence.
Metropolitan Phoenix is defined on the Minimum Network Standard page specific to
GSA #6.
Offerors bidding in GSA's other than GSA 10 and GSA 12 are encouraged to
contract with the hospitals in their provider network. However, AHCCCSA will not
award additional points in the evaluation process for hospital contracts in
rural areas. At a minimum, the Offeror shall have a physician with admitting and
treatment privileges with each hospital in its network. Offerors bidding in GSA
10 and/or GSA 12 must have at least one hospital contract in each service
district as depicted on the respective maps for GSA 10 and GSA 12. This
requirement is part of the Hospital Reimbursement Pilot Program, described more
fully in Section D, Paragraph 35, Hospital Reimbursement. For offerors'
convenience, a list of Phoenix and Tucson area hospitals are included on the
reverse of the Phoenix and Tucson maps which follow.
Provider categories required at various service delivery sites included in the
Service Area Minimum Network Standards are indicated as follows:
H Hospitals
P Primary Care Providers (physicians, certified nurse
practitioners and physician assistants)
D Dentists
PH Pharmacies
Acute Care Renewal
Revised 10/1/99
HOSPITALS IN PHOENIX METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
CENTRAL DISTRICT
85006 Good Samaritan Regional Medical Center
Phoenix Children's Hospital
St. Luke's Medical Center
85007 Phoenix Memorial Hospital
85008 Maricopa Medical Center
85013 St. Joseph's Hospital & Medical Center
85015 Community Hospital Medical Center
Phoenix Baptist Hospital & Medical Center
85016 Phoenix Regional Medical Center
85020 John C. Lincoln Hospital & Health Center
85027 Phoenix General Hospital & Medical Center
NORTHWEST DISTRICT
85031 Maryvale Samaritan Medical Center
85031 Paradise Valley Hospital
85306 Thunderbird Samaritan Medical Center
85308 Arrowhead Community Hospital & Medical Center
85351 Walter O. Boswell Memorial Hospital
85375 Del E. Webb Memorial Hospital
85259 Mayo Clinic Hospital
SOUTHWEST DISTRICT
85201 Mesa General Hospital Medical Center
Mesa Lutheran Hospital
85202 Desert Samaritan Medical Center
85206 Valley Lutheran Hospital
85224 Chandler Regional Hospital
85251 Scottsdale Memorial Hospital - Osborn
85261 Scottsdale Memorial Hospital - North
85281 Tempe St. Luke's Hospital
Acute Care Renewal
Revised 10/1/99
HOSPITALS IN TUCSON METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
NORTHWEST DISTRICT
85719 Tucson General Hospital
University Medical Center
85741 Northwest Hospital
85745 Carondelet St. Mary's Hospital
SOUTHEAST DISTRICT
85711 Carondelet St. Joseph's Hospital
85712 El Dorado Hospital
Tucson Medical Center
85713 Kino Community Hospital
Acute Care Renewal
Revised 10/1/99
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 2
COUNTY: YUMA
HOSPITALS
Yuma
PRIMARY CARE PROVIDERS
Yuma
Somerton
Wellton
DENTISTS
Yuma
PHARMACIES
Yuma
Wellton
[Map of Yuma County, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 4
COUNTIES: LA PAZ AND MOHAVE
HOSPITALS
Bullhead City
Kingman
Lake Havasu City
Parker
St. George, Utah
PRIMARY CARE PROVIDERS
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah/Mesquite
DENTISTS
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah/Mesquite
PHARMACIES
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah/Mesquite
[Map of La Paz and Mohave Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 6
COUNTIES: COCONINO AND YAVAPAI
HOSPITALS
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Winslow
PRIMARY CARE PROVIDERS
Camp Verde Sedona
Cottonwood Williams
Flagstaff Winslow
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Prescott Valley
DENTISTS
Camp Verde Sedona
Cottonwood Williams
Flagstaff Winslow
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Prescott Valley
PHARMACIES
Camp Verde Sedona
Cottonwood Williams
Flagstaff Winslow
Kanab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Prescott Valley
[May of Coconino and Yavapai Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 8
COUNTIES: GILA AND PINAL
HOSPITALS
Casa Grande
Claypool
Mesa
Payson
PRIMARY CARE PROVIDERS
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Hayden/Winkelman
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
DENTISTS
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
PHARMACIES
Apache Junction
Casa Grande
Coolidge/Florence
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
[Map of Gila and Pinal Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 10
COUNTY: PIMA
HOSPITALS
Tucson
Northwest Service Sector
Contract Requirement
Southwest Service Sector
Contract Requirement
Nogales
Physician[s] with admit and treatment
privileges required
PRIMARY CARE
PROVIDERS
Ajo
Catalina
Green/Valley/Continental
Marana
Nogales
Oro Valley
Tucson++
DENTISTS
Ajo
Catalina
Green Valley/Continental
Nogales
Ora Valley
Tucson++
PHARMACIES
Ajo
Catalina
Green Valley/Continental
Nogales
Ora Valley
Tucson++
[Map of Pima County, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 12
COUNTY: MARICOPA
HOSPITALS
Metropolitan Phoenix++
Northwest Service Sector
Contract Requied
Central Service Sector
Contract Required
Southeast Service Sector
Contract Required
Wickenburg
Physician[s] with admit and treatment
privileges required
PRIMARY CARE
PROVIDERS
Avondale/Goodyear/Litchfield Park/Tolleson
Buckeye
Gila Bend
Metropolitan Phoenix++
Queen Creek
Wickenburg
DENTISTS
Avondale/Buckeye/Goodyear/Litchfield Park/Tolleson
Metropolitan Phoenix++
Wickenburg
PHARMACIES
Avondale/Goodyear/Litchfield Park/Tolleson
Buckeye
Metropolitan Phoenix++
Wickenburg
[Map of Maricopa County, Arizona]
++ For purposes of this RFP, Metropolitan Phoenix encompasses the
following: Phoenix, Paradise Valley, Cave Creek/Carefree, Fountain
Hills, Scottsdale, Glendale, Sun City/Sun City West, Tempe, Mesa,
Gilbert, Chandler, Apache Junction, Peoria, El Mirage, Guadalupe,
Surprise and Youngtown. Within this area, distance standards must
be met as specified in Attachment B.
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 14
COUNTIES: GRAHAM AND GREENLEE
HOSPITALS
Safford
PRIMARY CARE
PROVIDERS
Morenci/Clifton
Safford
DENTISTS
Morenci/Clifton
Safford
PHARMACIES
Morenci/Clifton
Safford/Thatcher
[Map of Graham and Greenlee Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 16
COUNTIES: APACHE AND NAVAJO
HOSPITALS
Gallup, NM
Showlow
Spingerville
Winslow
PRIMARY CARE PROVIDERS
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
DENTISTS
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
PHARMACIES
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
[Map of Apache and Navajo Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT B
MINIMUM NETWORK STANDARDS
GEOGRAPHIC SERVICE AREA 18
COUNTIES: COCHISE AND SANTA CRUZ
HOSPITALS
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Willcox
PRIMARY CARE PROVIDERS
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Willcox
DENTISTS
Benson/Willcox
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
PHARMACIES
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Willcox
[Map of Cochise and Santa Cruz Counties, Arizona]
H = HOSPITAL P = PRIMARY CARE PHYSICIAN D = DENTIST PH = PHARMACY
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
- ---------------------------------- ------------------------------- --------------------------- ------------------
AHCCCS
REPORT WHEN DUE SOURCE/REFERENCE CONTACT
- ---------------------------------- ------------------------------- --------------------------- ------------------
Monthly Financial Report 45 days after the end of the Reporting Guide Financial Manager
month, as applicable
Quarterly Financial Report 60 days after the end of each Reporting Guide Financial Manager
quarter
Draft Annual Audit Report 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Draft Management Letter 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Final Annual Audit Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Final Management Letter 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Accountant's Report on Compliance 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Reconciliation - Annual Audit 120 days after the end of Reporting Guide Financial Manager
and Plan Year-to-Date Financial
Report Information
Financial Disclosure Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Annual Analysis of Profitability 120 days after the end of Reporting Guide Financial Manager
by Major Rate Code (by County) each fiscal year
Provider Affiliation Tape 10 business days after the PMMIS Provider-to- Health Plan
beginning of each quarter Health Plan magnetic tape Operations Manager
submission and
processing
18-20 NON-SMI Status Report 15 days after the end of Instructions on form Behavioral Health
each month Manager
Encounter Data - Magnetic Monthly, according to Encounter Manual Encounter
Tape Submission established schedule Administrator
Corrected Pended Encounter Monthly, according to Encounter Manual Encounter
Tape established schedule Administrator
New Day Tape Monthly, according to Encounter Manual Encounter
established schedule Administrator
Medical Records for Data 6 weeks after the request RFP, Section C, Data Validation
Validation received from AHCCSA Paragraph 1 Manager
Quarterly Grievance Report 45 days after the end of RFP, Section D, Administrative
each quarter Paragraph 26 Assistant
Comprehensive EPSDT Plan Annually on December 1 RFP, Section D, Acute Care Program
including Dental Paragraph 16 Manager
Acute Care Renewal
Revised 10/1/99
- ---------------------------------- ------------------------------- --------------------------- ------------------
AHCCCS
REPORT WHEN DUE SOURCE/REFERENCE CONTACT
- ---------------------------------- ------------------------------- --------------------------- ------------------
Update Manager
Quarterly Inpatient Hospital 15 day after the end of each State Medicaid Manual Acute Care Program
Showing quarter and the AMPM, Chapter 900 Manager
Quality Management/Utilization Annually on November 15th AMPM, Chapter 900 Acute Care Program
Management Plan Evaluation and Manager
Revision
AIDS/HIV Reports 90 days after the end of each AMPM, Chapter 900 Acute Care Program
contract year Manager
Acute Pharmacy Report 90 days after the end of each AMPM, Chapter 900 Acute Care Program
quarter, annually within 90 Manager
days following the end of
each contract year
Monthly Pregnancy End of the month following AMPM, Chapter 400 Acute Care Program
Termination Report the pregnancy termination Manager
Maternity Care Plan Annually on December 1st AMPM, Chapter 400 Acute Care Program
Manager
Clinical Study Proposal Annually on November 15th AMPM, Chapter 900 Acute Care Program
Manager
Clinical Study Results Annually within 90 days AMPM, Chapter 900 Acute Care Program
following the end of each Manager
contract year
Provider Fraud/Abuse Report Immediately following AHCCCS Internal Audit/ Office of Program
discovery Program Investigation Integrity Manager
Policy for Prevention,
Detection and Reporting
of Fraud and Abuse
Eligible Person Fraud/Abuse Immediately following AHCCCS Internal Audit/ Office of Program
Report discovery Program Investigation Integrity Manager
Policy for Prevention,
Detection and Reporting
of Fraud and Abuse
Non-Transplant Catastrophic - Annually, within 30 days of RFP, Section D, OMD/FFS Unit
Reinsurance covered diseases the beginning of the contract Paragraph 39 Reinsurance
year, enrollment to the plan, Manager
and when newly diagnosed.
Acute Care Renewal
Revised 10/1/99
ATTACHMENT H: GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers which defines their rights regarding any adverse action by the
Contractor. The Contractor shall also ensure compliance with the Members' Rights
and Responsibilities Policy. The written grievance policy shall be in accordance
with applicable federal and State laws and AHCCCS Rules and policy including,
but not limited to, AHCCCS Rules R9-22-512; R9-22-518(A); R9-22-802; and
R9-22-804. The grievance policy shall include the following provisions:
a. The grievance procedure will be provided all subcontractors at time of
contract, and to non-contracting providers within 10 days of the date
of receipt of the claim. For non-contracting providers, the grievance
procedure may be mailed with the remittance advice provided the
remittance is sent within 45 days of receipt of claim.
b. Specific individual(s) are appointed with authority to require
corrective action to administer the grievance policy.
c. A log is maintained for all grievances containing sufficient
information to identify the grievant, date of receipt, nature of the
grievance and the date grievance is resolved. Separate logs must be
maintained for provider and member grievances. The logs must contain
sufficient information to identify the grievant, date of receipt,
nature of the grievance and the date grievance is resolved.
d. Within five working days of receipt, the grievant is informed by letter
that the grievance has been received. The letter must also be in a
second language when 200 members or 5% of the Contractor's population,
whichever is greater speak the second language.
e. Each grievance is thoroughly investigated using the applicable
statutory, regulatory and contractual provisions as well as the
Contractor's policies and procedures, ensuring that facts are gathered
from all parties.
f. All documentation received and mailed by Contractor during the
grievance process is dated upon date of receipt.
g. All grievances are filed in a secure, designated area and are
retained for five years following the final decision, judicial appeal
or close of a grievance.
h. A copy of the Contractor's final decision will be either hand-delivered
or delivered by certified mail to all parties whose interest has been
adversely affected by the decision. The final decision shall be mailed
to all other individuals by regular mail. The date of the final
decision shall be the date of personal delivery or, if mailed, the
postmark date of the mailing. The final decision must include, and
describe in detail, the following:
1. the nature of the grievance
2. the issues involved
3. the reasons supporting the Contractor's decision
including references to applicable statute, rule and
procedure
4. the grievant's right to appeal the Contractor's
decision to AHCCCSA by filing the appeal to the
Contractor no later than 15 days after the date of
the Contractor's final decision. This must also be
written in a second language, if applicable.
i. If the Contractor's final decision is appealed, all supporting
documentation must be received by the AHCCCSA, Office of Legal
Assistance no later than five working days from the date the Contractor
receives the appeal or from the date of the oral or written request
from AHCCCSA, Office of Legal Assistance. The appeal file must contain
a cover letter that includes:
1. grievant's name
2. grievant's AHCCCS ID number
3. grievant's address
4. phone number (if applicable)
5. date of receipt of grievance and appeal
6. summary of the Contractor's actions undertaken to
resolve the grievance and basis thereof
j. The following material shall be included in the appeal file:
1. written request of the grievant asking for the appeal
2. copies of the entire file which include the
investigations and/or medical records; and the
Contractor's grievance decision
3. other information used by the Contractor to resolve
the grievance and that would be necessary to AHCCCSA
to resolve the grievance.
k. The Contractor may attempt to use alternative resolution procedures to
resolve disputes presented to the Contractor verbally or in writing. If
the Contractor elects to use an alternative resolution process, it must
be administered and completed within 10 days from receipt of the
dispute. If the matter is not resolved to the grievant's satisfaction
within the 10 day period, the dispute must then be adjudicated using
the grievance standards contained above. However, the Contractor must
render the written grievance decision within a maximum of 30 days from
the date of the initial filing of the grievance or dispute unless a
longer period was agreed to by the parties involved.
l. For all disputes where an alternative resolution is proposed, the
Contractor must maintain a separate log, complying with paragraphs c.
and g. above.
Hospital Reimbursement Pilot Program -- Maricopa and Pima counties only (See
Section D, Paragraph 35): Arbitration may be used in lieu of the grievance and
appeal procedure. If arbitration is used, the hospital contract must identify:
a. The parties agreement on arbitrating claims arising from the contract;
b. Whether arbitration is non-binding or binding;
c. Timeliness of arbitration;
d. What contract provisions may be appealed;
e. What rules will govern arbitrations;
f. The number of arbitrators that will be used;
g. How arbitrators will be selected; and
h. How arbitrators will be compensated.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT MODIFICATION
Page 1 of 1
- ------------------------------------------------------------------------------------------------
1. Amendment No.: 2. Contract No.: 3. Effective Date of Modification: 4. Program:
11 YH8-0001-05 UPON LAST SIGNATURE BELOW OMC
- ------------------------------------------------------------------------------------------------
5. Contractor/Provider Name and Address:
HEALTH CHOICE AZ
1600 W. BROADWAY SUITE 260
TEMPE, AZ 85282-1502
- ------------------------------------------------------------------------------------------------
6. Purpose: TO REVISE THE RECONCILIATION PROCESS DESCRIBED IN SECTION D, PARAGRAPH 37,
COMPENSATION, RECONCILIATION OF PPC COSTS TO REIMBURSEMENT.
- ------------------------------------------------------------------------------------------------
7. The above referenced contract is hereby modified as follows:
In Section D, Program Requirements, on page 40 of the October 1, 1999 revision
of the contract the paragraph entitled "Reconciliation of PPC Costs to
Reimbursement" is changed as follows:
Reconciliation of PPC Costs to Reimbursement: For CYE '98 and CYE '99, AHCCCSA
will offer a reconciliation process for contractors whose total PPC medical cost
experience (excluding administrative and non-operating expenses) is more than
10% higher than the reimbursement associated with PPC in two areas: the "retro"
portion of the capitation rate for all rate categories, and the prospective
three-day notification period for MNMI recipients only. Expenses will be net of
reinsurance for both the retro and prospective periods.
AHCCCSA will reimburse 100% of a Contractor's excess reasonable costs in excess
of a 10% limit as determined by reported encounters. AHCCCS will recoup profit
amounts in excess of a 10% limit.
___ CYE '00, a full reconciliation to 0% profit or loss will be done by AHCCCSA
for the same eligibility time periods and risk group noted above. AHCCCSA will
reimburse the health plans 100% of any excess reasonable costs as determined by
reported encounters, and all profits will be recouped. Refer to the Office of
Managed Care's PPC Reconciliation Policy for further details of the
reconciliation process.
NOTE: PLEASE SIGN, DATE AND RETURN DOUG PEEPLES
BOTH ORIGINALS TO: AHCCCS CONTRACTS AND PURCHASING
701 E. JEFFERSON STREET
PHOENIX, AZ 85034
- ------------------------------------------------------------------------------------------------
8. Except as provided for herein, all terms and conditions of the original contract not
heretofore changed and/or amended remain unchanged and in full effect.
In witness whereof the parties hereto sign their names in agreement
- ------------------------------------------------------------------------------------------------
9. Contractor: HEALTH CHOICE AZ 10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
- ------------------------------------------------------------------------------------------------
Signature of Authorized Individual: Signature:
/s/ Carolyn Rose /s/ Michael Veit
- ------------------------------------------------------------------------------------------------
Typed Name: CAROLYN ROSE Typed Name: MICHAEL VEIT
- ------------------------------------------------------------------------------------------------
Title: INTERIM CEO Title: CONTRACTS AND PURCHASING ADMINISTRATOR
- ------------------------------------------------------------------------------------------------
Date: 3/22/00 Date:
- ------------------------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
- --------------------------------------------------------------------------------
AMENDMENT NUMBER: CONTRACT NUMBER: EFFECTIVE DATE OF AMENDMENT: PROGRAM:
12 YH8-0001-05 OCTOBER 1, 2000 OMC
- --------------------------------------------------------------------------------
CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE ARIZONA
1600 WEST BROADWAY SUITE 260
TEMPE, AZ 85282-1502
- --------------------------------------------------------------------------------
PURPOSE OF AMENDMENT: TO EXTEND THE TERM OF THE CONTRACT FOR ONE YEAR AND TO
INCORPORATE CHANGES TO CONTRACT REQUIREMENTS.
- --------------------------------------------------------------------------------
THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. EXTENSION OF CONTRACT: In accordance with Section D, Paragraph 50, Term
of Contract and Option to Renew, this contract is extended for the
period 10/01/00-- 09/30/01. The Contractor's response affirming or
declining the extension must be received by AHCCCSA no later the 3 PM,
SEPTEMBER 15, 2000.
B. CONTRACT RESTATEMENT: this amendment consists of a complete restatement
of Sections B, C, D, E and Attachments A, F, H and I with new or
changed requirements.
C. By signing this contract amendment, the Contractor is (1) agreeing to
perform for an additional year according to the terms of the contract
as amended, and (2) agreeing to the new and changed requirements
contained herein.
NOTE: Please sign and date both and then return one to: MICHAEL VEIT, MD 5700
AHCCCS CONTRACTS AND PURCHASING
701 EAST JEFFERSON STREET
PHOENIX, ARIZONA 85034
- --------------------------------------------------------------------------------
EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT
NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
- --------------------------------------------------------------------------------
SIGNATURE OF AUTHORIZED REPRESENTATIVE: SIGNATURE OF AHCCCSA CONTRACTING
OFFICER:
/s/ Carolyn Rose /s/ Michael Veit
- --------------------------------------------------------------------------------
TYPED NAME: TYPED NAME:
CAROLYN ROSE MICHAEL VEIT
- --------------------------------------------------------------------------------
TITLE: TITLE:
INTERIM CHIEF EXECUTIVE CONTRACTS AND PURCHASING ADMINISTRATOR
OFFICER
- --------------------------------------------------------------------------------
DATE: DATE:
9/6/00 October 1, 2000
- --------------------------------------------------------------------------------
1
[TABLE OF CONTENTS]
TABLE OF CONTENTS..................................................................................................
SECTION B - CAPITATION RATES.......................................................................................
SECTION C: DEFINITIONS.............................................................................................
SECTION D: PROGRAM REQUIREMENTS....................................................................................
1. SCOPE OF SERVICES.......................................................................................12
2. BEHAVIORAL HEALTH SERVICES..............................................................................20
3. AHCCCS MEDICAL POLICY MANUAL............................................................................21
4. VACCINE FOR CHILDREN PROGRAM............................................................................22
5. DENIALS OR REDUCTIONS OF SERVICES.......................................................................22
6. ENROLLMENT AND DISENROLLMENT............................................................................22
7. MAINSTREAMING OF AHCCCS MEMBERS.........................................................................25
8. MEMBER INFORMATION......................................................................................26
9. MEMBER SURVEYS..........................................................................................28
10. MARKETING PLANS.........................................................................................29
11. ANNUAL ENROLLMENT CHOICE................................................................................29
12. TRANSITION OF MEMBERS...................................................................................29
13. STAFF REQUIREMENTS AND SUPPORT SERVICES.................................................................30
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS.......................................................31
15. ADVANCE DIRECTIVES......................................................................................32
16. PERFORMANCE MEASUREMENT.................................................................................32
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)...................................................35
18. PHYSICIAN INCENTIVES....................................................................................36
19. APPOINTMENT STANDARDS...................................................................................36
20. REFERRAL PROCEDURES AND STANDARDS.......................................................................37
21. PROVIDER MANUAL.........................................................................................38
22. PRIMARY CARE PROVIDER STANDARDS.........................................................................39
23. OTHER PROVIDER STANDARDS................................................................................40
24. NETWORK DEVELOPMENT.....................................................................................41
25. NETWORK MANAGEMENT......................................................................................42
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)...............................................................43
27. PROVIDER REGISTRATION...................................................................................44
28. PROVIDER AFFILIATION TAPE...............................................................................44
29. PERIODIC REPORT REQUIREMENTS............................................................................44
30. DISSEMINATION OF INFORMATION............................................................................45
31. REQUESTS FOR INFORMATION................................................................................45
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS.............................................................45
33. OPERATIONAL AND FINANCIAL REVIEWS.......................................................................45
34. CLAIMS PAYMENT SYSTEM...................................................................................46
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT...............................................................47
36. NURSING FACILITY REIMBURSEMENT..........................................................................47
37. COMPENSATION............................................................................................48
38. INCENTIVE FUND..........................................................................................49
39. REINSURANCE.............................................................................................50
2
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY..........................................................52
41. MEDICARE SERVICES AND COST SHARING......................................................................54
42. COPAYMENTS..............................................................................................55
43. RECORDS RETENTION.......................................................................................55
44. MEDICAL RECORDS.........................................................................................55
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS..........................................................56
46. ACCUMULATED FUND DEFICIT................................................................................56
47. DATA EXCHANGE REQUIREMENT...............................................................................56
48. ENCOUNTER DATA REPORTING................................................................................58
49. MONTHLY ROSTER RECONCILIATION...........................................................................58
50. TERM OF CONTRACT AND OPTION TO RENEW....................................................................59
51. SUBCONTRACTS............................................................................................60
52. SPECIALTY CONTRACTS.....................................................................................61
53. MANAGEMENT SERVICES SUBCONTRACTORS......................................................................62
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS................................................................62
55. MINIMUM CAPITALIZATION REQUIREMENTS.....................................................................62
56. PERFORMANCE BOND OR BOND SUBSTITUTE.....................................................................63
57. AMOUNT OF PERFORMANCE BOND..............................................................................64
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES.......................................................64
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP..........................................................65
60. SANCTIONS...............................................................................................65
61. AUTO-ASSIGNMENT ALGORITHM...............................................................................66
62. GRIEVANCE PROCESS AND STANDARDS.........................................................................66
63. QUARTERLY GRIEVANCE REPORT..............................................................................66
64. KIDSCARE................................................................................................66
65. PENDING LEGISLATIVE ISSUES..............................................................................67
66. SEPARATE INCORPORATION..................................................................................67
67. CULTURAL COMPETENCY.....................................................................................67
68. MEDICAID IN THE PUBLIC SCHOOLS..........................................................................68
SECTION E: CONTRACT CLAUSES
1. APPLICABLE LAW..........................................................................................72
2. AUTHORITY...............................................................................................72
3. ORDER OF PRECEDENCE.....................................................................................72
4. CONTRACT INTERPRETATION AND AMENDMENT...................................................................72
5. SEVERABILITY............................................................................................72
6. RELATIONSHIP OF PARTIES.................................................................................72
7. ASSIGNMENT AND DELEGATION...............................................................................73
8. GENERAL INDEMNIFICATION.................................................................................73
9. INDEMNIFICATION - PATENT AND COPYRIGHT..................................................................73
10. COMPLIANCE WITH APPLICABLE LAWS.........................................................................73
11. ADVERTISING AND PROMOTION OF CONTRACT...................................................................73
12. PROPERTY OF THE STATE...................................................................................73
13. THIRD PARTY ANTITRUST VIOLATIONS........................................................................74
14. RIGHT TO ASSURANCE......................................................................................74
15. TERMINATION FOR CONFLICT OF INTEREST....................................................................74
16. GRATUITIES..............................................................................................74
17. SUSPENSION OR DEBARMENT.................................................................................74
3
18. TERMINATION FOR CONVENIENCE.............................................................................75
19. TERMINATION FOR DEFAULT.................................................................................75
20. TERMINATION - AVAILABILITY OF FUNDS.....................................................................75
21. RIGHT OF OFFSET.........................................................................................76
22. NON-EXCLUSIVE REMEDIES..................................................................................76
23. NON-DISCRIMINATION......................................................................................76
24. EFFECTIVE DATE..........................................................................................76
25. INSURANCE...............................................................................................76
26. DISPUTES................................................................................................77
27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS.............................................................77
28. INCORPORATION BY REFERENCE..............................................................................77
29. COVENANT AGAINST CONTINGENT FEES........................................................................77
30. CHANGES.................................................................................................77
31. TYPE OF CONTRACT........................................................................................78
32. AMERICANS WITH DISABILITIES ACT.........................................................................78
33. WARRANTY OF SERVICES....................................................................................78
34. NO GUARANTEED QUANTITIES................................................................................78
35. CONFLICT OF INTEREST....................................................................................78
36. DISCLOSURE OF CONFIDENTIAL INFORMATION..................................................................78
37. COOPERATION WITH OTHER CONTRACTORS......................................................................79
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY...................................................................79
39. OWNERSHIP OF INFORMATION AND DATA.......................................................................79
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR.....................................................................80
41. AUDITS AND INSPECTIONS..................................................................................81
42. FRAUD AND ABUSE.........................................................................................81
43. LOBBYING................................................................................................81
44. CHOICE OF FORUM.........................................................................................81
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS....................................................................A-1
1. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES......................................A-1
2. RECORDS AND REPORTS....................................................................................A-1
3. LIMITATIONS ON BILLING AND COLLECTION PRACTICES........................................................A-2
4. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES...............................................A-2
5. APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS...................................................A-2
6. WARRANTY OF SERVICES...................................................................................A-2
7. SUBJECTION OF SUBCONTRACT..............................................................................A-2
8. AWARDS OF OTHER SUBCONTRACTORS.........................................................................A-2
9. INDEMNIFICATION BY CONTRACTOR..........................................................................A-2
10. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES........................................A-3
11. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS............................................................A-3
12. SEVERABILITY...........................................................................................A-3
13. VOIDABILITY OF SUBCONTRACT.............................................................................A-3
14. CONFIDENTIALITY REQUIREMENT............................................................................A-3
15. GRIEVANCE AND REQUEST FOR HEARING PROCEDURES...........................................................A-3
16. TERMINATION OF SUBCONTRACT.............................................................................A-3
17. PRIOR AUTHORIZATION AND UTILIZATION REVIEW.............................................................A-4
4
18. NON-DISCRIMINATION REQUIREMENTS........................................................................A-4
19. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION..........................................A-5
20. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION........................................................A-5
21. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING.....................................A-5
22. CONFLICT IN INTERPRETATION OF PROVISIONS...............................................................A-5
23. ENCOUNTER DATA REQUIREMENT.............................................................................A-5
24. CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988...............................................A-5
25. INSURANCE..............................................................................................A-6
26. FRAUD AND ABUSE........................................................................................A-6
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS......................................................................F-1
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS...........................................H-1
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS.................................................................I-1
5
SECTION B - CAPITATION RATES
The Contractor shall provide services as described in this contract. In
consideration for these services, the Contractor will be paid the attached rates
for the term October 1, 2000 through September 30, 2001
(CYE 01).
CAPITATION RATES
(per member per month)
Capitation rates specific to contractor
HEALTH CHOICE ARIZONA
The new capitation rates effective 10/01/00 are as follows:
GSA #10 (Pima)
- ---------------------------------------------------------------------------------------------------
RISK POOL PROSPECTIVE PPC* KIDSCARE
MNMI IS A DAILY RATE
- ---------------------------------------------------------------------------------------------------
TANF 45+M/F 223.08 180.25 N/A
- ---------------------------------------------------------------------------------------------------
TANF 14-44 F 112.35 136.50 128.04
- ---------------------------------------------------------------------------------------------------
TANF 14-44M 90.15 76.91 80.71
- ---------------------------------------------------------------------------------------------------
MN/MI 500.15 784.78 N/A
- ---------------------------------------------------------------------------------------------------
SB1O TANF/SOBRA 4968.79 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB2O SSIW 4968.79 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB21 SSIN 4968.79 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB3O MN/MI 4968.79 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB5O SOBRA F 4968.79 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB6O KIDSCARE N/A N/A 4968.79
- ---------------------------------------------------------------------------------------------------
SSI w/o MEDICARE 346.72 61.79 N/A
- ---------------------------------------------------------------------------------------------------
SSI w/ MEDICARE 155.68 14.50 N/A
- ---------------------------------------------------------------------------------------------------
TANF<1,M/F 314.71 1164.82 270.86
- ---------------------------------------------------------------------------------------------------
TANF 1-13 M/F 68.17 32.70 79.24
- ---------------------------------------------------------------------------------------------------
SFP 18.84 N/A N/A
- ---------------------------------------------------------------------------------------------------
GSA #12 (Maricopa)
- ---------------------------------------------------------------------------------------------------
RISK POOL PROSPECTIVE PPC* KIDSCARE
MNMI IS A DAILY RATE
- ---------------------------------------------------------------------------------------------------
TANF 45+M/F 236.90 180.25 N/A
- ---------------------------------------------------------------------------------------------------
TANF 14-44 F 103.02 136.50 118.58
- ---------------------------------------------------------------------------------------------------
TANF 14-44 M 93.62 76.91 81.01
- ---------------------------------------------------------------------------------------------------
MN/MI 612.63 554.15 N/A
- ---------------------------------------------------------------------------------------------------
SB1O TANF/SOBRA 5315.01 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB2O SSIW 5315.01 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB21 SSIN 5315.01 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB3O MN/MI 5315.01 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB5O SOBRA F 5315.01 N/A N/A
- ---------------------------------------------------------------------------------------------------
SB6O KIDSCARE N/A N/A 5315.01
- ---------------------------------------------------------------------------------------------------
SSI w/o MEDICARE 344.18 61.79 N/A
- ---------------------------------------------------------------------------------------------------
SSI w/ MEDICARE 173.04 14.50 N/A
- ---------------------------------------------------------------------------------------------------
TANF<1, M/F 333.30 1164.82 281.83
- ---------------------------------------------------------------------------------------------------
TANF 1-13 M/F 71.06 32.70 82.56
- ---------------------------------------------------------------------------------------------------
SFP 19.68 N/A N/A
- ---------------------------------------------------------------------------------------------------
1
SECTION C: DEFINITIONS
ADHS Arizona Department of Health Services, the
state agency mandated to serve the public health
needs of all Arizona citizens.
AGENT Any person who has been delegated the authority to
obligate or act on behalf of another person or
entity.
AHCCCS Arizona Health Care Cost Containment System, which is
composed of the Administration, contractors, and
other arrangements through which health care services
are provided to an eligible person, as defined by
A.R.S. ss. 36-2902, et seq.
AHCCCS BENEFITS See "COVERED SERVICES"
AHCCCS MEMBER See "MEMBER".
AHCCCSA Arizona Health Care Cost Containment System
Administration.
ALTCS The Arizona Long Term Care System (ALTCS), a program
under AHCCCSA that delivers long term, acute,
behavioral health and case management services to
members, as authorized by A.R.S. ss. 36-2932.
AMBULATORY Preventive, diagnostic and treatment services
CARE provided on an outpatient basis by physicians,
nurse practitioners, physician assistants and other
health care providers.
AMPM AHCCCS Medical Policy Manual.
ARIZONA State regulations established pursuant to relevant
ADMINISTRATIVE statutes. For purposes of this solicitation, the
CODE relevant sections of the AAC are referred to
(A.A.C.) throughout this document as "AHCCCS Rules".
A.R.S. Arizona Revised Statutes.
AT RISK Refers to the period of time that a member is
enrolled with a contractor during which time the
Contractor is responsible to provide AHCCCS covered
services under capitation.
BIDDERS LIBRARY A repository of manuals, statutes, rules and other
reference material located at the AHCCCS office in
Phoenix.
BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
(2)
CAPITATION Payment to contractor by AHCCCSA of a fixed monthly
payment per person in advance for which the
contractor provides a full
2
range of covered services as authorized under A.R.S.
ss. 36-2942 and ss. 36-2931.
(3)
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider of service
or from a third party; but does not include claims
under investigation for fraud or abuse or claims
under review for medical necessity, as defined by
A.R.S. ss. 36-2904.
(4)
COMPETITIVE BID A state procurement system used to select contractors
PROCESS to provide covered services on a geographic basis.
3
CONTINUING An AHCCCS contractor during CYE 97 that submits a
OFFEROR proposal pursuant to this solicitation
4
CONTRACT See "COVERED SERVICES".
SERVICES
CONTRACT YEAR Corresponds to federal fiscal year (Oct. 1 through
(CY) Sept. 30). For example, Contract Year 01 is
10/01/00-- 9/30/01.
CONTRACTOR A person, organization or entity agreeing through a
direct contracting relationship with AHCCCSA to
provide the goods and services specified by this
contract in conformance with the stated contract
requirements, AHCCCS statute and rules and federal
law and regulations.
CONVICTED A judgment of conviction has been entered by a
federal, state or local court, regardless of whether
an appeal from that judgment is pending.
CO-PAYMENT A monetary amount specified by the Director that the
member pays directly to a contractor or provider at
the time covered services are rendered, as defined in
R9-22-107.
COUNTRY Amount of funds contributed to the AHCCCS fund by
CONTRIBUTION each Arizona county based on funding formulas
established by law.
COVERED SERVICES Health care services to be delivered by a contractor
which are designated in Section D of this contract
and also AHCCCS Rules R9-22, Article 2 and R9-31,
Article 2.
CRS Children's Rehabilitative Services, as defined in
R9-22-114.
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified as defined
in the text, as defined in R9-22-101.
DIRECTOR The Director of AHCCCSA.
DISCLOSING ENTITY An AHCCCS provider or a fiscal agent.
DME Durable Medical Equipment, which is an item, or
appliance that can withstand repeated use, is
designated to serve a medical purpose, and is not
generally useful to a person in the absence of a
medical condition, illness or injury as defined in
R9-22-102.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
EAC Eligible Assistance Child as defined in A.R.S.
ss. 36-2905.03(B); an AHCCCS state program for
children under age 14 receiving food stamps.
5
ELIC Eligible Low-Income Child as defined in A.R.S.
ss. 36-2905.05(C) and (D); an AHCCCS state program
for children under age 14 whose household income
exceeds the income limit for the MN/MI program but is
less than 100% of the federal poverty level.
ELIGIBILITY A process of determining, through a written
DETERMINATION application, including required documentation,
whether an applicant meets the qualifications for
Title XIX, Title XXI and/or state-only eligibility.
EMERGENCY A medical condition manifesting itself by acute
MEDICAL symptoms of sufficient severity (including severe
CONDITION pain) such that a prudent layperson, who possess an
average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in: a) placing the patient's
health in serious jeopardy; b) serious impairment to
bodily functions; or c) serious dysfunction of any
bodily organ or part.
EMERGENCY Services provided after the sudden onset of a medical
MEDICAL SERVICE condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that the
absence of immediate medical attention could
reasonably be expected to result in: a) placing the
patient's health in serious jeopardy; b) serious
impairment to bodily functions; or c) serious
dysfunction of any bodily organ or part, as defined
in R9-22-102.
ENCOUNTER A record of a medically related service rendered by a
provider or providers registered with AHCCCSA to a
member who is enrolled with a Contractor on the date
of service. It includes all services for which the
contractor incurred any financial liability.
ENROLLMENT The process by which an eligible person becomes a
member of a contractor's health plan.
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; services for persons under 21 years of age
as described in AHCCCS rules R9-22, Article 2.
FAMILY PLANNING A program that provides family planning services only
SERVICES for a maximum of 24 months to women whose pregnancy
EXTENSION SOBRA has ended and the woman is not otherwise eligible for
PROGRAM Title XIX.
6
FEDERALLY An entity which meets the requirements and receives a
QUALIFIED HEALTH grant and funding pursuant to Section 330 of the
CENTER (FQHC) Public Health Service Act. An FQHC includes an
outpatient health program or facility operated by a
tribe or tribal organization under the Indian
Self-Determination Act (PL 93-638) or an urban Indian
organization receiving funds under Title V of the
Indian Health Care Improvement Act.
FEE-FOR-SERVICE A method of payment to registered providers on an
(FFS) amount-per service basis.
FFP Federal financial participation (FFP) refers to the
contribution that the federal government makes to the
Title XIX and Title XXI program portions of AHCCCS as
defined in 42 CFR 400.203.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1
through September 30; State fiscal year: July 1
through June 30.
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered and who makes
referrals as necessary and monitors the member's
treatment.
GEOGRAPHIC A specific county or defined grouping of counties
SERVICE AREA (GSA) designated by the Administration within which a
contractor of record provides, directly or through
subcontract, covered health care to members enrolled
with that contractor of record.
GROUP OF Two or more health care professionals who practice
PROVIDERS their profession at a common location (whether or not
they share facilities, supporting staff, or
equipment).
HCFA Health Care Financing Administration, an organization
within the U.S. Department of Health and Human
Services, which administers the Medicare and Medicaid
programs and Children's Health Insurance Program.
HEALTH Various forms of plan organization, including staff
MAINTENANCE and group models, that meet the HMO licensing
ORGANIZATION requirements of the federal and/or state government
(HMO) and offer a full array of health care services to
members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported: Liability for services
rendered for which claims have not been received.
IHS Indian Health Service, authorized as a federal agency
pursuant to 25 U.S.C. 1661.
LIEN A legal claim filed with the County Recorder's office
in which a member resides and in the county an injury
was sustained for the
7
purpose of ensuring that AHCCCS receives
reimbursement for medical services paid. The lien is
attached to any settlement the member may receive as
a result of an injury.
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by means
of arrangements with selected providers to furnish
comprehensive services to members; establish explicit
criteria for the selection of health care providers;
have significant financial incentives for members to
use providers and procedures associated with the
plan; and have formal programs for quality assurance
and utilization review.
MANAGEMENT A person or organization that agrees to perform any
SERVICES administrative function or service for the Contractor
SUBCONTRACTOR specifically related to securing or fulfilling the
Contractor's obligations to AHCCCSA under the terms
of the contract.
MANAGING EMPLOYEE A general manager, business manager, administrator,
director, or other individual who exercises
operational or managerial control over, or who
directly or indirectly conducts the day-to-day
operation of, an institution, organization or agency.
MATERIAL A fact, data or other information excluded from a
OMISSION report, contract, etc. the absence of which could
lead to erroneous conclusions following reasonable
review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEMBER A person eligible who is enrolled in the system, as
defined in A.R.Sss. 36-2901.
MN/MI Medically Needy/Medically Indigent; state program for
individuals not eligible for Medicaid but who meet
the eligibility requirements for the state program.
NEW OFFEROR The organization, entity or person which submits a
proposal in response to this solicitation and which
has not been an AHCCCS contractor during CYE 97.
NON-CONTRACTING A person who provides services as prescribed in
A.R.S.ss.36-2939 and who does not have a subcontract
with an AHCCCS contractor.
OFFEROR A person or other entity that submits a proposal to
the Administration in response to an RFP, as defined
in R9-22-106.
PERFORMANCE A set of standardized indicators designed to assist
MEASURES AHCCCS in evaluating, comparing and improving the
performance of its
8
contractors. Specific descriptions of health services
measurement goals are found in Section D, Paragraph
16, Performance Measures.
PMMIS AHCCCSA's Prepaid Medical Management Information
System.
PRIMARY CARE An individual who meets the requirements of
PROVIDER (PCP) A.R.S.ss.36-2901, and who is responsible for the
management of a member's health care. A PCP may be a
physician defined as a person licensed as allopathic
or osteopathic physician according to A.R.S. Title
32, Chapter 13 or Chapter 17 or a practitioner
defined as a physician assistant licensed under
A.R.S. Title 32, Chapter 25, or a certified nurse
practitioner licensed under A.R.S. Title 32, Chapter
15.
PRIOR PERIOD The period of time from the 1st day of the month of
application or the 1st eligible month whichever is
later to the day a member is enrolled with the
Contractor. The Contractor receives notification from
the Administration of the member's enrollment.
PRIOR QUARTER The three-month period immediately proceeding the
month in which the member applies for Title XIX
benefits. If it is determined that the member would
have been eligible had the member applied in the
month in which services were provided, AHCCCSA may
pay for unpaid Title XIX services on a
fee-for-service basis. The Contractor is not liable
for the prior quarter period.
PROVIDER Any person who contracts with the Administration for
the provision of hospitalization and medical care to
members according to the provisions A.R.S.ss. 36-2901
or any subcontractor of provider delivering services
pursuant to A.R.S.ss. 36-2901.
QUALIFIED A person, eligible under A.R.S.ss.36-2971(4), who is
MEDICARE entitled to Medicare Part A insurance, meets certain
BENEFICIARY (QMB) income, resource and residency requirements of the
Qualified Medicare Beneficiary program. A QMB who is
also categorically eligible for Medicaid is commonly
referred to as a QMB dual eligible.
RATE CODE Eligibility classification for capitation payment
purposes.
REGIONAL An organization under contract with ADHS to
BEHAVIORAL administer covered behavioral health services in a
HEALTH AUTHORITY geographically specific area of the state. Tribal
(RBHA) governments, through an agreement with ADHS, may
operate a tribal regional behavioral health authority
(TRBHA) for the provision of behavioral health
services to Native American members living
on-reservation.
REINSURANCE A risk-sharing program provided by the Administration
to contractors for the reimbursement of certain
contract service costs incurred by a member beyond a
certain monetary threshold.
RELATED PARTY A party that has, or may have, the ability to control
or significantly
9
influence a contractor, or a party that is, or may
be, controlled or significantly influenced by a
contractor. "Related parties" include, but are not
limited to, agents, managing employees, persons with
an ownership or controlling interest in the
disclosing entity, and their immediate families,
subcontractors, wholly-owned subsidiaries or
suppliers, parent companies, sister companies,
holding companies, and other entities controlled or
managed by any such entities or persons.
RFP Request For Proposals which is a document prepared by
AHCCCSA which describes the services required and
which instructs prospective offerors how to prepare a
response (proposal), as defined in R9-22-107.
SCOPE OF SERVICES See "COVERED SERVICES".
SOBRA Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act, 1986, amended by the Medicare
Catastrophic Coverage Act of 1988, 42 CFR U.S.C.
1396a(a)(10)(A)(ii)(IX), July 1, 1988. STATE The
State of Arizona.
STATE PLAN The written agreements between the State and HCFA
which describes how the AHCCCS program meets HCFA
requirements for participation in the Medicaid
program and the Children's Health Insurance Program.
STATE-ONLY A member who is not eligible for Title XIX or XXI but
MEMBER is eligible for one of the state-funded eligibility
categories which include Medically Needy/Medically
Indigent (MN/MI), Eligible Assistance Children (EAC),
Eligible Low Income Children (ELIC), and SSI-related
non-qualified aliens.
SUBCONTRACT An agreement entered into by Contractor with a
provider of health care services who agrees to
furnish covered services to members, or with a
marketing organization, or with any other
organization or person who agrees to perform any
administrative function or service for Contractor
specifically related to fulfilling Contractor's
obligations to AHCCCSA under the terms of this
contract, as defined in R9-22-101.
SUBCONTRACTOR (1) A person, agency or organization to that a
contractor has contracted with or delegated some of
its management functions or responsibilities to
provide covered services to its members; or (2) A
person, agency or organization that a fiscal agent
has entered into a contract, agreement, purchase
order or lease (or leases of real property) to obtain
space, supplies, equipment or services provided under
the AHCCCS agreement.
SUPPLEMENTAL Federal cash assistance program under Title XVI of
SECURITY INCOME the Social Security Act.
(SSI)
10
TEFRA RISK HMO A Health Maintenance Organization or Comprehensive
Medical Plan, which provides Medicare, services to
Medicare beneficiaries pursuant to a Medicare risk
contract with HCFA under ss. 1876 of the Social
Security Act.
TEMPORARY A Federal cash assistance program under Title IV-A
ASSISTANCE TO of the Social Security Act. It replaced Aid To
NEEDY FAMILIES Families With Dependent Children (AFDC).
(TANF)
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS applicant
or member, as defined in R9-22-110.
THIRD PARTY The resources available from a person or entity that
LIABILITY is, or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the medical
expenses incurred by an AHCCCS applicant or member,
as defined in R9-22-110
TITLE XIX MEMBER Member eligible for Medicaid under Title XIX of the
Social Security Act including those eligible under
1931 provisions of the Social Security Act
(previously AFDC), Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI) or SSI-related groups.
TITLE XXI MEMBER Member eligible for acute care services under
Title XXI of the Social Security Act, referred to in
federal legislation as the "State Children's Health
Insurance Program" (SCHIP). The Arizona version of
SCHIP is referred to as "KidsCare."
TRIBAL FACILITY A facility that is operated by an Indian tribe and
(638 TRIBAL that is authorized to provide services pursuant to
FACILITY) Public Law 93-638, as amended.
YEAR See "Contract Year".
[END OF DEFINITIONS]
11
SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22, Article 2, the AHCCCS Medical Policy
Manual (AMPM), and the document entitled "AHCCCS Health Plan Performance
Indicators", all of which are incorporated herein by reference and may be found
in the Bidder's Library. The covered services are briefly described below.
Covered services must be medically necessary and provided by, or coordinated
with, a primary care provider, except for behavioral health and children's
preventive dental services. Services must be rendered by providers that are
appropriately licensed or certified, operating within their scope of practice,
and registered as an AHCCCS provider. The Contractor shall provide the same
standard of care for all members regardless of the member's eligibility
category.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options even if needed services are not
covered by the Contractor.
KIDS CARE COVERED SERVICES: KidsCare members are eligible for the same services
covered for members under the Title XIX and state-only programs, with the
following differences, exclusions and/or limitations:
a. Non-emergency transportation is not covered.
b. Chiropractic services are not covered.
c. Vision services are limited to one eye examination per contract year
and one pair of glasses or contacts every contract year.
d. EPSDT services are limited to those services specified in this
contract.
e. Behavioral health services are limited to 30 inpatient days and 30
outpatient visits per contract year. (See details under Section D
Paragraph 2, Behavioral Health Services.)
f. Licensed midwives and home deliveries are not covered.
For further details regarding the KidsCare program, see Section D, Paragraph 64,
KidsCare, and the AHCCCS Medical Policy Manual (AMPM).
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a freestanding surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 21 including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through other than medical or surgical means
(i.e. hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2, Behavioral Health Services.
12
CHILDRENS REHABILITATIVE SERVICES (CRS): The program for children with
CRS-covered conditions is administered by the Arizona Department of Health
Services (ADHS) for children who meet CRS eligibility criteria. The Contractor
shall refer children to the CRS program who are potentially eligible for
services related to CRS covered conditions, as specified in R9-22, Article 2
A.R.S. Title 36, Chapter 2, Article 3.. Eligibility criteria and the referral
process are described in the CRS Policy and Procedures Manual available in the
Bidder's Library.
The Contractor shall monitor referrals to CRS to ensure CRS covered services are
provided in a timely manner to eligible members. Referral to CRS does not
relieve the Contractor of the responsibility for providing medically necessary
services not covered by CRS to CRS eligible members. The Contractor is also
responsible for initial care of newborn members, who are CRS eligible. The
Contractor must require the member's Primary Care Provider (PCP) to coordinate
their care with the CRS program. All services provided must be included in the
member's medical record maintained by the PCP.
A member with private insurance is not required to utilize CRS. If the member
uses their private insurance network for a CRS covered condition, and the member
is not enrolled with CRS, the Contractor is responsible for all applicable
deductibles and copays.
The Contractor remains ultimately responsible for the provision of all covered
services to its members. If the Contractor becomes aware that CRS has failed to
meet the established appointment standards, or has failed to provide medically
necessary CRS covered services, the Contractor shall immediately notify AHCCCSA,
Office of Medical Management, of the occurrence. In accordance with AHCCCS
policy, the Contractor may seek reimbursement from CRS for providing CRS covered
services.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
Title XIX members under age 21 when prescribed by the member's PCP and approved
by the Contractor in order to ameliorate the member's medical condition.
Medicare approved chiropractic services shall also be covered, subject to
limitations specified in CFR 410.22, for Qualified Medicare Beneficiaries if
prescribed by the member's PCP and approved by the Contractor.
DENTAL: The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services; dental
screening and preventive services in accordance with the AHCCCS periodicity
schedule; therapeutic dental services; dentures; and pretransplantation dental
services. The Contractor shall monitor compliance with the EPSDT periodicity
schedule for dental screening services and ensure that dental service reports
are included in the member's medical record maintained by the PCP. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 16, Performance Measures. The Contractor shall
ensure that members are notified when dental screenings are due if the member
has not been scheduled for a visit. If no dental screening is received by the
member, a second notice must be sent. Members under the age of 21 may request
dental services without referral and may choose a dental provider from the
Contractor's provider network. For members who are 21 years of age and older,
the Contractor shall provide emergency dental care, medically necessary dentures
and dental services for transplantation services as specified in the AMPM.
Dental standards may be found in the AMPM, Section 310, which is incorporated
herein by reference and which may be found in the Bidder's Library.
13
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment to correct or
ameliorate defects and physical or mental illness discovered by the screenings
for members under age 21. The Contractor shall ensure that these members receive
required health screenings, including developmental/behavioral health, in
compliance with the AHCCCS periodicity schedule (Exhibit 430-1 in the AMPM) and
to submit to the AHCCCS Office of Medical Management, all EPSDT reports as
required by AHCCCS medical policy. The Contractor is required to meet specific
participation/utilization rates for members as described in Section D, Paragraph
16, Performance Measures. Because the behavioral health benefit for Title XIX
and Title XXI is provided through the ADHS/RBHA system, the Contractor shall
ensure the initiation and coordination of the referral of these members to the
RBHA and shall follow up with the RBHA to monitor whether members have received
behavioral health services. Title XXI members are not entitled to the
all-encompassing EPSDT service package required for Title XIX children. Title
XXI children are entitled only to the EPSDT and other covered services specified
in this document, the AMPM and the Title XXI State Plan.
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide prehospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically
emergent condition as defined by AHCCCS Rule R9-22-101 and R9-31-101.
Emergency medical services are covered without prior authorization. The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged
to contract with or employ the services of non-emergency facilities
(e.g. urgent care centers) to address member non-emergency care issues
occurring after regular office hours or on weekends. The Contractor
shall be responsible for educating members and providers regarding
appropriate utilization of emergency room services including behavioral
health emergencies. The Contractor shall monitor emergency service
utilization (by both provider and member) and shall have guidelines for
implementing corrective action for inappropriate utilization. For
utilization review, the test for appropriateness of the request for
emergency services shall be whether a prudent layperson, similarly
situated, would have requested such services. For purposes of this
contract, a "prudent layperson" is a person who possesses an average
knowledge of health and medicine.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
e. The Contractor shall comply with guidelines regarding the coordination
of post-stabilization care.
14
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for
conditions of the eye for all members under the age of 21, with the exception of
KidsCare members. See limitations for KidsCare members described at the
beginning of this section, titled "KidsCare Covered Services." For members who
are 21 years of age and older, the Contractor shall provide emergency care for
eye conditions which meet the definition of an emergency medical condition,
cataract removal, and/or medically necessary vision examinations and
prescriptive lenses if required following cataract removal and other eye
conditions as specified in the AMPM.
FAMILY PLANNING: The Contractor shall provide family planning services in
accordance with the AMPM, Section 420 for all members who choose to delay or
prevent pregnancy. These include medical, surgical, pharmacological and
laboratory services, as well as contraceptive devices. Information and
counseling necessary to allow the members to make informed decisions regarding
family planning methods shall also be included. If the Contractor does not
provide family planning services, it must contract for these services through
another health care delivery system, which allows members freedom of choice in
selecting a provider. A prospective offeror may discuss arrangements for family
planning services only with other prospective offerors during the RFP process
for the purpose of making arrangements for the provision of family planning
services.
The Contractor shall provide services to members enrolled in the Family Planning
Services Extension Program; a program that provides only family planning
services for a maximum of 24 months to women whose SOBRA eligibility has
terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification may be made at the time
the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually transmitted diseases, tuberculosis and
HIV/AIDS; nutritional assessment in cases when the member has a chronic
debilitating disease affected by nutritional needs; mammograms and prostate
screenings; physical examinations and diagnostic work-ups; and immunizations.
Required assessment and screening services for members under age 21 are included
in the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: The Contractor shall provide part-time or intermittent care for
members who do not require hospital care. This service is provided under the
direction of a physician to prevent re-hospitalization or institutionalization
and may include nursing, therapies, supplies and home health aide services.
HOSPICE. These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL. Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis services. If the member's
medical condition requires isolation; private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
15
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the above
services, which may be provided on an outpatient or ambulatory basis (i.e.
laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if determined
reasonable and necessary to decide whether the member should be admitted for
inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS. The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
oral/inactivated polio vaccine (OPV/IPV), measles, mumps, rubella vaccine (MMR),
H. influenza, type B (HIB), hepatitis B (Hep B), and varicella vaccine. The
Contractor is required to meet specific immunization rates for members under the
age of 21, which are described in Section D, Paragraph 16, Performance Measures.
INDIAN HEALTH SERVICES (IHS): The Contractor may choose to subcontract with and
pay an IHS or 638 tribal facility as part of their provider network for covered
services provided to members. Effective October 1, 1999, the Contractor is
responsible for reimbursement to IHS or tribal facilities for emergency services
provided to state-only and Title XXI Native American members enrolled with the
Contractor. The Contractor has no responsibility for non-emergency services to
state-only and Title XXI Native American members unless the Contractor refers or
prior authorizes the service. AHCCCSA will reimburse claims for acute care
services that are medically necessary and eligible for 100% Federal
reimbursement, provided to Title XIX members in an IHS or a 638 tribal facility.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending physician
or dentist, and provided by a CLIA (Clinical Laboratory Improvement Act)
approved free standing laboratory or hospital laboratory, clinic, physician
office or other health care facility laboratory.
Upon written request, a Contractor may obtain laboratory test data on members
from a laboratory or hospital based laboratory subject to the requirements
specified in A.R.S. ss. 36-2903(R) and (S). The data shall be used exclusively
for quality improvement activities and health care outcome studies required
and/or approved by the Administration.
MATERNITY. The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants or nurse practitioners certified in
midwifery. Members may select or be assigned to a PCP specializing in
obstetrics. Circumcisions are covered as described in the AMPM. Title XIX and
state-only members anticipated to have a low-risk delivery may elect to receive
labor and delivery services in their home from their maternity provider if this
setting is included in allowable settings for the Contractor, and the Contractor
has providers in its network that offer home labor and delivery services. Title
XIX and state-only members anticipated to have a low-risk prenatal course and
delivery may elect to receive maternity services of prenatal care, labor and
delivery and postpartum care provided by licensed midwives if they are in the
Contractor's provider network. All licensed midwife labor and delivery services
must be provided in the
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member's home since licensed midwives do not have admitting privileges in
hospitals or AHCCCS registered freestanding birthing centers. Members receiving
maternity services from a licensed midwife must also be assigned to a PCP for
other health care and medical services. Home delivery and licensed midwives are
not covered for Title XXI members.
The Contractor shall allow women and their newborns to receive up to 48 hours of
inpatient hospital care after a routine vaginal delivery and up to 96 hours of
inpatient care after a cesarean delivery. The attending health care provider, in
consultation with the mother, may discharge the mother or newborn prior to the
48-hour minimum length of stay. A normal newborn may be granted an extended stay
in the hospital of birth when the mother's continued stay in the hospital is
beyond the 48 or 96 hour stay.
The Contractor shall inform all assigned AHCCCS pregnant women of voluntary
prenatal HIV testing and the availability of medical counseling if the test is
positive. The Contractor shall provide information in the member handbook and
annually in the member newsletter to encourage pregnant women to be tested and
instructions on where to be tested. Semi-annually, the Contractor shall report
to AHCCCS the number of pregnant women who have been identified as HIV/AIDS
positive. This report is due no later than 30 days after the end of the second
and fourth quarters of the contract year.
MEDICAL FOODS: Medical foods are covered within limitations defined in the AMPM
for members diagnosed with a metabolic condition included under the ADHS Newborn
Screening Program and specified in the AMPM. The medical foods, including
metabolic formula and modified low protein foods, must be prescribed or ordered
under the supervision of a physician.
MEDICALLY-NECESSARY ABORTIONS. This service is covered for a member if the
member suffers from a medical condition or disorder, physical injury, or illness
caused by or rising from the pregnancy. The service is also covered for Title
XIX and Title XXI members if the pregnancy is caused by rape or incest.
Physician certification of the condition, disorder, illness or injury must be
provided to the Contractor. In addition, providers must submit to the Contractor
a Certificate of Medical Necessity for Pregnancy Termination. Prior
authorization is required. If the procedure is performed on an emergency basis,
documentation must be submitted to the Contractor within two working days.
Additional documentation, outlined in the AMPM, is required for members under 18
years of age or members who are considered an incapacitated adult who seek a
medically necessary abortion due to rape or incest.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP,
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide nursing facility services,
including religious nonmedical health care institutions, for members who require
short-term convalescent care not to exceed 90 days per contract year. In lieu of
a nursing facility, the member may be placed in an alternative living facility
or receive home and community based services (HCBS) as defined in
17
R9-22, Article 2 and R9-28, Article 2 that meet the provider standards described
in R9-28, Article 5, and subject to the limitations set forth in Chapter 1200 of
the AMPM.
Nursing facility services must be provided in a dually-certified
Medicare/Medicaid facility which includes in the per-diem rate: nursing
services, basic patient care equipment and sickroom supplies, dietary services,
administrative physician visits, non-customized DME, necessary maintenance
rehabilitation therapies, over-the-counter medications, social, recreational and
spiritual activities, and administrative, operational medical direction
services. The Contractor shall provide medically necessary nursing facility
services for any member who has a pending ALTCS application, who is currently
residing in a nursing facility and is eligible for services provided under this
contract. If the member becomes ALTCS eligible and is enrolled with an ALTCS
Program Contractor before the end of the maximum 90 days of nursing facility
coverage, the Contractor is only responsible for nursing facility coverage
during the time the member is enrolled with the Contractor. Nursing facility
services covered by a third party insurer (including Medicare) while the member
is enrolled with the Contractor shall be applied to the 90 day limitation. See
Paragraph 36, Nursing Facility Reimbursement, for further details.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application and to prepare for potential fee-for-service coverage if the stay
goes beyond the 90-day maximum.
NUTRITION: Nutritional assessments may be conducted as a part of the EPSDT
screenings for members under age 21, and to assist members 21 years of age and
older whose health status may improve with nutritional intervention. Assessment
of nutritional status on a periodic basis may be provided as determined
necessary, and as a part of the health risk assessment and screening services
provided by the member's PCP. AHCCCS covers nutritional therapy on an enteral,
parenteral or oral basis, when determined medically necessary to provide either
complete daily dietary requirements, or to supplement a member's daily
nutritional and caloric intake and when AHCCCS criteria specified in the AMPM
are met.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS AND PHARMACY: Medications ordered by a PCP, attending
physician or dentist and dispensed under the direction of a licensed pharmacist
are covered subject to limitations related to prescription supply amounts,
Contractor formularies and prior authorization requirements, as well as
restrictions for immunosuppressant drugs addressed in AHCCCS medical policies
for transplantations. Over-the-counter medication may be prescribed when it is
determined to be a lower-cost alternative to prescription medication.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member
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for specialty medical services, behavioral health and dental services. The PCP
is responsible for maintaining the member's primary medical record, which
contains documentation of all health risk assessments and health care services
of which they are aware whether or not they were provided by the PCP.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those members who are 21 and over;
physical therapy for all members and occupational and speech therapies for
members under the age of 21 are covered on both an inpatient and outpatient
basis if not used as a maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient basis
when prescribed by the member's PCP or attending physician and is necessary to
restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services are covered within limitations defined in the AMPM for members
diagnosed with specified medical conditions. Such limitations include whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions that substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service. Services include pre-transplant inpatient or outpatient
evaluation; donor search; organ/tissue harvesting or procurement; preparation
and transplantation services; and convalescent care. In addition, if a member
receives a transplant covered by a source other than AHCCCS, medically necessary
non-experimental services are provided within limitations after the discharge
from the acute care hospitalization for the transplantation. AHCCCS has
contracted with transplantation providers for the Contractor's use or the
Contractor may select its own transplantation provider. However, the quality of
services must be equal to or exceed those of the AHCCCS provider and the rate
paid can not exceed the AHCCCS provider's negotiated rate.
Transplantations for the MN/MI population are subject to available funding.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided for
Title XIX and state-only members who are unable to provide their own
transportation for medically necessary services. Title XXI members are not
eligible for non-emergency transportation services except for transfers between
facilities.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists,
19
assess the severity of the member's medical condition and determine services
necessary to alleviate or stabilize the emergent condition. The provider must
notify the Contractor within 12 hours of the member's registration with the
facility for emergency services. Supporting documentation for services rendered
must be provided when reporting or billing a service. Triage/screening services
must be reasonable, cost effective and meet the criteria for severity of illness
and intensity of service.
2. BEHAVIORAL HEALTH SERVICES
Title XIX and Title XXI members are eligible for comprehensive behavioral health
services. The behavioral health benefit for these members is provided through
the ADHS - Regional Behavioral Health Authority (RBHA) system. The Contractor
shall be responsible for member education regarding these benefits; provision of
limited emergency inpatient services; and screening and referral to the RBHA
system of members identified as requiring behavioral health services.
MEMBER EDUCATION: The Contractor shall be responsible for educating members in
the member handbook and other printed documents about covered behavioral health
services and where and how to access services. Covered services for Title XIX
and Title XXI are similar with the exception that non-emergency transportation
is not covered for Title XXI members. For Title XXI members inpatient services
and specified outpatient services are limited to 30 days/30 visits per contract
year. Covered services include:
a. Inpatient services (Title XXI limited to 30 days per contract year)
b. Individual, group and family therapy and counseling (limited for Title
XXI)
c. Psychotropic medication
d. Psychotropic medication adjustment and monitoring
e. Partial care, basic and intensive (limited for Title XXI)
f. Emergency crisis services
g. Behavior management (limited for Title XXI)
h. Psychosocial rehabilitation (limited for Title XXI)
i. Evaluation, screening and diagnosis (limited for Title XXI)
j. Laboratory and radiology services for psychotropic medication
regulation and diagnosis
k. Emergency and medically necessary transportation (Title XXI members
limited to emergency transportation only)
l. Case management services
m. Respite
REFERRALS: As specified in Section D, Paragraph 1, EPSDT, the Contractor must
provide developmental/behavioral health screenings for members up to 21 years of
age in compliance with the AHCCCS periodicity schedule. The Contractor shall
ensure the initiation and coordination of behavioral health referrals of these
members to the RBHA when determined necessary through the screening process.
The Contractor is responsible for RBHA referral and follow-up collaboration, as
necessary, for other Title XIX and Title XXI members identified as needing
behavioral health evaluation and treatment. Members may also access the RBHA
system for evaluation by self-referral or be referred by schools, State agencies
or other service providers. The Contractor is responsible for providing
transportation to Title XIX members first RBHA evaluation appointments if
members are unable to provide their own transportation.
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EMERGENCY SERVICES: For Title XIX and Title XXI members not enrolled with ADHS,
the Contractor is responsible for up to three days of inpatient behavioral
health services per emergency episode not to exceed 12 days per contract year. A
referral to the RBHA for evaluation and enrollment should be initiated as soon
as possible after admission.
For state-only members (MN/MI, EAC, ELIC): The Contractor is responsible for up
to three days of inpatient emergency behavioral health services not to exceed 12
days per contract year regardless of whether the member is enrolled with a RBHA.
For members who become eligible during an emergency episode, the three (3) days
of coverage for this hospital benefit are the first three (3) days of
eligibility.
Coordination of Care: The Contractor is responsible for ensuring that a medical
record is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has not yet
seen the assigned member. The Contractor shall require the PCP to respond to
RBHA provider information requests pertaining to ADHS enrolled members
including, but not limited to, current diagnosis, medication, pertinent
laboratory results, last PCP visit, and last hospitalization. For prior period
coverage, the Contractor is responsible for payment of all claims for medically
necessary covered behavioral health services to members not enrolled with ADHS.
MEDICATION MANAGEMENT SERVICES: The Contractor shall allow PCPs to provide
medication management services (prescriptions, medication monitoring visits,
laboratory and other diagnostic tests necessary for diagnosis and treatment of
behavioral disorders) to members with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder. The Contractor shall make available,
on the Contractor's formulary, medications for the treatment of these disorders.
The Contractor shall ensure that training and education is available to PCPs
regarding behavioral health referral and consultation procedures. The Contractor
shall establish policies and procedures for referral and consultation and shall
include them in their provider manual. Also, Contractors shall inform PCPs about
the availability of resource information through the Maricopa Integrated Health
System's Psychiatric Residency Training Program and the Arizona Medical
Association regarding the diagnosis and treatment of behavioral health
disorders.
The Contractor shall ensure that its quality management and peer review programs
incorporate monitoring of the PCP's management of behavioral health disorders.
3. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. The Contractor is responsible for complying with the requirements
set forth within. The AMPM with search capability and linkages to AHCCCS rules,
Statutes and other resources is available to all interested parties through the
AHCCCS Home Page on the Internet (www.ahcccs.state.az.us). Upon adoption by
AHCCCSA, AMPM updates will be available through the Internet at the beginning of
each month. If required, the Contractors may receive one hard copy of the AMPM,
free of charge, from AHCCCSA, Office of Medical Management, however, the
Contractor shall be responsible for maintaining such copies current with these
updates.
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4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program, the federal and state governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. Therefore, the Contractor shall not utilize AHCCCS
funding to purchase vaccines for members under the age of 19. Any provider,
licensed by the State to administer immunizations, may register with ADHS as a
"VFC provider" and receive free vaccines. The Contractor shall comply with all
VFC requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When a covered service is denied, reduced, suspended or terminated, the
Contractor shall comply with the notice, appeal and continuation of benefits
requirements specified in the Office of Managed Care Member Rights and
Responsibilities Policy.
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
Social Security Administration (SSA) SSA determines eligibility for the
Supplementary Security Income (SSI) cash
program. SSI Cash recipients are
automatically eligible for AHCCCS
coverage.
Department of Economic Security (DES) DES determines eligibility for the
Temporary Assistance to Needy Families
(TANF) program (formerly Aid to Families
with Dependent Children), 1931 Group
Medical Assistance Only (MAO) groups,
SOBRA women and children, the Eligible
Assistance Children state program (EAC),
the Adoption Subsidy Program, Title IV-E
foster care children, Young Adults
Transition Insurance Program, and the
Federal Emergency Services program (FES)
related to the TANF, 1931 Group, or
SOBRA programs.
AHCCCSA AHCCCSA determines eligibility for the
SSI/MAO groups, including the FES
program related to the SSI-Cash program
(aged, disabled, blind), the Arizona
Long-
22
Term Care System (ALTCS), the Qualified
Medicare Beneficiary program and other
Medicare cost sharing programs, and the
Title XXI program.
Arizona's 15 Counties Each county determines eligibility for
the Medically Needy/Medically Indigent
(MN/MI), Eligible Low Income Children
(ELIC), and the State Emergency Services
state programs.
AHCCCS acute care members are enrolled with contractors in accordance with the
rules set forth in R9-22, Article 17.
HEALTH PLAN CHOICE
Acute members, except for those eligible under the MN/MI program have a choice
of available health plans. A listing of the available health plans and their
telephone numbers will be given to each applicant during the application process
for AHCCCS benefits. Also included are instructions to applicants to call the
health plans directly with specific questions concerning the health plan. If
there is only one health plan available for the applicant's Geographical Service
Area, no choice is offered. Members who do not choose prior to AHCCCSA' s being
notified of their eligibility are automatically assigned to a health plan based
on family continuity or the auto-assignment algorithm.
Title XXI members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. When a member is transferred from
Title XIX to Title XXI and has not made a health plan choice for Title XXI, the
member will remain with the Title XIX health plan and a choice notice will be
sent to the member. The member may then change plans no later than 16 days from
the date the choice notice is sent.
AHCCCSA assigns MN/MI members to an available health plan based on family
continuity or through AHCCCSA's auto-assignment algorithm. These members do not
get a choice of available contractors until their annual enrollment choice
period.
Exceptions to the above enrollment policies for Title XIX and state-only members
include: previously enrolled members who have been disenrolled for less than 90
days will be automatically enrolled with the same contractor, if that contractor
is still available. Also, women who are eligible for the Family Planning
Services Extension Program will automatically remain assigned to the same health
plan. The Family Planning Services Extension Program provides a maximum of 24
months of family planning services.
The effective date of enrollment for a new Title XIX or state-only member with
the Contractor will generally be the day prior to the date the Contractor
receives notification from AHCCCSA via the daily roster. However, the Contractor
is responsible for payment of medically necessary covered services retroactive
to the member's beginning date of eligibility, excluding any prior quarter
coverage period.
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The effective date of enrollment for a Title XXI member will be the first day of
the month following notification to the health plan. If a Title XXI member is
determined eligible by the 25th of the month, the member will be enrolled with
the health plan as of the 1st of the following month. If the member is
determined eligible AFTER the 25th of the month, the member will be enrolled
with the health plan as of the 1st of the second following month.
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for Title XIX and
state-only members. For Title XIX members, prior period coverage starts from the
first day of the month of application, or first eligible month, whichever is
later. The Contractor is responsible for payment of all claims for medically
necessary covered services provided to Title XIX members during prior period
coverage. For state-only EAC members, prior period coverage does not apply. For
state-only MN/MI and ELIC members prior period coverage is generally limited to
the two days prior to the date of AHCCCSA being notified of eligibility.
However, prior period coverage could include additional days prior to the date
of enrollment. The Contractor is responsible for payment of all claims for
medically necessary covered services provided on an emergency basis to
state-only members pursuant to A.R.S. ss. 36-2908 and A.R.S. ss. 36-2909 for the
first two days of the prior period coverage. Any additional prior period
coverage for state-only members will include all claims for medically necessary
covered services. This may include services provided prior to the contract year.
(See Section D, Paragraph 37, Compensation, for a description of the
Contractor's reimbursement from AHCCCSA for this eligibility time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers, including Title XXI mothers,
who were enrolled at the time of the child's birth and whose newborn
notification was received by AHCCCSA will be enrolled with the mother's health
plan. The Contractor is responsible for notifying AHCCCSA of a child's birth to
an enrolled member. Capitation to the Contractor will begin on the date
notification is received by AHCCCSA (except for cases of births during prior
period coverage). The effective date of AHCCCS eligibility will be the newborn's
date of birth, and the Contractor is responsible for all covered services to the
newborn whether or not AHCCCSA has received notification of the child's birth.
Note that AHCCCSA is currently available to receive notification calls 24 hours
a day, 7 days a week. Title XIX and Title XXI eligible mothers of newborns are
sent a letter advising them of their right to choose a different contractor for
their child; otherwise the child will remain with the mother's contractor.
Newborns of MN/MI mothers are enrolled with the mother's contractor for a
minimum of 30 days up to a maximum of 60 days.
Newborns of FES mothers are auto-assigned to a health plan and mothers of these
newborns are sent a letter advising them of their right to choose a different
health plan for their child. In the event the FES mother chooses a different
health plan, AHCCCS will recoup all capitation paid to the originally assigned
plan and the baby will be enrolled retroactive to the date of birth in the
second plan. The second plan will receive prior period capitation from the date
of birth to the day before assignment and prospective capitation from the date
of assignment forward. The second contractor will be responsible for all covered
services to the newborn from date of birth.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, or as an Eligible Assistance Child (EAC), the member is guaranteed a
minimum of five full months of continuous enrollment. Upon initial capitated
enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of
12 full months of continuous enrollment. Enrollment guarantees do not apply to
Native Americans who choose to obtain their covered services through Indian
Health Services (IHS) on a fee-for-service basis or children enrolled with
24
Department of Economic Security/Comprehensive Medical and Dental Program. The
enrollment guarantee applies a maximum of one time per member per eligibility
category for Title XIX, Title XXI and EAC members. If a member changes from one
contractor to another within the enrollment guarantee period, the remainder of
the guarantee period applies to the new contractor. The enrollment guarantee may
not be granted or may be terminated if the member is incarcerated or, if a minor
child is adopted. AHCCCS Rule R9-22, Article 17 and R9-31, Article 3 describes
other reasons for which the enrollment guarantee may not apply.
NATIVE AMERICANS. Native Americans eligible under any coverage group other than
MN/MI, on or off-reservation, have a choice to receive services from Indian
Health Service (IHS), a PL 93-638 tribal facility or any available contractor.
If choice is not available or made within the specified time limit, Native
American Title XIX and state-only members living on-reservation will be assigned
to IHS and Native American Title XIX and state-only members living
off-reservation will be assigned to an available contractor using AHCCCSA's
family continuity policy and auto-assignment algorithm. Native Americans may
change from IHS to a contractor or from a contractor to IHS at any time. Native
American Title XXI members must make a choice prior to being determined
eligible.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, or physical or mental handicap, except where
medically indicated. Contractors must take into account a member's culture, when
addressing members and their concerns, and must take reasonable steps to
encourage subcontractors to do the same. The Contractor must make interpreters
available for members to ensure appropriate delivery of covered services.
Examples of prohibited practices include, but are not limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
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If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. The reading level and name of the
evaluation methodology used should be included when 200 members or 5% of the
Contractor's enrolled population, whichever is greater, speak a 2nd language,
the Contractor shall provide member information in that 2nd language. The
Contractor shall comply whenever it is aware that a population meets this
standard. When there are program or service site changes notification will be
provided to the affected members at least 14 days before implementation. The
Contractor shall review and update the Member Handbook at least once a year. The
Handbook must be submitted to AHCCCSA Office of Managed Care for approval by
Sept. 1 of each contract year, or within four weeks of receiving the annual
renewal amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A Member Handbook which, at a minimum, shall include the following
items that are also listed in the Office of Managed Care, Operations
Policy #404, Member Information Policy:
a. A table of contents
b. A general description of how managed care works, particularly
in regards to member responsibilities, appropriate utilization
of services and the PCP's role as gatekeeper of services
c. A description of all available covered services and an
explanation of any service limitations or exclusions from
coverage and a notice stating that the Contractor will be
liable only for those services authorized by the Contractor.
The description should include a brief explanation of the
Contractor's approval and denial process.
d. Information on what to do when family size changes
e. How to obtain a PCP
f. How to change PCPs
g. How to make, change and cancel appointments with a PCP or
dentist
h. List of applicable copayments (including a statement that care
will not be denied due to lack of copayment). The member
handbook must clearly state that members cannot be billed for
covered services (other than applicable copayments), what to
do if they are billed, and under what circumstances a member
may be billed for non-covered services.
i. Dual eligibility (i.e. Medicare and Medicaid); services
received in and out of the Contractor's network; copayments.
See Section D, Paragraph 41, Medicare Services and Cost
Sharing.
j. The process of referral to specialists and other providers,
including access to behavioral health services provided by the
ADHS RBHA system.
26
k. How to contact Member Services and a description of its
function
l. What to do in case of an emergency and instructions for
receiving advice on getting care in case of an emergency. In a
life-threatening situation, the member handbook should
instruct members to use the emergency medical services (EMS)
available and/or activate EMS by dialing 9-1-1. Handbook
should contain information on proper emergency service
utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. A description of the purpose and benefits of
EPSDT services, including the required components of EPSDT
screenings and the provision of all medically necessary
services to treat a physical or mental illness discovered by
the screenings. Screenings include a comprehensive history and
developmental/behavioral health screening, comprehensive
unclothed physical examination, appropriate vision testing,
hearing testing, laboratory tests, dental screening and
immunizations.
o. Maternity and family planning services
p. Description of covered behavioral health services and how to
access them
q. Description of all covered dental services for members under
21 and how to access these services
r. Out of county/out of state moves
s. Grievance and request for hearing procedures, including a
clear explanation of the member's right to file a grievance
and request for hearing and to appeal any decision that
affects the member's receipt of covered services.
t. Contributions the member can make towards his/her own health,
member responsibilities, appropriate and inappropriate
behavior, and any other information deemed essential by the
Contractor or AHCCCS. This shall include a statement that the
member is responsible for protecting his or her ID card and
that misuse of the card, including loaning, selling or giving
it to others could result in loss of the member's eligibility
and/or legal action. A sentence shall be included that
stresses the importance of members keeping, not discarding,
the swipe ID card.
u. How to access after-hours care (urgent care).
v. Advance directives for adults
w. Use of other sources of insurance. See Section D, Paragraph
40, Coordination of Benefits.
x. The last revision date
y. Member's notification rights and responsibilities under AAC
R9-22, Article 13 and AHCCCS policy
z. A description of Fraud and Abuse including instructions on how
to report suspected fraud or abuse. This shall include a
statement that misuse of a member's identification card,
including loaning, selling or giving it to others could result
in loss of the member's eligibility and/or legal action
against the member
aa. A statement that informs the member of their right to request
information on whether or not the health plan has Physician
Incentive Plans (PIP) that affect the use of referral
services, the right to know the types of compensation
arrangements the plan uses, the right to know whether
stop-loss insurance is required and the right to a summary of
member survey results. (in accordance with PIP regulation).
bb. Member's right to be treated fairly regardless of race,
religion, sex, age or ability to pay.
27
cc. Instructions for obtaining culturally competent materials,
including translated member materials.
dd. A description of the criteria and procedures for requesting a
health plan change.
ee. Information regarding prenatal HIV testing and counseling
services.
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type style and size, which can easily be read by members with
varying degrees of visual impairment. At a minimum, the member handbook shall
also contain the following language regarding questions, problems, grievances
and requests for hearings (Ref. AHCCCS Rule R9-22-518 and R9-31-518):
Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call _________ and ask to
talk to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 60 days after the date of the
action, decision, or incident.
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
I. A list of the names, telephone numbers and service site addresses of
PCPs available for selection by the member and a description of the
selection process. Upon request by the member, the Contractor must make
information available regarding provider qualifications.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs; communication
between members and the Contractor; and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in each survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, unless waived by AHCCCSA, the Contractor shall
perform its own annual general or focused member survey. All such contractor
surveys must be approved in advance by AHCCCSA.
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10. MARKETING PLANS
The Contractor shall submit all proposed marketing plans and materials to
AHCCCSA for prior approval in accordance with the AHCCCS Health Plan Marketing
Policy, a copy of which is available in the Bidder's Library. The Contractor
must have signed contracts with hospitals (in Maricopa and Pima counties), PCPs,
specialists and pharmacies in order for them to be included in marketing
materials.
11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment on a limited basis as
deemed necessary. During AEC, members may change contractors subject to the
availability of other contractors within their Geographic Service Area. Members
are mailed a printed enrollment form and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process. If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if the Contractor's contract is renewed and the member
continues to live in the Contractor's service area. The Contractor shall comply
with the Office of Managed Care Member Transition for Annual Enrollment Choice
and Other Plan Changes policy.
12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM, and the Office of Managed Care Member
Transition for Annual Enrollment Choice and Other Plan Changes standards for
member transitions between health plans or GSAs, to or from an ALTCS program
contractor, IHS, a PL 93-638 tribal entity, or a Title XXI direct service
provider and upon termination or expiration of a contract. The Contractor shall
develop and implement policies and procedures, which comply with AHCCCS medical
policy to address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy or who are hospitalized
at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services.
29
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
A1{CCCSA:
d. A monthly claims aging report by provider/creditor including IBNR
amounts;
e. A monthly summary of cash disbursements;
f. Copies of all bank statements received by the Contractor.
g. Such reports shall be due on the fifth day of each succeeding month for
the prior month.
h. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
i. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
j. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff is required.
a. A full-time ADMINISTRATOR/CEO/COO who is available at all times to
fulfill the responsibilities of the position and to oversee the entire
operation of the health plan. The Administrator shall devote sufficient
time to the Contractor's operations to ensure adherence to program
requirements and timely response to AHCCCS Administration.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all-major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A CHIEF FINANCIAL OFFICER/CFO who is available at all times to fulfill
the responsibilities of the position and to oversee the budget and
accounting systems implemented by the Contractor.
30
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20. The Behavioral
Health Coordinator shall devote sufficient time to ensure that the
Contractor's behavioral health referral and coordination activities are
implemented per AHCCCSA requirements.
g. PRIOR AUTHORIZATION STAFF to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems, and to meet the Contractor's standards for telephone
abandonment rates and telephone hold times.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A CLAIMS ADMINISTRATOR AND CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
l. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE COORDINATOR who will manage and adjudicate member and
provider grievances.
n. CLERICAL AND SUPPORT STAFF to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCSA, Office of Managed Care, in writing and
provide a resume within seven days of staffing changes in the following key
positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/EPSDT Coordinator Quality Management/Utilization
Management Coordinator
Grievance Coordinator Behavioral Health Coordinator
The Contractor shall ensure that all staff has appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
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14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
15. ADVANCE DIRECTIVES
The Contractor shall maintain policies and procedures addressing advanced
directives for adult members that specify:
a. Each contract or agreement with a hospital, nursing facility, home
health agency, hospice or organization responsible for providing
personal care must comply with federal and State law regarding advance
directives for adult members. Requirements include:
(1) Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the
right to accept or refuse medical care, and the right to
execute an advance directive. If the agency/organization has a
conscientious objection to carrying out an advance directive,
it must be explained in policies. (A health care provider is
not prohibited from making such objection when made pursuant
to A.R.S. ss. 36-3205.C.1.)
(2) Provide written information to adult members regarding each
individual's rights under State law to make decisions
regarding medical care, and the health care provider's written
policies concerning advance directives (including any
conscientious objections).
(3) Documenting in the member's medical record whether or not the
adult member has been provided the information and whether an
advance directive has been executed.
(4) Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and
not making it a condition for the provision of care.
(5) Providing education to staff on issues concerning advance
directives including notification of direct care providers of
services, such as home health care and personal care, of any
advanced directives executed by members to whom they are
assigned to provide services.
a. Contractors shall encourage subcontracted PCPs to comply with the
requirements of subparagraph a. (2) through (5) above. Contractors
shall also encourage health care providers specified in subparagraph a.
to provide a copy of the member's executed advanced directive, or
documentation of refusal, to the member's PCP for inclusion in the
member's medical record.
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16. PERFORMANCE MEASUREMENT
All performance measures described below apply to Title XIX, Title XXI, and
state-only member populations.
Effective October 1, 2000, AHCCCS will require Contractors to adopt the Quality
Improvement System for Managed Care (QISMC). AHCCCS will work with the
Contractors to develop quality improvement projects that will meet the QISMC
guidelines. Compliance with this requirement will become a part of the
Operational and Financial Review after October 1, 2001.
Contractors shall strive to meet the AHCCCS stated performance measure goals.
However, it is equally important that Contractors continually improve their
performance measure outcomes from year to year. Improvement in performance is to
be measured by a reduction in the health plan's adverse outcomes. AHCCCS
requires the Contractor to achieve a reduction of ten percent or more from the
previous year's adverse outcomes. The Contractor's performance will also be
evaluated against the adjusted AHCCCS statewide average performance level,
excluding the effect of the Contractor's data.
33
AHCCCS will require the Contractor to have a quality improvement plan in place
when:
(a) the Contractor has not achieved the AHCCCS statewide performance level
for any measure but has shown significant improvement, or
(b) the Contractor's rate has declined but is at or above the AHCCCS
statewide performance level for any measure.
The Contractor will be required to submit a corrective action plan and may be
subject to sanctions if:
(a) the Contractor has not achieved the AHCCCS statewide performance level
for any measure and has failed to show adequate improvement, or
(b) if the Contractor's rate has declined and fallen below the AHCCCS
statewide performance level for any measure.
Corrective action plans must be received by the Office of Medical Management
within 30 days of receipt of notification from AHCCCS. AHCCCS may conduct one or
more follow-up on-site reviews to verify compliance with a corrective action
plan.
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program to at least 80% of all enrolled
members under age 21 during CYE 2001. The participant rate is the number of
children receiving at least one medical screen compared to the number of
children expected to receive at least one medical screen. The number of children
expected to receive at least one medical screen is based on the federal
periodicity schedule and the average period of eligibility.
AHCCCSA will measure participation levels through encounter data and will not
use information from prior period coverage (see Paragraph D.6, Prior Period
Coverage) in evaluating the Contractor's performance.
EPSDT IMMUNIZATIONS: The Contractor shall ensure members under age 21 receive
age-appropriate immunizations as specified in the AMPM. During CYE 2001, the
Contractor shall meet or exceed the following:
Immunization Percentage of Number of Doses
Members
Immunized
Diphtheria, Tetanus, Pertussis vaccine (DPT) 82% 4
Oral/Inactivated Polio Vaccine 88% 3
Measles, Mumps, Rubella Vaccine (MMR) 90% 1
H. Influenza, Type B (2 HIB) 90% 2
Hepatitis B (Hep B) 87% 3
Combined 3-Antigen Rate (4 DPT, 3 OPV, 1 MMR) 82% 8
Combined All Antigen 73% 13
Varicella Vaccine 67% 1
34
The Contractor shall participate in an annual immunization audit based on random
sampling to assess and verify the immunization status of two-year-old members.
AHCCCSA will provide the Contractor, within two weeks after the end of the
contract year, the selected sample, specifications for conducting the audit, the
AHCCCSA reporting requirements, and technical assistance. The Contractor shall
identify each child's PCP, conduct the assessment, and report to AHCCCSA in the
required format all immunization data for the sampled two-year-old children no
later than December 15 after the end of the contract year. If medical records
are missing for more than 5% of the sample group, the Contractor is subject to
sanctions by AHCCCSA. The External Quality Review Contractor will conduct a
study to validate the Contractor's reported rates.
PERFORMANCE INDICATORS: For CYE 2001, the Contractor shall comply with AHCCCS
quality management requirements to improve performance for all AHCCCS
established performance indicators. Complete descriptions of these indicators
can be found in the document Health Plan Performance Indicators, User and
Technical Specifications. AHCCCS has established goals for the following
indicators: annual dental visits; well-child visits in the first 15 months of
life; and well-child visits in the 3rd, 4th, 5th and 6th years of life.
ANNUAL DENTAL VISITS: The Contractor shall take affirmative steps to increase
utilization of dental services for members under age 21. At least 55% of all
enrolled members between the ages of 3 to 21 shall have at least one dental
visit during CYE 2001. AHCCCSA will monitor utilization through reported
encounter data.
WELL CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE: The Contractor shall ensure
that members under the age of 15 months receive all recommended well-child
visits as specified in the AMPM. During CYE 2001, the Contractor shall ensure
that a minimum of 64% of its members receive all recommended well-child visits.
WELL-CHILD VISITS IN THE 3RD, 4TH, 5TH AND 6TH YEARS OF LIFE: The Contractor
shall ensure that members 3, 4, 5 and 6 years of age receive all recommended
well-child visits as specified in the AMPM. During CYE 2001, the Contractor
shall ensure that a minimum of 64% of its members receive at least one
well-child visit during the contract year.
CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS. The Contractor shall ensure
that members under age 21 have access to primary care provider (PCP) services.
During CYE 2001, the Contractor shall ensure that a minimum of 70% of members
under age 21 visit their PCP at least once during the contract year.
ACCESS TO CARE: During the contract year AHCCCSA will be developing and
establishing baseline information for three new measures: Provider Turnover,
Board Certification/Residency Completion and Availability of Language
Interpretation Services.
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
The Contractor shall provide to members quality medical care as described in the
AMPM, Chapter 900, regardless of payer source or eligibility category. The
Contractor shall institute processes to assess, plan, implement and evaluate
quality improvement activities. The Contractor shall conduct two clinical
studies each contract year as required in Chapter 900 of the AMPM. AHCCCSA will
determine the subject matter and study methodology for one of the annual
35
studies and the Contractor shall submit to AHCCCSA by November 15 of each
contract year its proposed subject matter and methodology for the other. The
results of the studies shall be submitted to AHCCCS, Office of Medical
Management, within 180 days after the end of each contract year.
The Contractor must maintain a written QM/UM plan, which details plans for
compliance with the AMPM. The Contractor shall incorporate in its QM/UM plan an
action plan for improving the performance rates for those indicators with
established baselines.
18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. In order to
obtain approval, the following must be submitted to the Office of Managed Care
45 days prior to the implementation of the contract:
1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the substantial
financial risk definition.
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or HCFA.
Please refer to the "Physician Incentive Guidelines" in the Bidder's Library for
details on providing required disclosures.
19. APPOINTMENT STANDARDS
For purposes of this section, "urgent" is defined as an acute but not
necessarily severe disorder, which, if not attended to, could endanger the
patient's health. The Contractor shall have procedures in place that ensure the
following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within two days of request
c. Routine care PCP appointments - within 21 days of request
36
For SPECIALTY REFERRALS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within three days of referral
c. Routine care appointments - within 30 days of referral
For DENTAL APPOINTMENTS, the Contractor shall be able to provide:
a. emergency appointments - within 24 hours of request
b. urgent appointments - within three days of request
c. routine care appointments - within 45 days of request
For MATERNITY CARE, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within three days of request
d. High risk pregnancies - within three days of
identification of high risk by the Contractor
or maternity care provider, or immediately if
an emergency exists
If a member needs medically-necessary transportation, the Contractor shall
require its transportation provider to schedule the transportation so that the
member arrives no sooner than one hour before the appointment; does not have to
wait more than one hour after making the call to be picked up; nor have to wait
for more than one hour after conclusion of the appointment for transportation
home.
The Contractor shall actively monitor the adequacy of its appointment processes
and reduce the unnecessary use of alternative methods such as emergency room
visits. The Contractor shall actively monitor and ensure that a member's waiting
time for a scheduled appointment at the PCP's or specialist's office is no more
than 45 minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network about appointment time requirements. The Contractor must assign
a specific staff member or unit within its organization to monitor compliance
with appointment standards and shall require a corrective action plan when
appointment standards are not met. Appointment standards shall be included in
the Provider Manual.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists to include, at a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
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c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
The Contractor shall comply with all applicable physician referral requirements
and conditions defined in Sections 1903(s) and 1877 of the Social Security Act.
Upon finalization of the regulations, the Contractor shall comply with all
applicable physician referral requirements and conditions defined in 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician's
family has a financial relationship. Designated health services include:
Clinical laboratory services
Physical therapy services
Occupational therapy services
Radiology services
Radiation therapy services and supplies
Durable medical equipment and supplies
Parenteral and enteral nutrients, equipment and supplies
Prosthetics, orthotics and prosthetic devices and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of the
provider
c. Overview of the Contractor's Provider Service department and function
d. Listing and description of covered and non-covered services,
requirements and limitations including behavioral health services
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing,
laboratory tests, dental screenings and immunizations
g. Dental services
h. Maternity/Family Planning services
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i. The Contractor's policy regarding PCP assignments
j. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS/RBHA system.
k. Grievance and request for hearing rights
l. Billing and encounter submission information
- indicate which form UB92, HCFA 1500, or Form C is to be used for
services
- indicate which fields are required for a claim to be considered
acceptable by the Contractor. A completed sample of each form shall
be included
m. Contractor's written policies and procedures which affect the
provider(s) and/or the provider network
n. Claims re-submission policy and procedure
o. Reimbursement, including reimbursement for dual eligibles (i.e.
Medicare and Medicaid) or members with other insurance
p. Explanation of remittance advice
q. Prior authorization requirement
r. Claims medical review
s. Concurrent review
t. Fraud and Abuse
u. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
v. AHCCCS appointment standards
w. Americans with Disabilities Act (ADA) requirements, as applicable
x. Eligibility verification
y. Cultural competency information.
22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics, gynecology, or pediatrics; certified nurse practitioners or
certified nurse midwifes; or physician's assistants.
At a minimum, the Contractor's number of full-time equivalent PCPs to enrolled
members shall not exceed a ratio of 1:1800 for adults and 1:1200 for children
who are 12 or younger. If the PCP contracts with more than one AHCCCS health
plan, the ratio shall be adjusted by the Contractor to ensure the total number
of AHCCCS members does not exceed the above ratio. The Contractor should
consider the PCP's total patient panel size (i.e. AHCCCS and non-AHCCCS
patients) when assessing the PCP's ability to meet AHCCCS' appointment and other
standards. In addition, AHCCCS members shall not comprise the majority of the
PCP's panel of patients. The Contractor shall also reduce the number of members
assigned to its network PCPs as necessary to meet the appointment standards
specified in Section D, Paragraph 19, Appointment Standards. Any variation to
the above standards must be submitted to AHCCCSA, Office of Medical Management
for prior approval. PCPs with assigned members diagnosed with AIDS or as
HIV-positive shall meet criteria and standards set forth in AHCCCS Medical
Policy and AHCCCS AIDS Advisory Committee Guidelines.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The
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Contractor is encouraged to assign members with complex medical conditions
who are age 12 and younger to Board-certified pediatricians.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP assignment, should the member desire to do so. The
Contractor shall confirm any PCP change in writing to the member. Members may
make both their initial PCP selection and any subsequent PCP changes either
verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of Managed Care, and shall be monitored through operational
audits. PCPs and specialists who provide inpatient services to the Contractor's
members shall have admitting and treatment privileges in a minimum of one
general acute care hospital that is located within the Contractor's service
area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet
the medical needs of its members.
b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English.
Contractor policies shall be subject to approval by AHCCCSA, Office of Managed
Care, and shall be monitored through operational audits.
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For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services, except
that women shall have direct access to GYN providers without a referral
for preventive and routine services. Any waiver of this requirement by
the Contractor must be approved in advance by AHCCCSA.
b. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies of test
results if applicable, treatment services provided and the resulting
outcome for each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians and certified nurse practitioners and certified nurse midwives who
include such services within their practice.
24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient personnel for the
provision of covered services, including emergency medical care on a
24-hour-a-day, 7-days-a-week basis. The proposed network shall be sufficient to
provide covered services within designated time and distance limits. For
Maricopa and Pima Counties only, this includes a network such that 95% of its
members residing within the boundary area of metropolitan Phoenix and Tucson do
not have to travel more than 5 miles to see a PCP or pharmacy. 95% of its
members residing outside the boundary area must not have to travel more than 10
miles to see such providers. See Attachment B, Minimum Network Requirements, for
details on network requirements by Geographic Service Area. Also see Section D,
Paragraph 35, Hospital Subcontracting and Reimbursement, for details on changes
in hospital subcontracting effective October 1, 1998.
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Under the Balanced Budget Act of 1997, the Contractor shall not discriminate
with respect to participation in the AHCCCS program, reimbursement or
indemnification against any provider based solely on the provider's type of
licensure or certification. This provision, however, does not prohibit the
Contractor from limiting provider participation to the extent necessary to meet
the needs of the Contractor's members. This provision also does not interfere
with measures established by the Contractor to control costs consistent with its
responsibilities under this contract.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertains to all
service specifications described in the AMPM Chapters 300, 600 and 900. In
addition, the Contractor shall have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements
b. Monitor and control network compliance with policies and rules of
AHCCCSA and the Contractor, including compliance with all policies and
procedures related to the grievance process and ensuring the member's
care is not compromised during the grievance process.
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area
e. Monitor network capacity to ensure that there are sufficient providers
to handle the volume of members
f. Ensure service accessibility, including monitoring appointment
procedures standards, appointment waiting times, and service provision
standards
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one,
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract. The
Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun, for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
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26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates. This legislation gives FQHCs the
option to require state Medicaid programs to reimburse the FQHC at 100% of
reasonable costs for the services delivered to Title XIX members. AHCCCSA and
its contractors are required to comply with this legislation. The following
payment methodology for reasonable cost reimbursement was implemented effective
October 1, 1997.
If the FQHC elects reasonable cost reimbursement, the FQHC will receive a
quarterly payment per Title XIX member per month from AHCCCSA. The initial
capitation amount will be $1.75 PMPM statewide. In accordance with the Balanced
Budget Act of 1997 and BBA Refinements Legislation, this additional
reimbursement will be phased out over a five-year period beginning in contract
year ending 2000:
Contract Year Phase-Out PMPM
Percentage Amount
1997 through 1999 No phase-out $ 1.75
2000 95% $ 1.66
2001 95% $ 1.66
2002 95% $ 1.66
2003 90% $ 1.58
2004 85% $ 1.49
2005 0% $ 0.00
Contractors are required to submit member month information for Title XIX
members for each FQHC on a quarterly basis to AHCCCS Office of Managed Care.
AHCCCSA will perform periodic audits of the member month information submitted.
Contractors should refer to the Office of Managed Care's policy on FQHC
reimbursement for further guidance. The following FQHCs are currently recognized
by HCFA:
Ajo Community Health Center
Chiricahua Community Health Centers, Inc.
Clinica Adelante, Inc.
El Rio Health Center
Inter-Tribal Health Care Center
Lake Powell Medical Center
Marana Health Center
Mariposa Community Health Center, Inc.
Mountain Park Health Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
North Country Community Health Center
Sun Life Family Health Center
Sunset Community Health Center (formerly Valley Health Center, Inc.)
United Community Health Center, Inc.
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Any other clinics that subsequently become FQHCS will be subject to the
reimbursement methodology described above upon electing reasonable cost
reimbursement from AHCCCSA.
27. PROVIDER REGISTRATION
The Contractor shall ensure that all of its subcontractors register with AHCCCSA
as an approved service provider and receive an AHCCCS Provider ID Number. A
Provider Participation Agreement must be signed with each provider who does not
already have a current AHCCCS ID number. The original shall be forwarded to
AHCCCSA. This provider registration process must be completed in order for the
Contractor to report services a subcontractor renders to enrolled members and
for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TAPE
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Tape User Manual on October 15, January 15, April 15, and
July 15 of each contract year. The Manual may be found in the Bidder's Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its HCFA grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on
or before scheduled due dates.
b. Accuracy: Reports or other required data shall be prepared in
strict conformity with appropriate authoritative
sources and/or AHCCCS defined standards.
c. Completeness: All required information shall be fully disclosed
in a manner that is both responsive and pertinent
to report intent with no material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
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30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA, or the federal government, to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials that are produced by the Contractor and refer
to covered services shall state that such services are funded under contract
with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business for the initial contract year beginning 10/1/97.
The purpose of Readiness Reviews is to assess new contractors' readiness and
ability to provide contract services to members at the start of the contract
year. A new contractor will be permitted to commence operations only if the
Readiness Review factors are met to AHCCCSA's satisfaction.
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with HCFA requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The Contractor shall comply
with all other medical audit provisions as required by AHCCCS Rule R9-22-521 and
R9-3l-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel as identified in advance shall be
available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
workspace, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the
45
Contractor has obtained accreditation from NCQA or any other nationally
recognized accrediting body. The Contractor must submit the entire NCQA report
to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AIHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in implementing recommendations and
achieving program compliance. Follow-up reviews may be conducted at any time
after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost avoiding and paying claims in accordance with AHCCCS Rule
R9-22-705, a copy of which may be found in the Bidder's Library. In the absence
of a subcontract provision to the contrary, claims submission deadlines shall be
calculated from the date of service or the effective date of eligibility
posting, whichever is later. Remittance advices accompanying the Contractor's
payments to providers must contain, at a minimum, adequate descriptions of all
denials and adjustments, the reasons for such denials and adjustments, the
amount billed, the amount paid, and grievance and request for hearing rights.
The Contractor's claims payment system, as well as its prior authorization and
concurrent review process, must minimize the likelihood of having to recoup
already-paid claims. Any recoupment in excess of $50,000 per provider within a
contract year must be approved in advance by AHCCCSA, Office of Managed Care.
In accordance with the Balanced Budget Act of 1997, unless a subcontract
specifies otherwise, the Contractor shall ensure that 90% of all clean claims
are paid within 30 days of receipt of the clean claim and 99% are paid within 90
days of receipt of the clean claim.
During the term of this contract, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout. All formats are subject to changes as required by federal
law. Reasonable implementation timeframes will be negotiated with each plan.
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35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
The Contractor shall reimburse hospitals for member care in accordance with
AHCCCS Rule R9-22-705. The Contractor is encouraged to obtain contracts with
hospitals in all GSA's and must submit copies of these contracts to AHCCCSA,
Office of Managed Care, at least seven days prior to the effective dates
thereof.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor fails to identify lack of medical necessity
through concurrent review and/or prepayment medical review, lack of medical
necessity identified during postpayment medical review shall not constitute a
basis for recoupment by the Contractor. See also Section D, Paragraph 34, Claims
Payment System. For a more complete description of the guidelines for hospital
reimbursement, please consult the Bidder's Library for applicable statutes and
rules.
FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment. The Contractor is
responsible for payment of services while the member is enrolled with the
Contractor. The Contractor is not responsible for the full 90 days of nursing
facility coverage if ALTCS enrollment occurs before the 90 days has ended.
The Contractor shall provide medically necessary nursing facility services for
any member who has a pending ALTCS application, who is currently residing in a
nursing facility and is eligible for services provided under this contract. If
the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days of nursing facility coverage,
the Contractor is only responsible for nursing facility coverage during the time
the member is enrolled with the Contractor. Nursing facility services covered by
a third party insurer (including Medicare) while the member is enrolled with the
Contractor shall be applied to the 90 day limitation.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application process and to prepare for potential fee-for-service coverage if the
stay goes beyond the 90-day maximum.
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37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, delivery supplement, HIV-AIDS
supplement, reinsurance (PPC and prospective), and third party liability, as
described and defined within this contract and appropriate laws, regulations or
policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of A.R.S. Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, and as
otherwise specified in this section, any savings remaining to the Contractor as
a result of favorable claims experience and efficiencies in service delivery at
the end of the contract term may be kept by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in A.R.S. ss.36-2913. An error discovered by the State with
or without an audit in the amount of fees paid to Contractor will be subject to
adjustment or repayment by Contractor making a corresponding decrease in a
current Contractor's payment or by making an additional payment by AHCCCSA to
the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation for newborns of
members who were enrolled at the time of delivery.
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RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE `98 and CYE `99, AHCCCSA
will offer a reconciliation process for contractors whose total PPC medical cost
experience (excluding administrative and non-operating expenses) is more than
10% higher than the reimbursement associated with PPC in two areas: the "retro"
portion of the capitation rate for all rate categories, and the prospective
three-day notification period for MN/MI recipients only. Expenses will be net of
reinsurance for both the retro and prospective period.
AHCCCSA will reimburse 100% of a Contractor's excess reasonable costs in excess
of a 10% limit as determined by reported encounters. AHCCCS will recoup profit
amounts in excess of a 10% limit.
For CYE `00 and `01, a full reconciliation to 0% profit or loss will be done by
AHCCCSA for the same eligibility time periods and risk groups noted above.
AHCCCSA will reimburse the health plans 100% of any excess reasonable costs as
determined by reported encounters, and all profits will be recouped. Refer to
the Office of Managed Care's PPC Reconciliation Policy for further details of
the reconciliation process.
DELIVERY SUPPLEMENT. When the Contractor has an enrolled woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
supplemental payment. Supplemental payments will not apply to women who deliver
in a prior period coverage time period. AHCCCSA reserves the right at any time
during the term of this contract to adjust the amount of this payment for women
who deliver at home.
HIV-AIDS SUPPLEMENT: On a quarterly basis, AHCCCSA shall utilize encounters to
determine the number of members receiving approved HIV/AIDS drugs and calculate
the amount of the supplemental payment. The rate of reimbursement for this
separate per member per month payment is specified in Section B and is subject
to review during the term of the contract. AHCCCSA reserves the right to recoup
any amounts paid for ineligible members as determined through an encounter data
review as well as an associated penalty for incorrect encounter reporting.
Refer to the Office of Managed Care's HIV/AIDS supplemental payment and review
policies for further details and requirements.
38. INCENTIVE FUND. AHCCCSA MAY RETAIN A SPECIFIED PERCENTAGE OF CAPITATION
REIMBURSEMENT IN ORDER TO DISTRIBUTE TO CONTRACTORS BASED ON THEIR PERFORMANCE
MEASURE OUTCOMES. AHCCCSA WILL NOTIFY CONTRACTORS 60 DAYS PRIOR TO A NEW
CONTRACT YEAR IF THIS METHODOLOGY WILL BE IMPLEMENTED AND WILL PROVIDE DETAILS
OF THE REIMBURSEMENT METHODOLOGY AT THAT TIME. CAPITATION ADJUSTMENTS
Except for changes made specifically in accordance with this contract, the rates
set forth in Section B shall not be subject to re-negotiation or modification
during the contract period. AHCCCSA may, at its option, review the effect of a
program change and determine if a capitation adjustment is needed. In these
instances the adjustment will be prospective with assumptions discussed with the
Contractor prior to modifying capitation rates. The Contractor may request a
review of a program change if it believes the program change was not equitable;
AHCCCSA will not unreasonably withhold such a review.
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If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits from the date
of incarceration)
c. duplicate capitation to the same contractor
d. adjustment based on change in member's contract type
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503 and R9-31-503). Per
diem rates paid for nursing facility services, including room and board,
provided in lieu of hospitalization for up to 90 days in any contract year shall
be eligible for reinsurance coverage. Refer to the AHCCCS Reinsurance Claims
Processing Manual for further details on the Reinsurance Program.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's statewide AHCCCS acute care
enrollment (not including SOBRA Family Planning Extension services) as of
October 1st each contract year for all rate codes and counties, as shown in the
following table. These deductible levels are subject to change by AHCCCSA during
the term of this contract. Any change would have a corresponding impact on
capitation rates.
Prospective Reinsurance PPC Reinsurance
------------------------------------------------------------------------------------------------------------------
MNMI NON MNMI
STATEWIDE PLAN ENROLLMENT DEDUCTIBLE DEDUCTIBLE COINSURANCE ALL RATE CODES COINSURANCE
------------------------------------------------------------------------------------------------------------------
0-19,999 $ 15,000 $ 20,000 75% $ 5,000 100%
------------------------------------------------------------------------------------------------------------------
20,000-49,999 $ 15,000 $ 35,000 75% $ 5,000 100%
------------------------------------------------------------------------------------------------------------------
50,000 and over $ 15,000 $ 50,000 75% $ 5,000 100%
------------------------------------------------------------------------------------------------------------------
A Contractor whose enrollment qualifies for the $35,000 or $50,000 non-MN/MI
deductible level may, prior to the start of the contract period, elect one of
the lower deductible levels indicated in the above table. Contractors may not
elect to increase their deductible level. If a Contractor's actual non-MN/MI
deductible is $35,000 or $50,000, AHCCCSA will increase the Contractor's
capitation rate awarded by defined amounts for each capitation risk group. These
specific capitation adjustments are available from the Office of Managed Care.
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PRIOR PERIOD COVERAGE REINSURANCE: A separate reinsurance deductible and
coinsurance percentage will apply during prior period coverage. As noted in the
table above, all Contractors, regardless of enrollment, will be subject to a
$5,000 deductible level. The coinsurance percentage for the prior period
coverage reinsurance is 100%. Expenses incurred during prior period coverage
will not apply toward the prospective reinsurance thresholds.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
Effective October 1, 1998, when a member changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs incurred for that
member will follow the member to the receiving health plan. Therefore, all
submitted encounters from the health plan the member is leaving (for dates of
service within the current contract year) will be applied toward the receiving
health plan's deductible level. For further details regarding this policy and
other reinsurance policies refer to the AHCCCS Reinsurance Claims Processing
Manual.
Medical review on prospective and prior period coverage reinsurance cases will
be determined based on statistically valid retrospective random sampling.
AHCCCSA, Office of Medical Management, will generate the sampling and will
notify the Contractor of documentation needed for the retrospective medical
review process to occur at the Contractor's offices. Reinsurance consideration
will be given to inpatient facility contracts, and hearing decisions rendered by
the Office of Legal Assistance. Prehearing and/or hearing penalties discoverable
during the review process will not be reimbursed under reinsurance. A recoupment
of reinsurance reimbursements made to the Contractor will occur based on the
results of the medical review sampling. The results of the medical review
sampling will be separately extrapolated to the entire prospective and prior
period coverage reinsurance reimbursement populations in the review time frame
for the Contractor. AHCCCSA will give the Contractor at least 45 days advance
notice of any on-site review. The Contractor shall have all requested medical
records on-site. Any documents not requested in advance by AHCCCSA shall be made
available upon request of the Review Team during the course of the review. The
Contractor representative shall be available to the Review Team at all times
during AHCCCSA on-site review activities. While on-site, the Contractor shall
provide the Review Team with workspace, access to a telephone, electrical
outlets and privacy for conferences. The Contractor will be furnished a copy of
the Reinsurance Review Report within 60 days of the on-site review and given an
opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia, von Willebrand's Disease, and Gaucher's Disease. This program
also covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver, kidney,
and other organ transplantation. For additional detail and restrictions refer to
the AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All catastrophic claims are
subject to medical review by AHCCCSA.
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The Contractor shall notify AHCCCSA, Office of Medical Management, Reinsurance
Unit, of cases identified for catastrophic non-transplant reinsurance coverage
within 30 days of (a) initial diagnosis, (b) enrollment with the Contractor, and
(c) the beginning of each contract year. Catastrophic reinsurance will be paid
for a maximum 30-day retroactive period from the date of notification to
AHCCCSA.
HEMOPHILIA: When a member is identified as being catastrophically eligible by
AHCCCSA due to the specific diagnosis of hemophilia (ICD9 codes 286.0, 286.1,
286.2), all medically necessary covered services provided during the contract
year shall be eligible for reimbursement at 85% of the Contractor's paid amount.
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII. The Contractor must promptly notify AHCCCS
Office of Medical Management Reinsurance Unit after diagnosis. All medically
necessary covered services provided during the contract year shall be eligible
for reimbursement at 85% of the Contractor's paid amount.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy. All medically necessary covered services provided during
the contract year shall be eligible for reimbursement at 85% of the Contractor's
paid amount.
TRANSPLANTS: Bone grafts and cornea transplantation services are not eligible
for catastrophic reinsurance coverage but are eligible under the regular
(non-catastrophic) reinsurance program. Refer to the AMPM, Chapter 300 for
covered services for organ and tissue transplants. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor's paid amount,
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library. When a member is referred to a transplant facility for an
AHCCCS-covered organ transplant, the Contractor shall notify AHCCCSA, Office of
Medical Management.
Encounter data will not be used to determine catastrophic reinsurance benefits
for transplants. However, this does not relieve the Contractor of the
responsibility for submitting encounters for all catastrophic reinsurance
services.
All reinsurance claims must be submitted in accordance with R9-22-703 and the
AHCCCS Re-insurance Claims Processing Manual.
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. See Section D, Paragraph 41, Medicare
Services and Cost Sharing.
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires
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the member to pay any copayment, coinsurance or deductible, the Contractor is
responsible for making these payments, even if the services are provided outside
of the Contractor's network. The Contractor's liability for coinsurance and
deductibles is limited to what the Contractor would have paid for the entire
service pursuant to a written contract with the provider or the AHCCCS
fee-for-service rate, less any amount paid by the third party. (The Contractor
must decide whether it is more cost-effective to provide the service within its
network or pay coinsurance and deductibles for a service outside its network.
For continuity of care, the Contractor may also choose to provide the service
within its network.) If the Contractor refers the member for services to a
third-party insurer (other than Medicare), and the insurer requires payment in
advance of all copayments, coinsurance and deductibles, the Contractor must make
such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
pre-natal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES. Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost-avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA's authorized representative:
Uninsured/underinsured motorist insurance Adoption recovery
First-and third-party liability insurance Worker's Compensation
Tortfeasors Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-l002 and R9-31-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related costs, subsequent to the
referral of any and all relevant case information to AHCCCSA's authorized
representative by the Contractor. AHCCCSA's authorized representative is also
responsible for negotiating and acting
53
in the best interest of all parties to obtain a reasonable settlement in joint
cases and may compromise a settlement in order to maximize overall
reimbursement, net of legal and other costs. For total plan cases involving only
payments from the Contractor, the Contractor is responsible for performing all
research, investigation, the filing of liens and payment of lien filing fees and
other related costs. The Contractor shall use the cover sheet as prescribed by
AHCCCS when filing Liens.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING. The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. In addition, upon AHCCCS's request, the Contractor shall
provide an electronic extract of the Casualty cases, including open and closed
cases. Data elements include, but are not limited to: the member's first and
last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount;
and case status. The AHCCCSA TPL Section shall provide the format and reporting
schedule for this information to the Contractor. The Contractor shall notify
AHCCCSA's authorized representative within five working days of the
identification of a third-party liability case with reinsurance. Failure to
report reinsurance cases may result in one of the remedies specified in
Paragraph 60 (Sanctions) of Section D. The Contractor shall communicate any
known change in health insurance information, including Medicare, to AHCCCS
Administration, Division of Member Services, not later than 10 days from the
date of discovery using the AHCCCS Third-Party Coverage Form found in the
Bidder's Library.
AHCCCSA will provide the Contractor, on an agreed upon schedule, with a complete
file of all third-party coverage information (other than Medicare) for the
purpose of updating the Contractor's files. The Contractor shall notify AHCCCSA
of any known changes in coverage within deadlines and in a format prescribed by
AHCCCSA.
TITLE XXI (KIDSCARE): Eligibility for KidsCare benefits requires that the
applicant/member not be enrolled with or entitled to any other health insurance
benefits. If the Contractor becomes aware of any such potential coverage, the
Contractor shall notify AHCCCSA immediately. The Contractor shall follow the
same cost avoidance and postpayment recovery practices for the KidsCare
population as it does for the Title XIX population, and shall maintain a
reporting system which allows Title XIX and KidsCare information to be reported
separately.
CONTRACT TERMINATION. Upon termination of this contract, the Contractor will
complete the existing third party liability cases or make any necessary
arrangements to transfer the cases to AHCCCSA's authorized TPL representative.
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41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligible". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
sharing responsibilities that apply to dual eligible members based on a variety
of factors. The Contractor is responsible for adhering to the cost sharing
responsibilities presented in the AHCCCS Medicare Cost Sharing policy. Effective
10/1/97, the Contractor shall have no cost sharing obligation if the Medicare
payment exceeds what the Contractor would have paid for the same service of a
non-Medicare member.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-711 and R9-31-711. The Contractor may not
collect copayments for family planning and EPSDT services.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or federal government.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
If this contract is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available for a period of five
years from the date of any such termination. Records which relate to grievances,
disputes, litigation or the settlement of claims arising out of the performance
of this contract, or costs and expenses of this contract to which exception has
been taken by AHCCCSA, shall be retained by the Contractor for a period of five
years after the date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request. The Contractor is responsible for ensuring that a medical
record is established when information is received about a member. If the PCP
has not yet seen the member, such information may be kept temporarily in an
appropriately labeled file,
55
in lieu of actually establishing a medical record, but must be associated with
the member's medical record as soon as one is established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (A.R.S.ss.36-664I)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSAs as a result of an accumulated deficit, even if unaudited.
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47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCSA shall be responsible for
any incorrect or delayed payment to the Contractor's AHCCCS services providers
(subcontractors) resulting from such error, omission, deletion, or erroneous
input data caused by the Contractor in the submission of AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
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ELECTRONIC DATA INTERCHANGE (EDI): In addition to the requirements outlined in
Section D, Paragraph 34, Claims Payment System, the Contractor will be required
to comply with all administrative simplification provisions resulting from the
Health Insurance Portability and Accountability Act (HIPAA). The administrative
simplification section standardizes electronic transaction formats and code
sets; establishes national identifiers for providers, employers, health plans,
and individuals; and sets standards for security and privacy. Each of these
provisions will be published as one or more Final Rules in the Federal Register.
Implementation of these provisions will be required two years after the
effective date of each provision's final rule as published by the Department of
Health and Human Services.
in the event that systems fail.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance measures. The
Contractor shall submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability, including services provided
during prior period coverage. This requirement is a condition of the HCFA grant
award.
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA supplied formats. Formatting and specific
requirements for encounter data are described in the AHCCCS Encounter Reporting
User Manual and the AHCCCS Technical Interface Guidelines, copies of which may
be found in the Bidder's Library. The Encounter Submission Requirements are
included herein as Attachment I.
An Encounter Submission Tracking Report must be maintained and made available to
AHCCCSA upon request. The Tracking Report's purpose is to link each claim to an
adjudicated or pended encounter returned to the Contractor. Further information
regarding the Encounter Submission Tracking Report may be found in The Encounter
User's Manual.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data, which the Contractor
shall use to update its member records. The daily roster which is run prior to
the monthly roster is referred to as the "last daily" and will contain all rate
code changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next month. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
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Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/97 through 9/30/98. In addition,
AHCCCSA reserves the sole option to extend the term of the contract, not to
exceed a total contracting period of five years. The terms and conditions of any
such contract extension shall remain the same as the original contract, as
amended. Any contract extension, however, shall not affect the maximum
contracting period of five years. All contract extensions shall be through
contract amendment. If, in conjunction with a contract extension, AHCCCSA elects
to increase the capitation rate for any risk category, such increase will not
exceed in aggregate the inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
AHCCCSA may require a contractor to renew all GSAs, or may terminate remaining
GSAs if the Contractor does not agree to renew all GSAs.
When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses to sign the extension amendment. If the Contractor provides such
notification, AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 180 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
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51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See policy on claims processing by
subcontracted providers in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
The Contractor shall maintain a fully executed original of all subcontracts,
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is voidable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of federal and State laws,
regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the
contract year refuses to enter into a written agreement with the
Contractor, the Contractor shall submit documentation of such refusal
to AHCCCS Office of Managed Care within seven days of its final attempt
to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care.
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Each subcontract must contain verbatim all the provisions of Attachment A,
Minimum Subcontract Provisions. In addition, each subcontract must contain the
following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor.
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and
for which compensation will be paid.
e. The term of the subcontract including beginning and ending dates,
methods of extension, termination and re-negotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and
other third-party liability coverage and to seek such Medicare or third
party liability payment before submitting claims to the Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality
assurance programs and comply with the utilization control and review
procedures specified in 42 CFR Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in
ownership of a subcontractor that is related to or affiliated with the
Contractor shall require a contract amendment and prior approval of
AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population
(may also refer to the Provider Manual).
l. A provision that the subcontractor shall be fully responsible for all
tax obligations, Worker's Compensation Insurance, and all other
applicable insurance coverage obligations which arise under this
subcontract, for itself and its employees, and that AHCCCSA shall have
no responsibility or liability for any such taxes or insurance
coverage.
m. A provision that the subcontractor must obtain any necessary
authorization from the Contractor or AHCCCSA for services provided to
eligible and/or enrolled members.
n. A provision that the subcontractor must comply with encounter reporting
and claims submission requirements as described in the subcontract.
52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over and supersede existing and future subcontracts for services
that are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement for
transplant surgery exceed that payable under the relevant AHCCCSA specialty
contract.
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During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
AHCCCSA shall provide at least 60 days advance written notice to the Contractor
prior to the implementation of any specialty contract.
53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees charged and/or corporate
allocations made. If the fees or allocations actually paid out are determined to
be unjustified or excessive, amounts may be subject to repayment to the
Contractor, the Contractor may be placed on monthly financial reporting, and/or
financial sanctions may be imposed.
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are less than $50,000, AHCCCSA will waive the requirement for an audit of that
consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award.
Minimum capitalization requirements by GSA are as follows:
Geographic Service Area Capitalization Requirement
GSA #2 Yuma $1,400,000
GSA #4 Mohave, La Paz 1,150,000
GSA #6 Yavapai, Coconino 1,250,000
GSA #8 Pinal, Gila 1,450,000
GSA #10 Pima 1,250,000
GSA #12 Maricopa 2,500,000
GSA #14 Graham, Greenlee 350,000
GSA #16 Apache, Navajo 650,000
GSA #18 Cochise, Santa Cruz 1,450,000
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NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSAs, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSAs awarded. This requirement is in addition to the
Performance Bond requirements defined in Paragraphs 56 and 57 below and must be
met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above). Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the Contractor's obligations to
providers, non-contracting providers, and non-providers; and (2) performance by
the Contractor of its obligations under this contract. The Performance Bond
shall be in a form acceptable to AHCCCSA as described in the AHCCCS Performance
Bond policy available in the Office of Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers and
nonproviders by reason of a breach of the Contractor's obligations under
this contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses incurred
by reason of a breach of the Contractor's obligations under this contract,
including, but not limited to, expenses incurred after termination of this
contract for reasons other than the convenience cf the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and
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necessary UCC filings pursuant to the Arizona Uniform Commercial Code. In the
event such substitute security is agreed to and accepted by AHCCCSA, the
Contractor acknowledges that it has granted AHCCCSA a security interest in such
substitute security to secure performance of its obligations under this
contract. The Contractor is solely responsible for establishing the
credit-worthiness of all forms of substitute security. AHCCCSA may, after
written notice to the Contractor, withdraw its permission for substitute
security, in which case the Contractor shall provide AHCCCSA with a form of
security described above. The Contractor may not change the amount, duration or
scope of the performance bond without prior written approval from AHCCCSA,
Office of Managed Care.
The Contractor shall not leverage the bond for another loan or create other
creditors using the bond as security.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement must be satisfied by the Contractor not
later than 15 days after notification by AHCCCSA of the amount required.
Thereafter, AHCCCSA shall evaluate the enrollment statistics of the Contractor
on a monthly basis. If there is an increase in capitation payment that exceeds
10% of the performance bond amount, AHCCCSA may require an increase in the
amount of the Performance Bond. The Contractor shall have 15 days following
notification by AHCCCSA to increase the amount of the Performance Bond. The
Performance Bond amount that must be maintained after the contract term shall be
sufficient to cover all outstanding liabilities and will be determined by
AHCCCSA. The Contractor may not change the amount of the performance bond
without prior written approval from AHCCCSA, Office of Managed Care.
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES
AHCCCSA has established the following financial viability criteria/performance
goals:
CURRENT RATIO Current assets divided by current
liabilities. "Current assets" includes
any long-term investments that can be
converted to cash within 24 hours
without significant penalty (i.e.,
greater than 20%).
Standard: At least 1.00
EQUITY PER MEMBER Equity, less on-balance sheet
performance bond, divided by the number
of non-SOBRA Family Planning Extension
Services members enrolled at the end of
the period.
Standard: At least $150
(Failure to meet this standard may
result in an enrollment cap being
imposed in any or all contracted
GSAS.I)
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MEDICAL EXPENSE RATIO Total medical expenses (net of
reinsurance, TPL, HIV/AIDS Supplement)
divided by total capitation + Delivery
Supplement.
Standard: At least 85%
ADMINISTRATIVE COST PERCENTAGE Total administrative expenses
(excluding income taxes), divided by
total capitation + Delivery Supplement
+ TPL + reinsurance + HIV/AIDS
Supplement.
Standard: No more than 10%
RECEIVED BUT UNPAID CLAIMS Received but unpaid claims divided by
(DAYS OUTSTANDING) the average daily medical expenses for
the period, net of sub-capitation
expense
Standard: No more than 30 days
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor must submit a detailed merger, reorganization and/or
transition plan to AHCCCSA Contracting Office for AHCCCSA review. The purpose of
the plan review is to ensure uninterrupted services to members, evaluate the new
entity's ability to support the provider network, ensure that services to
members are not diminished and that major components of the organization and
AHCCCS programs are not adversely affected by such merger, reorganization or
change in ownership.
60. SANCTIONS
AHCCCSA may impose sanctions, suspend, deny, refuse to renew, or terminate this
contract or any related subcontracts in accordance with AHCCCS Rules R9-22-405
and 406 and R9-31-405 and 406 and the terms of this contract and applicable
federal or State law and regulations. Written notice will be provided to the
Contractor specifying the sanction to be imposed, the grounds for such sanction
and either the length of suspension or the amount of capitation prepayment to be
withheld. The Contractor may appeal the decision to impose a sanction in
accordance with AHCCCS Rule R9-22-804.
In addition to the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS financial viability standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
e. Failure to meet AHCCCS encounter standards
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CURE NOTICE PROCESS - Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right, are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals. The algorithm favors those
contractors with lower capitation rates. For further details on the AHCCCS
Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any time during the term of the contract and frequently does so in
response to contractor-specific issues of non-compliance (e.g. imposition of an
enrollment cap). The Contractor should consider this in preparing its response
to this RFP. AHCCCSA is not obligated to adjust for any financial impacts this
may have on the Contractor.
62. GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers, which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22, Article 8 and R9-31, Article 8, the
Alternate Resolution Process and the Members Rights and Responsibilities. The
grievance process may not be delegated or subcontracted outside of the health
plan. Refer to Attachment H for a complete description of grievance process
requirements.
63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Legal Assistance, using the Quarterly Grievance Report Format on file in the
Bidders Library. The Quarterly Grievance Report must be received by the AHCCCSA,
Office of Legal Assistance, no later than 45 days from the end of the quarter.
64. KIDSCARE
On November 1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance
Program, referred to as "KidsCare". KidsCare provides health care coverage
statewide to eligible children under age 19 and is provided through the existing
AHCCCS health plans, state employee HMOs that elect to participate at the
beginning of a contract cycle, and tribal facilities or Indian Health Service
for Native Americans who elect to receive services through them. Services will
also be directly provided by participating community health clinics and
hospitals, which predominantly serve low income children.
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The KidsCare service package is established by the legislature and approved by
HCFA through the State Plan. Services, limitations and exclusions are described
in Section D, Paragraph 1, Scope of Services. Capitation rates payable to the
Contractor for KidsCare members will be set by AHCCCSA in conjunction with an
independent actuary.
Effective October 1, 1999, KidsCare members in families with gross household
income over 150% and up to 200% of the federal poverty limit shall pay a premium
to AHCCCSA. The premium amount shall be based on the number of members in the
household and the gross family income in accordance with 9 A.A.C., Article 14.
TITLE XVI PARENT/GUARDIAN HEALTH INSURANCE COVERAGE. A.R.S. ss.36.2984 mandates
that the Contractor offer health insurance coverage to the parent(s) or legal
guardian(s) of a child who is eligible for Title XXI. The Contractor shall
establish rates for this coverage, which must be approved by AHCCCSA, Office of
Managed Care, prior to implementation. Title XXI funds or any other federal or
state funds shall not be used to subsidize family coverage. The full cost of the
premium shall be paid by the parent or legal guardian who elects this coverage.
The Contractor may include provisions for pre-existing conditions and any other
medical underwriting considerations that are necessary to protect it from
adverse risk. For further information, refer to the Title XXI Parent Guardian
Health Insurance Coverage Guidelines on file in the Bidder's Library.
65. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that could have an impact on services provided by the
Contractor on or after October 1, 2000. The following is a brief description of
the issues that AHCCCS is aware of at the time of the issuance of this renewal
amendment:
ELIGIBILITY BASED ON 100% OF THE FEDERAL POVERTY LEVEL (FPL): Through a
successful initiative effort, eligibility for AHCCCS has been expanded to allow
persons with income up to 100% of the FPL to become eligible for the Medicaid
program. Legislative action will be required to implement this new eligibility
guideline and HCFA must approve the expansion. If HCFA approval is granted,
there will be a significant number of new persons who will be eligible for the
program and enrolled with the health plans at some future date.
66. SEPARATE INCORPORATION
As specified in A.R.S. ss. 36-2906.01, within 60 days of contract award, a
non-governmental Contractor shall have established a separate corporation for
the purposes of this contract, whose sole activity is the performance of
contract function with AHCCCS.
67. CULTURAL COMPETENCY
The Contractor shall have a Cultural Competency Plan that meets the requirements
of the AHCCCS Cultural Competency Policy. The Contractor must identify a staff
member responsible for the cultural competency plan and inform the office of
Managed Care of that person's identity.
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68. MEDICAID IN THE PUBLIC SCHOOLS
Pursuant to an Intergovernmental Agreement with the Arizona Department of
Education, AHCCCS will begin paying participating school districts for
specifically identified Medicaid services provided to Medicaid eligible children
with special educational needs. The Medicaid service shall be identified in a
child's Individualized Education Plan (IEP) as a medically necessary service. In
the first phase, AHCCCS shall directly reimburse school districts for speech,
physical and occupational therapies with dates of service beginning July 1,
2000. The Administration's intent is to add other Medicaid reimbursable services
in the future.
To ensure that there is coordination of care, the Administration shall require
that a participating school district notify the primary care provider that
Medicaid services are being provided to the child in a school-based setting. If
a child is enrolled with the Contractor and a request is made for a school-based
Medicaid covered service, the Contractor shall evaluate the request on the same
basis as any request for a covered service. The determination to provide the
service shall include consideration of whether the school-based services are
sufficient to meet the child's needs.
[END OF SECTION D]
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SECTION E: CONTRACT CLAUSES
1) APPLICABLE LAW
ARIZONA LAW - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.
IMPLIED CONTRACT TERMS - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.
2) AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3) ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable federal regulations; the terms of the HCFA 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4) CONTRACT INTERPRETATION AND AMENDMENT
NO PAROL EVIDENCE - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
NO WAIVER - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.
WRITTEN CONTRACT AMENDMENTS - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5) SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract, which may remain in effect without the invalid
provision, or application.
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6) RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
7) ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8) GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to injury, disease, or
death of persons or damage to or loss of property resulting from or in
connection with the negligent performance of this contract by the Contractor,
its agents, employees, and subcontractors or anyone for whom the Contractor may
be responsible. The obligations, indemnities and liabilities assumed by the
Contractor under this paragraph shall not extend to any liability caused by the
negligence of the State or its employees. The Contractors liability shall not be
limited by any provisions or limits of insurance set forth in this contract. The
State shall reasonably notify the Contractor of any claim for which it may be
liable under this paragraph.
9) INDEMNIFICATION - PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The materials and services supplied under this contract shall comply with all
applicable federal, state and local laws, and the Contractor shall maintain all
applicable licenses and permits.
11) ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12) PROPERTY OF THE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
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13) THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14) RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified mail, return
receipt required. Failure by the Contractor to provide written assurance within
the number of days specified in the demand may, at the State's option, be the
basis for terminating the contract.
15) TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
16) GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCSA, in addition to any other rights or
remedies, shall be entitled to recover exemplary damages in the amount of three
times the value of the gratuity offered by the Contractor.
17) SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from federal procurement activity.
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AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18) TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19) TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
20) TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
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21) RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
22) NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23) NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 99-4, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable federal and state laws, rules and regulations, including
the Americans with Disabilities Act. The Contractor shall take positive action
to ensure that applicants for employment, employees, and persons to whom it
provides service are not discriminated against due to race, creed, color,
religion, sex, national origin or disability.
24) EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
25) INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000 for
each occurrence for bodily injury and property damage to others as a
result of accidents on the premises of or as the result of operations of
the Contractor.
b. Commercial Automobile Liability: Provides coverage of at least $1,000,000
for each occurrence for bodily injury and property damage to others
resulting from accidents caused by vehicles operated by the Contractor.
c. Workers Compensation: Provides coverage to employees of the Contractor for
injuries sustained in the course of their employment. Coverage must meet
the obligations imposed by federal and state statutes and must also
include Employer's Liability minimum coverage of $100,000. Evidence of
qualified self-insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct on lack of ordinary skills in the performance of a
professional act of service.
The above coverages may be evidenced by either one of the following.
73
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the
form. The Contractor's agent or broker must fill in the pertinent policy
information and ensure the required special conditions are included in the
Contractor's policy.
b. The Accord form: This standard insurance industry certificate of insurance
does not contain the preprinted special conditions required by this
contract. These conditions must be entered on the certificate by the agent
or broker and read as follows:
The State of Arizona and Arizona Health Care Cost Containment System are
hereby added as additional insureds. Coverages afforded under this
Certificate shall be primary and any insurance carried by the State or any
of its agencies, boards, departments or commissions shall be in excess of
that provided by the insured Contractor. No policy shall expire, be
canceled or materially changed without 30 days written notice to the
State. This Certificate is not valid unless countersigned by an authorized
representative of the insurance company.
26) DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with AHCCCS Rule R9-28-804(C).
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor that is related to the performance
of this contract, in accordance with A.R.S. ss.41-2547.
28) INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
29) COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30) CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change
74
notice. Any dispute or disagreement caused by such notice shall constitute a
dispute within the meaning of Section E, Paragraph 26, Disputes, and be
administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31) TYPE OF CONTRACT
Firm Fixed-Price
32) AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Michael Veit at (602) 417-4762.
33) WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's expense, require prompt correction of any services failing to meet
the Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
34) NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35) CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose any situation that may present a conflict of interest. If
the Contractor is now performing or elects to perform during the term of this
contract any services for any PAHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.
36) DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information,
75
data, material, or exhibits created, developed, produced, or otherwise obtained
during the course of the work required by this contract. This nondisclosure
requirement shall also pertain to any information contained in reports,
documents, or other records furnished to the Contractor by AHCCCSA.
37) COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39) OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by Contractor pursuant to this contract, shall be deemed to
be owned by AHCCCSA. The federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, or otherwise use
and to authorize others to use for federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software
which is provided at established catalog or market prices and sold or leased to
the general public shall not be subject to the ownership or licensing provisions
of this section.
Data, information and reports collected or prepared by Contractor in the course
of performing its duties and obligations under this contract shall be deemed to
be owned by AHCCCSA. The ownership provision is in consideration of Contractor's
use of public funds in collecting or preparing such data, information and
reports. These items shall not be used by Contractor for any independent project
of Contractor or publicized by Contractor without the prior written permission
of AHCCCSA. Subject to applicable state and federal laws and regulations,
AHCCCSA shall have full and complete rights to reproduce, duplicate, disclose
and otherwise use all such information. At the termination of the contract,
Contractor shall make available all such data to AHCCCSA within 30 days
following termination of the contract or such longer period as approved by
AHCCCSA, Office of the Director. For purposes of this subsection, the term
"data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by Contractor in the course of performance of this
contract, the federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or federal
government purposes. Contractor shall additionally be subject to the applicable
provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
76
40) AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, Contractor's performance is in material breach
of the contract or Contractor is insolvent, AHCCCSA may directly operate
Contractor to assure delivery of care to members enrolled with Contractor until
cure by Contractor of its breach, by demonstrated financial solvency or until
the successful transition of those members to other contractors.
If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through
designees appointed by the Director shall be vested with full and exclusive
power of management and control of the Contractor as necessary to ensure the
uninterrupted care to persons and accomplish the orderly transition of persons
to a new or existing Contractor, or until the Contractor corrects the Contract
Performance failure to the satisfaction of AHCCCS. AHCCCS shall have the power
to employ any necessary assistants, to execute any instrument in the name of the
Contractor, to commence, defend and conduct in its name any action or proceeding
in which the Contractor may be a party.
All reasonable expenses of AHCCCS related to the direct operation of the
Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets
of the Contractor, shall be paid by the Contractor or withheld from payment due
from AHCCCS to the Contractor.
41) AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and -521 and AHCCCS policies and procedures relating to the
audit of Contractor's records and the inspection of Contractor's facilities.
Contractor shall fully cooperate with AHCCCSA staff and allow them reasonable
access to Contractor's staff, subcontractors, members, and records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
AHCCCSA and the federal government may evaluate through on-site inspection or
other means, the quality, appropriateness and timeliness of services performed
under this contract.
42) FRAUD AND ABUSE
It shall be the responsibility of the Contractor to report all cases of
suspected fraud and abuse by subcontractors, members or employees. The
Contractor shall provide written notification of all such incidents to AHCCCSA.
The Contractor shall comply with the AHCCCS Health Plans and Program Contractors
Policy for Prevention, Detection and Reporting of Fraud and Abuse which is
available in the Bidder's Library and incorporated herein by reference.
As stated in A.R.S. ss. 13-2310, incorporated herein by reference, any person
who knowingly obtains any benefit by means of false or fraudulent pretenses,
representations, promises, or material omissions is guilty of a class 2 felony.
Contractors are required to research potential overpayments identified by a
fraud and abuse investigation or audit conducted by AHCCCSA. After conducting a
cost benefit analysis to
77
determine if such action is warranted, the Contractor should attempt to recover
any overpayments identified due to erroneous, false or fraudulent billings.
43) LOBBYING
No funds paid to the Contractor by AHCCCSA, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any federal or
State contract, the making of any federal or State grant, the making of any
federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds other than those paid to the Contractor by AHCCCSA have
been used or will be used to influence the persons and entities indicated above
and will assist AHCCCSA in making such disclosures to HCFA.
44) CHOICE OF FORUM
The parties agree that jurisdiction over any action arising out of or relating
to this contract shall be brought or filed in a court of competent jurisdiction
located in the State of Arizona.
[END OF SECTION E]
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ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1) EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract.
2) RECORDS AND REPORTS
The Contractor shall maintain all forms, records, reports and working papers
used in the preparation of reports, files, correspondence, financial statements,
records relating to quality of care, medical records, prescription files,
statistical information and other records specified by AHCCCSA for purposes of
audit and program management. The Contractor shall comply with all
specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect
each service provided and all net costs, direct and indirect, of labor,
materials, equipment, supplies and services, and other costs and expenses of
whatever nature for which payment is made to the Contractor. Such material shall
be subject to inspection and copying by the state, AHCCCSA and the U.S.
Department of Health and Human Services during normal business hours at the
place of business of the person or organization maintaining the records.
The Contractor agrees to make available at the office of the Contractor, at all
times reasonable times, any of its records for inspection, audit or
reproduction, by any authorized representative of the state or federal
governments.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this subcontract except as
provided in paragraphs a. and b. below:
a. If this subcontract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available
for a period of five years from the date of any such termination.
b. Records which relate to disputes, litigation or the settlement of
claims arising out of the performance of this subcontract, or costs
and expenses of this subcontract to which exception has been taken by
the state, shall be retained by the Contractor until such disputes,
litigation, claims or exceptions have been disposed of.
The Contractor shall provide all reports requested by AHCCCSA, and all
information from records relating to the performance of the Contractor which
AHCCCSA may reasonably require. The Contractor reporting requirements may
include, but are not limited to, timely and detailed utilization statistics,
information and reports.
A-1
3) LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Contractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered
services. This provision shall not apply to patient contributions to the cost of
services delivered by nursing homes.
4) ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Contractor under this subcontract may be assigned without the
prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5) APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The prime contractor
shall notify AHCCCSA in the event of any proposed amendment or termination
during the term hereof. Any such amendment or termination is subject to the
prior approval of AHCCCSA. Approval of the subcontract may be rescinded by the
Director of AHCCCSA for violation of federal or state laws or rules.
6) WARRANTY OF SERVICES
The Contractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
7) SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Contractor and AHCCCSA for
the provision of covered services.
8) AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the prime contractor may undertake or award other contracts for
additional or related work to the work performed by the Contractor and the
Contractor shall fully cooperate with such other contractors, subcontractors or
state employees. The Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor, subcontractor or
state employee.
9) INDEMNIFICATION BY CONTRACTOR
The Contractor agrees to hold harmless the state, all state officers and
employees, AHCCCSA and other appropriate state agencies, and all officers and
employees of AHCCCSA and all AHCCCS eligible persons in the event of nonpayment
to the Contractor. The Contractor shall further indemnify and hold harmless the
state, AHCCCSA, other appropriate state agencies, AHCCCS contractors, and their
agents, officers and employees against all injuries, deaths,
2
losses, damages, claims, suits, liabilities, judgments, costs and expenses which
may, in any manner, accrue against the State, AHCCCSA or its agents, officers or
employees, or AHCCCS contractors, through the intentional conduct, negligence or
omission of the Contractor, its agent, officers or employees.
10) MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Contractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
11) COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Contractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract.
12) SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
13) VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
14) CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, A.R.S. ss.36-107, 36-2903, 41-1959 and 46-135, and AHCCCS and/or
ALTCS Rules.
15) GRIEVANCE AND REQUEST FOR HEARING PROCEDURES
Any grievance and request for hearings filed by the Contractor shall be
adjudicated in accordance with AHCCCS Rules.
16) TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Contractor, terminate this subcontract if
it is found, after notice and hearing by the State, that gratuities in the form
of entertainment, gifts, or otherwise were offered or given by the Contractor,
or any agent or representative of the
3
Contractor, to any officer or employee of the State with a view towards securing
a contract or securing favorable treatment with respect to the awarding,
amending or the making of any determinations with respect to the performance of
the Contractor; provided, that the existence of the facts upon which the state
makes such findings shall be in issue and may be reviewed in any competent
court. If the subcontract is terminated under this section, unless the prime
contractor is a governmental agency, instrumentality or subdivision thereof,
AHCCCSA shall be entitled to a penalty, in addition to any other damages to
which it may be entitled by law, and to exemplary damages in the amount of three
times the cost incurred by the Contractor in providing any such gratuities to
any such officer or employee.
17) PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The prime contractor and Contractor shall develop, maintain and use a system for
Prior Authorization and Utilization Review which is consistent with AHCCCS Rules
and the prime contractor's policies.
18) NON-DISCRIMINATION REQUIREMENTS
If applicable, the Contractor shall comply with:
a. The Equal Pay Act of 1963, as amended, which prohibits sex discrimination
in the payment of wages to men and women performing substantially equal
work under similar working conditions in the same establishment.
b. Title VI of the Civil Rights Act of 1964, as amended, which prohibits the
denial of benefits of, or participation in, contract services on the basis
of race, color, or national origin.
c. Title VII of the Civil Rights Act of 1964, as amended which prohibits
private employers, state and local governments, and educational
institutions from discriminating against their employees and job
applicants on the basis of race, religion, color, sex, or national origin.
d. Title I of the Americans with Disabilities Act of 1990, as amended, which
prohibits private employers and state and local governments from
discriminating against job applicants and employees on the basis of
disability.
e. The Civil Rights Act of 1991, which reverses in whole or in part, several
recent Supreme Court decisions interpreting Title VII.
f. The Age Discrimination in Employment Act (A.R.S. Title 41-1461, et seq.);
which prohibits discrimination based on age.
g. State Executive Order 99-4 and Federal Order 11246 which mandates that all
persons, regardless of race, color, religion, sex, age, national origin or
political affiliation, shall have equal access to employment
opportunities.
4
h. Section 503 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination in the employment or advancement of the employment of
qualified persons because of physical or mental handicap.
i. Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination on the basis of handicap in delivering contract services.
19) COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Contractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Contractor's records and the inspection of the
Contractor's facilities. If the Contractor is an inpatient facility, the
Contractor shall file uniform reports and Title XVIII and Title XIX cost reports
with AHCCCSA.
20) CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Contractor certifies that all representations
set forth herein are true to the best of its knowledge.
21) CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Contractor certifies that it has not engaged in
any violation of the Medicare Anti-Kickback statute (42 USC ss. ss. 1320a-7b) or
the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Contractor provides
laboratory testing, it certifies that it has complied with 42 CFR ss.411.361 and
has sent to AHCCCSA simultaneous copies of the information required by that rule
to be sent to the Health Care Financing Administration.
22) CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
23) ENCOUNTER DATA REQUIREMENT
If the Contractor does not bill the prime contractor (e.g., Contractor is
capitated), the Contractor shall submit encounter data to the prime contractor
in a form acceptable to AHCCCSA.
24) CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
5
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. Prime contractor may not reimburse providers
who do not comply with the above requirements.
25) INSURANCE
[This provision applies only if the Contractor provides services directly to
AHCCCS members]
The Contractor shall maintain for the duration of this subcontract a policy or
policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance. The Contractor agrees that any
insurance protection required by this subcontract, or otherwise obtained by the
Contractor, shall not limit the responsibility of Contractor to indemnify, keep
and save harmless and defend the State and AHCCCSA, their agents, officers and
employees as provided herein. Furthermore, the Contractor shall be fully
responsible for all tax obligations, Worker's Compensation Insurance, and all
other applicable insurance coverage, for itself and its employees, and AHCCCSA
shall have no responsibility or liability for any such taxes or insurance
coverage.
26) FRAUD AND ABUSE
If the Contractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Contractor shall report the incident to the
prime contractor, who shall proceed in accordance with the AHCCCS Health Plans
and Program Contractors Policy for Prevention, Detection and Reporting of Fraud
and Abuse. Incidents involving potential member eligibility fraud should be
reported to AHCCCSA, Office of Managed Care, Member Fraud Unit. All other
incidents of potential fraud should be reported to AHCCCSA, Office of the
Director, Office of Program Integrity. (See AHCCCS Rule R9-22-511.)
6
ATTACHMENT B: MINIMUM NETWORK STANDARDS
(By Geographic Service Area)
INSTRUCTIONS:
NOTE: OFFERORS ARE PERMITTED TO BID ONLY BY GEOGRAPHIC SERVICE AREA. PLEASE SEE
SECTION H, PARAGRAPH 9, AWARD OF CONTRACTS, FOR FURTHER INFORMATION ON BIDDING
BY GEOGRAPHIC SERVICE AREA.
Offerors shall have in place an adequate network of providers capable of meeting
contract requirements. The information that follows describes the minimum
network requirements by Geographic Service Area (GSA). The minimum bid is a
single entire GSA, as depicted on the following page.
In some GSA's there are required service sites located outside of the
geographical boundary of a GSA. The reason for this relates to practical access
to care. In certain instances, a member must travel a much greater distance to
receive services within their assigned GSA if the member were not allowed to
receive services in an adjoining GSA or state.
Split zip codes occur in some counties. Split zip codes are those which straddle
two different counties. Enrollment for members residing in these zip codes is
based upon the county and GSA to which the entire zip code has been assigned by
AHCCCS. The Offeror shall be responsible for providing services to members
residing in the entire zip code that is assigned to the GSA for which the
Offeror has agreed to provide services. The split zip codes GSA assignments are
as follows:
ZIP CODE SPLIT BETWEEN COUNTY ASSIGNED ASSIGNED GSA
THESE COUNTIES TO
-------- --------------------- --------------- ------------
85220 Pinal and Maricopa Maricopa 12
85242 Pinal and Maricopa Maricopa 12
85292 Gila and Pinal Gila 8
85342 Yavapai and Maricopa Maricopa 12
85358 Yavapai and Maricopa Maricopa 12
85390 Yavapai and Maricopa Maricopa 12
85643 Graham and Cochise Cochise 18
85645 Pima and Santa Cruz Santa Cruz 18
85943 Apache and Navajo Navajo 16
86336 Coconino and Yavapai Yavapai 6
86351 Coconino and Yavapai Coconino 6
86434 Mohave and Yavapai Yavapai 6
If outpatient specialty services (OB, family planning, and pediatrics) are not
included in the primary care provider contract, at least one subcontract is
required for each of these specialties in the service sites specified. General
surgeons must be available within 50 miles of service sites.
In Tucson (GSA 10) and Metropolitan Phoenix (GSA 12), the Offeror must
demonstrate its ability to provide PCP, dental and pharmacy services so that
members don't need to travel more than 5 miles from their residence.
Metropolitan Phoenix is defined on the Minimum Network Standard page specific to
GSA # 6.
Offerors bidding in GSA's other than GSA 10 and GSA 12 are encouraged to
contract with the hospitals in their provider network. However, AHCCCSA will not
award additional points in the evaluation process for hospital contracts in
rural areas. At a minimum, the Offeror shall have a physician with admitting and
treatment privileges with each hospital in its network. Offerors bidding in GSA
10 and/or GSA 12 must have at least one hospital contract in each service
district as depicted on the respective maps for GSA 10 and GSA 12. This
requirement is part of the Hospital Reimbursement Pilot Program, described more
fully in Section D, Paragraph 35, Hospital Reimbursement. For offerors'
convenience, a list of Phoenix and Tucson area hospitals are included on the
reverse of the Phoenix and Tucson maps which follow.
Provider categories required at various service delivery sites included in the
Service Area Minimum Network Standards are indicated as follows:
H Hospitals
P Primary Care Providers (physicians, certified nurse
practitioners and physician assistants)
D Dentists
PH Pharmacies
HOSPITALS IN PHOENIX METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
CENTRAL DISTRICT
85006 Good Samaritan Regional Medical Center
Phoenix Children's Hospital
St. Luke's Medical Center
85007 Phoenix Memorial Hospital
85008 Maricopa Medical Center
85013 St. Joseph's Hospital & Medical Center
85015 Phoenix Baptist Hospital & Medical Center
85020 John C. Lincoln Hospital -- North Mountain
85027 John C. Lincoln Hospital -- Deer Valley
NORTHWEST DISTRICT
85031 Maryvale Hospital Medical Center
85032 Paradise Valley Hospital
85306 Thunderbird Samaritan Medical Center
85308 Arrowhead Community Hospital & Medical Center
85351 Walter O. Boswell Memorial Hospital
85375 Del E. Webb Memorial Hospital
85054 Mayo Clinic Hospital
SOUTHWEST DISTRICT
85201 Mesa General Hospital Medical Center
Mesa Lutheran Hospital
85202 Desert Samaritan Medical Center
85206 Valley Lutheran Hospital
85224 Chandler Regional Hospital
85251 Scottsdale Healthcare Osborn
85260 Scottsdale Healthcare Shea
85281 Tempe St. Luke's Hospital
HOSPITALS IN TUCSON METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
NORTHWEST DISTRICT
85719 Tucson General Hospital
University Medical Center
85741 Northwest Hospital
85745 Carondelet St. Mary's Hospital
SOUTHEAST DISTRICT
85711 Carondelet St. Joseph's Hospital
85712 El Dorado Hospital
Tucson Medical Center
85713 Kino Community Hospital
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
- ----------------------------------------------------------------------------------------------------------------------
REPORT WHEN DUE SOURCE/REFERENCE AHCCS CONTACT:
- ----------------------------------------------------------------------------------------------------------------------
Monthly Financial Report 45 days after the end of Reporting Guide Financial Manager
the month, as applicable
- ----------------------------------------------------------------------------------------------------------------------
Quarterly Financial Report 60 days after the end of Reporting Guide Financial Manager
each quarter
- ----------------------------------------------------------------------------------------------------------------------
Draft Annual Audit Report 90 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Draft Management Letter 90 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
First Annual Audit Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Final Management Letter 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Accountant's Report on 120 days after the end of Reporting Guide Financial Manager
Compliance each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Reconciliation - Annual Audit 120 days after the end of Reporting Guide Financial Manager
and Plan Year-to-Date each fiscal year
Financial Report Information
- ----------------------------------------------------------------------------------------------------------------------
Financial Disclosure Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Annual Analysis of 120 days after the end of Reporting Guide Financial Manager
Profitability by Major Rate each fiscal year
Code (by County)
- ----------------------------------------------------------------------------------------------------------------------
PPC Lag Schedules 120 days after the end of Reporting Guide Financial Manager
each fiscal year
- ----------------------------------------------------------------------------------------------------------------------
Physician Incentive Plan Annually by October 1st RFP, Section D, Paragraph 18 Financial Manager
(PIP) reporting of each year
- ----------------------------------------------------------------------------------------------------------------------
Quarterly FQHC Reports 60 days after the end of RFP, Section D, paragraph 26 Financial Manager
each quarter
- ----------------------------------------------------------------------------------------------------------------------
Provider Affiliation Tape 10 business days after PMMIS Provider-to-Health Plan Health Plan
the beginning of each magnetic tape submission and Operations Manager
quarter processing
- ----------------------------------------------------------------------------------------------------------------------
Corrected Pended Encounter Monthly, according to Encounter Manual Encounter
Data established schedule Administrator
- ----------------------------------------------------------------------------------------------------------------------
New Day Encounter Data Monthly, according to Encounter Manual Encounter
established schedule Administrator
- ----------------------------------------------------------------------------------------------------------------------
Medical Records for Data 90 days after the request RFP, Section C, Paragraph 1 Data Validation
Validation received from AHCCCSA Manager
- ----------------------------------------------------------------------------------------------------------------------
F-1
- ----------------------------------------------------------------------------------------------------------------------
Quarterly Grievance and 45 days after the end of RFP, Section D, Paragraph 26 Administrative
Request for Hearing Report each quarter Assistant
- ----------------------------------------------------------------------------------------------------------------------
Comprehensive EPSDT Plan Annually on December 1 RFP, Section D, Paragraph 16 AHCCCS Chief Medical
Including Dental Officer
- ----------------------------------------------------------------------------------------------------------------------
EPSDT Progress Report 15 days after the end of AMPM, Chapter 400 AHCCCS Chief Medical
including Dental - Quarterly each quarterly Officer
Update
- ----------------------------------------------------------------------------------------------------------------------
Quarterly Inpatient Hospital 15 days after the end of State Medicaid Manual and the AHCCCS Chief Medical
Showing each quarter AMPM, Chapter 900 Officer
- ----------------------------------------------------------------------------------------------------------------------
Quarterly Annually on November 15th AMPM, Chapter 900 AHCCCS Chief Medical
Management/Utilization Officer
Management Plan Evaluation
and Revision
- ----------------------------------------------------------------------------------------------------------------------
AIDS/HIV Reports 90 days after the end of AMPM, Chapter 900 AHCCCS Chief Medical
each contract year Officer
- ----------------------------------------------------------------------------------------------------------------------
Acute Pharmacy Report 90 days after the end of AMPM, Chapter 900 AHCCCS Chief Medical
each quarter, annually Officer
within 90 days following
the end of each contract
year
- ----------------------------------------------------------------------------------------------------------------------
Monthly Pregnancy Termination End of the month AMPM, Chapter 400 AHCCCS Chief Medical
Report following the pregnancy Officer
termination
- ----------------------------------------------------------------------------------------------------------------------
Maternity Care Plan Annually on December 1st AMPM, Chapter 400 AHCCCS Chief Medical
Officer
- ----------------------------------------------------------------------------------------------------------------------
Semi-annual report of number 30 days after the end of AMPM, Chapter 900 AHCCCS Chief Medical
of pregnant women who are the 2nd and 4th quarter Officer
HIV/AIDS positive of each contract year
- ----------------------------------------------------------------------------------------------------------------------
Clinical Study Proposal Annual on November 15 AMPM, Chapter 900 AHCCCS Chief Medical
Officer
- ------------------------------- --------------------------- ----------------------------------- ----------------------
Clinical Study Results Annually within 90 days AMPM, Chapter 900 AHCCCS Chief Medical
following the end of each Officer
contract year
- ----------------------------------------------------------------------------------------------------------------------
Provider Fraud/Abuse Report Immediately following AHCCCS Internal Audit/Program Office of Program
discovery Investigation Policy for Integrity Manager
Prevention, Detection and
Reporting of Fraud and Abuse
- ----------------------------------------------------------------------------------------------------------------------
Eligible Person Fraud/Abuse Immediately following AHCCCS Internal Audit/Program Office of Program
Report discovery Investigation Policy for Integrity Manager
Prevention, Detection and
Reporting of Fraud and Abuse
- ----------------------------------------------------------------------------------------------------------------------
Non-Transplant Catastrophic Annually, within 30 days RFP, Section D, Paragraph 39 OMM/FFS Unit
Reinsurance covered Diseases of the beginning of the Reinsurance Manager
contract year, enrollment
to the plan, and when
newly diagnosed.
- ----------------------------------------------------------------------------------------------------------------------
F-2
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND
STANDARDS
The Contractor shall have in place a written grievance and request for hearing
policy for members and providers which defines their rights regarding any
adverse action by the Contractor. The Contractor shall also ensure compliance
with 9 A.C.C. R9-28-Article 12 the Members' Rights and Responsibilities Policy.
The written grievance and request for hearing policy shall be in accordance with
applicable federal and State laws and AHCCCS Rules and policy including, but not
limited to, AHCCCS Rules R9-22-512; R9-22-518 (A); R9-22-802 and R9-22-804. The
grievance and request for hearing policy shall include the following provisions:
a. The grievance and request for hearing procedure will be provided all
subcontractors at time of contract, and to non-contracting providers
within 10 days of the date of receipt of the claim. For non-contracting
providers, the grievance and request for hearing procedure may be
mailed with the remittance advice provided the remittance is sent
within 45 days of receipt of claim.
b. Specific individual(s) are appointed with authority to require
corrective action to administer the grievance and request for hearing
policy.
c. A log is maintained for all grievance and request for hearings
containing sufficient information to identify the grievant, date of
receipt, nature of the grievance and request for hearing and the date
grievance and request for hearing is resolved. Separate logs must be
maintained for provider and member grievance and request for hearings.
The logs must contain sufficient information to identify the grievant,
date of receipt, nature of the grievance and request for hearing and
the date grievance and request for hearing is resolved.
d. Within five working days of receipt, the grievant is informed by letter
that the grievance and request for hearing has been received. The
letter must also be in a second language when 200 members or 5% of the
Contractor's population, whichever is greater speak the second
language.
e. Each grievance and request for hearing is thoroughly investigated using
the applicable statutory, regulatory and contractual provisions as well
as the Contractor's policies and procedures, ensuring that facts are
gathered from all parties.
f. All documentation received and mailed by Contractor during the
grievance and request for hearing process is dated upon date of
receipt.
g. All grievance and request for hearings are filed in a secure,
designated area and are retained for five years following the final
decision, judicial appeal or close of a grievance and request for
hearing.
h. A copy of the Contractor's final decision will be either hand-delivered
or delivered by certified mail to all parties. The final decision shall
be mailed to all other individuals by regular mail. The date of the
final decision shall be the date of the notice. The final decision must
include, and describe in detail, the following:
1. the nature of the grievance and request for hearing
2. the issues involved
3. the reasons supporting the Contractor's decision including
references to applicable statute, rule and procedure
H-1
4. the grievant's right to appeal the Contractor's decision to
AHCCCSA by filing the appeal to the Contractor no later than
15 days after the date of the Contractor's final decision.
This must also be written in a second language, if applicable.
i. If the member requests a hearing, all supporting documentation must be
received by the AHCCCSA, Office of Legal Assistance no later than five
working days from the date the Contractor receives the appeal or from
the date of the oral or written request from AHCCCSA, Office of Legal
Assistance. The appeal file must contain a cover letter that includes:
1. grievant's name
2. grievant's AHCCCS ID number
3. grievant's address
4. phone number (if applicable)
5. date of receipt of grievance and request for hearing and
appeal
6. summary of the Contractor's actions undertaken to resolve
the grievance and request for hearing and basis thereof
j. The following material shall be included in the appeal file:
1. written request of the grievant asking for the appeal
2. copies of the entire file which include the investigations
and/or medical records; and the Contractor's grievance and
request for hearing decision
3. other information used by the Contractor to resolve the
grievance and request for hearing and that would be necessary
to AHCCCSA to resolve the grievance and request for hearing.
k. The Contractor may attempt to use alternative resolution procedures to
resolve disputes presented to the Contractor verbally or in writing. If
the Contractor elects to use an alternative resolution process, it must
be administered and completed within 10 days from receipt of the
dispute. If the matter is not resolved to the grievant's satisfaction
within the 10-day period, the dispute must then be adjudicated using
the grievance and request for hearing standards contained above.
However, the Contractor must render the written grievance and request
for hearing decision within a maximum of 30 days from the date of the
initial filing of the grievance and request for hearing or dispute
unless a longer period was agreed to by the parties involved.
l. For all disputes where an alternative resolution is proposed, the
Contractor must maintain a separate log, complying with paragraphs c.
and g. above.
H-2
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed sanctions for noncompliance with encounter
submission requirements. AHCCCSA may also perform special reviews of encounter
data, such as comparing encounter reports to the Contractor's claims files. Any
findings of incomplete or inaccurate encounter data may result in the imposition
of sanctions or requirement of a corrective action plan.
PENDED ENCOUNTER CORRECTIONS
The Contractor must resolve all pended encounters within 120 days of the
original processing date. Sanctions will be imposed according to the following
schedule for each encounter pended for more than 120 days unless the pend is due
to AHCCCSA error:
0-l20 days 121-l80 day's 181-240 days 241-360 days 361+ days
No sanction $ 5 per month $ 10 per month $ 15 per month $ 20 per month
"AHCCCSA error" is defined as a pended encounter which (1) AHCCCSA acknowledges
to be the result of its own error, and (2) requires a change to the system
programming, an update to the database reference table, or further research by
AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA in writing that the resolution of a pended
encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will respond in
writing within 30 days of receipt of such notification. The AHCCCSA response
will report the status of each pending encounter problem or issue in question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor in writing of the
total number of sanctionable encounters pended more than 120 days.
Pended encounters shall not be deleted by the Contractor as a means of avoiding
sanctions for failure to correct encounters within 120 days. The Contractor
shall document deleted encounters and shall maintain a record of the deleted
CRNs with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCSA for review.
ENCOUNTER VALIDATION STUDIES
Per HCFA requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's
I-1
submitted encounter data. Any and all covered services may be validated as part
of these studies. Encounter validation studies will be conducted at least
yearly. The following reflects AHCCCSA'S encounter validation study process and
sanction policy as of 10/1/97. AHCCCSA may revise study methodology, timelines,
and sanction amounts based on agency review or as a result of consultations with
HCFA. The Contractor will be notified in writing of any significant change in
study methodology.
AHCCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to AHCCCSA. In the case of medical records
requests, the Contractor's failure to provide AHCCCSA with the records requested
within 90 days may result in a sanction of $1,000 per missing medical record. If
AHCCCSA does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor
may be sanctioned up to 5% of its annual capitation payment.
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date that the
encounter is received at AHCCCS. All encounters must be received by AHCCCSA no
later than 240 days after the end of the month in which the service was
rendered, or the effective date of enrollment with the Contractor, whichever is
later. For all encounters for which timeliness is evaluated, a sanction per
encounter error extrapolated to the population of encounters may be assessed if
the encounter record is received by AHCCCSA more than 240 days after the date
determined above. It is anticipated that the sanction amount will be $1.00 per
error extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has changed, or if
HCFA changes sanction requirements. The Contractor will be notified of the
sanction amount in effect for the studies at the time the studies begin.
Correctness: A correct encounter contains a complete and accurate description of
AHCCCS covered services provided to a member. A sanction per encounter error
extrapolated to the population of encounters may be assessed if the encounter is
incomplete or incorrectly coded. It is anticipated that the sanction amount will
be $1.00 per error extrapolated to the population of encounters; however,
sanction amounts may be adjusted if AHCCCSA determines that encounter quality
has changed, or if HCFA changes sanction requirements. The Contractor will be
notified of the sanction amount in effect for the studies at the time the
studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA'S pending encounter file or historical
files in lieu of correction of such record. For Study "A" and for Study "B", a
sanction per encounter error extrapolated to the population of encounters may be
assessed for an omission. It is anticipated that the sanction amount will be
$5.00 per error extrapolated to the population of encounters for Study "A" and
$10.00 per error extrapolated to the population of encounters for Study "B";
however, sanction amounts may be adjusted if AHCCCSA determines that encounter
quality has changed, or if
I-2
HCFA changes sanction requirements. The Contractor will be notified of the
sanction amount in effect for the studies at the time the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors found by the number of encounters reviewed. A 95% confidence interval
will be used to account for limitations caused by sampling. The confidence
interval shows the range within which the true error rate is estimated to be. If
error rates are based on a sample, the error rate used for sanction purposes
will be the lower limit of the confidence interval.
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples, which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to HCFA, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance and request for hearing pursuant to Article
8 of AHCCCS Rules. Sanction amounts will be deducted from the Contractor's
capitation payment.
ENCOUNTER ADJUSTMENTS
Contractors are required to submit adjusted or voided encounters in the event
that claims are subsequently adjusted or denied after the initial encounter
submission. This includes adjustments for inaccuracies identified by fraud and
abuse audits or investigations conducted by AHCCCSA or the Contractor.
Contractors shall refer to the Encounter User's Manual for further instructions
regarding adjustments to encounters.
I-3
Contract/RFP No. YH8-0001
[AHCCCS LOGO] ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
SECTION A. CONTRACT AMENDMENT
===============================================================================================
1. AMENDMENT 2. CONTRACT 3. EFFECTIVE DATE OF 4. PROGRAM:
NUMBER: NO.: AMENDMENT:
13 YH8-0001-05 APRIL 1, 2001 OMC
===============================================================================================
5. CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE ARIZONA
1600 W. BROADWAY SUITE 260
TEMPE, AZ 85282-1502
===============================================================================================
6. PURPOSE OF AMENDMENT: TO INCORPORATE CHANGES TO CONTRACT REQUIREMENTS DUE TO THE PASSAGE
OF PROPOSITION 204.
===============================================================================================
7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. Proposition 204. The attached pages represent modifications to the contract
requirements as a result of the passage of Proposition 204.
B. Capitation Rates. Included in this amendment are revised capitation rates for
the period beginning April 1, 2001 and ending September 30, 2001.
NOTE: PLEASE SIGN AND DATE BOTH AND THEN RETURN ONE TO: MICHAEL VEIT, MD 5700
AHCCCS CONTRACTS AND PURCHASING
701 E JEFFERSON STREET
PHOENIX AZ 85034
===============================================================================================
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL
EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
===============================================================================================
9. SIGNATURE OF AUTHORIZED 10. SIGNATURE OF AHCCCSA CONTRACTING
REPRESENTATIVE: OFFICER:
/S/ CAROLYN ROSE /S/ MICHAEL VEIT
===============================================================================================
TYPED NAME: CAROLYN ROSE MICHAEL VEIT
===============================================================================================
TITLE: CHIEF EXECUTIVE OFFICER CONTRACTS & PURCHASING
ADMINISTRATOR
===============================================================================================
DATE: 3/6/01 DATE 3/12/01:
===============================================================================================
1
CONTRACT/RFP NO. YH8-0001
TABLE OF CONTENTS
SECTION A CONTRACT AMENDMENT ............................................... 1
SECTION B CAPITATION RATES ................................................. 5
SECTION C DEFINITIONS ...................................................... 7
SECTION D PROGRAM REQUIREMENTS ............................................. 15
1. SCOPE OF SERVICES ................................................... 15
2. BEHAVIORAL HEALTH SERVICES .......................................... 22
3. AHCCCS MEDICAL POLICY MANUAL ........................................ 23
4. VACCINE FOR CHILDREN PROGRAM ........................................ 24
5. DENIALS OR REDUCTIONS OF SERVICES ................................... 24
6. ENROLLMENT AND DISENROLLMENT ........................................ 24
7. MAINSTREAMING OF AHCCCS MEMBERS ..................................... 27
8. MEMBER INFORMATION .................................................. 28
9. MEMBER SURVEYS ...................................................... 30
10. MARKETING PLANS ..................................................... 30
11. ANNUAL ENROLLMENT CHOICE ............................................ 30
12. TRANSITION OF MEMBERS ............................................... 31
13. STAFF REQUIREMENTS AND SUPPORT SERVICES ............................. 32
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS ................... 33
15. ADVANCE DIRECTIVES .................................................. 33
16. PERFORMANCE MEASUREMENT ............................................. 34
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM) ............... 36
18. PHYSICIAN INCENTIVES ................................................ 36
19. APPOINTMENT STANDARDS ............................................... 36
20. REFERRAL PROCEDURES AND STANDARDS ................................... 37
21. PROVIDER MANUAL ..................................................... 38
22. PRIMARY CARE PROVIDER STANDARDS ..................................... 39
23. OTHER PROVIDER STANDARDS ............................................ 40
24. NETWORK DEVELOPMENT ................................................. 41
25. NETWORK MANAGEMENT .................................................. 41
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) ........................... 42
27. PROVIDER REGISTRATION ............................................... 43
28. PROVIDER AFFILIATION TAPE ........................................... 43
29. PERIODIC REPORT REQUIREMENTS ........................................ 43
30. DISSEMINATION OF INFORMATION ........................................ 44
31. REQUESTS FOR INFORMATION ............................................ 44
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS ......................... 44
33. OPERATIONAL AND FINANCIAL REVIEWS ................................... 44
34. CLAIMS PAYMENT SYSTEM ............................................... 45
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT ........................... 45
36. NURSING FACILITY REIMBURSEMENT ...................................... 46
37. COMPENSATION ........................................................ 46
38. CAPITATION ADJUSTMENTS .............................................. 48
39. REINSURANCE ......................................................... 48
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY ...................... 50
41. MEDICARE SERVICES AND COST SHARING .................................. 52
42. COPAYMENTS .......................................................... 53
43. RECORDS RETENTION ................................................... 53
44. MEDICAL RECORDS ..................................................... 53
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS ...................... 54
2
CONTRACT/RFP NO. YH8-0001
46. ACCUMULATED FUND DEFICIT ............................................ 54
47. DATA EXCHANGE REQUIREMENT ........................................... 54
48. ENCOUNTER DATA REPORTING ............................................ 55
49. MONTHLY ROSTER RECONCILIATION ....................................... 56
50. TERM OF CONTRACT AND OPTION TO RENEW ................................ 56
51. SUBCONTRACTS ........................................................ 57
52. SPECIALTY CONTRACTS ................................................. 58
53. MANAGEMENT SERVICES SUBCONTRACTORS .................................. 59
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS ............................ 59
55. MINIMUM CAPITALIZATION REQUIREMENTS ................................. 59
56. PERFORMANCE BOND OR BOND SUBSTITUTE ................................. 60
57. AMOUNT OF PERFORMANCE BOND .......................................... 60
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES ................... 61
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP ...................... 61
60. SANCTIONS ........................................................... 62
61. AUTO-ASSIGNMENT ALGORITHM ........................................... 62
62. GRIEVANCE PROCESS AND STANDARDS ..................................... 62
63. QUARTERLY GRIEVANCE REPORT .......................................... 63
64. KIDSCARE ............................................................ 63
65. PENDING LEGISLATIVE ISSUES .......................................... 63
66. SEPARATE INCORPORATION .............................................. 64
67. CULTURAL COMPETENCY ................................................. 64
68. MEDICAID IN THE PUBLIC SCHOOLS ...................................... 64
69. PROPOSITION 204 AND HCFA WAIVER ..................................... 64
SECTION E: CONTRACT CLAUSES................................................. 66
1) APPLICABLE LAW ...................................................... 66
2) AUTHORITY ........................................................... 66
3) ORDER OF PRECEDENCE ................................................. 66
4) CONTRACT INTERPRETATION AND AMENDMENT ............................... 66
5) SEVERABILITY ........................................................ 66
6) RELATIONSHIP OF PARTIES ............................................. 66
7) ASSIGNMENT AND DELEGATION ........................................... 66
8) GENERAL INDEMNIFICATION ............................................. 66
9) INDEMNIFICATION -- PATENT AND COPYRIGHT ............................. 67
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS ............. 67
11) ADVERTISING AND PROMOTION OF CONTRACT ............................... 67
12) PROPERTY OF THE STATE ............................................... 67
13) THIRD PARTY ANTITRUST VIOLATIONS .................................... 67
14) RIGHT TO ASSURANCE .................................................. 67
15) TERMINATION FOR CONFLICT OF INTEREST ................................ 67
16) GRATUITIES .......................................................... 67
17) SUSPENSION OR DEBARMENT ............................................. 68
18) TERMINATION FOR CONVENIENCE ......................................... 68
19) TERMINATION FOR DEFAULT ............................................. 68
20) TERMINATION - AVAILABILITY OF FUNDS ................................. 68
21) RIGHT OF OFFSET ..................................................... 69
22) NON-EXCLUSIVE REMEDIES .............................................. 69
23) NON-DISCRIMINATION .................................................. 69
24) EFFECTIVE DATE ...................................................... 69
25) INSURANCE ........................................................... 69
26) DISPUTES ............................................................ 70
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS ......................... 70
28) INCORPORATION BY REFERENCE .......................................... 70
29) COVENANT AGAINST CONTINGENT FEES .................................... 70
3
CONTRACT/RFP NO. YH8-0001
30) CHANGES ............................................................. 70
31) TYPE OF CONTRACT .................................................... 70
32) AMERICANS WITH DISABILITIES ACT ..................................... 70
33) WARRANTY OF SERVICES ................................................ 70
34) NO GUARANTEED QUANTITIES ............................................ 71
35) CONFLICT OF INTEREST ................................................ 71
36) DISCLOSURE OF CONFIDENTIAL INFORMATION .............................. 71
37) COOPERATION WITH OTHER CONTRACTORS .................................. 71
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY ............................... 71
39) OWNERSHIP OF INFORMATION AND DATA ................................... 71
40) AHCCCSA RIGHT TO OPERATE CONTRACTOR ................................. 72
41) AUDITS AND INSPECTIONS .............................................. 72
42) FRAUD AND ABUSE ..................................................... 72
43) LOBBYING ............................................................ 73
44) CHOICE OF FORUM ..................................................... 73
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS ............................... 1
1) EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES ... 1
2) RECORDS AND REPORTS ................................................. 1
3) LIMITATIONS ON BILLING AND COLLECTION PRACTICES ..................... 1
4) ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES ............ 1
5) APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS ................ 2
6) WARRANTY OF SERVICES ................................................ 2
7) SUBJECTION OF SUBCONTRACT ........................................... 2
8) AWARDS OF OTHER SUBCONTRACTS ........................................ 2
9) INDEMNIFICATION BY CONTRACTOR ....................................... 2
10) MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES ..... 2
11) COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS ......................... 2
12) SEVERABILITY ........................................................ 2
13) VOIDABILITY OF SUBCONTRACT .......................................... 2
14) CONFIDENTIALITY REQUIREMENT ......................................... 2
15) GRIEVANCE AND REQUEST FOR HEARING PROCEDURES ........................ 3
16) TERMINATION OF SUBCONTRACT .......................................... 3
17) PRIOR AUTHORIZATION AND UTILIZATION REVIEW .......................... 3
18) NON-DISCRIMINATION REQUIREMENTS ..................................... 3
19) COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION ....... 4
20) CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION ..................... 4
21) CERTIFICATION OF COMPLIANCE-ANTI-KICKBACK AND LABORATORY TESTING .... 4
22) CONFLICT IN INTERPRETATION OF PROVISIONS ............................ 4
23) ENCOUNTER DATA REQUIREMENT .......................................... 4
24) CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988 ............ 4
25) INSURANCE ........................................................... 4
26) FRAUD AND ABUSE ..................................................... 5
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS ................................. 1
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS ...... 1
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS ........................... 1
4
CAPITATION RATES CONTRACT/RFP NO. YH8-0001
SECTION B - CAPITATION RATES
The Contractor shall provide services as described in this contract. In
consideration for these services, the Contractor will be paid the attached rates
for the term April 1, 2001 through September 30, 2001.
CAPITATION RATES
(per member per month)
Capitation rates specific to contractor
5
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
HEALTH CHOICE
CAPITATION RATE FOR SSI W/MEDICARE AND MN/MI
EFFECTIVE 4/1/01
SSI W/MED SSI W/MED MN/MI MN/MI
--------- --------- ------- -------
10/1/00 4/1/01 10/1/00 4/1/01
------- ------- ------- -------
GSA #10 (PIMA) $155.68 $168.56 $500.15 $509.02
------- ------- ------- -------
GSA #12 (MARICOPA) $173.04 $187.38 $612.63 $622.12
------- ------- ------- -------
6
DEFINITIONS CONTRACT/RFP NO. YH8-0001
SECTION C: DEFINITIONS
ADHS Arizona Department of Health Services, the state
agency mandated to serve the public health needs
of all Arizona citizens.
AGENT Any person who has been delegated the authority to
obligate or act on behalf of another person or
entity.
AHCCCS Arizona Health Care Cost Containment System, which
is composed of the Administration, contractors,
and other arrangements through which health care
services are provided to an eligible person, as
defined by A.R.S. ss. 36-2902, et seq.
AHCCCS BENEFITS See "COVERED SERVICES".
AHCCCS MEMBER See "MEMBER".
AHCCCSA Arizona Health Care Cost Containment System
ALTCS Administration. The Arizona Long Term Care System
(ALTCS), a program under AHCCCSA that delivers
long term, acute, behavioral health and case
management services to members, as authorized by
A.R.S. ss. 36-2932.
AMBULATORY CARE Preventive, diagnostic and treatment services
provided on an outpatient basis by physicians,
nurse practitioners, physician assistants and
other health care providers.
AMPM AHCCCS Medical Policy Manual.
ARIZONA ADMINISTRATIVE CODE State regulations established pursuant to relevant
(A.A.C.) statutes. For purposes of this solicitation, the
relevant sections of the AAC are referred to
throughout this document as "AHCCCS Rules".
A.R.S. Arizona Revised Statutes.
AT RISK Refers to the period of time that a member is
enrolled with a contractor during which time the
Contractor is responsible to provide AHCCCS
covered services under capitation.
BIDDERS LIBRARY A repository of manuals, statutes, rules and other
reference material located at the AHCCCS office in
Phoenix.
BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board
and successfully passed the required examination
for certification.
CAPITATION Payment to contractor by AHCCCSA of a fixed
monthly payment per person in advance for which
the contractor provides a full range of covered
services as authorized under A.R.S. ss. 36-2942
and ss. 36-2931.
CATEGORICALLY Member eligible for Medicaid under Title XIX of
LINKED TITLE XIX the Social Security Act including those eligible
MEMBER under 1931 provisions of the Social Security Act
(previously AFDC), Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI), SSI-related groups. To be
categorically linked, the member must be aged (65
or over), blind, disabled, a child under age 19,
parent of a dependent child, or pregnant.
7
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider of
service or from a third party; but does not
include claims under investigation for fraud or
abuse or claims under review for medical
necessity, as defined by A.R.S. ss. 36-2904.
COMPETITIVE BID A state procurement system used to select
PROCESS contractors to provide covered services on a
geographic basis.
CONTINUING An AHCCCS contractor during CYE 97 that submits a
OFFEROR proposal pursuant to this solicitation.
CONTRACT See "COVERED SERVICES".
SERVICES
CONTRACT YEAR Corresponds to federal fiscal year (Oct. 1 through
(CY) Sept. 30). For example, Contract Year 01 is
10/01/00 - 9/30/01.
CONTRACTOR A person, organization or entity agreeing through
a direct contracting relationship with AHCCCSA to
provide the goods and services specified by this
contract in conformance with the stated contract
requirements, AHCCCS statute and rules and federal
law and regulations.
CONVICTED A judgment of conviction has been entered by a
federal, state or local court, regardless of
whether an appeal from that judgment is pending.
CO-PAYMENT A monetary amount specified by the Director that
the member pays directly to a contractor or
provider at the time covered services are
rendered, as defined in R9-22-107.
COUNTY Amount of funds contributed to the AHCCCS fund by
CONTRIBUTION each Arizona county based on funding formulas
established by law.
COVERED SERVICES Health care services to be delivered by a
contractor which are designated in Section D of
this contract and also AHCCCS Rules R9-22, Article
2 and R9-31, Article 2.
CRS Children's Rehabilitative Services, as defined in
R9-22-114.
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified as
defined in the text, as defined in R9-22-101.
DIRECTOR The Director of AHCCCSA.
DISCLOSING ENTITY An AHCCCS provider or a fiscal agent.
DME Durable Medical Equipment, which is an item, or
appliance that can withstand repeated use, is
designated to serve a medical purpose, and is not
generally useful to a person in the absence of a
medical condition, illness or injury as defined in
R9-22-102.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
8
EAC Eligible Assistance Child as defined in A.R.S. ss.
36-2905.03(B); an AHCCCS state program for
children under age 14 receiving food stamps.
Effective 10/1/01, EAC members will become Title
XIX Waiver members.
ELIC Eligible Low-Income Child as defined in A.R.S. ss.
36-2905.05(C) and (D); an AHCCCS state program for
children under age 14 whose household income
exceeds the income limit for the MN/MI program but
is less than 100% of the federal poverty level.
Effective 10/1/01, ELIC members will become Title
XIX Waiver members.
ELIGIBILITY A process of determining, through a written
DETERMINATION application, including required documentation,
whether an applicant meets the qualifications for
Title XIX Title XXI, and/or state-only
eligibility.
EMERGENCY A medical condition manifesting itself by acute
MEDICAL symptoms of sufficient severity (including severe
CONDITION pain) such that a prudent layperson, who possess
an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in: a) placing the patient's
health in serious jeopardy; b) serious impairment
to bodily functions; or c) serious dysfunction of
any bodily organ or part.
EMERGENCY Services provided after the sudden onset of a
MEDICAL medical condition manifesting itself by acute
SERVICE symptoms of sufficient severity (including severe
pain) that the absence of immediate medical
attention could reasonably be expected to result
in: a) placing the patient's health in serious
jeopardy; b) serious impairment to bodily
functions; or c) serious dysfunction of any bodily
organ or part, as defined in R9-22-102.
ENCOUNTER A record of a medically related service rendered
by a provider or providers registered with AHCCCSA
to a member who is enrolled with a Contractor on
the date of service. It includes all services for
which the contractor incurred any financial
liability.
ENROLLMENT The process by which an eligible person becomes a
member of a contractor's health plan.
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; services for persons under 21 years of
age as described in AHCCCS rules R9-22, Article 2.
FAMILY PLANNING A program that provides family planning services
SERVICES only for a maximum of 24 months to SOBRA women
EXTENSION whose pregnancy has ended and the woman is not
PROGRAM otherwise eligible for Title XIX.
FEDERALLY An entity which meets the requirements and
QUALIFIED HEALTH receives a grant and funding pursuant to Section
CENTER (FQHC) 330 of the Public Health Service Act. An FQHC
includes an outpatient health program or facility
operated by a tribe or tribal organization under
the Indian Self-Determination Act (PL 93-638) or
an urban Indian organization receiving funds under
Title V of the Indian Health Care Improvement Act.
FEE-FOR-SERVICE A method of payment to registered providers on an
(FFS) amount-per service basis.
9
FFP Federal financial participation (FFP) refers to
the contribution that the federal government makes
to the Title XIX and Title XXI program portions of
AHCCCS as defined in 42 CFR 400.203.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1
through September 30; State fiscal year: July 1
through June 30.
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered and who makes
referrals as necessary and monitors the member's
treatment.
GEOGRAPHIC A specific county or defined grouping of counties
SERVICE AREA designated by the Administration within which a
(GSA) contractor of record provides, directly or through
subcontract, covered health care to members
enrolled with that contractor of record
GROUP OF Two or more health care professionals who practice
PROVIDERS their profession at a common location (whether or
not they share facilities, supporting staff, or
equipment).
HCFA Health Care Financing Administration, an
organization within the U.S. Department of Health
and Human Services, which administers the Medicare
and Medicaid programs and Children's Health
Insurance Program.
HEALTH Various forms of plan organization, including
MAINTENANCE staff and group models, that meet the HMO
ORGANIZATION licensing requirements of the federal and/or state
(HMO) government and offer a full array of health care
services to members on a capitated basis.
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported: Liability for services
rendered for which claims have not been received.
IHS Indian Health Services, authorized as a federal
agency pursuant to 25 U.S.C. 1661.
LIEN A legal claim filed with the County Recorder's
office in which a member resides and in the county
an injury was sustained for the purpose of
ensuring that AHCCCS receives reimbursement for
medical services paid. The lien is attached to any
settlement the member may receive as a result of
an injury.
MANAGED CARE Systems that integrate the financing and delivery
of health care services to covered individuals by
means of arrangements with selected providers to
furnish comprehensive services to members;
establish explicit criteria for the selection of
health care providers; have significant financial
incentives for members to use providers and
procedures associated with the plan; and have
formal programs for quality assurance and
utilization review.
MANAGEMENT A person or organization that agrees to perform
SERVICES any administrative function or service for the
SUBCONTRACTOR Contractor specifically related to securing or
fulfilling the Contractor's obligations to AHCCCSA
under the terms of the contract.
MANAGING A general manager, business manager,
EMPLOYEE administrator, director, or other individual who
exercises operational or managerial control over,
or who directly or indirectly conducts the
day-to-day operation of, an institution,
organization or agency.
10
MATERIAL A fact, data or other information excluded from a
OMISSION report, contract, etc. the absence of which could
lead to erroneous conclusions following reasonable
review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended.
MEDICAL Title XIX Waiver member whose income is more than
EXPENSE 100% of the Federal Poverty Level, and spends down
DEDUCTION to or below 40% of the 2000 Federal Poverty Level.
(MED) The 40% of 2000 Federal Poverty Level will not be
adjusted annually to reflect annual Federal
Poverty Level adjustments.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEMBER A person eligible who is enrolled in the system,
as defined in A.R.S.ss.36-2901.
MN/MI Medically Needy/Medically Indigent; state program
for individuals not eligible for Medicaid but who
meet the eligibility requirements for the state
program. Beginning 4/1/01, individuals under this
program will be eligible for Medicaid as a Title
XIX Waiver member.
NEW OFFEROR The organization, entity or person which submits a
proposal in response to this solicitation and
which has not been an AHCCCS contractor during CYE
97.
NON-CONTRACTING A person who provides services as prescribed in
PROVIDER A.R.S.ss.36-2939 and who does not have a
subcontract with an AHCCCS contractor.
OFFEROR A person or other entity that submits a proposal
to the Administration in response to an RFP, as
defined in R9-22-106.
PERFORMANCE A set of standardized indicators designed to
MEASURES assist AHCCCS in evaluating, comparing and
improving the performance of its contractors.
Specific descriptions of health services
measurement goals are found in Section D,
Paragraph 16, Performance Measures.
PMMIS AHCCCSA's Prepaid Medical Management Information
System.
PRIMARY CARE An individual who meets the requirements of A.R.S.
PROVIDER (PCP) ss. 36-2901, and who is responsible for the
management of a member's health care. A PCP may be
a physician defined as a person licensed as
allopathic or osteopathic physician according to
A.R.S. Title 32, Chapter 13 or Chapter 17 or a
practitioner defined as a physician assistant
licensed under A.R.S. Title 32, Chapter 25, or a
certified nurse practitioner licensed under A.R.S.
Title 32, Chapter 15.
PRIOR PERIOD The period of time from the 1st day of the month
of application or the 1st eligible month,
whichever is later, to the day a member is
enrolled with the Contractor. The Contractor
receives notification from the Administration of
the member's enrollment.
PRIOR QUARTER The three-month period immediately preceding the
month in which the member applies for Title XIX
benefits. If it is determined that the member
would have been eligible had the member applied in
the month in which services were provided, AHCCCSA
may pay for unpaid Title XIX services on a
fee-for-service basis. The Contractor is not
liable for the prior quarter period. Prior quarter
coverage will discontinue for eligibility
determinations on or after 10/1/01.
11
PROPOSITION 204 Referendum that increased eligibility for AHCCCS
services to individuals whose income is at or less
than 100% of Federal Poverty Level.
PROVIDER Any person who contracts with the Administration
for the provision of hospitalization and medical
care to members according to the provisions
A.R.S.ss. 36-2901 or any subcontractor of provider
delivering services pursuant to A.R.S.ss. 36-2901.
QUALIFIED A person, eligible under A.R.S.ss.36-2971(4), who
MEDICARE is entitled to Medicare Part A insurance, meets
BENEFICIARY certain income and residency requirements of the
(QMB) Qualified Medicare Beneficiary program. A QMB who
is also eligible for Medicaid is commonly referred
to as a QMB dual eligible. Effective 4/1/01, all
QMB eligible members will be eligible for full
AHCCCS medical services under the SSI-MAO
category.
RATE CODE Eligibility classification for capitation payment
purposes.
REGIONAL An organization under contract with ADHS to
BEHAVIORAL administer covered behavioral health services in a
HEALTH geographically specific area of the state. Tribal
AUTHORITY governments, through an agreement with ADHS, may
(RBHA) operate a tribal regional behavioral health
authority (TRBHA) for the provision of behavioral
health services to Native American members living
on-reservation.
REINSURANCE A risk-sharing program provided by the
Administration to contractors for the
reimbursement of certain contract service costs
incurred by a member beyond a certain monetary
threshold.
RELATED PARTY A party that has, or may have, the ability to
control or significantly influence a contractor,
or a party that is, or may be, controlled or
significantly influenced by a contractor. "Related
parties" include, but are not limited to, agents,
managing employees, persons with an ownership or
controlling interest in the disclosing entity, and
their immediate families, subcontractors,
wholly-owned subsidiaries or suppliers, parent
companies, sister companies, holding companies,
and other entities controlled or managed by any
such entities or persons.
RFP Request For Proposals which is a document prepared
by AHCCCSA which describes the services required
and which instructs prospective offerors how to
prepare a response (proposal), as defined in
R9-22-107.
SCOPE OF SERVICES See "COVERED SERVICES".
SOBRA Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act, 1986, amended by the Medicare
Catastrophic Coverage Act of 1988, 42 CFR U.S.C.
1396a(a)(10)(A)(ii)(IX), July 1, 1988.
STATE The State of Arizona.
STATE PLAN The written agreements between the State and HCFA
which describes how the AHCCCS program meets HCFA
requirements for participation in the Medicaid
program and the Children's Health Insurance
Program.
12
STATE-ONLY A member who is not eligible for Title XIX or XXI
MEMBER but is eligible for one of the state-funded
eligibility categories which include Medically
Needy/Medically Indigent (MN/MI), Eligible
Assistance Children (EAC), Eligible Low Income
Children (ELIC). Beginning 4/1/01, MNMI's will no
longer be "state only," but funded by both state
and federal dollars.
SUBCONTRACT An agreement entered into by Contractor with a
provider of health care services who agrees to
furnish covered services to members, or with a
marketing organization, or with any other
organization or person who agrees to perform any
administrative function or service for Contractor
specifically related to fulfilling Contractor's
obligations to AHCCCSA under the terms of this
contract, as defined in R9-22-101.
SUBCONTRACTOR (1) A person, agency or organization to that a
contractor has contracted with or delegated some
of its management functions or responsibilities to
provide covered services to its members; or (2) A
person, agency or organization that a fiscal agent
has entered into a contract, agreement, purchase
order or lease (or leases of real property) to
obtain space, supplies, equipment or services
provided under the AHCCCS agreement.
SUPPLEMENTAL Federal cash assistance program under Title XVI of
SECURITY the Social Security Act.
INCOME
(SSI)
TEFRA RISK HMO A Health Maintenance Organization or Comprehensive
Medical Plan, which provides Medicare, services to
Medicare beneficiaries pursuant to a Medicare risk
contract with HCFA under ss.1876 of the Social
Security Act.
TEMPORARY A Federal cash assistance program under the
ASSISTANCE TO Social Security Act. It replaced Aid To Families
NEEDY FAMILIES With Dependent Children (AFDC).
(TANF)
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS
applicant or member, as defined in R9-22-110
THIRD PARTY LIABILITY The resources available from a person or entity
that is, or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the
medical expenses incurred by an AHCCCS applicant
or member, as defined in R9-22-110.
TITLE XIX MEMBER Member eligible for Federally funded Medicaid
programs under Title XIX of the Social Security
Act including those eligible under 1931 provisions
of the Social Security Act (previously AFDC),
Sixth Omnibus Budget Reconciliation Act (SOBRA),
Supplemental Security Income (SSI), SSI-related
groups, and Title XIX Waiver groups.
TITLE XIX WAIVER All MED (Medical Expense Deduction) members, and
MEMBER adults or childless couples at or under 100% of
the Federal Poverty Level who are not
categorically linked to another Title XIX program.
TITLE XXI MEMBER Member eligible for acute care services under
Title XXI of the Social Security Act, referred to
in federal legislation as the "State Children's
Health Insurance Program" (SCHIP). The Arizona
version of SCHIP is referred to as "KidsCare."
13
TRIBAL FACILITY A facility that is operated by an Indian tribe and
(638 TRIBAL that is authorized to provide ) services pursuant
FACILITY to Public Law 93-638, as amended.
YEAR See "Contract Year".
[END OF DEFINITIONS]
14
PROGRAM REQUIREMENTS CONTRACT/RFP NO. YH8-0001
SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R9-22, Article 2, the AHCCCS Medical Policy
Manual (AMPM), and the document entitled "AHCCCS Health Plan Performance
Indicators", all of which are incorporated herein by reference and may be found
in the Bidder's Library. The covered services are briefly described below.
Covered services must be medically necessary and provided by, or coordinated
with, a primary care provider, except for behavioral health and children's
preventive dental services. Services must be rendered by providers that are
appropriately licensed or certified, operating within their scope of practice,
and registered as an AHCCCS provider. The Contractor shall provide the same
standard of care for all members regardless of the member's eligibility
category.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options even if needed services are not
covered by the Contractor.
KIDSCARE COVERED SERVICES: KidsCare members are eligible for the same services
covered for members under the Title XIX and state-only programs, with the
following differences, exclusions and/or limitations:
a. Non-emergency transportation is not covered.
b. Chiropractic services are not covered.
c. Vision services are limited to one eye examination per contract year
and one pair of glasses or contacts every contract year.
d. EPSDT services are limited to those services specified in this
contract.
e. Behavioral health services are limited to 30 inpatient days and 30
outpatient visits per contract year. (See details under Section D
Paragraph 2, Behavioral Health Services.)
f. Licensed midwives and home deliveries are not covered.
For further details regarding the KidsCare program, see Section D, Paragraph 64,
KidsCare, and the AHCCCS Medical Policy Manual (AMPM).
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a free-standing surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 21 including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through other than medical or surgical means
(i.e. hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2, Behavioral Health Services.
15
CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for children with
CRS-covered conditions is administered by the Arizona Department of Health
Services (ADHS) for children who meet CRS eligibility criteria. The Contractor
shall refer children to the CRS program who are potentially eligible for
services related to CRS covered conditions, as specified in R9-22, Article 2
A.R.S. Title 36, Chapter 2, Article 3. Eligibility criteria and the referral
process are described in the CRS Policy and Procedures Manual available in the
Bidder's Library.
The Contractor shall monitor referrals to CRS to ensure CRS covered services are
provided in a timely manner to eligible members. Referral to CRS does not
relieve the Contractor of the responsibility for providing medically necessary
services not covered by CRS to CRS eligible members. The Contractor is also
responsible for initial care of newborn members, who are CRS eligible. The
Contractor must require the member's Primary Care Provider (PCP) to coordinate
their care with the CRS program. All services provided must be included in the
member's medical record maintained by the PCP.
A member with private insurance is not required to utilize CRS. If the member
uses their private insurance network for a CRS covered condition, and the member
is not enrolled with CRS, the Contractor is responsible for all applicable
deductibles and copays.
The Contractor remains ultimately responsible for the provision of all covered
services to its members. If the Contractor becomes aware that CRS has failed to
meet the established appointment standards, or has failed to provide medically
necessary CRS covered services, the Contractor shall immediately notify AHCCCSA,
Office of Medical Management, of the occurrence. In accordance with AHCCCS
policy, the Contractor may seek reimbursement from CRS for providing CRS covered
services.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
Title XIX members under age 21 when prescribed by the member's PCP and approved
by the Contractor in order to ameliorate the member's medical condition.
Medicare approved chiropractic services shall also be covered, subject to
limitations specified in CFR 410.22, for Qualified Medicare Beneficiaries if
prescribed by the member's PCP and approved by the Contractor.
DENTAL: The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services; dental
screening and preventive services in accordance with the AHCCCS periodicity
schedule; therapeutic dental services; dentures; and pre-transplantation dental
services. The Contractor shall monitor compliance with the EPSDT periodicity
schedule for dental screening services and ensure that dental service reports
are included in the member's medical record maintained by the PCP. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 16, Performance Measures. The Contractor shall
ensure that members are notified when dental screenings are due if the member
has not been scheduled for a visit. If no dental screening is received by the
member, a second notice must be sent. Members under the age of 21 may request
dental services without referral and may choose a dental provider from the
Contractor's provider network. For members who are 21 years of age and older,
the Contractor shall provide emergency dental care, medically necessary dentures
and dental services for transplantation services as specified in the AMPM.
Dental standards may be found in the AMPM, Section 310, which is incorporated
herein by reference and which may be found in the Bidder's Library.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
16
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment to correct or
ameliorate defects and physical or mental illness discovered by the screenings
for members under age 21. The Contractor shall ensure that these members receive
required health screenings, including developmental/behavioral health, in
compliance with the AHCCCS periodicity schedule (Exhibit 430-1 in the AMPM) and
to submit to the AHCCCS Office of Medical Management, all EPSDT reports as
required by AHCCCS medical policy. The Contractor is required to meet specific
participation/utilization rates for members as described in Section D, Paragraph
16, Performance Measures. Because the behavioral health benefit for Title XIX
and Title XXI is provided through the ADHS/RBHA system, the Contractor shall
ensure the initiation and coordination of the referral of these members to the
RBHA and shall follow up with the RBHA to monitor whether members have received
behavioral health services. Title XXI members are not entitled to the
all-encompassing EPSDT service package required for Title XIX children. Title
XXI children are entitled only to the EPSDT and other covered services specified
in this document, the AMPM and the Title XXI State Plan.
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically
emergent condition as defined by AHCCCS Rule R9-22-101 and R9-31-101.
Emergency medical services are covered without prior authorization. The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged
to contract with or employ the services of non-emergency facilities
(e.g. urgent care centers) to address member non-emergency care issues
occurring after regular office hours or on weekends. The Contractor
shall be responsible for educating members and providers regarding
appropriate utilization of emergency room services including behavioral
health emergencies. The Contractor shall monitor emergency service
utilization (by both provider and member) and shall have guidelines for
implementing corrective action for inappropriate utilization. For
utilization review, the test for appropriateness of the request for
emergency services shall be whether a prudent layperson, similarly
situated, would have requested such services. For purposes of this
contract, a "prudent layperson" is a person who possesses an average
knowledge of health and medicine.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
e. The Contractor shall comply with guidelines regarding the coordination
of post-stabilization care.
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for
conditions of the eye for all members under the age of 21, with the exception of
KidsCare members. See limitations for KidsCare members described at the
beginning of this section, titled "KidsCare Covered Services." For members who
are 21 years of age and older, the Contractor shall provide emergency care for
eye conditions which meet the definition of an emergency medical condition,
cataract removal, and/or medically necessary vision examinations and
prescriptive lenses if required following cataract removal and other eye
conditions as specified in the AMPM.
FAMILY PLANNING: The Contractor shall provide family planning services in
accordance with the AMPM, Section 420 for all members who choose to delay or
prevent pregnancy. These include medical, surgical, pharmacological and
laboratory services, as well as contraceptive devices. Information and
counseling necessary to allow the members to make informed decisions regarding
family planning methods shall also be included. If the Contractor does not
provide family planning services, it must contract for these services through
another health care delivery system, which allows members freedom of choice in
selecting a provider.
17
A prospective offeror may discuss arrangements for family planning services
only with other prospective offerors during the RFP process for the purpose of
making arrangements for the provision of family planning services.
The Contractor shall provide services to members enrolled in the Family Planning
Services Extension Program; a program that provides only family planning
services for a maximum of 24 months to women whose SOBRA eligibility has
terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification may be made at the time
the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually transmitted diseases, tuberculosis and
HIV/AIDS; nutritional assessment in cases when the member has a chronic
debilitating disease affected by nutritional needs; mammograms and prostate
screenings; physical examinations and diagnostic work-ups; and immunizations.
Required assessment and screening services for members under age 21 are included
in the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: The Contractor shall provide part-time or intermittent care for
members who do not require hospital care. This service is provided under the
direction of a physician to prevent re-hospitalization or institutionalization
and may include nursing, therapies, supplies and home health aide services.
HOSPICE: These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis services. If the member's
medical condition requires isolation; private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the above
services, which may be provided on an outpatient or ambulatory basis (i.e.
laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if determined
reasonable and necessary to decide whether the member should be admitted for
inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
oral/inactivated polio vaccine (OPV/IPV), measles, mumps, rubella vaccine (MMR),
H. influenza, type B (HIB), hepatitis B (Hep B), and varicella vaccine. The
Contractor is required to meet specific immunization rates for members under the
age of 21, which are described in Section D, Paragraph 16, Performance Measures.
INDIAN HEALTH SERVICES (IHS): The Contractor may choose to subcontract with and
pay an IHS or 638 tribal facility as part of their provider network for covered
services provided to members. Effective October 1, 1999, the Contractor is
responsible for reimbursement to IHS or tribal facilities for emergency services
provided to state-only and Title XXI Native American members enrolled with the
Contractor. The Contractor has no responsibility for non-emergency services to
state-only and Title XXI Native American members
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unless the Contractor refers or prior authorizes the service. AHCCCSA will
reimburse claims for acute care services that are medically necessary and
eligible for 100% Federal reimbursement, provided to Title XIX members in an IHS
or a 638 tribal facility.
LABORATORY: Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending physician
or dentist, and provided by a CLIA (Clinical Laboratory Improvement Act)
approved free standing laboratory or hospital laboratory, clinic, physician
office or other health care facility laboratory.
Upon written request, a Contractor may obtain laboratory test data on members
from a laboratory or hospital based laboratory subject to the requirements
specified in A.R.S. ss. 36-2903(R) and (S). The data shall be used exclusively
for quality improvement activities and health care outcome studies required
and/or approved by the Administration.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants or nurse practitioners certified in
midwifery. Members may select or be assigned to a PCP specializing in
obstetrics. Circumcisions are covered as described in the AMPM. Title XIX and
state-only members anticipated to have a low-risk delivery may elect to receive
labor and delivery services in their home from their maternity provider if this
setting is included in allowable settings for the Contractor, and the Contractor
has providers in its network that offer home labor and delivery services. Title
XIX and state-only members anticipated to have a low-risk prenatal course and
delivery may elect to receive maternity services of prenatal care, labor and
delivery and postpartum care provided by licensed midwives if they are in the
Contractor's provider network. All licensed midwife labor and delivery services
must be provided in the member's home since licensed midwives do not have
admitting privileges in hospitals or AHCCCS registered free-standing birthing
centers. Members receiving maternity services from a licensed midwife must also
be assigned to a PCP for other health care and medical services. Home delivery
and licensed midwives are not covered for Title XXI members.
The Contractor shall allow women and their newborns to receive up to 48 hours of
inpatient hospital care after a routine vaginal delivery and up to 96 hours of
inpatient care after a cesarean delivery. The attending health care provider, in
consultation with the mother, may discharge the mother or newborn prior to the
48-hour minimum length of stay. A normal newborn may be granted an extended stay
in the hospital of birth when the mother's continued stay in the hospital is
beyond the 48 or 96 hour stay.
The Contractor shall inform all assigned AHCCCS pregnant women of voluntary
prenatal HIV testing and the availability of medical counseling if the test is
positive. The Contractor shall provide information in the member handbook and
annually in the member newsletter to encourage pregnant women to be tested and
instructions on where to be tested. Semi-annually, the Contractor shall report
to AHCCCS the number of pregnant women who have been identified as HIV/AIDS
positive. This report is due no later than 30 days after the end of the second
and fourth quarters of the contract year.
MEDICAL FOODS: Medical foods are covered within limitations defined in the AMPM
for members diagnosed with a metabolic condition included under the ADHS Newborn
Screening Program and specified in the AMPM. The medical foods, including
metabolic formula and modified low protein foods, must be prescribed or ordered
under the supervision of a physician.
MEDICALLY-NECESSARY ABORTIONS: This service is covered for a member if the
member suffers from a medical condition or disorder, physical injury, or illness
caused by or rising from the pregnancy. The service is also covered for Title
XIX and Title XXI members if the pregnancy is caused by rape or incest.
Physician
19
certification of the condition, disorder, illness or injury must be provided to
the Contractor. In addition, providers must submit to the Contractor a
Certificate of Medical Necessity for Pregnancy Termination. Prior authorization
is required. If the procedure is performed on an emergency basis, documentation
must be submitted to the Contractor within two working days. Additional
documentation, outlined in the AMPM, is required for members under 18 years of
age or members who are considered an incapacitated adult who seek a medically
necessary abortion due to rape or incest.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP,
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY: The Contractor shall provide nursing facility services,
including religious nonmedical health care institutions, for members who require
short-term convalescent care not to exceed 90 days per contract year. In lieu of
a nursing facility, the member may be placed in an alternative living facility
or receive home and community based services (HCBS) as defined in R9-22, Article
2 and R9-28, Article 2 that meet the provider standards described in R9-28,
Article 5, and subject to the limitations set forth in Chapter 1200 of the AMPM.
Nursing facility services must be provided in a dually-certified
Medicare/Medicaid facility which includes in the per-diem rate: nursing
services, basic patient care equipment and sickroom supplies, dietary services,
administrative physician visits, non-customized DME, necessary maintenance
rehabilitation therapies, over-the-counter medications, social, recreational and
spiritual activities, and administrative, operational medical direction
services. The Contractor shall provide medically necessary nursing facility
services for any member who has a pending ALTCS application, who is currently
residing in a nursing facility and is eligible for services provided under this
contract. If the member becomes ALTCS eligible and is enrolled with an ALTCS
Program Contractor before the end of the maximum 90 days of nursing facility
coverage, the Contractor is only responsible for nursing facility coverage
during the time the member is enrolled with the Contractor. Nursing facility
services covered by a third party insurer (including Medicare) while the member
is enrolled with the Contractor shall be applied to the 90 day limitation. See
Paragraph 36, Nursing Facility Reimbursement, for further details.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application and to prepare for potential fee-for-service coverage if the stay
goes beyond the 90-day maximum.
NUTRITION: Nutritional assessments may be conducted as a part of the EPSDT
screenings for members under age 21, and to assist members 21 years of age and
older whose health status may improve with nutritional intervention. Assessment
of nutritional status on a periodic basis may be provided as determined
necessary, and as a part of the health risk assessment and screening services
provided by the member's PCP. AHCCCS covers nutritional therapy on an enteral,
parenteral or oral basis, when determined medically necessary to provide either
complete daily dietary requirements, or to supplement a member's daily
nutritional and caloric intake and when AHCCCS criteria specified in the AMPM
are met.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
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PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS AND PHARMACY: Medications ordered by a PCP, attending
physician or dentist and dispensed under the direction of a licensed pharmacist
are covered subject to limitations related to prescription supply amounts,
Contractor formularies and prior authorization requirements, as well as
restrictions for immunosuppressant drugs addressed in AHCCCS medical policies
for transplantations. Over-the-counter medication may be prescribed when it is
determined to be a lower-cost alternative to prescription medication.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member for specialty medical services,
behavioral health and dental services. The PCP is responsible for maintaining
the member's primary medical record, which contains documentation of all health
risk assessments and health care services of which they are aware whether or not
they were provided by the PCP.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those members who are 21 and over;
physical therapy for all members and occupational and speech therapies for
members under the age of 21 are covered on both an inpatient and outpatient
basis if not used as a maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient basis
when prescribed by the member's PCP or attending physician and is necessary to
restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services are covered within limitations defined in the AMPM for members
diagnosed with specified medical conditions. Such limitations include whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions that substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service. Services include pre-transplant inpatient or outpatient
evaluation; donor search; organ/tissue harvesting or procurement; preparation
and transplantation services; and convalescent care. In addition, if a member
receives a transplant covered by a source other than AHCCCS, medically necessary
non-experimental services are provided within limitations after the discharge
from the acute care hospitalization for the transplantation. AHCCCS has
contracted with transplantation providers for the Contractor's use or the
Contractor may select its own transplantation provider. However, the quality of
services must be equal to or exceed those of the AHCCCS provider and the rate
paid can not exceed the AHCCCS provider's negotiated rate.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911,
21
may be provided by ground, air or water ambulance to manage an AHCCCS member's
emergency medical condition at an emergency scene and transport the member to
the nearest appropriate medical facility. Non-emergency transportation shall be
provided for Title XIX and state-only members who are unable to provide their
own transportation for medically necessary services. Title XXI members are not
eligible for non-emergency transportation services except for transfers between
facilities.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine services necessary to alleviate or stabilize the
emergent condition. The provider must notify the Contractor within 12 hours of
the member's registration with the facility for emergency services. Supporting
documentation for services rendered must be provided when reporting or billing a
service. Triage/screening services must be reasonable, cost effective and meet
the criteria for severity of illness and intensity of service.
2. BEHAVIORAL HEALTH SERVICES
Title XIX and Title XXI members are eligible for comprehensive behavioral health
services. The behavioral health benefit for these members is provided through
the ADHS - Regional Behavioral Health Authority (RBHA) system. The Contractor
shall be responsible for member education regarding these benefits; provision of
limited emergency inpatient services; and screening and referral to the RBHA
system of members identified as requiring behavioral health services.
MEMBER EDUCATION: The Contractor shall be responsible for educating members in
the member handbook and other printed documents about covered behavioral health
services and where and how to access services. Covered services for Title XIX
and Title XXI are similar with the exception that non-emergency transportation
is not covered for Title XXI members. For Title XXI members inpatient services
and specified outpatient services are limited to 30 days/30 visits per contract
year. Covered services include:
a. Inpatient services (Title XXI limited to 30 days per contract year)
b. Individual, group and family therapy and counseling (limited for Title
XXI)
c. Psychotropic medication
d. Psychotropic medication adjustment and monitoring
e. Partial care, basic and intensive (limited for Title XXI)
f. Emergency crisis services
g. Behavior management (limited for Title XXI)
h. Psychosocial rehabilitation (limited for Title XXI)
i. Evaluation, screening and diagnosis (limited for Title XXI)
j. Laboratory and radiology services for psychotropic medication
regulation and diagnosis
k. Emergency and medically necessary transportation (Title XXI members
limited to emergency transportation only)
l. Case management services
m. Respite (Title XIX Only)
REFERRALS: As specified in Section D, Paragraph 1, EPSDT, the Contractor must
provide developmental/behavioral health screenings for members up to 21 years of
age in compliance with the AHCCCS periodicity schedule. The Contractor shall
ensure the initiation and coordination of behavioral health referrals of these
members to the RBHA when determined necessary through the screening process.
The Contractor is responsible for RBHA referral and follow-up collaboration, as
necessary, for other Title XIX and Title XXI members identified as needing
behavioral health evaluation and treatment. Members may
22
also access the RBHA system for evaluation by self-referral or be referred by
schools, State agencies or other service providers. The Contractor is
responsible for providing transportation to Title XIX members first RBHA
evaluation appointments if members are unable to provide their own
transportation.
EMERGENCY SERVICES: For Title XIX and Title XXI members not enrolled with ADHS,
the Contractor is responsible for up to three days of inpatient behavioral
health services per emergency episode not to exceed 12 days per contract year. A
referral to the RBHA for evaluation and enrollment should be initiated as soon
as possible after admission.
For state-only members (EAC, ELIC): The Contractor is responsible for up to
three days of inpatient emergency behavioral health services not to exceed 12
days per contract year regardless of whether the member is enrolled with a RBHA.
For members who become eligible during an emergency episode, the three (3) days
of coverage for this hospital benefit are the first three (3) days of
eligibility.
COORDINATION OF CARE: The Contractor is responsible for ensuring that a medical
record is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has not yet
seen the assigned member. The Contractor shall require the PCP to respond to
RBHA/provider information requests pertaining to ADHS enrolled members
including, but not limited to, current diagnosis, medication, pertinent
laboratory results, last PCP visit, and last hospitalization. For prior period
coverage, the Contractor is responsible for payment of all claims for medically
necessary covered behavioral health services to members not enrolled with ADHS.
MEDICATION MANAGEMENT SERVICES: The Contractor shall allow PCPs to provide
medication management services (prescriptions, medication monitoring visits,
laboratory and other diagnostic tests necessary for diagnosis and treatment of
behavioral disorders) to members with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder. The Contractor shall make available,
on the Contractor's formulary, medications for the treatment of these disorders.
The Contractor shall ensure that training and education is available to PCPs
regarding behavioral health referral and consultation procedures. The Contractor
shall establish policies and procedures for referral and consultation and shall
include them in their provider manual. Also, Contractors shall inform PCPs about
the availability of resource information through the Maricopa Integrated Health
System's Psychiatric Residency Training Program and the Arizona Medical
Association regarding the diagnosis and treatment of behavioral health
disorders.
The Contractor shall ensure that its quality management and peer review programs
incorporate monitoring of the PCP's management of behavioral health disorders.
3. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. The Contractor is responsible for complying with the requirements
set forth within. The AMPM with search capability and linkages to AHCCCS rules,
Statutes and other resources is available to all interested parties through the
AHCCCS Home Page on the Internet (www.ahcccs.state.az.us). Upon adoption by
AHCCCSA, AMPM updates will be available through the Internet at the beginning of
each month. If required, the Contractors may receive one hard copy of the AMPM,
free of charge, from AHCCCSA, Office of Medical Management, however, the
Contractor shall be responsible for maintaining such copies current with these
updates.
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4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program, the federal and state governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. Therefore, the Contractor shall not utilize AHCCCS
funding to purchase vaccines for members under the age of 19. Any provider,
licensed by the State to administer immunizations, may register with ADHS as a
"VFC provider" and receive free vaccines. The Contractor shall comply with all
VFC requirements and monitor its providers to ensure that, if providing
immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When a covered service is denied, reduced, suspended or terminated, the
Contractor shall comply with the notice, appeal and continuation of benefits
requirements specified in the Office of Managed Care Member Rights and
Responsibilities Policy.
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
Social Security Administration (SSA) SSA
determines eligibility for the
Supplementary Security Income (SSI)
cash program. SSI Cash recipients
are automatically eligible for
AHCCCS coverage.
Department of Economic Security (DES) DES determines eligibility for the
Temporary Assistance to Needy
Families (TANF) program (formerly
Aid to Families with Dependent
Children), 1931 Group Medical
Assistance Only (MAO) groups, SOBRA
women and children, the Eligible
Assistance Children state program
(EAC), the Adoption Subsidy
Program, Title IV-E foster care
children, Young Adults Transition
Insurance Program, and the Federal
Emergency Services program (FES)
related to the TANF, 1931 Group, or
SOBRA programs.
AHCCCSA AHCCCSA determines eligibility for
the SSI/MAO groups, including the
FES program related to the SSI-Cash
program (aged, disabled, blind),
the Arizona Long-Term Care System
(ALTCS), the Qualified Medicare
Beneficiary program and other
Medicare cost sharing programs, and
the Title XXI program.
Arizona's 15 Counties Each county determines eligibility
for the Medically Needy/Medically
Indigent (MN/MI), Eligible Low
Income Children (ELIC), and the
State Emergency Services state
programs.
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AHCCCS acute care members are enrolled with contractors in accordance with the
rules set forth in R9-22, Article 17.
HEALTH PLAN CHOICE
Title XIX members, except for those eligible under the MN/MI program have a
choice of available health plans. A listing of the available health plans and
their telephone numbers will be given to each applicant during the application
process for AHCCCS benefits. Also included are instructions to applicants to
call the health plans directly with specific questions concerning the health
plan. If there is only one health plan available for the applicant's
Geographical Service Area, no choice is offered. Members who do not choose prior
to AHCCCSA's being notified of their eligibility are automatically assigned to a
health plan based on family continuity or the auto-assignment algorithm.
Title XXI members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. When a member is transferred from
Title XIX to Title XXI and has not made a health plan choice for Title XXI, the
member will remain with the Title XIX health plan and a choice notice will be
sent to the member. The member may then change plans no later than 16 days from
the date the choice notice is sent.
AHCCCSA assigns MN/MI members to an available health plan based on family
continuity or through AHCCCSA's auto-assignment algorithm. These members do not
get a choice of available contractors until their annual enrollment choice
period. Beginning 10/1/01, all Title XIX Waiver members, including MED's will
have a choice of available health plans.
Exceptions to the above enrollment policies for Title XIX and state-only members
include: previously enrolled members who have been disenrolled for less than 90
days will be automatically enrolled with the same contractor, if that contractor
is still available. Also, women who are eligible for the Family Planning
Services Extension Program will automatically remain assigned to the same health
plan. The Family Planning Services Extension Program provides a maximum of 24
months of family planning services.
The effective date of enrollment for a new Title XIX or state-only member with
the Contractor will generally be the day prior to the date the Contractor
receives notification from AHCCCSA via the daily roster. However, the Contractor
is responsible for payment of medically necessary covered services retroactive
to the member's beginning date of eligibility, excluding any prior quarter
coverage period.
The effective date of enrollment for a Title XXI member will be the first day of
the month following notification to the health plan. If a Title XXI member is
determined eligible by the 25th of the month, the member will be enrolled with
the health plan as of the 1st of the following month. If the member is
determined eligible AFTER the 25th of the month, the member will be enrolled
with the health plan as of the 1st of the second following month.
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Proposition 204 and Title XIX Waiver Member Expansion/Conversion
DATE EXPANSION OR ENROLLMENT
EXPANSION AND CONVERSION POPULATION CONVERSION IS INITIATED METHODOLOGY
----------------------------------- ----------------------- -----------
QMB Only to QMB Dual Conversion 4/1/01 Current Title XIX rules
New SSI's from 76% to 100% FPL 4/1/01 onward Current Title XIX rules
Eligible parents of SOBRA children and KidsCare children up 7/1/01-9/1/01 Family Continuity
to 100% FPL
17 & 18 year old KidsCare children converting to Title XIX Redetermination date Remain in current health plan
MNMI (prior to 10/1/01) 4/1/01-10/1/01 Current MNMI rules
SOBRA Family Planning 10/1/01 Remain in current health plan
SMI SSI's 7/1/01-9/1/01 Current Title XIX rules
Premium Sharing Conversion members 10/1/01 Remain in current health plan
EAC/ELIC's who don't convert to KidsCare 10/1/01 Remain in current health plan
Title XIX Waiver members 10/1/01 Current Title XIX rules
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for Title XIX and
state-only members. For Title XIX members except for MNMI's enrolled between
4/1/01 and 10/1/01, prior period coverage starts from the first day of the month
of application, or first eligible month, whichever is later. The Contractor is
responsible for payment of all claims for medically necessary covered services
provided to members during prior period coverage. During the period 4/1/01
through 10/1/01, MNMI's will continue to have a two day retro period for prior
period coverage; however they will be entitled to all medically necessary
services due to their Title XIX eligibility. For state-only EAC members, prior
period coverage does not apply. For state-only ELIC members, prior period
coverage is generally limited to the two days prior to the date of AHCCCSA being
notified of eligibility. However, prior period coverage could include additional
days prior to the date of enrollment. The Contractor is responsible for payment
of all claims for medically necessary covered services provided on an emergency
basis to state-only members pursuant to A.R.S. ss.36-2908 and A.R.S. ss.36-2909
for the first two days of the prior period coverage. Any additional prior period
coverage for state-only members will include all claims for medically necessary
covered services. This may include services provided prior to the contract year
(See Section D, Paragraph 37, Compensation, for a description of the
Contractor's reimbursement from AHCCCSA for this eligibility time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers, including Title XXI mothers,
who were enrolled at the time of the child's birth and whose newborn
notification was received by AHCCCSA will be enrolled with the mother's health
plan. The Contractor is responsible for notifying AHCCCSA of a child's birth to
an enrolled member. Capitation to the Contractor will begin on the date
notification is received by AHCCCSA (except for cases of births during prior
period coverage). The effective date of AHCCCS eligibility will be the newborn's
date of birth, and the Contractor is responsible for all covered services to the
newborn whether or not AHCCCSA has received notification of the child's birth.
Note that AHCCCSA is currently available to receive notification calls 24 hours
a day, 7 days a week. Title XIX and Title XXI eligible mothers of newborns are
sent a letter advising them of their right to choose a different contractor for
their child; otherwise the child will remain with the mother's contractor.
Beginning 4/1/01, newborns of MNMI eligible women will become eligible and
enrolled under Title XIX rules.
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Newborns of FES mothers are auto-assigned to a health plan and mothers of these
newborns are sent a letter advising them of their right to choose a different
health plan for their child. In the event the FES mother chooses a different
health plan, AHCCCS will recoup all capitation paid to the originally assigned
plan and the baby will be enrolled retroactive to the date of birth in the
second plan. The second plan will receive prior period capitation from the date
of birth to the day before assignment and prospective capitation from the date
of assignment forward. The second contractor will be responsible for all covered
services to the newborn from date of birth.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, or as an Eligible Assistance Child (EAC), the member is guaranteed a
minimum of five full months of continuous enrollment. Upon initial capitated
enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of
12 full months of continuous enrollment. Enrollment guarantees do not apply to
Native Americans who choose to obtain their covered services through Indian
Health Services (IHS) on a fee-for-service basis or children enrolled with
Department of Economic Security/Comprehensive Medical and Dental Program. The
enrollment guarantee applies a maximum of one time per member per eligibility
category for Title XIX, Title XXI, and EAC members. If a member changes from one
contractor to another within the enrollment guarantee period, the remainder of
the guarantee period applies to the new contractor. The enrollment guarantee may
not be granted or may be terminated if the member is incarcerated or, if a minor
child is adopted. AHCCCS Rule R9-22, Article 17 and R9-31, Article 3 describes
other reasons for which the enrollment guarantee may not apply.
NATIVE AMERICANS: Native Americans, on or off-reservation, have a choice to
receive services from Indian Health Service (IHS), a PL 93-638 tribal facility
or any available contractor. If choice is not available or made within the
specified time limit, Native American Title XIX and state-only members living
on-reservation will be assigned to IHS and Native American Title XIX and
state-only members living off-reservation will be assigned to an available
contractor using AHCCCSA's family continuity policy and auto-assignment
algorithm. Native Americans may change from IHS to a contractor or from a
contractor to IHS at any time. Native American Title XXI members must make a
choice prior to being determined eligible.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, or physical or mental handicap, except where
medically indicated. Contractors must take into account a member's culture, when
addressing members and their concerns, and must take reasonable steps to
encourage subcontractors to do the same. The Contractor must make interpreters
available for members to ensure appropriate delivery of covered services.
Examples of prohibited practices include, but are not limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
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d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. The reading level and name of the
evaluation methodology used should be included when 200 members or 5% of the
Contractor's enrolled population, whichever is greater, speak a 2nd language,
the Contractor shall provide member information in that 2nd language. The
Contractor shall comply whenever it is aware that a population meets this
standard. When there are program or service site changes notification will be
provided to the affected members at least 14 days before implementation. The
Contractor shall review and update the Member Handbook at least once a year. The
Handbook must be submitted to AHCCCSA Office of Managed Care for approval by
Sept. 1 of each contract year, or within four weeks of receiving the annual
renewal amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A Member Handbook which, at a minimum, shall include the following
items that are also listed in the Office of Managed Care, Operations
Policy #404, Member Information Policy:
a. A table of contents.
b. A general description of how managed care works, particularly
in regards to member responsibilities, appropriate utilization
of services and the PCP's role as gatekeeper of services.
c. A description of all available covered services and an
explanation of any service limitations or exclusions from
coverage and a notice stating that the Contractor will be
liable only for those services authorized by the Contractor.
The description should include a brief explanation of the
Contractor's approval and denial process.
d. Information on what to do when family size changes.
e. How to obtain a PCP.
f. How to change PCPs.
g. How to make, change and cancel appointments with a PCP or
dentist.
h. List of applicable copayments (including a statement that care
will not be denied due to lack of copayment). The member
handbook must clearly state that members cannot be billed for
covered services (other than applicable copayments), what to
do if they are billed, and under what circumstances a member
may be billed for non-covered services.
i. Dual eligibility (i.e. Medicare and Medicaid); services
received in and out of the Contractor's network; copayments.
See Section D, Paragraph 41, Medicare Services and Cost
Sharing.
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j. The process of referral to specialists and other providers,
including access to behavioral health services provided by the
ADHS RBHA system.
k. How to contact Member Services and a description of its
function.
l. What to do in case of an emergency and instructions for
receiving advice on getting care in case of an emergency. In a
life-threatening situation, the member handbook should
instruct members to use the emergency medical services (EMS)
available and/or activate EMS by dialing 9-1-1. Handbook
should contain information on proper emergency service
utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. A description of the purpose and benefits of
EPSDT services, including the required components of EPSDT
screenings and the provision of all medically necessary
services to treat a physical or mental illness discovered by
the screenings. Screenings include a comprehensive history and
developmental/behavioral health screening, comprehensive
unclothed physical examination, appropriate vision testing,
hearing testing, laboratory tests, dental screening and
immunizations.
o. Maternity and family planning services.
p. Description of covered behavioral health services and how to
access them.
q. Description of all covered dental services for members under
21 and how to access these services.
r. Out of county/out of state moves.
s. Grievance and request for hearing procedures, including a
clear explanation of the member's right to file a grievance
and request for hearing and to appeal any decision that
affects the member's receipt of covered services.
t. Contributions the member can make towards his/her own health,
member responsibilities, appropriate and inappropriate
behavior, and any other information deemed essential by the
Contractor or AHCCCS. This shall include a statement that the
member is responsible for protecting his or her ID card and
that misuse of the card, including loaning, selling or giving
it to others could result in loss of the member's eligibility
and/or legal action. A sentence shall be included that
stresses the importance of members keeping, not discarding,
the swipe ID card.
u. How to access after-hours care (urgent care).
v. Advance directives for adults.
w. Use of other sources of insurance. See Section D, Paragraph
40, Coordination of Benefits.
x. The last revision date.
y. Member's notification rights and responsibilities under AAC
R9-22, Article 13 and AHCCCS policy.
z. A description of Fraud and Abuse including instructions on how
to report suspected fraud or abuse. This shall include a
statement that misuse of a member's identification card,
including loaning, selling or giving it to others could result
in loss of the member's eligibility and/or legal action
against the member
aa. A statement that informs the member of their right to request
information on whether or not the health plan has Physician
Incentive Plans (PIP) that affect the use of referral
services, the right to know the types of compensation
arrangements the plan uses, the right to know whether
stop-loss insurance is required and the right to a summary of
member survey results. (in accordance with PIP regulation).
bb. Member's right to be treated fairly regardless of race,
religion, sex, age or ability to pay.
cc. Instructions for obtaining culturally competent materials,
including translated member materials.
dd. A description of the criteria and procedures for requesting a
health plan change.
ee. Information regarding prenatal HIV testing and counseling
services.
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type style and size, which can easily be read by members with
varying degrees of visual impairment. At a minimum, the
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member handbook shall also contain the following language regarding questions,
problems, grievances and requests for hearings (Ref. AHCCCS Rule R9-22-518 and
R9-31-518):
Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call ________ and ask to talk
to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 60 days after the date of the
action, decision, or incident.
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
I. A list of the names, telephone numbers and service site addresses of
PCPs available for selection by the member and a description of the
selection process. Upon request by the member, the Contractor must make
information available regarding provider qualifications.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs; communication
between members and the Contractor; and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in each survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, unless waived by AHCCCSA, the Contractor shall
perform its own annual general or focused member survey. All such contractor
surveys must be approved in advance by AHCCCSA.
10. MARKETING PLANS
The Contractor shall submit all proposed marketing plans and materials to
AHCCCSA for prior approval in accordance with the AHCCCS Health Plan Marketing
Policy, a copy of which is available in the Bidder's Library. The Contractor
must have signed contracts with hospitals (in Maricopa and Pima counties), PCPs,
specialists and pharmacies in order for them to be included in marketing
materials.
11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment on a limited basis as
deemed necessary. During AEC, members may change contractors subject to the
availability of other contractors within their Geographic Service Area.
30
Members are mailed a printed enrollment form and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process. If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if the Contractor's contract is renewed and the member
continues to live in the Contractor's service area. The Contractor shall comply
with the Office of Managed Care Member Transition for Annual Enrollment Choice
and Other Plan Changes policy.
12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM, and the Office of Managed Care Member
Transition for Annual Enrollment Choice and Other Plan Changes standards for
member transitions between health plans or GSAs, to or from an ALTCS program
contractor, IHS, a PL 93-638 tribal entity, or a Title XXI direct service
provider and upon termination or expiration of a contract. The Contractor shall
develop and implement policies and procedures, which comply with AHCCCS medical
policy to address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy or who are hospitalized
at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services.
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
d. A monthly claims aging report by provider/creditor including IBNR
amounts;
e. A monthly summary of cash disbursements;
f. Copies of all bank statements received by the Contractor.
g. Such reports shall be due on the fifth day of each succeeding month for
the prior month.
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h. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
i. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
j. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff is required.
a. A full-time ADMINISTRATOR/CEO/COO who is available at all times to
fulfill the responsibilities of the position and to oversee the entire
operation of the health plan. The Administrator shall devote sufficient
time to the Contractor's operations to ensure adherence to program
requirements and timely response to AHCCCS Administration.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all-major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A CHIEF FINANCIAL OFFICER/CFO who is available at all times to fulfill
the responsibilities of the position and to oversee the budget and
accounting systems implemented by the Contractor.
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20. The Behavioral
Health Coordinator shall devote sufficient time to ensure that the
Contractor's behavioral health referral and coordination activities are
implemented per AHCCCSA requirements.
g. PRIOR AUTHORIZATION STAFF to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems, and to meet the Contractor's standards for telephone
abandonment rates and telephone hold times.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A CLAIMS ADMINISTRATOR AND CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
32
l. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE COORDINATOR who will manage and adjudicate member and
provider grievances.
n. CLERICAL AND SUPPORT STAFF to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCSA, Office of Managed Care, in writing and
provide a resume within seven days of staffing changes in the following key
positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/ EPSDT Coordinator Quality Management/Utilization Management Coordinator
Grievance Coordinator Behavioral Health Coordinator
The Contractor shall ensure that all staff has appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
15. ADVANCE DIRECTIVES
The Contractor shall maintain policies and procedures addressing advanced
directives for adult members that specify:
a. Each contract or agreement with a hospital, nursing facility, home
health agency, hospice or organization responsible for providing
personal care must comply with federal and State law regarding advance
directives for adult members. Requirements include:
(1) Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the
right to accept or refuse medical care, and the right to
execute an advance directive. If the agency/organization has a
conscientious objection to carrying out an advance directive,
it must be explained in policies. (A health care provider is
not prohibited from making such objection when made pursuant
to A.R.S. ss. 36-3205.C.1.)
(2) Provide written information to adult members regarding each
individual's rights under State law to make decisions
regarding medical care, and the health care provider's written
policies concerning advance directives (including any
conscientious objections).
(3) Documenting in the member's medical record whether or not the
adult member has been provided the information and whether an
advance directive has been executed.
33
(4) Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and
not making it a condition for the provision of care.
(5) Providing education to staff on issues concerning advance
directives including notification of direct care providers of
services, such as home health care and personal care, of any
advanced directives executed by members to whom they are
assigned to provide services.
b. Contractors shall encourage subcontracted PCPs to comply with the
requirements of subparagraph a. (2) through (5) above. Contractors
shall also encourage health care providers specified in subparagraph a.
to provide a copy of the member's executed advanced directive, or
documentation of refusal, to the member's PCP for inclusion in the
member's medical record.
16. PERFORMANCE MEASUREMENT
All performance measures described below apply to Title XIX, Title XXI, and
state-only member populations.
Effective October 1, 2000, AHCCCS will require Contractors to adopt the Quality
Improvement System for Managed Care (QISMC). AHCCCS will work with the
Contractors to develop quality improvement projects that will meet the QISMC
guidelines. Compliance with this requirement will become a part of the
Operational and Financial Review after October 1, 2001.
Contractors shall strive to meet the AHCCCS stated performance measure goals.
However, it is equally important that Contractors continually improve their
performance measure outcomes from year to year. Improvement in performance is to
be measured by a reduction in the health plan's adverse outcomes. AHCCCS
requires the Contractor to achieve a reduction of ten percent or more from the
previous year's adverse outcomes. The Contractor's performance will also be
evaluated against the adjusted AHCCCS statewide average performance level,
excluding the effect of the Contractor's data.
A. AHCCCS will require the Contractor to have a quality improvement plan
in place when:
(1) the Contractor has not achieved the AHCCCS statewide performance level
for any measure but has shown significant improvement, or
(2) the Contractor's rate has declined but is at or above the AHCCCS
statewide performance level for any measure.
B. The Contractor will be required to submit a corrective action plan and
may be subject to sanctions if:
(1) the Contractor has not achieved the AHCCCS statewide performance level
for any measure and has failed to show adequate improvement, or
(2) if the Contractor's rate has declined and fallen below the AHCCCS
statewide performance level for any measure.
Corrective action plans must be received by the Office of Medical Management
within 30 days of receipt of notification from AHCCCS. AHCCCS may conduct one or
more follow-up on-site reviews to verify compliance with a corrective action
plan.
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program to at least 80% of all enrolled
members under age 21 during CYE 2001. The participant rate is the number of
children receiving at least one medical screen compared to the number of
children expected to receive at least one medical screen. The number of children
expected to receive at least one medical screen is based on the federal
periodicity schedule and the average period of eligibility.
34
AHCCCSA will measure participation levels through encounter data and will not
use information from prior period coverage (see Paragraph D.6, Prior Period
Coverage) in evaluating the Contractor's performance.
EPSDT IMMUNIZATIONS: The Contractor shall ensure members under age 21 receive
age-appropriate immunizations as specified in the AMPM. During CYE 2001, the
Contractor shall meet or exceed the following:
Immunization Percentage of Number of Doses
Members
Immunized
Diphtheria, Tetanus, Pertussis vaccine (DPT) 82% 4
Oral/Inactivated Polio Vaccine 88% 3
Measles, Mumps, Rubella Vaccine (MMR) 90% 1
H. Influenza, Type B (2 HIB) 90% 2
Hepatitis B (Hep B) 87% 3
Combined 3-Antigen Rate (4 DPT, 3 OPV, 1 MMR) 82% 8
Combined All Antigen 73% 13
Varicella Vaccine 67% 1
The Contractor shall participate in an annual immunization audit based on random
sampling to assess and verify the immunization status of two-year-old members.
AHCCCSA will provide the Contractor, within two weeks after the end of the
contract year, the selected sample, specifications for conducting the audit, the
AHCCCSA reporting requirements, and technical assistance. The Contractor shall
identify each child's PCP, conduct the assessment, and report to AHCCCSA in the
required format all immunization data for the sampled two-year-old children no
later than December 15 after the end of the contract year. If medical records
are missing for more than 5% of the sample group, the Contractor is subject to
sanctions by AHCCCSA. The External Quality Review Contractor will conduct a
study to validate the Contractor's reported rates.
PERFORMANCE INDICATORS: For CYE 2001, the Contractor shall comply with AHCCCS
quality management requirements to improve performance for all AHCCCS
established performance indicators. Complete descriptions of these indicators
can be found in the document Health Plan Performance Indicators, User and
Technical Specifications. AHCCCS has established goals for the following
indicators: annual dental visits; well-child visits in the first 15 months of
life; and well-child visits in the 3rd, 4th, 5th and 6th years of life.
ANNUAL DENTAL VISITS: The Contractor shall take affirmative steps to increase
utilization of dental services for members under age 21. At least 55% of all
enrolled members between the ages of 3 to 21 shall have at least one dental
visit during CYE 2001. AHCCCSA will monitor utilization through reported
encounter data.
WELL CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE: The Contractor shall ensure
that members under the age of 15 months receive all recommended well-child
visits as specified in the AMPM. During CYE 2001, the Contractor shall ensure
that a minimum of 64% of its members receive all recommended well-child visits.
WELL-CHILD VISITS IN THE 3RD, 4TH, 5TH AND 6TH YEARS OF LIFE: The Contractor
shall ensure that members 3, 4, 5 and 6 years of age receive all recommended
well-child visits as specified in the AMPM. During CYE 2001, the Contractor
shall ensure that a minimum of 64% of its members receive at least one
well-child visit during the contract year.
35
CHILDREN'S ACCESS TO PRIMARY CARE PRACTITIONERS: The Contractor shall ensure
that members under age 21 have access to primary care provider (PCP) services.
During CYE 2001, the Contractor shall ensure that a minimum of 70% of members
under age 21 visit their PCP at least once during the contract year.
ACCESS TO CARE: During the contract year AHCCCSA will be developing and
establishing baseline information for three new measures: Provider Turnover,
Board Certification/Residency Completion and Availability of Language
Interpretation Services.
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
The Contractor shall provide to members quality medical care as described in the
AMPM, Chapter 900, regardless of payer source or eligibility category. The
Contractor shall institute processes to assess, plan, implement and evaluate
quality improvement activities. The Contractor shall conduct two clinical
studies each contract year as required in Chapter 900 of the AMPM. AHCCCSA will
determine the subject matter and study methodology for one of the annual studies
and the Contractor shall submit to AHCCCSA by November 15 of each contract year
its proposed subject matter and methodology for the other. The results of the
studies shall be submitted to AHCCCS, Office of Medical Management, within 180
days after the end of each contract year.
The Contractor must maintain a written QM/UM plan, which details plans for
compliance with the AMPM. The Contractor shall incorporate in its QM/UM plan an
action plan for improving the performance rates for those indicators with
established baselines.
18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. In order to
obtain approval, the following must be submitted to the Office of Managed Care
45 days prior to the implementation of the contract:
1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the
substantial financial risk definition.
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or HCFA.
Please refer to the "Physician Incentive Guidelines" in the Bidder's Library for
details on providing required disclosures.
19. APPOINTMENT STANDARDS
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For purposes of this section, "urgent" is defined as an acute but not
necessarily severe disorder, which, if not attended to, could endanger the
patient's health. The Contractor shall have procedures in place that ensure the
following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within two days of request
c. Routine care PCP appointments - within 21 days of request
For SPECIALTY REFERRALS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within three days of referral
c. Routine care appointments - within 30 days of referral
For DENTAL APPOINTMENTS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of request
b. Urgent appointments - within three days of request
c. Routine care appointments - within 45 days of request
For MATERNITY CARE, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within three days of request
d. High risk pregnancies - within three days of identification of high
risk by the Contractor or maternity care provider, or immediately if an
emergency exists
If a member needs medically-necessary transportation, the Contractor shall
require its transportation provider to schedule the transportation so that the
member arrives no sooner than one hour before the appointment; does not have to
wait more than one hour after making the call to be picked up; nor have to wait
for more than one hour after conclusion of the appointment for transportation
home.
The Contractor shall actively monitor the adequacy of its appointment processes
and reduce the unnecessary use of alternative methods such as emergency room
visits. The Contractor shall actively monitor and ensure that a member's waiting
time for a scheduled appointment at the PCP's or specialist's office is no more
than 45 minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network about appointment time requirements. The Contractor must assign
a specific staff member or unit within its organization to monitor compliance
with appointment standards and shall require a corrective action plan when
appointment standards are not met. Appointment standards shall be included in
the Provider Manual.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists to include, at a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
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b. A system for resolving disputes regarding the referrals
c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
The Contractor shall comply with all applicable physician referral requirements
and conditions defined in Sections 1903(s) and 1877 of the Social Security Act.
Upon finalization of the regulations, the Contractor shall comply with all
applicable physician referral requirements and conditions defined in 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician's
family has a financial relationship. Designated health services include:
Clinical laboratory services
Physical therapy services
Occupational therapy services
Radiology services
Radiation therapy services and supplies
Durable medical equipment and supplies
Parenteral and enteral nutrients, equipment and supplies
Prosthetics, orthotics and prosthetic devices and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of the
provider
c. Overview of the Contractor's Provider Service department and function
d. Listing and description of covered and non-covered services,
requirements and limitations including behavioral health services
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing,
laboratory tests, dental screenings and immunizations
g. Dental services
h. Maternity/Family Planning services
i. The Contractor's policy regarding PCP assignments
j. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS/RBHA system.
k. Grievance and request for hearing rights
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l. Billing and encounter submission information
-indicate which form UB92, HCFA 1500, or Form C is to be used for
services
-indicate which fields are required for a claim to be considered
acceptable by the Contractor. A completed sample of each form shall be
included
m. Contractor's written policies and procedures which affect the
provider(s) and/or the provider network
n. Claims re-submission policy and procedure
o. Reimbursement, including reimbursement for dual eligibles (i.e.
Medicare and Medicaid) or members with other insurance
p. Explanation of remittance advice
q. Prior authorization requirement
r. Claims medical review
s. Concurrent review
t. Fraud and Abuse
u. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
v. AHCCCS appointment standards
w. Americans with Disabilities Act (ADA) requirements, as applicable
x. Eligibility verification
y. Cultural competency information.
22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics, gynecology, or pediatrics; certified nurse practitioners or
certified nurse midwifes; or physician's assistants.
At a minimum, the Contractor's number of full-time equivalent PCPs to enrolled
members shall not exceed a ratio of 1:1800 for adults and 1:1200 for children
who are 12 or younger. If the PCP contracts with more than one AHCCCS health
plan, the ratio shall be adjusted by the Contractor to ensure the total number
of AHCCCS members does not exceed the above ratio. The Contractor should
consider the PCP's total patient panel size (i.e. AHCCCS and non-AHCCCS
patients) when assessing the PCP's ability to meet AHCCCS' appointment and other
standards. In addition, AHCCCS members shall not comprise the majority of the
PCP's panel of patients. The Contractor shall also reduce the number of members
assigned to its network PCPs as necessary to meet the appointment standards
specified in Section D, Paragraph 19, Appointment Standards. Any variation to
the above standards must be submitted to AHCCCSA, Office of Medical Management
for prior approval. PCPs with assigned members diagnosed with AIDS or as
HIV-positive shall meet criteria and standards set forth in AHCCCS Medical
Policy and AHCCCS AIDS Advisory Committee Guidelines.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions who are age 12 and younger to Board-certified
pediatricians.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP assignment, should the member desire to do so. The
Contractor shall confirm any PCP change in writing to the member. Members may
make both their initial PCP selection and any subsequent PCP changes either
verbally or in writing.
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At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of Managed Care, and shall be monitored through operational
audits. PCPs and specialists who provide inpatient services to the Contractor's
members shall have admitting and treatment privileges in a minimum of one
general acute care hospital that is located within the Contractor's service
area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet
the medical needs of its members.
b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English.
Contractor policies shall be subject to approval by AHCCCSA, Office of Managed
Care, and shall be monitored through operational audits.
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services, except
that women shall have direct access to GYN providers without a referral
for preventive and routine services. Any waiver of this requirement by
the Contractor must be approved in advance by AHCCCSA.
b. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies of test
results if applicable, treatment services provided and the resulting
outcome for each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
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Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians and certified nurse practitioners and certified nurse midwives who
include such services within their practice.
24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient personnel for the
provision of covered services, including emergency medical care on a
24-hour-a-day, 7-days-a-week basis. The proposed network shall be sufficient to
provide covered services within designated time and distance limits. For
Maricopa and Pima Counties only, this includes a network such that 95% of its
members residing within the boundary area of metropolitan Phoenix and Tucson do
not have to travel more than 5 miles to see a PCP or pharmacy. 95% of its
members residing outside the boundary area must not have to travel more than 10
miles to see such providers. See Attachment B, Minimum Network Requirements, for
details on network requirements by Geographic Service Area. Also see Section D,
Paragraph 35, Hospital Subcontracting and Reimbursement, for details on changes
in hospital subcontracting effective October 1, 1998.
Under the Balanced Budget Act of 1997, the Contractor shall not discriminate
with respect to participation in the AHCCCS program, reimbursement or
indemnification against any provider based solely on the provider's type of
licensure or certification. This provision, however, does not prohibit the
Contractor from limiting provider participation to the extent necessary to meet
the needs of the Contractor's members. This provision also does not interfere
with measures established by the Contractor to control costs consistent with its
responsibilities under this contract.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertains to all
service specifications described in the AMPM, Chapters 300, 600 and 900. In
addition, the Contractor shall have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements
b. Monitor and control network compliance with policies and rules of
AHCCCSA and the Contractor, including compliance with all policies and
procedures related to the grievance process and ensuring the member's
care is not compromised during the grievance process.
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area
e. Monitor network capacity to ensure that there are sufficient providers
to handle the volume of members
f. Ensure service accessibility, including monitoring appointment
procedures standards, appointment waiting times, and service provision
standards
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All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one,
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract. The
Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun, for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates. This legislation gives FQHCs the
option to require state Medicaid programs to reimburse the FQHC at 100% of
reasonable costs for the services delivered to Title XIX members. Effective
4/1/01, Title XIX Waiver members will also be eligible for reasonable cost
reimbursement. AHCCCSA and its contractors are required to comply with this
legislation. The following payment methodology for reasonable cost reimbursement
was implemented effective October 1, 1997.
If the FQHC elects reasonable cost reimbursement, the FQHC will receive a
quarterly payment per Title XIX member per month from AHCCCSA. The initial
capitation amount will be $1.75 PMPM statewide. In accordance with the Balanced
Budget Act of 1997 and BBA Refinements Legislation, this additional
reimbursement will be phased out over a five-year period beginning in contract
year ending 2000:
Contract Year Phase-Out Percentage PMPM Amount
1997 through 1999 No phase-out $ 1.75
2000 95% $ 1.66
2001 95% $ 1.66
2002 95% $ 1.66
2003 90% $ 1.58
2004 85% $ 1.49
2005 0% $ 0.00
Contractors are required to submit member month information for Title XIX
members for each FQHC on a quarterly basis to AHCCCS Office of Managed Care.
AHCCCSA will perform periodic audits of the member month information submitted.
Contractors should refer to the Office of Managed Care's policy on FQHC
reimbursement for further guidance. The following FQHCs are currently recognized
by HCFA:
Ajo Community Health Center
Chiricahua Community Health Centers, Inc.
Clinica Adelante, Inc.
El Rio Health Center
Inter-Tribal Health Care Center
Lake Powell Medical Center
Marana Health Center
Mariposa Community Health Center, Inc.
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Mountain Park Health Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
North Country Community Health Center
Sun Life Family Health Center
Sunset Community Health Center (formerly Valley Health
Center, Inc.)
United Community Health Center, Inc.
Any other clinics that subsequently become FQHCs will be subject to the
reimbursement methodology described above upon electing reasonable cost
reimbursement from AHCCCSA.
27. PROVIDER REGISTRATION
The Contractor shall ensure that all of its subcontractors register with AHCCCSA
as an approved service provider and receive an AHCCCS Provider ID Number. A
Provider Participation Agreement must be signed with each provider who does not
already have a current AHCCCS ID number. The original shall be forwarded to
AHCCCSA. This provider registration process must be completed in order for the
Contractor to report services a subcontractor renders to enrolled members and
for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TAPE
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Tape User Manual on October 15, January 15, April 15, and
July 15 of each contract year. The Manual may be found in the Bidder's Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its HCFA grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be received on
or before scheduled due dates.
b. Accuracy: Reports or other required data shall be prepared in
strict conformity with appropriate authoritative sources and/or AHCCCS
defined standards.
c. Completeness: All required information shall be fully disclosed in
a manner that is both responsive and pertinent to report intent with no
material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
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The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA, or the federal government, to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials that are produced by the Contractor and refer
to covered services shall state that such services are funded under contract
with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business for the initial contract year beginning 10/1/97.
The purpose of Readiness Reviews is to assess new contractors' readiness and
ability to provide contract services to members at the start of the contract
year. A new contractor will be permitted to commence operations only if the
Readiness Review factors are met to AHCCCSA's satisfaction.
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with HCFA requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The Contractor shall comply
with all other medical audit provisions as required by AHCCCS Rule R9-22-521 and
R9-31-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel as identified in advance shall be
available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
workspace, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the Contractor has obtained accreditation from NCQA or
any other nationally
44
recognized accrediting body. The Contractor must submit the entire NCQA report
to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in implementing recommendations and
achieving program compliance. Follow-up reviews may be conducted at any time
after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost avoiding and paying claims in accordance with AHCCCS Rule
R9-22-705, a copy of which may be found in the Bidder's Library. In the absence
of a subcontract provision to the contrary, claims submission deadlines shall be
calculated from the date of service or the effective date of eligibility
posting, whichever is later. Remittance advices accompanying the Contractor's
payments to providers must contain, at a minimum, adequate descriptions of all
denials and adjustments, the reasons for such denials and adjustments, the
amount billed, the amount paid, and grievance and request for hearing rights.
The Contractor's claims payment system, as well as its prior authorization and
concurrent review process, must minimize the likelihood of having to recoup
already-paid claims. Any recoupment in excess of $50,000 per provider within a
contract year must be approved in advance by AHCCCSA, Office of Managed Care.
In accordance with the Balanced Budget Act of 1997, unless a subcontract
specifies otherwise, the Contractor shall ensure that 90% of all clean claims
are paid within 30 days of receipt of the clean claim and 99% are paid within 90
days of receipt of the clean claim.
During the term of this contract, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout. All formats are subject to changes as required by federal
law. Reasonable implementation timeframes will be negotiated with each plan.
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
The Contractor shall reimburse hospitals for member care in accordance with
AHCCCS Rule R9-22-705. The Contractor is encouraged to obtain contracts with
hospitals in all GSA's and must submit copies of these contracts to AHCCCSA,
Office of Managed Care, at least seven days prior to the effective dates
thereof.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor fails to identify lack of medical necessity
through concurrent review and/or prepayment medical review, lack of medical
necessity
45
identified during postpayment medical review shall not constitute a basis for
recoupment by the Contractor. See also Section D, Paragraph 34, Claims Payment
System. For a more complete description of the guidelines for hospital
reimbursement, please consult the Bidder's Library for applicable statutes and
rules.
FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment. The Contractor is
responsible for payment of services while the member is enrolled with the
Contractor. The Contractor is not responsible for the full 90 days of nursing
facility coverage if ALTCS enrollment occurs before the 90 days has ended.
The Contractor shall provide medically necessary nursing facility services for
any member who has a pending ALTCS application, who is currently residing in a
nursing facility and is eligible for services provided under this contract. If
the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days of nursing facility coverage,
the Contractor is only responsible for nursing facility coverage during the time
the member is enrolled with the Contractor. Nursing facility services covered by
a third party insurer (including Medicare) while the member is enrolled with the
Contractor shall be applied to the 90 day limitation.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application process and to prepare for potential fee-for-service coverage if the
stay goes beyond the 90-day maximum.
37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, delivery supplement, HIV-AIDS
supplement, reinsurance (PPC and prospective), and third party liability, as
described and defined within this contract and appropriate laws, regulations or
policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of A.R.S. Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, and as
otherwise specified in this section, any savings
46
remaining to the Contractor as a result of favorable claims experience and
efficiencies in service delivery at the end of the contract term may be kept by
the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund, as described in A.R.S. ss.36-2913. An error discovered by the State with
or without an audit in the amount of fees paid to Contractor will be subject to
adjustment or repayment by Contractor making a corresponding decrease in a
current Contractor's payment or by making an additional payment by AHCCCSA to
the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. This
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months, including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation for newborns of
members who were enrolled at the time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE '98 and CYE '99, AHCCCSA
will offer a reconciliation process for contractors whose total PPC medical cost
experience (excluding administrative and non-operating expenses) is more than
10% higher than the reimbursement associated with PPC in two areas: the "retro"
portion of the capitation rate for all rate categories, and the prospective
three-day notification period for MN/MI recipients only. Expenses will be net of
reinsurance for both the retro and prospective period.
AHCCCSA will reimburse 100% of a Contractor's excess reasonable costs in excess
of a 10% limit as determined by reported encounters. AHCCCS will recoup profit
amounts in excess of a 10% limit.
For CYE '00 and `01, a full reconciliation to 0% profit or loss will be done by
AHCCCSA for the same eligibility time periods and risk groups noted above.
AHCCCSA will reimburse the health plans 100% of any excess reasonable costs as
determined by reported encounters, and all profits will be recouped. Refer to
the Office of Managed Care's PPC Reconciliation Policy for further details of
the reconciliation process.
DELIVERY SUPPLEMENT: When the Contractor has an enrolled woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
supplemental payment. Supplemental payments will not apply to women who deliver
in a prior period coverage time period. AHCCCSA reserves the right at any time
during the term of this contract to adjust the amount of this payment for women
who deliver at home.
HIV-AIDS SUPPLEMENT: On a quarterly basis, AHCCCSA shall utilize encounters to
determine the number of members receiving approved HIV/AIDS drugs and calculate
the amount of the supplemental payment. The
47
rate of reimbursement for this separate per member per month payment is
specified in Section B and is subject to review during the term of the contract.
AHCCCSA reserves the right to recoup any amounts paid for ineligible members as
determined through an encounter data review as well as an associated penalty for
incorrect encounter reporting.
Refer to the Office of Managed Care's HIV/AIDS supplemental payment and review
policies for further details and requirements.
38. CAPITATION ADJUSTMENTS
INCENTIVE FUND: AHCCCSA may retain a specified percentage of capitation
reimbursement in order to distribute to Contractors based on their performance
measure outcomes. AHCCCSA will notify Contractors 60 days prior to a new
contract year if this methodology will be implemented and will provide details
of the reimbursement methodology at that time.
CAPITATION ADJUSTMENTS: Except for changes made specifically in accordance with
this contract, the rates set forth in Section B shall not be subject to
re-negotiation or modification during the contract period. AHCCCSA may, at its
option, review the effect of a program change and determine if a capitation
adjustment is needed. In these instances the adjustment will be prospective with
assumptions discussed with the Contractor prior to modifying capitation rates.
The Contractor may request a review of a program change if it believes the
program change was not equitable; AHCCCSA will not unreasonably withhold such a
review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the default. The Contractor shall reimburse AHCCCSA
and/or AHCCCSA may deduct from future monthly capitation for any portion of a
month during which the Contractor was not at risk due to, for example:
a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits from the date
of incarceration)
c. duplicate capitation to the same contractor
d. adjustment based on change in member's contract type
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503 and R9-31-503). Per
diem rates paid for nursing facility services, including room and board,
provided in lieu of hospitalization for up to 90 days in any contract year shall
be eligible for reinsurance coverage. Refer to the AHCCCS Reinsurance Claims
Processing Manual for further details on the Reinsurance Program.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's
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statewide AHCCCS acute care enrollment (not including SOBRA Family Planning
Extension services) as of October 1st each contract year for all rate codes and
counties, as shown in the following table. No changes to the deductibles will be
made due to Proposition 204. These deductible levels are subject to change by
AHCCCSA during the term of this contract. Any change would have a corresponding
impact on capitation rates.
Prospective Reinsurance PPC Reinsurance
Statewide Plan MNMI Non MNMI All Rate
Enrollment Deductible Deductible Coinsurance Codes Coinsurance
- ---------- ---------- ---------- ----------- ----- -----------
0-19,999 $15,000 $20,000 75% $5,000 100%
20,000-49,999 $15,000 $35,000 75% $5,000 100%
50,000 and over $15,000 $50,000 75% $5,000 100%
A Contractor whose enrollment qualifies for the $35,000 or $50,000 non-MN/MI
deductible level may, prior to the start of the contract period, elect one of
the lower deductible levels indicated in the above table. Contractors may not
elect to increase their deductible level. If a Contractor's actual non-MN/MI
deductible is $35,000 or $50,000, AHCCCSA will increase the Contractor's
capitation rate awarded by defined amounts for each capitation risk group. These
specific capitation adjustments are available from the Office of Managed Care.
Prior Period Coverage Reinsurance: A separate reinsurance deductible and
coinsurance percentage will apply during prior period coverage. As noted in the
table above, all Contractors, regardless of enrollment, will be subject to a
$5,000 deductible level. The coinsurance percentage for the prior period
coverage reinsurance is 100%. Expenses incurred during prior period coverage
will not apply toward the prospective reinsurance thresholds.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
Effective October 1, 1998, when a member changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs incurred for that
member will follow the member to the receiving health plan. Therefore, all
submitted encounters from the health plan the member is leaving (for dates of
service within the current contract year) will be applied toward the receiving
health plan's deductible level. For further details regarding this policy and
other reinsurance policies refer to the AHCCCS Reinsurance Claims Processing
Manual. Medical review on prospective and prior period coverage reinsurance
cases will be determined based on statistically valid retrospective random
sampling. AHCCCSA, Office of Medical Management, will generate the sampling and
will notify the Contractor of documentation needed for the retrospective medical
review process to occur at the Contractor's offices. Reinsurance consideration
will be given to inpatient facility contracts, and hearing decisions rendered by
the Office of Legal Assistance. Pre-hearing and/or hearing penalties
discoverable during the review process will not be reimbursed under reinsurance.
A recoupment of reinsurance reimbursements made to the Contractor will occur
based on the results of the medical review sampling. The results of the medical
review sampling will be separately extrapolated to the entire prospective and
prior period coverage reinsurance reimbursement populations in the review time
frame for the Contractor. AHCCCSA will give the Contractor at least 45 days
advance notice of any on-site review. The Contractor shall have all requested
medical records on-site. Any documents not requested in advance by AHCCCSA shall
be made available upon request of the Review Team during the course of the
review. The Contractor
49
representative shall be available to the Review Team at all times during AHCCCSA
on-site review activities. While on-site, the Contractor shall provide the
Review Team with workspace, access to a telephone, electrical outlets and
privacy for conferences. The Contractor will be furnished a copy of the
Reinsurance Review Report within 60 days of the onsite review and given an
opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia, von Willebrand's Disease, and Gaucher's Disease. This program
also covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver, kidney,
and other organ transplantation. For additional detail and restrictions refer to
the AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All catastrophic claims are
subject to medical review by AHCCCSA.
The Contractor shall notify AHCCCSA, Office of Medical Management, Reinsurance
Unit, of cases identified for catastrophic non-transplant reinsurance coverage
within 30 days of (a) initial diagnosis, (b) enrollment with the Contractor, and
(c) the beginning of each contract year. Catastrophic reinsurance will be paid
for a maximum 30-day retroactive period from the date of notification to
AHCCCSA.
HEMOPHILIA: When a member is identified as being catastrophically eligible by
AHCCCSA due to the specific diagnosis of hemophilia (ICD9 codes 286.0, 286.1,
286.2), all medically necessary covered services provided during the contract
year shall be eligible for reimbursement at 85% of the Contractor's paid amount.
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII. The Contractor must promptly notify AHCCCS
Office of Medical Management Reinsurance Unit after diagnosis. All medically
necessary covered services provided during the contract year shall be eligible
for reimbursement at 85% of the Contractor's paid amount.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy. All medically necessary covered services provided during
the contract year shall be eligible for reimbursement at 85% of the Contractor's
paid amount.
TRANSPLANTS: Bone grafts and cornea transplantation services are not eligible
for catastrophic reinsurance coverage but are eligible under the regular
(non-catastrophic) reinsurance program. Refer to the AMPM, Chapter 300 for
covered services for organ and tissue transplants. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor's paid amount,
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library. When a member is referred to a transplant facility for an
AHCCCS-covered organ transplant, the Contractor shall notify AHCCCSA, Office of
Medical Management.
Encounter data will not be used to determine catastrophic reinsurance benefits
for transplants. However, this does not relieve the Contractor of the
responsibility for submitting encounters for all catastrophic reinsurance
services.
All reinsurance claims must be submitted in accordance with R9-22-703 and the
AHCCCS Reinsurance Claims Processing Manual.
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
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By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. See Section D, Paragraph 41, Medicare
Services and Cost Sharing.
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for coinsurance and deductibles is limited
to what the Contractor would have paid for the entire service pursuant to a
written contract with the provider or the AHCCCS fee-for-service rate, less any
amount paid by the third party. (The Contractor must decide whether it is more
cost-effective to provide the service within its network or pay coinsurance and
deductibles for a service outside its network. For continuity of care, the
Contractor may also choose to provide the service within its network.) If the
Contractor refers the member for services to a third-party insurer (other than
Medicare), and the insurer requires payment in advance of all copayments,
coinsurance and deductibles, the Contractor must make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
pre-natal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost-avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA's authorized representative:
Uninsured/underinsured motorist insurance Adoption recovery
First-and third-party liability insurance Worker's Compensation
Tortfeasors Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-1002 and R9-31-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related
51
costs, subsequent to the referral of any and all relevant case information to
AHCCCSA's authorized representative by the Contractor. AHCCCSA's authorized
representative is also responsible for negotiating and acting in the best
interest of all parties to obtain a reasonable settlement in joint cases and may
compromise a settlement in order to maximize overall reimbursement, net of legal
and other costs. For total plan cases involving only payments from the
Contractor, the Contractor is responsible for performing all research,
investigation, the filing of liens and payment of lien filing fees and other
related costs. The Contractor shall use the cover sheet as prescribed by AHCCCS
when filing liens.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING: The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. In addition, upon AHCCCSA's request, the Contractor shall
provide an electronic extract of the Casualty cases, including open and closed
cases. Data elements include, but are not limited to: the member's first and
last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount;
and case status. The AHCCCSA TPL Section shall provide the format and reporting
schedule for this information to the Contractor. The Contractor shall notify
AHCCCSA's authorized representative within five working days of the
identification of a third-party liability case with reinsurance. Failure to
report reinsurance cases may result in one of the remedies specified in
Paragraph 60 (Sanctions) of Section D. The Contractor shall communicate any
known change in health insurance information, including Medicare, to AHCCCS
Administration, Division of Member Services, not later than 10 days from the
date of discovery using the AHCCCS Third-Party Coverage Form found in the
Bidder's Library.
AHCCCSA will provide the Contractor, on an agreed upon schedule, with a complete
file of all third-party coverage information (other than Medicare) for the
purpose of updating the Contractor's files. The Contractor shall notify AHCCCSA
of any known changes in coverage within deadlines and in a format prescribed by
AHCCCSA.
TITLE XXI (KIDSCARE): Eligibility for KidsCare benefits requires that the
applicant/member not be enrolled with or entitled to any other health insurance
benefits. If the Contractor becomes aware of any such potential coverage, the
Contractor shall notify AHCCCSA immediately. The Contractor shall follow the
same cost avoidance and postpayment recovery practices for the KidsCare
population as it does for the Title XIX population, and shall maintain a
reporting system which allows Title XIX and KidsCare information to be reported
separately.
CONTRACT TERMINATION. Upon termination of this contract, the Contractor will
complete the existing third party liability cases or make any necessary
arrangements to transfer the cases to AHCCCSA's authorized TPL representative.
41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligible". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
52
sharing responsibilities that apply to dual eligible members based on a variety
of factors. The Contractor is responsible for adhering to the cost sharing
responsibilities presented in the AHCCCS Medicare Cost Sharing policy. Effective
10/1/97, the Contractor shall have no cost sharing obligation if the Medicare
payment exceeds what the Contractor would have paid for the same service of a
non-Medicare member.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-711 and R9-31-711. Beginning 4/1/01, all
copayment amounts for MNMI's will be the same as current Title XIX copayment
amounts. The Contractor may not collect copayments for family planning and EPSDT
services.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or federal government.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
If this contract is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available for a period of five
years from the date of any such termination. Records which relate to grievances,
disputes, litigation or the settlement of claims arising out of the performance
of this contract, or costs and expenses of this contract to which exception has
been taken by AHCCCSA, shall be retained by the Contractor for a period of five
years after the date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request. The Contractor is responsible for ensuring that a medical
record is established when information is received about a member. If the PCP
has not yet seen the member, such information may be kept temporarily in an
appropriately labeled file, in lieu of actually establishing a medical record,
but must be associated with the member's medical record as soon as one is
established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
53
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (A.R.S. ss. 36-664I)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA prior approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSAs as a result of an accumulated deficit, even if unaudited.
47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
54
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCSA shall be responsible for
any incorrect or delayed payment to the Contractor's AHCCCS services providers
(subcontractors) resulting from such error, omission, deletion, or erroneous
input data caused by the Contractor in the submission of AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
ELECTRONIC DATA INTERCHANGE (EDI): In addition to the requirements outlined in
Section D, Paragraph 34, Claims Payment System, the Contractor will be required
to comply with all administrative simplification provisions resulting from the
Health Insurance Portability and Accountability Act (HIPAA). The administrative
simplification section standardizes electronic transaction formats and code
sets; establishes national identifiers for providers, employers, health plans,
and individuals; and sets standards for security and privacy. Each of these
provisions will be published as one or more Final Rules in the Federal Register.
Implementation of these provisions will be required two years after the
effective date of each provision's final rule as published by the Department of
Health and Human Services.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance measures. The
Contractor shall submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability, including services provided
during prior period coverage. This requirement is a condition of the HCFA grant
award.
55
Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA supplied formats. Formatting and specific
requirements for encounter data are described in the AHCCCS Encounter Reporting
User Manual and the AHCCCS Technical Interface Guidelines, copies of which may
be found in the Bidder's Library. The Encounter Submission Requirements are
included herein as Attachment I.
An Encounter Submission Tracking Report must be maintained and made available to
AHCCCSA upon request. The Tracking Report's purpose is to link each claim to an
adjudicated or pended encounter returned to the Contractor. Further information
regarding the Encounter Submission Tracking Report may be found in The Encounter
User's Manual.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data, which the Contractor
shall use to update its member records. The daily roster which is run prior to
the monthly roster is referred to as the "last daily" and will contain all rate
code changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next month. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/97 through 9/30/98. In addition,
AHCCCSA reserves the sole option to extend the term of the contract, not to
exceed a total contracting period of five years. The terms and conditions of any
such contract extension shall remain the same as the original contract, as
amended. Any contract extension, however, shall not affect the maximum
contracting period of five years. All contract extensions shall be through
contract amendment. If, in conjunction with a contract extension, AHCCCSA elects
to increase the capitation rate for any risk category, such increase will not
exceed in aggregate the inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
AHCCCSA may require a contractor to renew all GSAs, or may terminate remaining
GSAs if the Contractor does not agree to renew all GSAs.
When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses
56
to sign the extension amendment. If the Contractor provides such notification,
AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 180 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor conform to the provisions of this contract. Subject to such
conditions, any function required to be provided by the Contractor pursuant to
this contract may be subcontracted to a qualified person or organization. All
such subcontracts must be in writing. See policy on claims processing by
subcontracted providers in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
The Contractor shall maintain a fully executed original of all subcontracts,
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is violable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of federal and State laws,
regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the contract
year refuses to enter into a written agreement with the Contractor, the
Contractor shall submit documentation of such refusal to AHCCCS Office of
Managed Care within seven days of its final attempt to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
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These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor.
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be covered
by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and for
which compensation will be paid.
e. The term of the subcontract including beginning and ending dates, methods of
extension, termination and re-negotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and other
third-party liability coverage and to seek such Medicare or third party
liability payment before submitting claims to the Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality assurance
programs and comply with the utilization control and review procedures
specified in 42 CFR Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in ownership of
a subcontractor that is related to or affiliated with the Contractor shall
require a contract amendment and prior approval of AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population (may
also refer to the Provider Manual).
l. A provision that the subcontractor shall be fully responsible for all tax
obligations, Worker's Compensation Insurance, and all other applicable
insurance coverage obligations which arise under this subcontract, for
itself and its employees, and that AHCCCSA shall have no responsibility or
liability for any such taxes or insurance coverage.
m. A provision that the subcontractor must obtain any necessary authorization
from the Contractor or AHCCCSA for services provided to eligible and/or
enrolled members.
n. A provision that the subcontractor must comply with encounter reporting and
claims submission requirements as described in the subcontract.
52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over and supersede existing and future subcontracts for services
that are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement for
transplant surgery exceed that payable under the relevant AHCCCSA specialty
contract.
During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
AHCCCSA shall provide at least 60 days advance written notice to the Contractor
prior to the implementation of any specialty contract.
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53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees charged and/or corporate
allocations made. If the fees or allocations actually paid out are determined to
be unjustified or excessive, amounts may be subject to repayment to the
Contractor, the Contractor may be placed on monthly financial reporting, and/or
financial sanctions may be imposed.
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end. If services billed by a consultant or actuary
are less than $50,000, AHCCCSA will waive the requirement for an audit of that
consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award.
Minimum capitalization requirements by GSA are as follows:
Geographic Service Area Capitalization Requirement
GSA #2 Yuma $1,400,000
GSA #4 Mohave, La Paz 1,150,000
GSA #6 Yavapai, Coconino 1,250,000
GSA #8 Pinal, Gila 1,450,000
GSA #10 Pima 1,250,000
GSA #12 Maricopa 2,500,000
GSA #14 Graham, Greenlee 350,000
GSA #16 Apache, Navajo 650,000
GSA #18 Cochise, Santa Cruz 1,450,000
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSAs, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSAs awarded. This requirement is in addition to the
Performance Bond requirements defined in Paragraphs 56 and 57 below and must be
met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
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CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above). Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surety company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the Contractor's obligations to
providers, non-contracting providers, and non-providers; and (2) performance by
the Contractor of its obligations under this contract. The Performance Bond
shall be in a form acceptable to AHCCCSA as described in the AHCCCS Performance
Bond policy available in the Office of Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers and
nonproviders by reason of a breach of the Contractor's obligations under this
contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of
the Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative
expenses incurred by reason of a breach of the Contractor's obligations under
this contract, including, but not limited to, expenses incurred after
termination of this contract for reasons other than the convenience of the State
by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above. The Contractor may not change
the amount, duration or scope of the performance bond without prior written
approval from AHCCCSA, Office of Managed Care.
The Contractor shall not leverage the bond for another loan or create other
creditors using the bond as security.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement must be satisfied by the Contractor not
later than 15 days after notification by AHCCCSA of the amount required.
Thereafter, AHCCCSA shall evaluate the enrollment statistics of the Contractor
on a monthly basis. If there is an increase in capitation payment that
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exceeds 10% of the performance bond amount, AHCCCSA may require an increase in
the amount of the Performance Bond. The Contractor shall have 15 days following
notification by AHCCCSA to increase the amount of the Performance Bond. The
Performance Bond amount that must be maintained after the contract term shall be
sufficient to cover all outstanding liabilities and will be determined by
AHCCCSA. The Contractor may not change the amount of the performance bond
without prior written approval from AHCCCSA, Office of Managed Care. Due to
increased enrollment as a result of Proposition 204, required performance bond
amounts will be reviewed for 10/1/01.
58. FINANCIAL VIABILITY CRITERIA/PERFORMANCE MEASURES
AHCCCSA has established the following financial viability criteria/performance
goals:
CURRENT RATIO Current assets divided by current
liabilities. "Current assets" includes any
long-term investments that can be
converted to cash within 24 hours without
significant penalty (i.e., greater than
20%).
Standard: At least 1.00
EQUITY PER MEMBER Equity, less on-balance sheet performance
bond, divided by the number of non-SOBRA
Family Planning Extension Services members
enrolled at the end of the period.
Standard: At least $150
(Failure to meet this standard may result
in an enrollment cap being imposed in any
or all contracted GSAs.)
MEDICAL EXPENSE RATIO Total medical expenses (net of
reinsurance, TPL, HIV/AIDS Supplement)
divided by total capitation + Delivery
Supplement.
Standard: At least 85%
ADMINISTRATIVE COST PERCENTAGE Total administrative expenses (excluding
income taxes), divided by total capitation
+ Delivery Supplement + TPL + reinsurance
+ HIV/AIDS Supplement.
Standard: No more than 10%
RECEIVED BUT UNPAID CLAIMS Received but unpaid claims divided by the
(DAYS OUTSTANDING) average daily medical expenses for the
period, net of sub-capitation expense
Standard: No more than 30 days
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor must submit a detailed merger, reorganization and/or
transition plan to AHCCCSA Contracting Office for AHCCCSA review. The purpose of
the plan review is to ensure uninterrupted services to members, evaluate the new
entity's ability to support the provider network, ensure that services to
members are not diminished and that major components of the organization and
AHCCCS programs are not adversely affected by such merger, reorganization or
change in ownership.
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60. SANCTIONS
AHCCCSA may impose sanctions, suspend, deny, refuse to renew, or terminate this
contract or any related subcontracts in accordance with AHCCCS Rules R9-22-405
and 406 and R9-31-405 and 406 and the terms of this contract and applicable
federal or State law and regulations. Written notice will be provided to the
Contractor specifying the sanction to be imposed, the grounds for such sanction
and either the length of suspension or the amount of capitation prepayment to be
withheld. The Contractor may appeal the decision to impose a sanction in
accordance with AHCCCS Rule R9-22-804.
In addition to the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS financial viability standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
e. Failure to meet AHCCCS encounter standards
CURE NOTICE PROCESS - Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not have the right to choose a contractor or members who have the
right to choose but do not exercise this right, are assigned to contractors
through an auto-assignment algorithm. The algorithm is a mathematical formula
used to distribute members to the various contractors in a manner that is
predictable and consistent with AHCCCSA goals. The algorithm favors those
contractors with lower capitation rates. For further details on the AHCCCS
Auto-Assignment Algorithm, refer to Attachment G. AHCCCSA may change the
algorithm at any time during the term of the contract and frequently does so in
response to contractor-specific issues of non-compliance (e.g. imposition of an
enrollment cap). The Contractor should consider this in preparing its response
to this RFP. AHCCCSA is not obligated to adjust for any financial impacts this
may have on the Contractor.
62. GRIEVANCE PROCESS AND STANDARDS
The Contractor shall have in place a written grievance policy for members and
providers, which defines their rights regarding any adverse action by the
Contractor. This written policy shall be in accordance with applicable federal
and State law and AHCCCS Rules and policy including, but not limited to, AHCCCS
Rules R9-22-512; R9-22-518(A); R9-22, Article 8 and R9-31, Article 8 , the
Alternate Resolution Process and the Members Rights and Responsibilities. The
grievance process may not be delegated or subcontracted outside of the health
plan. Refer to Attachment H for a complete description of grievance process
requirements.
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63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Legal Assistance, using the Quarterly Grievance Report Format on file in the
Bidder's Library. The Quarterly Grievance Report must be received by the
AHCCCSA, Office of Legal Assistance, no later than 45 days from the end of the
quarter.
64. KIDSCARE
On November 1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance
Program, referred to as "KidsCare". KidsCare provides health care coverage
statewide to eligible children under age 19 and is provided through the existing
AHCCCS health plans, state employee HMOs that elect to participate at the
beginning of a contract cycle, and tribal facilities or Indian Health Service
for Native Americans who elect to receive services through them. Services will
also be directly provided by participating community health clinics and
hospitals, which predominantly serve low income children.
The KidsCare service package is established by the legislature and approved by
HCFA through the State Plan. Services, limitations and exclusions are described
in Section D, Paragraph 1, Scope of Services. Capitation rates payable to the
Contractor for KidsCare members will be set by AHCCCSA in conjunction with an
independent actuary.
Effective October 1, 1999, KidsCare members in families with gross household
income over 150% and up to 200% of the federal poverty limit shall pay a premium
to AHCCCSA. The premium amount shall be based on the number of members in the
household and the gross family income in accordance with 9 A.A.C., Article 14.
TITLE XXI PARENT/GUARDIAN HEALTH INSURANCE COVERAGE: A.R.S. ss.36.2984 mandates
that the Contractor offer health insurance coverage to the parent(s) or legal
guardian(s) of a child who is eligible for Title XXI. The Contractor shall
establish rates for this coverage, which must be approved by AHCCCSA, Office of
Managed Care, prior to implementation. Title XXI funds or any other federal or
state funds shall not be used to subsidize family coverage. The full cost of the
premium shall be paid by the parent or legal guardian who elects this coverage.
The Contractor may include provisions for pre-existing conditions and any other
medical underwriting considerations that are necessary to protect it from
adverse risk. For further information, refer to the Title XXI Parent/Guardian
Health Insurance Coverage Guidelines on file in the Bidder's Library.
65. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that could have an impact on services provided by the
Contractor on or after October 1, 2000. The following is a brief description of
the issues that AHCCCS is aware of at the time of the issuance of this renewal
amendment:
ELIGIBILITY BASED ON 100% OF THE FEDERAL POVERTY LEVEL (FPL): Through a
successful initiative effort, eligibility for AHCCCS has been expanded to allow
persons with income up to 100% of the FPL to become eligible for the Medicaid
program. Some legislative action will be required to fully implement this new
eligibility guideline. In January 2001, HCFA approved the waiver to federally
fund members eligible due to Proposition 204.
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66. SEPARATE INCORPORATION
As specified in A.R.S. ss. 36-2906.01, within 60 days of contract award, a
non-governmental Contractor shall have established a separate corporation for
the purposes of this contract, whose sole activity is the performance of
contract function with AHCCCS.
67. CULTURAL COMPETENCY
The Contractor shall have a Cultural Competency Plan that meets the requirements
of the AHCCCS Cultural Competency Policy. The Contractor must identify a staff
member responsible for the cultural competency plan and inform the office of
Managed Care of that person's identity.
68. MEDICAID IN THE PUBLIC SCHOOLS
Pursuant to an Intergovernmental Agreement with the Arizona Department of
Education, AHCCCS will begin paying participating school districts for
specifically identified Medicaid services provided to Medicaid eligible children
with special educational needs. The Medicaid service shall be identified in a
child's Individualized Education Plan (IEP) as a medically necessary service. In
the first phase, AHCCCS shall directly reimburse school districts for speech,
physical, occupational therapies, and behavioral health services with dates of
service beginning July 1, 2000. The Administration's intent is to add other
Medicaid reimbursable services in the future.
To ensure that there is coordination of care, the Administration shall require
that a participating school district notify the primary care provider that
Medicaid services are being provided to the child in a school-based setting. If
a child is enrolled with the Contractor and a request is made for a school-based
Medicaid covered service, the Contractor shall evaluate the request on the same
basis as any request for a covered service. The determination to provide the
service shall include consideration of whether the school-based services are
sufficient to meet the child's needs.
69. PROPOSITION 204 AND HCFA WAIVER
The passage of Proposition 204 in November of 2000, and the subsequent HCFA
waiver that raises the Medicaid eligibility limit to 100% Federal Poverty Level
for all populations has multiple effects on the program. The most significant
changes to AHCCCS acute care contractors are described below.
MNMI POPULATION
- - Beginning 4/1/01, the MNMI population will no longer be funded solely with
state dollars. The program will be Federally funded under Medicaid through
the Title XIX Waiver. However, until 10/1/01, the enrollment and eligibility
determination processes will not change.
- - Length of eligibility.
- For members enrolled as of 4/01/01.
- Non-spend down MNMI's will have twelve months of eligibility.
- Spend-down MNMI's will continue to have six months of eligibility.
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- For members enrolled on or after 4/01/01.
- Non-spend down MNMI's will have open ended enrollment.
- Spend-down MNMI's will continue to have up to six months of
enrollment.
- - Beginning 4/1/01, the service package will match the current Title XIX
service package, including
- Full behavioral health coverage
- Full coverage during the two day prior period coverage time period.
- - Beginning 10/1/01, Title XIX Waiver members will be divided into two main
groups:
- MED (Medical Expense Deduction). These are people that have income above
100% FPL that spend down to or below 40% of 2000 FPL. Generally, these
are the current medically needy (MN) population.
- Adults and couples who are not categorically linked to a Title XIX
program, and have income at or below 100% FPL. This group includes the
current medically indigent (MI) population.
- - Beginning 10/1/01, the Title XIX Waiver group, including MED's, will get a
six-month enrollment guarantee.
- - Beginning 10/1/01, the MED population will no longer have a two-day
retroactive enrollment period (PPC). Their eligibility effective date will
be the date on which they spent down. Prior period coverage will extend from
the date that AHCCCSA is notified that the member spent down, to the date of
spend down. Often notification to AHCCCSA and spend down will occur on the
same day.
- - Beginning 10/1/01, Non-MED Title XIX Waiver members' retroactive enrollment
rules will follow the current Title XIX retroactive enrollment rules.
NEW POPULATIONS
- - See paragraph 6, Enrollment and Disenrollment, for population timelines.
REIMBURSEMENT
- - Reinsurance deductibles will not change between 4/1/01 and 10/1/01. They
will be reviewed during normal contract renewal during the summer of 2001.
- - AHCCCSA reserves the right to make prospective capitation rate adjustments
if increased enrollment affects the actuarial soundness of the rates.
[END OF SECTION D]
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SECTION E: CONTRACT CLAUSES
1) APPLICABLE LAW
ARIZONA LAW - The law of Arizona applies to this contract
including, where applicable, the Uniform Commercial Code, as adopted in the
State of Arizona.
IMPLIED CONTRACT TERMS - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it. 2)
2) AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3) ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable federal regulations; the terms of the HCFA 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4) CONTRACT INTERPRETATION AND AMENDMENT
NO PAROL EVIDENCE - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
NO WAIVER - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.
WRITTEN CONTRACT AMENDMENTS - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5) SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract, which may remain in effect without the invalid
provision, or application.
6) RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
7) ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8) GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to
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injury, disease, or death of persons or damage to or loss of property resulting
from or in connection with the negligent performance of this contract by the
Contractor, its agents, employees, and subcontractors or anyone for whom the
Contractor may be responsible. The obligations, indemnities and liabilities
assumed by the Contractor under this paragraph shall not extend to any liability
caused by the negligence of the State or its employees. The Contractor's
liability shall not be limited by any provisions or limits of insurance set
forth in this contract. The State shall reasonably notify the Contractor of any
claim for which it may be liable under this paragraph.
9) INDEMNIFICATION -- PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The materials and services supplied under this contract shall comply with all
applicable federal, state and local laws, and the Contractor shall maintain all
applicable licenses and permits.
11) ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12) PROPERTY OF THE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
13) THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14) RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified mail, return
receipt required. Failure by the Contractor to provide written assurance within
the number of days specified in the demand may, at the State's option, be the
basis for terminating the contract.
15) TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
16) GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable treatment
concerning the contract, including the making of any determination or decision
about contract performance. AHCCCSA, in addition to any other rights or
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remedies, shall be entitled to recover exemplary damages in the amount of three
times the value of the gratuity offered by the Contractor.
17) SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from federal procurement activity.
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18) TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19) TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
20) TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
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21) RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
22) NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23) NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 99-4, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable federal and state laws, rules and regulations, including
the Americans with Disabilities Act. The Contractor shall take positive action
to ensure that applicants for employment, employees, and persons to whom it
provides service are not discriminated against due to race, creed, color,
religion, sex, national origin or disability.
24) EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
25) INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000 for
each occurrence for bodily injury and property damage to others as a result
of accidents on the premises of or as the result of operations of the
Contractor.
b. Commercial Automobile Liability: Provides coverage of at least $1,000,000
for each occurrence for bodily injury and property damage to others
resulting from accidents caused by vehicles operated by the Contractor.
c. Workers Compensation: Provides coverage to employees of the Contractor for
injuries sustained in the course of their employment. Coverage must meet the
obligations imposed by federal and state statutes and must also include
Employer's Liability minimum coverage of $100,000. Evidence of qualified
self-insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance of a
professional act of service.
The above coverages may be evidenced by either one of the following:
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the form.
The Contractor's agent or broker must fill in the pertinent policy
information and ensure the required special conditions are included in the
Contractor's policy.
b. The Accord form: This standard insurance industry certificate of insurance
does not contain the pre-printed special conditions required by this
contract. These conditions must be entered on the certificate by the agent
or broker and read as follows:
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The State of Arizona and Arizona Health Care Cost Containment System are
hereby added as additional insureds. Coverages afforded under this
Certificate shall be primary and any insurance carried by the State or any
of its agencies, boards, departments or commissions shall be in excess of
that provided by the insured Contractor. No policy shall expire, be
canceled or materially changed without 30 days written notice to the State.
This Certificate is not valid unless countersigned by an authorized
representative of the insurance company.
26) DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with AHCCCS Rule R9-28-804(C).
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor that is related to the performance
of this contract, in accordance with A.R.S. ss.41-2547.
28) INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
29) COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30) CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section E, Paragraph 26, Disputes,
and be administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31) TYPE OF CONTRACT
Firm Fixed-Price
32) AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Michael Veit at (602) 417-4762.
33) WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's
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expense, require prompt correction of any services failing to meet the
Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
34) NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35) CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose any situation that may present a conflict of interest. If
the Contractor is now performing or elects to perform during the term of this
contract any services for any AHCCCS health plan, provider or Contractor or an
entity owning or controlling same, the Contractor shall disclose this
relationship prior to accepting any assignment involving such party.
36) DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCSA.
37) COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39) OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by Contractor pursuant to this contract, shall be deemed to
be owned by AHCCCSA. The federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, or otherwise use
and to authorize others to use for federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software
which is provided at established catalog or market prices and sold or leased to
the general public shall not be subject to the ownership or licensing provisions
of this section.
Data, information and reports collected or prepared by Contractor in the course
of performing its duties and obligations under this contract shall be deemed to
be owned by AHCCCSA. The ownership provision is in consideration of Contractor's
use of public funds in collecting or preparing such data, information and
reports. These items shall not be used by Contractor for any independent project
of Contractor or publicized by Contractor without the prior written permission
of AHCCCSA. Subject to applicable state and federal laws and regulations,
AHCCCSA shall have full and complete rights to reproduce, duplicate, disclose
and otherwise use all such information. At the termination of the contract,
Contractor shall make available all such data to AHCCCSA within 30 days
following termination of the contract or such longer period as approved by
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AHCCCSA, Office of the Director. For purposes of this subsection, the term
"data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by Contractor in the course of performance of this
contract, the federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or federal
government purposes. Contractor shall additionally be subject to the applicable
provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
40) AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, Contractor's performance is in material breach
of the contract or Contractor is insolvent, AHCCCSA may directly operate
Contractor to assure delivery of care to members enrolled with Contractor until
cure by Contractor of its breach, by demonstrated financial solvency or until
the successful transition of those members to other contractors.
If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through
designees appointed by the Director shall be vested with full and exclusive
power of management and control of the Contractor as necessary to ensure the
uninterrupted care to persons and accomplish the orderly transition of persons
to a new or existing Contractor, or until the Contractor corrects the Contract
Performance failure to the satisfaction of AHCCCS. AHCCCS shall have the power
to employ any necessary assistants, to execute any instrument in the name of the
Contractor, to commence, defend and conduct in its name any action or proceeding
in which the Contractor may be a party.
All reasonable expenses of AHCCCS related to the direct operation of the
Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets
of the Contractor, shall be paid by the Contractor or withheld from payment due
from AHCCCS to the Contractor.
41) AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and -521 and AHCCCS policies and procedures relating to the
audit of Contractor's records and the inspection of Contractor's facilities.
Contractor shall fully cooperate with AHCCCSA staff and allow them reasonable
access to Contractor's staff, subcontractors, members, and records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
AHCCCSA and the federal government may evaluate through on-site inspection or
other means, the quality, appropriateness and timeliness of services performed
under this contract.
42) FRAUD AND ABUSE
It shall be the responsibility of the Contractor to report all cases of
suspected fraud and abuse by subcontractors, members or employees. The
Contractor shall provide written notification of all such incidents to AHCCCSA.
The Contractor shall comply with the AHCCCS Health Plans and Program Contractors
Policy for Prevention, Detection and Reporting of Fraud and Abuse which is
available in the Bidder's Library and incorporated herein by reference.
As stated in A.R.S. ss. 13-2310, incorporated herein by reference, any person
who knowingly obtains any benefit by means of false or fraudulent pretenses,
representations, promises or material omissions is guilty of a class 2 felony.
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Contractors are required to research potential overpayments identified by a
fraud and abuse investigation or audit conducted by AHCCCSA. After conducting a
cost benefit analysis to determine if such action is warranted, the Contractor
should attempt to recover any overpayments identified due to erroneous, false or
fraudulent billings.
43) LOBBYING
No funds paid to the Contractor by AHCCCSA, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any federal or
State contract, the making of any federal or State grant, the making of any
federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds other than those paid to the Contractor by AHCCCSA have
been used or will be used to influence the persons and entities indicated above
and will assist AHCCCSA in making such disclosures to HCFA.
44) CHOICE OF FORUM
The parties agree that jurisdiction over any action arising out of or relating
to this contract shall be brought or filed in a court of competent jurisdiction
located in the State of Arizona.
[END OF SECTION E]
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ATTACHMENT A CONTRACT/RFP NO. YH8-0001
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1) EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract.
2) RECORDS AND REPORTS
The Contractor shall maintain all forms, records, reports and working papers
used in the preparation of reports, files, correspondence, financial statements,
records relating to quality of care, medical records, prescription files,
statistical information and other records specified by AHCCCSA for purposes of
audit and program management. The Contractor shall comply with all
specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect
each service provided and all net costs, direct and indirect, of labor,
materials, equipment, supplies and services, and other costs and expenses of
whatever nature for which payment is made to the Contractor. Such material shall
be subject to inspection and copying by the state, AHCCCSA and the U.S.
Department of Health and Human Services during normal business hours at the
place of business of the person or organization maintaining the records.
The Contractor agrees to make available at the office of the Contractor, at all
times reasonable times, any of its records for inspection, audit or
reproduction, by any authorized representative of the state or federal
governments.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this subcontract except as
provided in paragraphs a. and b. below:
a. If this subcontract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available
for a period of five years from the date of any such termination.
b. Records which relate to disputes, litigation or the settlement of
claims arising out of the performance of this subcontract, or costs and
expenses of this subcontract to which exception has been taken by the
state, shall be retained by the Contractor until such disputes,
litigation, claims or exceptions have been disposed of.
The Contractor shall provide all reports requested by AHCCCSA, and all
information from records relating to the performance of the Contractor which
AHCCCSA may reasonably require. The Contractor reporting requirements may
include, but are not limited to, timely and detailed utilization statistics,
information and reports.
3) LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Contractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered
services. This provision shall not apply to patient contributions to the cost of
services delivered by nursing homes.
4) ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Contractor under this subcontract may be assigned without the
prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
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5) APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The prime contractor
shall notify AHCCCSA in the event of any proposed amendment or termination
during the term hereof. Any such amendment or termination is subject to the
prior approval of AHCCCSA. Approval of the subcontract may be rescinded by the
Director of AHCCCSA for violation of federal or state laws or rules.
6) WARRANTY OF SERVICES
The Contractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
7) SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Contractor and AHCCCSA for
the provision of covered services.
8) AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the prime contractor may undertake or award other contracts for
additional or related work to the work performed by the Contractor and the
Contractor shall fully cooperate with such other contractors, subcontractors or
state employees. The Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor, subcontractor or
state employee.
9) INDEMNIFICATION BY CONTRACTOR
The Contractor agrees to hold harmless the state, all state officers and
employees, AHCCCSA and other appropriate state agencies, and all officers and
employees of AHCCCSA and all AHCCCS eligible persons in the event of nonpayment
to the Contractor. The Contractor shall further indemnify and hold harmless the
state, AHCCCSA, other appropriate state agencies, AHCCCS contractors, and their
agents, officers and employees against all injuries, deaths, losses, damages,
claims, suits, liabilities, judgments, costs and expenses which may, in any
manner, accrue against the State, AHCCCSA or its agents, officers or employees,
or AHCCCS contractors, through the intentional conduct, negligence or omission
of the Contractor, its agent, officers or employees.
10) MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Contractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
11) COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Contractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract.
12) SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
13) VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
14) CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, A.R.S. ss.36-107, 36-2903, 41-1959 and 46-135, and AHCCCS and/or
ALTCS Rules.
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15) GRIEVANCE AND REQUEST FOR HEARING PROCEDURES
Any grievance and request for hearings filed by the Contractor shall be
adjudicated in accordance with AHCCCS Rules.
16) TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Contractor, terminate this subcontract if
it is found, after notice and hearing by the State, that gratuities in the form
of entertainment, gifts, or otherwise were offered or given by the Contractor,
or any agent or representative of the Contractor, to any officer or employee of
the State with a view towards securing a contract or securing favorable
treatment with respect to the awarding, amending or the making of any
determinations with respect to the performance of the Contractor; provided, that
the existence of the facts upon which the state makes such findings shall be in
issue and may be reviewed in any competent court. If the subcontract is
terminated under this section, unless the prime contractor is a governmental
agency, instrumentality or subdivision thereof, AHCCCSA shall be entitled to a
penalty, in addition to any other damages to which it may be entitled by law,
and to exemplary damages in the amount of three times the cost incurred by the
Contractor in providing any such gratuities to any such officer or employee.
17) PRIOR AUTHORIZATION and UTILIZATION REVIEW
The prime contractor and Contractor shall develop, maintain and use a system for
Prior Authorization and Utilization Review which is consistent with AHCCCS Rules
and the prime contractor's policies.
18) NON-DISCRIMINATION REQUIREMENTS
If applicable, the Contractor shall comply with:
a. The Equal Pay Act of 1963, as amended, which prohibits sex discrimination in
the payment of wages to men and women performing substantially equal work
under similar working conditions in the same establishment.
b. Title VI of the Civil Rights Act of 1964, as amended, which prohibits the
denial of benefits of, or participation in, contract services on the basis
of race, color, or national origin.
c. Title VII of the Civil Rights Act of 1964, as amended which prohibits
private employers, state and local governments, and educational institutions
from discriminating against their employees and job applicants on the basis
of race, religion, color, sex, or national origin.
d. Title I of the Americans with Disabilities Act of 1990, as amended, which
prohibits private employers and state and local governments from
discriminating against job applicants and employees on the basis of
disability.
e. The Civil Rights Act of 1991, which reverses in whole or in part, several
recent Supreme Court decisions interpreting Title VII.
f. The Age Discrimination in Employment Act (A.R.S. Title 41-1461, et seq.);
which prohibits discrimination based on age.
g. State Executive Order 99-4 and Federal Order 11246 which mandates that all
persons, regardless of race, color, religion, sex, age, national origin or
political affiliation, shall have equal access to employment opportunities.
h. Section 503 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination in the employment or advancement of the employment of
qualified persons because of physical or mental handicap.
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i. Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination on the basis of handicap in delivering contract services.
19) COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Contractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Contractor's records and the inspection of the
Contractor's facilities. If the Contractor is an inpatient facility, the
Contractor shall file uniform reports and Title XVIII and Title XIX cost reports
with AHCCCSA.
20) CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Contractor certifies that all representations
set forth herein are true to the best of its knowledge.
21) CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK and LABORATORY TESTING
By signing this subcontract, the Contractor certifies that it has not engaged in
any violation of the Medicare Anti-Kickback statute (42 USC ss.ss.1320a-7b) or
the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Contractor provides
laboratory testing, it certifies that it has complied with 42 CFR ss.411.361 and
has sent to AHCCCSA simultaneous copies of the information required by that rule
to be sent to the Health Care Financing Administration.
22) CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
23) ENCOUNTER DATA REQUIREMENT
If the Contractor does not bill the prime contractor (e.g., Contractor is
capitated), the Contractor shall submit encounter data to the prime contractor
in a form acceptable to AHCCCSA.
24) CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. Prime contractor may not reimburse providers
who do not comply with the above requirements.
25) INSURANCE
[This provision applies only if the Contractor provides services directly to
AHCCCS members]
The Contractor shall maintain for the duration of this subcontract a policy or
policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance. The Contractor agrees that any
insurance protection required by this subcontract, or otherwise obtained by the
Contractor, shall not limit the responsibility of Contractor to indemnify, keep
and save harmless and defend the State and AHCCCSA, their agents, officers and
employees as provided herein. Furthermore, the Contractor shall be fully
responsible for all tax obligations, Worker's Compensation Insurance, and all
other applicable insurance coverage, for itself and its employees, and AHCCCSA
shall have no responsibility or liability for any such taxes or insurance
coverage.
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26) FRAUD AND ABUSE
If the Contractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Contractor shall report the incident to the
prime contractor, who shall proceed in accordance with the AHCCCS Health Plans
and Program Contractors Policy for Prevention, Detection and Reporting of Fraud
and Abuse. Incidents involving potential member eligibility fraud should be
reported to AHCCCSA, Office of Managed Care, Member Fraud Unit. All other
incidents of potential fraud should be reported to AHCCCSA, Office of the
Director, Office of Program Integrity. (See AHCCCS Rule R9-22-511.)
A-5
ATTACHMENT F CONTRACT/RFP NO. YH8-0001
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
REPORT WHEN DUE SOURCE/REFERENCE AHCCCS CONTACT:
------------------------------- -------------------------- ----------------------------- -----------------
Monthly Financial Report 45 days after the end of Reporting Guide Financial Manager
the month, as applicable
Quarterly Financial Report 60 days after the end of Reporting Guide Financial Manager
each quarter
Draft Annual Audit Report 90 days after the end of Reporting Guide Financial Manager
each fiscal year
Draft Management Letter 90 days after the end of Reporting Guide Financial Manager
each fiscal year
Final Annual Audit Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Final Management Letter 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Accountant's Report on 120 days after the end of Reporting Guide Financial Manager
Compliance each fiscal year
Reconciliation - Annual Audit 120 days after the end of Reporting Guide Financial Manager
and Plan Year-to-Date each fiscal year
Financial Report Information
Financial Disclosure Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Annual Analysis of 120 days after the end of Reporting Guide Financial Manager
Profitability by Major Rate each fiscal year
Code (by County)
PPC Lag Schedules 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Physician Incentive Plan (PIP) Annually by October 1st of RFP, Section D, Paragraph 18 Financial Manager
reporting each year
Quarterly FQHC Reports 60 days after the end of RFP, Section D, paragraph 26 Financial Manager
each quarter
Provider Affiliation Tape 10 business days after the PMMIS Provider-to-Health Plan Health Plan
beginning of each quarter magnetic tape submission Operations
and processing Manager
Corrected Pended Encounter Data Monthly, according to Encounter Manual Encounter
established schedule Administrator
New Day Encounter Data Monthly, according to Encounter Manual Encounter
established schedule Administrator
Medical Records for Data 90 days after the request RFP, Section C, Paragraph 1 Data Validation
Validation received from Manager
AHCCCSA
F-1
REPORT WHEN DUE SOURCE/REFERENCE AHCCCS CONTACT:
----------------------------- -------------------------- ---------------------------- -----------------
Quarterly Grievance and 45 days after the end of RFP, Section D, Paragraph 26 Administrative
Request for Hearing Report each quarter Assistant
Comprehensive EPSDT Plan Annually on December 1 RFP, Section D, Paragraph 16 AHCCCS Chief
including Dental Medical Officer
EPSDT Progress Report 15 days after the end of AMPM, Chapter 400 AHCCCS Chief
including Dental - Quarterly each quarter Medical Officer
Update
Quarterly Inpatient Hospital 15 days after the end of State Medicaid Manual and AHCCCS Chief
Showing each quarter the AMPM, Chapter 900 Medical Officer
Quality Management/ Annually on November 15th AMPM, Chapter 900 AHCCCS Chief
Utilization Management Plan Medical Officer
Evaluation and Revision
Monthly Pregnancy Termination End of the month following AMPM, Chapter 400 AHCCCS Chief
Report the pregnancy termination Medical Officer
Maternity Care Plan Annually on December 1st AMPM, Chapter 400 AHCCCS Chief
Medical Officer
Semi-annual report of number 30 days after the end of AMPM, Chapter 900 AHCCCS Chief
of pregnant women who are the 2nd and 4th quarter of Medical Officer
HIV/AIDS positive each contract year
Clinical Study Proposal Annually on November 15th AMPM, Chapter 900 AHCCCS Chief
Medical Officer
Clinical Study Results Annually within 90 days AMPM, Chapter 900 AHCCCS Chief
following the end of each Medical Officer
contract year
Provider Fraud/Abuse Report Immediately following AHCCCS Internal Office of Program
discovery Audit/Program Investigation Integrity Manager
Policy for Prevention,
Detection and Reporting of
Fraud and Abuse
Eligible Person Fraud/Abuse Immediately following AHCCCS Internal Office of Program
Report discovery Audit/Program Investigation Integrity Manager
Policy for Prevention,
Detection and Reporting of
Fraud and Abuse
Non-Transplant Catastrophic Annually, within 30 days RFP, Section D, Paragraph 39 OMM/FFS Unit
Reinsurance covered Diseases of the beginning of the Reinsurance
contract year, enrollment Manager
to the plan, and when
newly diagnosed.
F-2
ATTACHMENT H CONTRACT/RFP NO. YH8-0001
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS
The Contractor shall have in place a written grievance and request for hearing
policy for members and providers which defines their rights regarding any
adverse action by the Contractor. The Contractor shall also ensure compliance
with 9 A.C.C. R9-28-Article 12 the Members' Rights and Responsibilities Policy.
The written grievance and request for hearing policy shall be in accordance with
applicable federal and State laws and AHCCCS Rules and policy including, but not
limited to, AHCCCS Rules R9-22-512; R9-22-518 (A); R9-22-802; and R9-22-804. The
grievance and request for hearing policy shall include the following provisions:
a. The grievance and request for hearing procedure will be provided all
subcontractors at time of contract, and to non-contracting providers within
10 days of the date of receipt of the claim. For non-contracting providers,
the grievance and request for hearing procedure may be mailed with the
remittance advice provided the remittance is sent within 45 days of receipt
of claim.
b. Specific individual(s) are appointed with authority to require corrective
action to administer the grievance and request for hearing policy.
c. A log is maintained for all grievance and request for hearings containing
sufficient information to identify the grievant, date of receipt, nature of
the grievance and request for hearing and the date grievance and request for
hearing is resolved. Separate logs must be maintained for provider and
member grievance and request for hearings. The logs must contain sufficient
information to identify the grievant, date of receipt, nature of the
grievance and request for hearing and the date grievance and request for
hearing is resolved.
d. Within five working days of receipt, the grievant is informed by letter that
the grievance and request for hearing has been received. The letter must
also be in a second language when 200 members or 5% of the Contractor's
population, whichever is greater speak the second language.
e. Each grievance and request for hearing is thoroughly investigated using the
applicable statutory, regulatory and contractual provisions as well as the
Contractor's policies and procedures, ensuring that facts are gathered from
all parties.
f. All documentation received and mailed by Contractor during the grievance and
request for hearing process is dated upon date of receipt.
g. All grievance and request for hearings are filed in a secure, designated
area and are retained for five years following the final decision, judicial
appeal or close of a grievance and request for hearing.
h. A copy of the Contractor's final decision will be either hand-delivered or
delivered by certified mail to all parties. The final decision shall be
mailed to all other individuals by regular mail. The date of the final
decision shall be the date of the notice. The final decision must include,
and describe in detail, the following:
1. the nature of the grievance and request for hearing
2. the issues involved
3. the reasons supporting the Contractor's decision including references to
applicable statute, rule and procedure
4. the grievant's right to appeal the Contractor's decision to AHCCCSA by
filing the appeal to the Contractor no later than 15 days after the date
of the Contractor's final decision. This must also be written in a
second language, if applicable.
e. If the member requests a hearing, all supporting documentation must be
received by the AHCCCSA, Office of Legal Assistance no later than five
working days from the date the Contractor receives the appeal or from the
date of the oral or written request from AHCCCSA, Office of Legal
Assistance. The appeal file must contain a cover letter that includes:
1. grievant's name
2. grievant's AHCCCS ID number
3. grievant's address
4. phone number (if applicable)
5. date of receipt of grievance and request for hearing and appeal
H-1
6. summary of the Contractor's actions undertaken to resolve the grievance
and request for hearing and basis thereof
e. The following material shall be included in the appeal file:
1. written request of the grievant asking for the appeal
2. copies of the entire file which include the investigations and/or
medical records; and the Contractor's grievance and request for hearing
decision
3. other information used by the Contractor to resolve the grievance and
request for hearing and that would be necessary to AHCCCSA to resolve
the grievance and request for hearing.
e. The Contractor may attempt to use alternative resolution procedures to
resolve disputes presented to the Contractor verbally or in writing. If the
Contractor elects to use an alternative resolution process, it must be
administered and completed within 10 days from receipt of the dispute. If
the matter is not resolved to the grievant's satisfaction within the 10-day
period, the dispute must then be adjudicated using the grievance and request
for hearing standards contained above. However, the Contractor must render
the written grievance and request for hearing decision within a maximum of
30 days from the date of the initial filing of the grievance and request for
hearing or dispute unless a longer period was agreed to by the parties
involved.
f. For all disputes where an alternative resolution is proposed, the Contractor
must maintain a separate log, complying with paragraphs c. and g. above.
H-2
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed sanctions for noncompliance with encounter
submission requirements. AHCCCSA may also perform special reviews of encounter
data, such as comparing encounter reports to the Contractor's claims files. Any
findings of incomplete or inaccurate encounter data may result in the imposition
of sanctions or requirement of a corrective action plan.
PENDED ENCOUNTER CORRECTIONS
The Contractor must resolve all pended encounters within 120 days of the
original processing date. Sanctions will be imposed according to the following
schedule for each encounter pended for more than 120 days unless the pend is due
to AHCCCSA error:
0 - 120 days 121 - 180 days 181 - 240 days 241 - 360 days 361 + days
No sanction $5 per month $10 per month $15 per month $20 per month
"AHCCCSA error" is defined as a pended encounter which (1) AHCCCSA acknowledges
to be the result of its own error, and (2) requires a change to the system
programming, an update to the database reference table, or further research by
AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA in writing that the resolution of a pended
encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will respond in
writing within 30 days of receipt of such notification. The AHCCCSA response
will report the status of each pending encounter problem or issue in question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor in writing of the
total number of sanctionable encounters pended more than 120 days.
Pended encounters shall not be deleted by the Contractor as a means of avoiding
sanctions for failure to correct encounters within 120 days. The Contractor
shall document deleted encounters and shall maintain a record of the deleted
CRNs with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCSA for review.
ENCOUNTER VALIDATION STUDIES
Per HCFA requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's submitted encounter data. Any and
all covered services may be validated as part of these studies. Encounter
validation studies will be conducted at least yearly.
The following reflects AHCCCSA's encounter validation study process and sanction
policy as of 10/1/97. AHCCCSA may revise study methodology, timelines, and
sanction amounts based on agency review or as a
I-1
result of consultations with HCFA. The Contractor will be notified in writing of
any significant change in study methodology.
AHCCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to AHCCCSA. In the case of medical records
requests, the Contractor's failure to provide AHCCCSA with the records requested
within 90 days may result in a sanction of $1,000 per missing medical record. If
AHCCCSA does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor
may be sanctioned up to 5% of its annual capitation payment.
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date that the
encounter is received at AHCCCS. All encounters must be received by AHCCCSA no
later than 240 days after the end of the month in which the service was
rendered, or the effective date of enrollment with the Contractor, whichever is
later. For all encounters for which timeliness is evaluated, a sanction per
encounter error extrapolated to the population of encounters may be assessed if
the encounter record is received by AHCCCSA more than 240 days after the date
determined above. It is anticipated that the sanction amount will be $1.00 per
error extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has changed, or if
HCFA changes sanction requirements. The Contractor will be notified of the
sanction amount in effect for the studies at the time the studies begin.
Correctness: A correct encounter contains a complete and accurate description of
AHCCCS covered services provided to a member. A sanction per encounter error
extrapolated to the population of encounters may be assessed if the encounter is
incomplete or incorrectly coded. It is anticipated that the sanction amount will
be $1.00 per error extrapolated to the population of encounters; however,
sanction amounts may be adjusted if AHCCCSA determines that encounter quality
has changed, or if HCFA changes sanction requirements. The Contractor will be
notified of the sanction amount in effect for the studies at the time the
studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA's pending encounter file or historical
files in lieu of correction of such record. For Study "A" and for Study "B", a
sanction per encounter error extrapolated to the population of encounters may be
assessed for an omission. It is anticipated that the sanction amount will be
$5.00 per error extrapolated to the population of encounters for Study "A" and
$10.00 per error extrapolated to the population of encounters for Study "B";
however, sanction amounts may be adjusted if AHCCCSA determines that encounter
quality has changed, or if HCFA changes sanction requirements. The Contractor
will be notified of the sanction amount in effect for the studies at the time
the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors
I-2
found by the number of encounters reviewed. A 95% confidence interval will be
used to account for limitations caused by sampling. The confidence interval
shows the range within which the true error rate is estimated to be. If error
rates are based on a sample, the error rate used for sanction purposes will be
the lower limit of the confidence interval.
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples, which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to HCFA, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance and request for hearing pursuant to Article
8 of AHCCCS Rules. Sanction amounts will be deducted from the Contractor's
capitation payment.
ENCOUNTER ADJUSTMENTS
Contractors are required to submit adjusted or voided encounters in the event
that claims are subsequently adjusted or denied after the initial encounter
submission. This includes adjustments for inaccuracies identified by fraud and
abuse audits or investigations conducted by AHCCCSA or the Contractor.
Contractors shall refer to the Encounter User's Manual for further instructions
regarding adjustments to encounters.
I-3
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
- ----------------------------------------------------------------------------------------------------------------------
1. AMENDMENT NUMBER: 2. CONTRACT 3. EFFECTIVE DATE 4. PROGRAM
14 NO.: OF AMENDMENT:
YH8-0001-05 JULY 1, 2001 OMC
- ----------------------------------------------------------------------------------------------------------------------
5. CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE ARIZONA
1600 W. BROADWAY, SUITE 260
TEMPE AZ 85282-1502
- ----------------------------------------------------------------------------------------------------------------------
6. PURPOSE OF AMENDMENT: TO REVISE CAPITATION RATES.
- ----------------------------------------------------------------------------------------------------------------------
7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. Capitation Rates. Included in this amendment are revised capitation rates for the period beginning
July 1, 2001 and ending September 30, 2001.
TANF TANF TANF
GSA 14-44, F 14-44, M 45+, M/F
Health Choice Arizona 10 $114.93 $92.22 $228.21
Health Choice Arizona 12 $105.39 $95.77 $242.35
NOTE: PLEASE SIGN AND DATE BOTH AND THEN RETURN ONE TO: MICHAEL VEIT, MD 5700
AHCCCS CONTRACTS AND PURCHASING
701 E JEFFERSON STREET
PHOENIX AZ 85034
- ----------------------------------------------------------------------------------------------------------------------
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED
AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
- ----------------------------------------------------------------------------------------------------------------------
9. SIGNATURE OF AUTHORIZED REPRESENTATIVE: 10. SIGNATURE OF AHCCCSA
CONTRACTING OFFICER:
/S/ GLORIA TOMSA (COO) /S/ MICHAEL VEIT
- ----------------------------------------------------------------------------------------------------------------------
TYPED NAME: CAROLYN ROSE MICHAEL VEIT
GLORIA TOMSA
- ----------------------------------------------------------------------------------------------------------------------
TITLE: CHIEF EXECUTIVE OFFICER - CONTRACTS & PURCHASING ADMINISTRATOR
HEALTH CHOICE ARIZONA
- ----------------------------------------------------------------------------------------------------------------------
DATE: DATE:
6/8/01 JUNE 12 2001
- ----------------------------------------------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
SECTION A: CONTRACT AMENDMENT
[AHCCCS LOGO]
- ---------------------------- ------------------------- ------------------------------------------ --------------------------
1. AMENDMENT 2. CONTRACT 6. EFFECTIVE DATE OF 4. PROGRAM
NUMBER: NO.: AMENDMENT:
15 YH8-0001-05 OCTOBER 1, 2001 OMC
- ---------------------------- ------------------------- ------------------------------------------ --------------------------
5. CONTRACTOR'S NAME AND ADDRESS:
HEALTH CHOICE ARIZONA
1600 W. BROADWAY, SUITE 260
TEMPE, AZ 85282-1502
- ----------------------------------------------------------------------------------------------------------------------------
6. PURPOSE OF AMENDMENT: TO INCORPORATE CHANGES TO CONTRACT REQUIREMENTS DUE TO THE PASSAGE OF PROPOSITION 204.
- ----------------------------------------------------------------------------------------------------------------------------
7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. Proposition 204. The attached pages represent modifications to the contract requirements as a result of the
passage of Proposition 204.
B. Included in this amendment are revised capitation rates for the period beginning October 1, 2001 and ending
September 30, 2002.
NOTE: PLEASE SIGN AND DATE BOTH AND THEN RETURN ONE TO: MICHAEL VEIT, MD 5700
AHCCCS CONTRACTS AND PURCHASING
701 E JEFFERSON STREET
PHOENIX, AZ 85034
- ----------------------------------------------------------------------------------------------------------------------------
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED
REMAIN UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
- ------------------------------------------------------------- --------------------------------------------------------------
9. SIGNATURE OF AUTHORIZED REPRESENTATIVE: 10. SIGNATURE OF AHCCCSA CONTRACTING OFFICER:
/s/ Carolyn Rose /s/ Michael Veit
- ------------------------------------------------------------- --------------------------------------------------------------
TYPED NAME:
CAROLYN ROSE MICHAEL VEIT
- ------------------------------------------------------------- --------------------------------------------------------------
- ------------------------------------------------------------- --------------------------------------------------------------
TITLE: CONTRACTS & PURCHASING
CHIEF EXECUTIVE OFFICER ADMINISTRATOR
- ------------------------------------------------------------- --------------------------------------------------------------
DATE: DATE:
9/6/01 8/31/01
- ------------------------------------------------------------- --------------------------------------------------------------
TABLE OF CONTENTS
SECTION A: CONTRACT AMENDMENT....................................................................................1
SECTION B: CAPITATION RATES......................................................................................5
SECTION C: DEFINITIONS...........................................................................................6
SECTION D: PROGRAM REQUIREMENTS.................................................................................13
1. SCOPE OF SERVICES.....................................................................................13
2. BEHAVIORAL HEALTH SERVICES............................................................................18
3. AHCCCS MEDICAL POLICY MANUAL..........................................................................19
4. VACCINE FOR CHILDREN PROGRAM..........................................................................19
5. DENIALS OR REDUCTIONS OF SERVICES.....................................................................20
6. ENROLLMENT AND DISENROLLMENT..........................................................................20
7. MAINSTREAMING OF AHCCCS MEMBERS.......................................................................22
8. MEMBER INFORMATION....................................................................................22
9. MEMBER SURVEYS........................................................................................24
10. MARKETING.............................................................................................25
11. ANNUAL ENROLLMENT CHOICE..............................................................................25
12. TRANSITION OF MEMBERS.................................................................................25
13. STAFF REQUIREMENTS AND SUPPORT SERVICES...............................................................26
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS.....................................................27
15. ADVANCE DIRECTIVES....................................................................................27
16. PERFORMANCE STANDARDS.................................................................................27
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM).................................................29
18. PHYSICIAN INCENTIVES..................................................................................30
19. APPOINTMENT STANDARDS.................................................................................30
20. REFERRAL PROCEDURES AND STANDARDS.....................................................................31
21. PROVIDER MANUAL.......................................................................................31
22. PRIMARY CARE PROVIDER STANDARDS.......................................................................32
23. OTHER PROVIDER STANDARDS..............................................................................33
24. NETWORK DEVELOPMENT...................................................................................34
25. NETWORK MANAGEMENT....................................................................................34
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC).............................................................34
27. PROVIDER REGISTRATION.................................................................................35
28. PROVIDER AFFILIATION TRANSMISSION.....................................................................35
29. PERIODIC REPORT REQUIREMENTS..........................................................................35
30. DISSEMINATION OF INFORMATION..........................................................................36
31. REQUESTS FOR INFORMATION..............................................................................36
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS...........................................................36
33. OPERATIONAL AND FINANCIAL REVIEWS.....................................................................36
34. CLAIMS PAYMENT SYSTEM.................................................................................37
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT.............................................................37
36. NURSING FACILITY REIMBURSEMENT........................................................................38
37. COMPENSATION..........................................................................................38
38. CAPITATION ADJUSTMENTS................................................................................39
39. REINSURANCE...........................................................................................40
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY........................................................42
41. MEDICARE SERVICES AND COST SHARING....................................................................43
42. COPAYMENTS............................................................................................43
43. RECORDS RETENTION.....................................................................................43
44. MEDICAL RECORDS.......................................................................................44
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS........................................................44
46. ACCUMULATED FUND DEFICIT..............................................................................44
47. DATA EXCHANGE REQUIREMENT.............................................................................45
2
48. ENCOUNTER DATA REPORTING..............................................................................45
49. MONTHLY ROSTER RECONCILIATION.........................................................................46
50. TERM OF CONTRACT AND OPTION TO RENEW..................................................................46
51. SUBCONTRACTS..........................................................................................46
52. SPECIALTY CONTRACTS...................................................................................48
53. MANAGEMENT SERVICES SUBCONTRACTORS....................................................................48
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS..............................................................48
55. MINIMUM CAPITALIZATION REQUIREMENTS...................................................................48
56. PERFORMANCE BOND OR BOND SUBSTITUTE...................................................................49
57. AMOUNT OF PERFORMANCE BOND............................................................................50
58. FINANCIAL VIABILITY STANDARDS/PERFORMANCE GUIDELINES..................................................50
59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP........................................................51
60. SANCTIONS.............................................................................................51
61. AUTO-ASSIGNMENT ALGORITHM.............................................................................51
62. GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS...............................................51
63. QUARTERLY GRIEVANCE REPORT............................................................................52
64. KIDSCARE..............................................................................................52
65. PENDING LEGISLATIVE ISSUES............................................................................52
66. SEPARATE INCORPORATION................................................................................52
67. CULTURAL COMPETENCY...................................................................................53
68. MEDICAID IN THE PUBLIC SCHOOLS........................................................................53
SECTION E: CONTRACT CLAUSES.....................................................................................54
1. APPLICABLE LAW........................................................................................54
2. AUTHORITY.............................................................................................54
3. ORDER OF PRECEDENCE...................................................................................54
4. CONTRACT INTERPRETATION AND AMENDMENT.................................................................54
5. SEVERABILITY..........................................................................................54
6. RELATIONSHIP OF PARTIES...............................................................................54
7. ASSIGNMENT AND DELEGATION.............................................................................54
8. GENERAL INDEMNIFICATION...............................................................................54
9. INDEMNIFICATION - PATENT AND COPYRIGHT................................................................55
10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS................................................55
11. ADVERTISING AND PROMOTION OF CONTRACT.................................................................55
12. PROPERTY OF TIlE STATE................................................................................55
13. THIRD PARTY ANTITRUST VIOLATIONS......................................................................55
14. RIGHT TO ASSURANCE....................................................................................55
15. TERMINATION FOR CONFLICT OF INTEREST..................................................................55
16. GRATUITIES............................................................................................55
17. SUSPENSION OR DEBARMENT...............................................................................56
18. TERMINATION FOR CONVENIENCE...........................................................................56
19. TERMINATION FOR DEFAULT...............................................................................56
20. TERMINATION - AVAILABILITY OF FUNDS...................................................................56
21. RIGHT OF OFFSET.......................................................................................56
22. NON-EXCLUSIVE REMEDIES................................................................................57
23. NON-DISCRIMINATION....................................................................................57
24. EFFECTIVE DATE........................................................................................57
25. INSURANCE.............................................................................................57
26. DISPUTES..............................................................................................57
27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS...........................................................58
28. INCORPORATION BY REFERENCE............................................................................58
29. COVENANT AGAINST CONTINGENT FEES......................................................................58
30. CHANGES...............................................................................................58
31. TYPE OF CONTRACT......................................................................................58
32. AMERICANS WITH DISABILITIES ACT.......................................................................58
33. WARRANTY OF SERVICES..................................................................................58
3
34. NO GUARANTEED QUANTITIES..............................................................................58
35. CONFLICT OF INTEREST..................................................................................58
36. DISCLOSURE OF CONFIDENTIAL INFORMATION................................................................59
37. COOPERATION WITH OTHER CONTRACTORS....................................................................59
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY.................................................................59
39. OWNERSHIP OF INFORMATION AND DATA.....................................................................59
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR...................................................................59
41. AUDITS AND INSPECTIONS................................................................................60
42. FRAUD AND ABUSE.......................................................................................60
43. LOBBYING..............................................................................................60
44. CHOICE OF FORUM.......................................................................................60
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS...................................................................A-1
1. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES....................................A-1
2. RECORDS AND REPORTS..................................................................................A-1
3. LIMITATIONS ON BILLING AND COLLECTION PRACTICES......................................................A-1
4. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES.............................................A-1
5. APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS.................................................A-1
6. WARRANTY OF SERVICES.................................................................................A-2
7. SUBJECTION OF SUBCONTRACT............................................................................A-2
8. AWARDS OF OTHER SUBCONTRACTS.........................................................................A-2
9. INDEMNIFICATION BY CONTRACTOR........................................................................A-2
10. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES......................................A-2
11. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS..........................................................A-2
12. SEVERABILITY.........................................................................................A-2
13. VOIDABILITY OF SUBCONTRACT...........................................................................A-2
14. CONFIDENTIALITY REQUIREMENT..........................................................................A-2
15. GRIEVANCE AND REQUEST FOR HEARING PROCEDURES.........................................................A-3
16. TERMINATION OF SUBCONTRACT...........................................................................A-3
17. PRIOR AUTHORIZATION AND UTILIZATION REVIEW...........................................................A-3
18. NON-DISCRIMINATION REQUIREMENTS......................................................................A-3
19. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION........................................A-3
20. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION......................................................A-4
21. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK and LABORATORY TESTING...................................A-4
22. CONFLICT IN INTERPRETATION OF PROVISIONS.............................................................A-4
23. ENCOUNTER DATA REQUIREMENT...........................................................................A-4
24. CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988.............................................A-4
25. INSURANCE............................................................................................A-4
26. FRAUD AND ABUSE......................................................................................A-4
ATTACHMENT B: MINIMUM NETWORK STANDARDS.........................................................................B-1
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS......................................................................F-1
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM.........................................................................G-1
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS...........................................H-1
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS.................................................................I-1
4
SECTION B: CAPITATION RATES
The Contractor shall provide services as described in this contract. In
consideration for these services, the Contractor will be paid the attached rates
for the term October 1, 2001 through September 30, 2002.
CAPITATION RATES
(per member per month)
Capitation rates specific to contractor
5
DEFINITIONS CONTRACT/RFP YH8-0001
SECTION C: DEFINITIONS
ADHS Arizona Department of Health Services, the state
agency mandated to serve the public health needs of
all Arizona citizens.
AGENT Any person who has been delegated the authority to
obligate or act on behalf of another person or
entity.
AHCCCS Arizona Health Care Cost Containment System, which is
composed of the Administration, contractors, and
other arrangements through which health care services
are provided to an eligible person, as defined by
A.R.S. ss. 36-2902, et seq.
AHCCCS BENEFITS See "COVERED SERVICES".
AHCCCS MEMBER See "MEMBER".
AHCCCSA Arizona Health Care Cost Containment System
Administration.
ALTCS The Arizona Long Term Care System (ALTCS), a program
under AHCCCSA that delivers long term, acute,
behavioral health and case management services to
members, as authorized by A.R.S. ss. 36-2932.
AMBULATORY CARE Preventive, diagnostic and treatment services
provided on an outpatient basis by physicians, nurse
practitioners, physician assistants and other health
care providers.
AMPM AHCCCS Medical Policy Manual.
ARIZONA State regulations established pursuant to relevant
ADMINISTRATIVE statutes. For purposes of this solicitation, the
CODE (A.A.C.) relevant sections of the AAC are referred to
throughout this document as "AHCCCS Rules".
A.R.S. Arizona Revised Statutes.
AT RISK Refers to the period of time that a member is
enrolled with a contractor during which time the
Contractor is responsible to provide AHCCCS covered
services under capitation.
BIDDERS LIBRARY A repository of manuals, statutes, rules and other
reference material located at the AHCCCS office in
Phoenix.
BOARD CERTIFIED An individual who has successfully completed all
prerequisites of the respective specialty board and
successfully passed the required examination for
certification.
CAPITATION Payment to contractor by AHCCCSA of a fixed monthly
payment per person in advance for which the
contractor provides a full range of covered services
as authorized under A.R.S. ss. 36-2942 and ss.
36-2931.
CATEGORICALLY LINKED Member eligible for Medicaid under Title XIX of the
TITLE XIX MEMBER Social Security Act including those eligible under
1931 provisions of the Social Security Act
(previously AFDC), Sixth Omnibus Budget
Reconciliation Act (SOBRA), Supplemental Security
Income (SSI), SSI-related groups. To be categorically
linked, the member must be aged (65 or over), blind,
disabled, a child under age 19, parent of a dependent
child, or pregnant.
CLEAN CLAIM A claim that may be processed without obtaining
additional information from the provider of service
or from a third party; but does not include claims
under investigation for fraud or abuse or claims
under review for medical necessity, as defined by
A.R.S. ss. 36-2904.
6
CMS (FORMALLY Center for Medicare and Medicaid Services, an
HCFA) organization within the U.S. Department of Health and
Human Services, which administers the Medicare and
Medicaid programs and the State Children's Health
Insurance Program.
COMPETITIVE BID A state procurement system used to select contractors
PROCESS to provide covered services on a geographic basis.
CONTINUING An AHCCCS contractor during CYE 97 that submits a
OFFEROR proposal pursuant to this solicitation.
CONTRACT See "COVERED SERVICES".
SERVICES
CONTRACT YEAR Corresponds to federal fiscal year (Oct. 1 through
(CY) Sept. 30). For example, Contract Year 02 is
10/01/01-- 9/30/02.
CONTRACTOR A person, organization or entity agreeing through a
direct contracting relationship with AHCCCSA to
provide the goods and services specified by this
contract in conformance with the stated contract
requirements, AHCCCS statute and rules and federal
law and regulations.
CONVICTED A judgment of conviction has been entered by a
federal, state or local court, regardless of whether
an appeal from that judgment is pending.
CO-PAYMENT A monetary amount specified by the Director that the
member pays directly to a contractor or provider at
the time covered services are rendered, as defined in
R9-22-107.
COUNTY Amount of funds contributed to the AHCCCS fund by
CONTRIBUTION each Arizona county based on funding formulas
established by law.
COVERED Health care services to be delivered by a contractor
SERVICES which are designated in Section D of this contract
and also AHCCCS Rules R9-22, Article 2 and R9-31.,
Article 2.
CRS Children's Rehabilitative Services, as defined in
R9-22-114.
CSHCN Children with Special Health Care Needs ,Children
under age 19 who are: Blind/Disabled Children and
Related Populations (eligible for SSI under Title
XVI). Children eligible under section 1902 (e)(3) of
the Social Security Act (Katie Beckett); In foster
care or other out-of-home placement; Receiving foster
care or adoption assistance; or receiving services
through a family-centered, community-based
coordinated care system that receives grant funds
under section 501(a)(1)(D) of Title V (CRS).
CY See "CONTRACT YEAR".
CYE Contract Year Ended; same as "CONTRACT YEAR".
DAYS Calendar days unless otherwise specified as defined
in the text, as defined in R9-22-101.
DIRECTOR The Director of AHCCCSA.
DISCLOSING An AHCCCS provider or a fiscal agent.
ENTITY
DME Durable Medical Equipment, which is an item, or
appliance that can withstand repeated use, is
designated to serve a medical purpose, and is not
generally useful to a person in the absence of a
medical condition, illness or injury as defined in
R9-22-102.
DUAL ELIGIBLE A member who is eligible for both Medicare and
Medicaid.
7
ELIGIBILITY A process of determining, through a written
DETERMINATION application, including required documentation,
whether an applicant meets the qualifications for
Title XIX or Title XXI.
EMERGENCY A medical condition manifesting itself by acute
MEDICAL symptoms of sufficient severity (including severe
CONDITION pain) such that a prudent layperson, who possess an
average knowledge of health and medicine, could
reasonably expect the absence of immediate medical
attention to result in: a) placing the patient's
health in serious jeopardy; b) serious impairment to
bodily functions; or c) serious dysfunction of any
bodily organ or part.
EMERGENCY Services provided after the sudden onset of a medical
MEDICAL condition manifesting itself by acute symptoms of
SERVICE sufficient severity (including severe pain) that the
absence of immediate medical attention could
reasonably be expected to result in: a) placing the
patient's health in serious jeopardy; b) serious
impairment to bodily functions; or c) serious
dysfunction of any bodily organ or part, as defined
in R9-22-102.
ENCOUNTER A record of a medically related service rendered by a
provider or providers registered with AHCCCSA to a
member who is enrolled with a Contractor on the date
of service. It includes all services for which the
contractor incurred any financial liability.
ENROLLMENT The process by which an eligible person becomes a
member of a contractor's health plan.
EPSDT Early and Periodic Screening, Diagnosis and
Treatment; services for persons under 21 years of age
as described in AHCCCS rules R9-22, Article 2.
FAMILY A program that provides family planning services only
PLANNING for a maximum of 24 months to SOBRA women whose
SERVICES pregnancy has ended and the woman is not otherwise
EXTENSION eligible for Title XIX.
PROGRAM
FEDERALLY An entity which meets the requirements and receives a
QUALIFIED grant and funding pursuant to Section 330 of the
HEALTH CENTER Public Health Service Act. An FQHC includes an
(FQHC) outpatient health program or facility operated by a
tribe or tribal organization under the Indian
Self-Determination Act (PL 93-638) or an urban Indian
organization receiving funds under Title V of the
Indian Health Care Improvement Act.
FEE-FOR-SERVICE A method of payment to registered providers on an
(FFS) amount per service basis.
FFP Federal financial participation (FFP) refers to the
contribution that the federal government makes to the
Title XIX and Title XXI program portions of AHCCCS as
defined in 42 CFR 400.203.
FISCAL YEAR (FY) The budget year - Federal Fiscal Year: October 1
through September 30; State fiscal year: July 1
through June 30
GATEKEEPER Primary care provider who is primarily responsible
for all medical treatment rendered and who makes
referrals as necessary and monitors the members
treatment.
GEOGRAPHIC A specific county or defined grouping of counties
SERVICE designated by the Administration within (GSA) which a
AREA contractor of record provides, directly or through
subcontract, covered health care to members enrolled
with that contractor of record
GROUP OF Two or more health care professionals who practice
PROVIDERS their profession at a common location (whether or not
they share facilities, supporting staff, or
equipment).
HEALTH Various forms of plan organization, including staff
MAINTENANCE and group models, that meet the (HMO) licensing
HMO ORGANIZATION requirements of the federal and/or state government
and offer a full array of health care services to
members on a capitated basis.
8
HEALTH PLAN See "CONTRACTOR".
IBNR Incurred But Not Reported: Liability for services
rendered for which claims have not been received.
IHS Indian Health Services authorized as a federal agency
pursuant to 25 U.S.C. 1661.
LIEN A legal claim filed with the County Recorder's office
in which a member resides and in the county an injury
was sustained for the purpose of ensuring that AHCCCS
receives reimbursement for medical services paid. The
lien is attached to any settlement the member may
receive as a result of an injury.
MANAGED CARE Systems that integrate the financing and delivery of
health care services to covered individuals by means
of arrangements with selected providers to furnish
comprehensive services to members; establish explicit
criteria for the selection of health care providers;
have significant financial incentives for members to
use providers and procedures associated with the
plan; and have formal programs for quality assurance
and utilization review.
MANAGEMENT A person or organization that agrees to perform any
SERVICES administrative function or service for the Contractor
SUBCONTRACTOR specifically related to securing or fulfilling the
Contractor's obligations to AHCCCSA under the terms
of the contract.
MANAGING A general manager, business manager, administrator,
EMPLOYEE director, or other individual who exercises
operational or managerial control over, or who
directly or indirectly conducts the day-to-day
operation of, an institution, organization or agency.
MATERIAL A fact, data or other information excluded from a
OMISSION report, contract, etc. the absence of which could
lead to erroneous conclusions following reasonable
review of such report, contract, etc.
MEDICAID A Federal/State program authorized by Title XIX of
the Social Security Act, as amended.
MEDICAL Title XIX Waiver member whose income is more than
EXPENSE 100% of the Federal Poverty Level, and has medical
DEDUCTION expenses that reduce income to or below 40% of the
(MED) Federal Poverty Level. The 40% Federal Poverty Level
will be adjusted annually to reflect annual Federal
Poverty Level adjustments. MED's may have a
categorical link to a Title XIX program; however,
their income exceeds the limits of the Title XIX
program.
MEDICARE A Federal program authorized by Title XVIII of the
Social Security Act, as amended.
MEMBER A person eligible who is enrolled in the system, as
defined in A.R.S. ss. 36-2901.
NEW OFFEROR The organization, entity or person which submits a
proposal in response to this solicitation and which
has not been an AHCCCS contractor during CYE 97.
NON- A person who provides services as prescribed in
CONTRACTING A.R.S. ss. 36-2939 and who does not have a
PROVIDER subcontract with an AHCCCS contractor.
OFFEROR A person or other entity that submits a proposal to
the Administration in response to an RFP, as defined
in R9-22-106.
PERFORMANCE A set of standardized indicators designed to assist
STANDARDS AHCCCS in evaluating, comparing and improving the
performance of its contractors. Specific descriptions
of health services measurement goals are found in
Section D, Paragraph 16, Performance standards.
9
PMMIS AHCCCSA's Prepaid Medical Management Information
System.
PRIMARY CARE An individual who meets the requirements of A.R.S.
PROVIDER (PCP) ss. 36-2901, and who is responsible for the
management of a member's health care. A PCP may be a
physician defined as a person licensed as allopathic
or osteopathic physician according to A.R.S. Title
32, Chapter 13 or Chapter 17 or a practitioner
defined as a physician assistant licensed under
A.R.S. Title 32, Chapter 25, or a certified nurse
practitioner licensed under A.R.S. Title 32, Chapter
15.
PRIOR PERIOD The period of time from the 1st day of the month of
application or the 1st eligible month, whichever is
later, to the day a member is enrolled with the
Contractor. The Contractor receives notification from
the Administration of the member's enrollment. Also,
the period of time between the date a MED member was
approved and the date the member met spenddown or 1st
day of the month the member reduced resources
whichever is later.
PROPOSITION 204 Referendum that increased eligibility for AHCCCS
services to individuals whose income is at or below
100% of Federal Poverty Level.
PROVIDER Any person who contracts with the Administration for
the provision of hospitalization and medical care to
members according to the provisions A.R.S. ss.
36-2901 or any subcontractor of provider delivering
services pursuant to A.R.S. ss. 36-2901
QUALIFIED A person, eligible under A.R.S. ss. 36-2971(4), who
MEDICARE is entitled to Medicare Part A insurance, meets
BENEFICIARY certain income and residency requirements of the
(QMB) Qualified Medicare Beneficiary program. A QMB who is
also eligible for Medicaid is commonly referred to as
a QMB dual eligible.
QISMC Quality Improvement System for Managed Care developed
by the Centers for Medicare/Medicaid (CMS), formerly
(HCFA), for use in evaluation and management of the
quality of care provided by Medicare and Medicaid
managed care contractors. QISMC serves as one of the
key elements for the AHCCCS QM and UM requirements
included in this contract.
RATE CODE Eligibility classification for capitation payment
purposes.
REGIONAL An organization under contract with ADHS to
BEHAVIORAL administer covered behavioral health services in a
HEALTH geographically specific area of the state. Tribal
AUTHORITY governments, through an agreement with ADHS, may
(RBHA) operate a tribal regional behavioral health authority
(TRBHA) for the provision of behavioral health
services to Native American members living
on-reservation.
REINSURANCE A risk-sharing program provided by the Administration
to contractors for the reimbursement of certain
contract service costs incurred by a member beyond a
certain monetary threshold.
RELATED PARTY A party that has, or may have, the ability, to
control or significantly influence a contractor, or a
party that is, or may be, controlled or significantly
influenced by a contractor. "Related parties"
include, but are not limited to, agents, managing
employees, persons with an ownership or controlling
interest in the disclosing entity, and their
immediate families, subcontractors, wholly-owned
subsidiaries or suppliers, parent companies, sister
companies, holding companies, and other entities
controlled or managed by any such entities or
persons.
RFP Request For Proposals which is a document prepared by
AHCCCSA which describes the services required and
which instructs prospective offerors how to prepare a
response (proposal), as defined in R9-22-107.
SCOPE OF See "COVERED SERVICES"
SERVICES
SOBRA Section 9401 of the Sixth Omnibus Budget and
Reconciliation Act, 1986, amended by the
10
Medicare Catastrophic Coverage Act of 1988, 42 CFR
U.S.C. 1396a(a)(10)(A)(ii)(IX), July 1, 1988.
STATE The State of Arizona.
STATE PLAN The written agreements between the State and CMS
which describes how the AHCCCS program meets CMS
requirements for participation in the Medicaid
program and the State Children's Health Insurance
Program
SUBCONTRACT An agreement entered into by Contractor with a
provider of health care services who agrees to
furnish covered services to members, or with a
marketing organization, or with any other
organization or person who agrees to perform any
administrative function or service for Contractor
specifically related to fulfilling Contractor's
obligations to AHCCCSA under the terms of this
contract, as defined in R9-22-101.
SUBCONTRACTOR (1) A person, agency or organization to that a
contractor has contracted with or delegated some of
its management functions or responsibilities to
provide covered services to its members; or (2) A
person, agency or organization that a fiscal agent
has entered into a contract, agreement, purchase
order or lease (or leases of real property) to obtain
space, supplies, equipment or services provided under
the AHCCCS agreement.
SUPPLEMENTAL Federal cash assistance program under Title XVI of
SECURITY the Social Security Act.
INCOME (SSI)
TEFRA RISK HMO A Health Maintenance Organization or Comprehensive
Medical Plan, which provides Medicare services to
Medicare beneficiaries pursuant to a Medicare risk
contract with CMS under ss. 1876 of the Social
Security Act.
TEMPORARY A Federal cash assistance program under the Social
ASSISTANCE TO Security Act. It replaced Aid To Families With
NEEDY FAMILIES Dependent Children (AFDC).
(TANF)
THIRD PARTY An individual, entity or program that is or may be
liable to pay all or part of the medical cost of
injury, disease or disability of an AHCCCS applicant
or member, as defined in R9-22-110.
THIRD PARTY The resources available from a person or entity that
LIABILITY is, or may be, by agreement, circumstance or
otherwise, liable to pay all or part of the medical
expenses incurred by an AHCCCS applicant or member,
as defined in P.9-22-110.
TITLE XIX Member eligible for Federally funded Medicaid
MEMBER programs under Title XIX of the Social Security Act
including those eligible under 1931 provisions of the
Social Security Act (previously AFDC), Sixth Omnibus
Budget Reconciliation Act (SOBRA), Supplemental
Security Income (SSI), SSI-related groups, and Title
XIX Waiver groups.
TITLE XIX All MED (Medical Expense Deduction) members, and
WAIVER MEMBER adults or childless couples at or below 100% of the
Federal Poverty Level who are not categorically
linked to another Title XIX program. This would also
include Title XIX linked individuals who's income
exceeds the limits of the categorical program.
TITLE XXI Member eligible for acute care services under Title
MEMBER XXI of the Social Security Act, referred to in
federal legislation as the "State Children's Health
Insurance Program" (SCHIP). The Arizona version of
SCHIP is referred to as "KidsCare."
TRIBAL FACILITY A facility that is operated by an Indian tribe and
(638 TRIBAL FACILITY) that is authorized to provide services pursuant to
Public Law 93-638, as amended.
11
YEAR See "Contract Year".
[END OF DEFINITIONS]
12
SECTION D: PROGRAM REQUIREMENTS
1. SCOPE OF SERVICES
The Contractor shall provide covered services to AHCCCS members in accordance
with all applicable federal, State and local laws, rules, regulations and
policies, including services listed in this document, listed by reference in
attachments, and AHCCCS policies referenced in this document. The services are
described in detail in AHCCCS Rules R 9-22, Article 2, the AHCCCS Medical Policy
Manual (AMPM), and the document entitled "AHCCCS Health Plan Performance
Indicators", all of which are incorporated herein by reference and may be found
in the Bidder's Library. The covered services are briefly described below.
Covered services must be medically necessary and provided by, or coordinated
with, a primary care provider, except for behavioral health and children's
preventive dental services. Services must be rendered by providers that are
appropriately licensed or certified, operating within their scope of practice,
and registered as an AHCCCS provider. The Contractor shall provide the same
standard of care for all members regardless of the member's eligibility
category.
The Contractor shall ensure that its providers are not restricted or inhibited
in any way from communicating freely with members regarding the members' health
care, medical needs and treatment options even if needed services are not
covered by the Contractor.
KIDSCARE COVERED SERVICES: Effective 10/1/01: KidsCare members are eligible for
the same services covered for members under the Title XIX program.
AMBULATORY SURGERY AND ANESTHESIOLOGY: The Contractor shall provide surgical
services for either emergency or scheduled surgeries when provided in an
ambulatory or outpatient setting such as a free-standing surgical center or a
hospital based outpatient surgical setting.
AUDIOLOGY: The Contractor shall provide audiology services to members under the
age of 2l including the identification and evaluation of hearing loss and
rehabilitation of the hearing loss through other than medical or surgical means
(i.e. hearing aids). Only the identification and evaluation of hearing loss are
covered for members 21 years of age and older unless the hearing loss is due to
an accident or injury-related emergent condition.
BEHAVIORAL HEALTH: The Contractor shall provide behavioral health services as
described in Section D, Paragraph 2, Behavioral Health Services.
CHILDREN'S REHABILITATIVE SERVICES (CRS): The program for children with
CRS-covered conditions is administered by the Arizona Department of Health
Services (ADHS) for children who meet CRS eligibility criteria. The Contractor
shall refer children to the CRS program who are potentially eligible for
services related to CRS covered conditions, as specified in R9-22, Article 2
A.R.S. Title 36, Chapter 2, Article 3. Eligibility criteria and the referral
process are described in the CRS Policy and Procedures Manual available in the
Bidder's Library.
The Contractor shall monitor referrals to CRS to ensure CRS covered services are
provided in a timely manner to eligible members. Referral to CRS does not
relieve the Contractor of the responsibility for providing medically necessary
services not covered by CRS to CRS eligible members. The Contractor is also
responsible for initial care of newborn members, who are CRS eligible. The
Contractor must require the member's Primary Care Provider (PCP) to coordinate
their care with the CRS program. All services provided must be included in the
member's medical record maintained by the PCP.
The Contractor is not responsible for payment of those CRS covered services for
which a CRS eligible member refuses to receive through the CRS program. A member
with private insurance is not required to utilize CRS. If the member uses their
private insurance network for a CRS covered condition, and the member is not
enrolled with CRS, the Contractor is responsible for all applicable deductibles
and copays.
The Contractor remains ultimately responsible for the provision of all covered
services to its members. If the Contractor becomes aware that CRS has failed to
meet the established appointment standards, or has failed to provide medically
necessary CRS covered services, the Contractor shall immediately notify AHCCCSA,
Office of Medical Management, of the occurrence. In accordance with AHCCCS
policy, the Contractor may seek reimbursement from CRS for providing CRS covered
services.
CHIROPRACTIC SERVICES: The Contractor shall provide chiropractic services to
members under age 21 when prescribed by the member's PCP and approved by the
Contractor in order to ameliorate the member's medical condition. Medicare
approved
13
chiropractic services shall also be covered, subject to limitations specified in
CFR 410.22, for Qualified Medicare Beneficiaries if prescribed by the member's
PCP and approved by the Contractor.
DENTAL. The Contractor shall provide all members under the age of 21 with all
medically necessary dental services including emergency dental services, dental
screening and preventive services in accordance with the AHCCCS periodicity
schedule, therapeutic dental services, dentures, and pre-transplantation dental
services. The Contractor shall monitor compliance with the EPSDT periodicity
schedule for dental screening services and ensure that dental service reports
are included in the member's medical record maintained by the PCP. The
Contractor is required to meet specific utilization rates for members as
described in Section D, Paragraph 16, Performance Standards. The Contractor
shall ensure that members are notified when dental screenings are due if the
member has not been scheduled for a visit. If no dental screening is received by
the member, a second notice must be sent. Members under the age of 21 may
request dental services without referral and may choose a dental provider from
the Contractor's provider network. For members who are 21 years of age and
older, the Contractor shall provide emergency dental care, medically necessary
dentures and dental services for transplantation services as specified in the
AMPM. Dental standards may be found in the AMPM, Section 310, which is
incorporated herein by reference and which may be found in the Bidder's Library.
DIALYSIS: The Contractor shall provide medically necessary dialysis, supplies,
diagnostic testing and medication for all members when provided by
Medicare-certified hospitals or Medicare-certified end stage renal disease
(ESRD) providers. Services may be provided on an outpatient basis, or on an
inpatient basis if the hospital admission is not solely to provide chronic
dialysis services.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT): The Contractor
shall provide comprehensive health care services through primary prevention,
early intervention, diagnosis and medically necessary treatment to correct or
ameliorate defects and physical or mental illness discovered by the screenings
for members under age 21. The Contractor shall ensure that these members receive
required health screenings, including developmental/behavioral health, in
compliance with the AHCCCS periodicity schedule (Exhibit 430-1 in the AMPM) and
to submit to the AHCCCS Office of Medical Management; all EPSDT reports as
required by AHCCCS medical policy. The Contractor is required to meet specific
participation/utilization rates for members as described in Section D, Paragraph
16, Performance Standards. Because behavioral health benefits for Title XIX and
Title XXI members are provided through the ADHS/RBHA system, the Contractor
shall ensure the initiation and coordination of the referral of these members to
the RBHA and shall follow up with the RBHA to monitor whether members have
received behavioral health services
EMERGENCY SERVICES: The Contractor shall have and/or provide the following as a
minimum:
a. Emergency services facilities adequately staffed by qualified medical
professionals to provide pre-hospital, emergency care on a
24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically
emergent condition as defined by AHCCCS Rule R9-22-10l and R9-31-101.
Emergency medical services are covered without prior authorization. The
Contractor is encouraged to contract with emergency service facilities
for the provision of emergency services. The Contractor is encouraged
to contract with or employ the services of non-emergency facilities
(e.g. urgent care centers) to address member non-emergency care issues
occurring after regular office hours or on weekends. The Contractor
shall be responsible for educating members and providers regarding
appropriate utilization of emergency room services including behavioral
health emergencies. The Contractor shall monitor emergency service
utilization (by both provider and member) and shall have guidelines for
implementing corrective action for inappropriate utilization. For
utilization review, the test for appropriateness of the request for
emergency services shall be whether a prudent layperson, similarly
situated, would have requested such services. For purposes of this
contract, a "prudent layperson" is a person who possesses an average
knowledge of health and medicine.
b. All medical services necessary to rule out an emergency condition
c. Emergency transportation
d. Member access by telephone to a physician, registered nurse, physician
assistant or nurse practitioner for advice in emergent or urgent
situations, 24 hours per day, 7 days per week.
e. The Contractor shall comply with guidelines regarding the coordination
of post-stabilization care.
EYE EXAMINATIONS/OPTOMETRY: The Contractor shall provide all medically necessary
emergency eye care, vision examinations, prescriptive lenses, and treatments for
conditions of the eye for all members under the age of 21. For members who are
21 years of age and older, the Contractor shall provide emergency care for eye
conditions which meet the definition of an emergency medical condition, cataract
removal, and/or medically necessary vision examinations and prescriptive lenses
if required following cataract removal and other eye conditions as specified in
the AMPM.
14
FAMILY PLANNING: The Contractor shall provide family planning services in
accordance with the AMPM, Section 420 for all members who choose to delay or
prevent pregnancy. These include medical, surgical, pharmacological and
laboratory services, as well as contraceptive devices. Information and
counseling necessary to allow the members to make informed decisions regarding
family planning methods shall also be included. If the Contractor does not
provide family planning services, it must contract for these services through
another health care delivery system, which allows members freedom of choice in
selecting a provider. A prospective offeror may discuss arrangements for family
planning services only with other prospective offerors during the RFP process
for the purpose of making arrangements for the provision of family planning
services.
The Contractor shall provide services to members enrolled in the Family Planning
Services Extension Program; a program that provides only family planning
services for a maximum of 24 months to women whose SOBRA eligibility has
terminated. The Contractor is also responsible for notifying AHCCCSA when a
SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA
Family Planning Services Extension Program. Notification may be made at the time
the newborn is reported or after the sterilization procedure is completed.
HEALTH RISK ASSESSMENT AND SCREENING: The Contractor shall provide these
services for non-hospitalized members 21 years of age and older. These services
include, but are not limited to, screening for hypertension, elevated
cholesterol, colon cancer, sexually transmitted diseases, tuberculosis and
HIV/AIDS; nutritional assessment in cases when the member has a chronic
debilitating disease affected by nutritional needs; mammograms and prostate
screenings; physical examinations and diagnostic work-ups; and immunizations.
Required assessment and screening services for members under age 21 are included
in the AHCCCS EPSDT periodicity schedule.
HOME HEALTH: The Contractor shall provide part-time or intermittent care for
members who do not require hospital care. This service is provided under the
direction of a physician to prevent re-hospitalization or institutionalization
and may include nursing, therapies, supplies and home health aide services.
HOSPICE: These services are covered for members under 21 years of age who are
certified by a physician as being terminally ill and having six months or less
to live. See the AMPM for details on covered hospice services.
HOSPITAL: Inpatient services include semi-private accommodations for routine
care, intensive and coronary care, surgical care, obstetrics and newborn
nurseries, and behavioral health emergency/crisis services. If the member's
medical condition requires isolation; private inpatient accommodations are
covered. Nursing services, dietary services and ancillary services such as
laboratory, radiology, pharmaceuticals, medical supplies, blood and blood
derivatives, etc. are also covered. Outpatient services include any of the above
services, which may be provided on an outpatient or ambulatory basis (i.e.
laboratory, radiology, therapies, ambulatory surgery, etc.). Observation
services may be provided on an outpatient basis for up to 24 hours if determined
reasonable and necessary to decide whether the member should be admitted for
inpatient care. Observation services include the use of a bed and periodic
monitoring by hospital nursing staff and/or other staff to evaluate, stabilize
or treat medical conditions of a significant degree of instability and/or
disability.
IMMUNIZATIONS: The Contractor shall provide immunizations for adults (21 years
of age and older) to include diphtheria-tetanus, influenza, pneumococcus,
rubella, measles and hepatitis-B. For all members under the age of 21,
immunization requirements include diphtheria, tetanus, pertussis vaccine (DPT),
inactivated polio vaccine (IPV), measles, mumps, rubella (MMR) vaccine, H.
influenza, type B (HIB) vaccine, hepatitis B (Hep B) vaccine, and varicella
zoster virus (VZV) vaccine, and pneumococcal conjugate vaccine (PCV). The
Contractor is required to meet specific immunization rates for members under the
age of 21, which are described in Section 16, Performance Standards.
INDIAN HEALTH SERVICES (IHS): The Contractor may choose to subcontract with and
pay an IHS or 638 tribal facility as part of their provider network for covered
services provided to members. The Contractor is responsible for reimbursement to
IHS or tribal facilities for emergency services provided to Title XXI Native
American members enrolled with the Contractor. AHCCCSA will reimburse claims on
a FFS basis to providers for acute care services that are medically necessary
and eligible for 100% Federal reimbursement, and that are provided to Title XIX
members in an IHS or a 638 tribal facility.
LABORATORY. Laboratory services for diagnostic, screening and monitoring
purposes are covered when ordered by the member's PCP, other attending physician
or dentist, and provided by a CLIA (Clinical Laboratory Improvement Act)
approved free standing laboratory or hospital laboratory, clinic, physician
office or other health care facility laboratory.
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Upon written request, a Contractor may obtain laboratory test data on members
from a laboratory or hospital based laboratory subject to the requirements
specified in A.R.S. ss. 36-2903(R) and (S). The data shall be used exclusively
for quality improvement activities and health care outcome studies required
and/or approved by the Administration.
MATERNITY: The Contractor shall provide pre-conception counseling, pregnancy
identification, prenatal care, treatment of pregnancy related conditions, labor
and delivery services, and postpartum care for members. Services may be provided
by physicians, physician assistants or nurse practitioners certified in
midwifery.
Members may select or be assigned to a PCP specializing in obstetrics.
Circumcisions are covered as described in the AMPM. All members anticipated to
have a low-risk delivery may elect to receive labor and delivery services in
their home from their maternity provider if this setting is included in
allowable settings for the Contractor, and the Contractor has providers in its
network that offer home labor and delivery services. All members anticipated to
have a low-risk prenatal course and delivery may elect to receive maternity
services of prenatal care, labor and delivery and postpartum care provided by
licensed midwives if they are in the Contractor's provider network. All licensed
midwife labor and delivery services must be provided in the member's home since
licensed midwives do not have admitting privileges in hospitals or AHCCCS
registered free-standing birthing centers. Members receiving maternity services
from a licensed midwife must also be assigned to a PCP for other health care and
medical services. The Contractor shall allow women and their newborns to receive
up to 48 hours of inpatient hospital care after a routine vaginal delivery and
up to 96 hours of inpatient care after a cesarean delivery. The attending health
care provider, in consultation with the mother, may discharge the mother or
newborn prior to the 48-hour minimum length of stay. A normal newborn may be
granted an extended stay in the hospital of birth when the mother's continued
stay in the hospital is beyond the 48 or 96 hour stay.
The Contractor shall inform all assigned AHCCCS pregnant women of voluntary
prenatal HIV testing and the availability of medical counseling if the test is
positive. The Contractor shall provide information in the member handbook and
annually in the member newsletter to encourage pregnant women to be tested and
instructions on where to be tested. Semi-annually, the Contractor shall report
to AHCCCS the number of pregnant women who have been identified as HIV/AIDS
positive. This report is due no later than 30 days after the end of the second
and fourth quarters of the contract year.
MEDICAL FOODS: Medical foods are covered within limitations defined in the AMPM
for members diagnosed with a metabolic condition included under the ADHS Newborn
Screening Program and specified in the AMPM. The medical foods, including
metabolic formula and modified low protein foods, must be prescribed or ordered
under the supervision of a physician.
MEDICALLY-NECESSARY PREGNANCY TERMINATIONS: AHCCCS covers pregnancy termination
when it is the result of rape or incest, or in circumstances where the member
suffers form a physical disorder, physical injury, or physical illness,
including a life endangering physical condition caused by or arising form the
pregnancy itself, that would, as certified by a physician, place the member in
danger of death unless the pregnancy is terminated. In addition, providers must
submit to the Contractor a Certificate of Medical Necessity for Pregnancy
Termination. Prior authorization is required. If the procedure is performed on
an emergency basis, documentation, outlined in the AMPM, is required for a
member under eighteen years of age or a member who is considered an
incapacitated adult who seeks a medically necessary pregnancy termination, as
defined above.
MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT (DME), ORTHOTIC AND PROSTHETIC
DEVICES: These services are covered when prescribed by the member's PCP,
attending physician or practitioner, or by a dentist. Medical equipment may be
rented or purchased only if other sources are not available which provide the
items at no cost. The total cost of the rental must not exceed the purchase
price of the item. Reasonable repairs or adjustments of purchased equipment are
covered to make the equipment serviceable and/or when the repair cost is less
than renting or purchasing another unit.
NURSING FACILITY. The Contractor shall provide nursing facility services,
including religious nonmedical health care institutions, for members who require
short-term convalescent care not to exceed 90 days per contract year. In lieu of
a nursing facility, the member may be placed in an assisted living facility or
alternative residential setting, or receive home and community based services
(HCBS) as defined in R9-22, Article 2 and R9-28, Article 2 that meet the
provider standards described in R9-28, Article 5, and subject to the limitations
set forth in Chapter 1200 of the AMPM.
Nursing facility services must be provided in a dually-certified
Medicare/Medicaid facility which includes in the per-diem rate: nursing
services, basic patient care equipment and sickroom supplies, dietary services,
administrative physician visits, non-customized DME, necessary maintenance
rehabilitation therapies, over-the-counter medications, social, recreational and
spiritual activities, and administrative, operational medical direction
services. The Contractor shall provide medically necessary nursing facility
services for any member who has a pending ALTCS application, who is currently
residing in a nursing facility and is eligible for services provided under this
contract. If the member becomes ALTCS eligible and is enrolled with an
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ALTCS Program Contractor before the end of the maximum 90 days of nursing
facility coverage, the Contractor is only responsible for nursing facility
coverage during the time the member is enrolled with the Contractor. Nursing
facility services covered by a third party insurer (including Medicare) while
the member is enrolled with the Contractor shall be applied to the 90 day
limitation. See Paragraph 36, Nursing Facility Reimbursement, for further
details.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing when a member has been residing in a nursing facility for 75
days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application and to prepare for potential fee-for-service coverage if the stay
goes beyond the 90-day maximum.
NUTRITION: Nutritional assessments may be conducted as a part of the EPSDT
screenings for members under age 21, and to assist members 21 years of age and
older whose health status may improve with nutritional intervention. Assessment
of nutritional status on a periodic basis may be provided as determined
necessary, and as a part of the health risk assessment and screening services
provided by the member's PCP. AHCCCS covers nutritional therapy on an enteral,
parenteral or oral basis, when determined medically necessary to provide either
complete daily dietary requirements, or to supplement a member's daily
nutritional and caloric intake and when AHCCCS criteria specified in the AMPM
are met.
PHYSICIAN: The Contractor shall provide physician services to include medical
assessment, treatments and surgical services provided by licensed allopathic or
osteopathic physicians.
PODIATRY: The Contractor shall provide podiatry services to include
bunionectomies, casting for the purpose of constructing or accommodating
orthotics, medically necessary orthopedic shoes that are an integral part of a
brace, and medically necessary routine foot care for patients with a severe
systemic disease which prohibits care by a nonprofessional person.
PRESCRIPTION MEDICATIONS: Medications ordered by a PCP, attending physician or
dentist and dispensed under the direction of a licensed pharmacist are covered
subject to limitations related to prescription supply amounts, Contractor
formularies and prior authorization requirements, as well as restrictions for
immunosuppressant drugs addressed in AHCCCS medical policies for
transplantation's. Appropriate over-the-counter medication may be prescribed
when it is determined to be a lower-cost alternative to prescription medication.
PRIMARY CARE PROVIDER (PCP): PCP services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned
to, the member. The PCP provides primary health care and serves as a gatekeeper
and coordinator in referring the member for specialty medical services,
behavioral health and dental services. The PCP is responsible for maintaining
the member's primary medical record, which contains documentation of all health
risk assessments and health care services of which they are aware whether or not
they were provided by the PCP.
RADIOLOGY AND MEDICAL IMAGING: These services are covered when ordered by the
member's PCP, attending physician or dentist and are provided for diagnosis,
prevention, treatment or assessment of a medical condition. Services are
generally provided in hospitals, clinics, physician offices and other health
care facilities.
REHABILITATION THERAPY: The Contractor shall provide occupational, physical and
speech therapies. Therapies must be prescribed by the member's PCP or attending
physician for an acute condition and the member must have the potential for
improvement due to the rehabilitation. Occupational and speech therapies are
only covered on an inpatient basis for those members who are 21 and over;
physical therapy for all members and occupational and speech therapies for
members under the age of 21 are covered on both an inpatient and outpatient
basis if not used as a maintenance regimen.
RESPIRATORY THERAPY: This therapy is covered on an inpatient or outpatient basis
when prescribed by the member's PCP or attending physician and is necessary to
restore, maintain or improve respiratory functioning.
TRANSPLANTATION OF ORGANS AND TISSUE, AND RELATED IMMUNOSUPPRESSANT DRUGS: These
services are covered within limitations defined in the AMPM for members
diagnosed with specified medical conditions. Such limitations include whether
the stage of the disease is such that the transplant can affect the outcome; the
member has no other conditions that substantially reduce the potential for
successful transplantation; and whether the member will be able to comply with
necessary and required regimens of treatment. Bone grafts are also covered under
this service. Services include pre-transplant inpatient or outpatient
evaluation; donor search; organ/tissue harvesting or procurement; preparation
and transplantation services; and convalescent care. In addition, if a member
receives a transplant covered by a source other than AHCCCS, medically necessary
non-experimental services are provided within limitations after the discharge
from the acute care hospitalization for the transplantation. AHCCCS has
contracted with transplantation providers for the Contractor's use or the
Contractor may select its
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own transplantation provider. However, the quality of services must be equal to
or exceed those of the AHCCCS provider and the rate paid can not exceed the
AHCCCS provider's negotiated rate.
AHCCCSA is in the process of releasing a Request for Proposal (RFP) for the
purpose of contracting with an entity that will coordinate transplant services
for all AHCCCS members. It is anticipated that the responsibility for transplant
services will be transferred to the new contractor on January 1, 2002.
TRANSPORTATION: These services include emergency and non-emergency medically
necessary transportation. Emergency transportation, including transportation
initiated by an emergency response system such as 911, may be provided by
ground, air or water ambulance to manage an AHCCCS member's emergency medical
condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided for
members who are unable to provide their own transportation for medically
necessary services.
TRIAGE/SCREENING AND EVALUATION: These are covered services when provided by
acute care hospitals, IHS facilities and urgent care centers to determine
whether or not an emergency exists, assess the severity of the member's medical
condition and determine services necessary to alleviate or stabilize the
emergent condition. The provider must notify the Contractor within 12 hours of
the member's registration with the facility for emergency services. Supporting
documentation for services rendered must be provided when reporting or billing a
service. Triage/screening services must be reasonable, cost effective and meet
the criteria for seventy of illness and intensity of service.
2. BEHAVIORAL HEALTH SERVICES
Title XIX and Title XXI members are eligible for comprehensive behavioral health
services. The behavioral health benefit for these members is provided through
the ADHS - Regional Behavioral Health Authority (RBHA) system. The Contractor
shall be responsible for member education regarding these benefits; provision of
limited emergency inpatient services; and screening and referral to the RBHA
system of members identified as requiring behavioral health services.
MEMBER EDUCATION: The Contractor shall be responsible for educating members in
the member handbook and other printed documents about covered behavioral health
services and where and how to access services. Covered services include:
a. Behavior Management (behavioral health personal assistance, family
support, peer support)
b. Case Management Services
c. Emergency/Crisis Behavioral Health Services
d. Emergency Transportation
e. Evaluation and Screening
f. Group Therapy and Counseling
g. Individual Therapy and Counseling
h. Family Therapy and Counseling
i. Inpatient Hospital
j. Inpatient Psychiatric Facilities for persons under 21 years of age
(residential treatment centers and subacute facilities)
k. Institutions for Mental Diseases (with limitations)
l. Laboratory and Radiology Services for Psychotropic Medication
Regulation and Diagnosis
m. Non-Emergency Transportation
n. Partial Care (Supervised day program, therapeutic day program, and
medical day program)
o. Psychosocial Rehabilitation (living skills training; health promotion;
per-job training, education and development; job coaching and
employment support)
p. Psychotropic Medication
q. Psychotropic Medication Adjustment and Monitoring
r. Respite Care
s. Therapeutic foster care
REFERRALS: As specified in Section D, Paragraph 1, EPSDT, the Contractor must
provide developmental/behavioral health screenings for members up to 21 years of
age in compliance with the AHCCCS periodicity schedule. The Contractor shall
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ensure the initiation and coordination of behavioral health referrals of these
members to the RBHA when determined necessary through the screening process.
The Contractor is responsible for RBHA referral and follow-up collaboration, as
necessary, for other Title XIX and Title XXI members identified as needing
behavioral health evaluation and treatment. Members may also access the RBHA
system for evaluation by self-referral or be referred by schools, State agencies
or other service providers. The Contractor is responsible for providing
transportation to a member's first RBHA evaluation appointment if a member is
unable to provide their own transportation.
EMERGENCY SERVICES: For Title XIX and Title XXI members not enrolled with ADHS,
the Contractor is responsible for up to three days of inpatient behavioral
health services per emergency episode not to exceed 12 days per contract year. A
referral to the RBHA for evaluation and enrollment should be initiated as soon
as possible after admission.
When Title XIX and Title XXI members present in an emergency room setting, the
Contractor is responsible for all emergency medical services including triage,
physician assessment and diagnostic tests. For Title XIX and Title XXI members
not enrolled with ADHS, the Contractor is responsible to provide medically
necessary psychiatric consultations or psychological consultations in emergency
room settings to help stabilize the member or determine the need for inpatient
behavioral health services. ADHS is responsible for medically necessary
psychiatric consultations provided to Title XIX and Title XXI ADHS enrolled
members in emergency room settings.
COORDINATION OF CARE: The Contractor is responsible for ensuring that a medical
record is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has not yet
seen the assigned member. In lieu of actually establishing a medical record,
such information may be kept in an appropriately labeled file but must be
associated with the member's medical record as soon as one is established. The
Contractor shall require the PCP to respond to RBHA/provider information
requests pertaining to ADHS enrolled members including, but not limited to,
current diagnosis, medication, pertinent laboratory results, last PCP visit, and
last hospitalization. For prior period coverage, the Contractor is responsible
for payment of all claims for medically necessary covered behavioral health
services to members not enrolled with ADHS.
MEDICATION MANAGEMENT SERVICES: The Contractor shall allow PCPs to provide
medication management services (prescriptions, medication monitoring visits,
laboratory and other diagnostic tests necessary for diagnosis and treatment of
behavioral disorders) to members with diagnoses of depression, anxiety and
attention deficit hyperactivity disorder. The Contractor shall make available,
on the Contractor's formulary, medications for the treatment of these disorders.
The Contractor shall ensure that training and education is available to PCPs
regarding behavioral health referral and consultation procedures. The Contractor
shall establish policies and procedures for referral and consultation and shall
include them in their provider manual. Also, Contractors shall inform PCPs about
the availability of resource information through the Maricopa Integrated Health
System's Psychiatric Residency Training Program and the Arizona Medical
Association regarding the diagnosis and treatment of behavioral health
disorders.
The Contractor shall ensure that its quality management program incorporates
monitoring of the PCP's management of behavioral health disorders.
3. AHCCCS MEDICAL POLICY MANUAL
The AHCCCS Medical Policy Manual (AMPM) is hereby incorporated by reference into
this contract. The Contractor is responsible for complying with the requirements
set forth within. The AMPM with search capability and linkages to AHCCCS rules,
Statutes and other resources is available to all interested parties through the
AHCCCS Home Page on the Internet (www.ahcccs.state.az.us). Upon adoption by
AHCCCSA, AMPM updates will be available through the Internet at the beginning of
each month. If required, the Contractors may receive one hard copy of the AMPM,
free of charge, from AHCCCSA, Office of Medical Management, however, the
Contractor shall be responsible for maintaining such copies current with these
updates.
4. VACCINE FOR CHILDREN PROGRAM
Federal legislation passed in 1993 (OBRA 93) amended Title XIX of the Social
Security Act and created the Vaccine for Children (VFC) program which became
effective 10/1/94. Through this program, the federal and state governments
purchase, and make available to providers free of charge, vaccines for AHCCCS
children under age 19. Therefore, the Contractor shall
19
not utilize AHCCCS funding to purchase vaccines for members under the age of 19.
Any provider, licensed by the State to administer immunizations, may register
with ADHS as a "VFC provider" and receive free vaccines. The Contractor shall
comply with all VFC requirements and monitor its providers to ensure that, if
providing immunizations to AHCCCS members under the age of 19, the providers are
registered with ADHS/VFC.
5. DENIALS OR REDUCTIONS OF SERVICES
When any covered service subject to prior authorization is denied, reduced,
suspended or terminated, the Contractor shall comply with the notice, request
for hearing and continuation of benefit requirements specified in 42 CFR ss.
431.200, et seq., A.A.C. R9-22-Article 13 and R9-3 1-Article 13, and the AHCCCS
Member Rights and Responsibilities Policy. This information must be explained in
the Member handbook provided for each member by the Contractor. The Contractor
is required to promptly provide any services specified in the AHCCCS Director's
decisions, irrespective of whether or not a Petition for Rehearing is filed.
Also, refer to Attachment H, Grievance and Request for Hearing Process and
Standards.
6. ENROLLMENT AND DISENROLLMENT
AHCCCSA has the exclusive authority to enroll and disenroll members. The
Contractor shall not disenroll any member for any reason unless directed to do
so by AHCCCSA. Eligibility for the various AHCCCS coverage groups is determined
by one of the following agencies:
Social Security Administration (SSA) SSA determines eligibility for the Supplementary Security Income (SSI) cash
program. SSI cash recipients are automatically eligible for AHCCCS
coverage.
Department of Economic Security (DES) DES determines eligibility for the families with children, pregnant women
and children under SOBRA, under section 1931 of the Social Security Act,
the Adoption Subsidy Program, Title IV-E foster care children, Young Adult
Transition Insurance Program, the Federal Emergency Services program
(FES), and effective 10/1/200 1, the Title XIX Waiver Members.
AHCCCSA AHCCCSA determines eligibility for the SSI/MAO groups, including the
FES program for this population (aged, disabled, blind), the Arizona Long-
Term Care System (ALTCS), the Qualified Medicare Beneficiary program
and other Medicare cost sharing programs, and the Title XXI program,
KidsCare.
Arizona's 15 Counties Proposition 204 legislation permits DES to allow counties to continue to
perform eligibility determinations for AHCCCS until October 1, 2002.
AHCCCS acute care members are enrolled with contractors in accordance with the
rules set forth in R9-22, Article 17.
HEALTH PLAN CHOICE
Title XIX members, including Title XIX waiver members, have a choice of
available health plans. A listing of the available health plans and their
telephone numbers will be given to each applicant during the application process
for AHCCCS benefits. Also included are instructions to applicants to call the
health plans directly with specific questions concerning the health plan. If
there is only one health plan available for the applicant's Geographical Service
Area, no choice is offered. Members who do not choose prior to AHCCCSA's being
notified of their eligibility are automatically assigned to a health plan based
on family continuity or the auto-assignment algorithm.
Title XXI members must select a health plan prior to being determined eligible
and therefore, will not be auto-assigned. When a member is transferred from
Title XIX to Title XXI and has not made a health plan choice for Title XXI, the
member will remain with the Title XIX health plan and a choice notice will be
sent to the member. The member may then change plans no later than 16 days from
the date the choice notice is sent.
Exceptions to the above enrollment policies for Title XIX members include:
previously enrolled members who have been disenrolled for less than 90 days will
be automatically enrolled with the same contractor, if that contractor is still
available. Also, women who are eligible for the Family Planning Services
Extension Program will automatically remain assigned to the
20
same health plan. The Family Planning Services Extension Program provides a
maximum of 24 months of family planning services.
The effective date of enrollment for a new Title XIX member with the Contractor
will generally be the day prior to the date the Contractor receives notification
from AHCCCSA via the daily roster. However, the Contractor is responsible for
payment of medically necessary covered services retroactive to the member's
beginning date of eligibility.
The effective date of enrollment for a Title XXI member will be the first day of
the month following notification to the health plan. If a Title XXI member is
determined eligible by the 25th of the month, the member will be enrolled with
the health plan as of the 1st of the following month. If the member is
determined eligible AFTER the 25th of the month, the member will be enrolled
with the health plan as of the 1st of the second following month.
Proposition 204 and Title XIX Waiver Member Expansion/Conversion:
DATE EXPANSION OR
EXPANSION AND CONVERSION POPULATION CONVERSION INITIATED ENROLLMENT METHODOLOGY
QMB Only to QMB Dual Conversion under SSI-MAO 4/1/01 Current Title XIX rules
New SSI-MAO's from 76% to 100% FPL 4/1/01 onward Current Title XIX rules
Eligible parents of SOBRA children and KidsCare children up to 7/1/01 - 9/1/01 Family Continuity
100% FPL
17 & 18 year old KidsCare children converting to Title XIX Redetermination date Remain in current health
plan
MNMI (prior to 10/1/01) 4/1/01 - 10/1/01 Current MNMI rules
SOBRA Family Planning notified of increase in Title XIX income limit 10/1/01 Remain in current health
to 100% FPL plan
SMI SSI's 7/1/01 - 9/1/01 Current Title XIX rules
Premium Sharing Conversion members with income at or below 100% FPL 10/1/01 Remain in current health
who are not parents of SOBRA children or KidsCare children plan
EAC/ELIC's who don't convert to KidsCare will be converted to a Title 10/1/01 Remain in current health
XIX group, probably SOBRA. plan
Title XIX Waiver members 10/1/01 Current Title XIX rules
PRIOR PERIOD COVERAGE: AHCCCS provides prior period coverage for Title XIX
members. Prior period coverage starts from the first day of the month of
application, or first eligible month, whichever is later, to the day a member is
enrolled with the Contractor. For MED's, prior period coverage is the time
period from the date the member met spenddown to the date of eligibility
approval. The Contractor is responsible for payment of all claims for medically
necessary covered services provided to members during prior period coverage.
This may include services provided prior to the contract year (See Section D,
Paragraph 37, Compensation, for a description of the Contractor's reimbursement
from AHCCCSA for this eligibility time period.)
NEWBORNS: Newborns born to AHCCCS-eligible mothers, including Title XXI mothers,
who were enrolled at the time of the child's birth, and whose newborn
notification was received by AHCCCSA, will be enrolled with the mother's health
plan. The Contractor is responsible for noticing AHCCCSA of a child's birth to
an enrolled member. Capitation to the Contractor will begin on the date
notification is received by AHCCCSA (except for cases of births during prior
period coverage). The effective date of AHCCCS eligibility will be the newborn's
date of birth, and the Contractor is responsible for all covered services to the
newborn whether or not AHCCCSA has received notification of the child's birth.
Note that AHCCCSA is currently available to receive notification calls 24 hours
a day, 7 days a week. Eligible mothers of newborns are sent a letter advising
them of their right to choose a different contractor for their child; otherwise
the child will remain with the mother's contractor. Newborns of FES mothers are
auto-assigned to a health plan and mothers of these newborns are sent a letter
advising them of their right to choose a different health plan for their child.
In the event the FES mother chooses a different health plan, AHCCCS will recoup
all capitation paid to the originally assigned plan and the baby will be
enrolled retroactive to the date of birth in the second plan. The second plan
will receive prior period capitation from the date of birth to the day before
assignment and prospective capitation from the date of assignment forward. The
second contractor will be responsible for all covered services to the newborn
from date of birth.
ENROLLMENT GUARANTEES: Upon initial capitated enrollment as a Title XIX-eligible
member, the member is guaranteed a minimum of five full months of continuous
enrollment. Upon initial capitated enrollment as a Title XXI-eligible member,
the
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member is guaranteed a minimum of 12 full months of continuous enrollment.
Enrollment guarantees do not apply to Native Americans who choose to obtain
their covered services through Indian Health Services (IHS) on a fee-for-service
basis or children enrolled with Department of Economic Security/Comprehensive
Medical and Dental Program. The enrollment guarantee applies a maximum of one
time per member per eligibility category for Title XIX and Title XXI members. If
a member changes from one contractor to another within the enrollment guarantee
period, the remainder of the guarantee period applies to the new contractor. The
enrollment guarantee may not be granted or may be terminated if the member is
incarcerated or, if a minor child is adopted. AHCCCS Rule R9-22, Article 17 and
R9-31, Article 3 describes other reasons for which the enrollment guarantee may
not apply.
NATIVE AMERICANS: Native Americans, on or off-reservation, have a choice to
receive services from Indian Health Services (IHS), a PL 93-638 tribal facility
or any available contractor. If choice is not available or made within the
specified time limit, Native American Title XIX members living on-reservation
will be assigned to IHS. Native American Title XIX members living
off-reservation will be assigned to an available contractor using AHCCCSA's
family continuity policy and auto-assignment algorithm. Native Americans may
change from IHS to a contractor or from a contractor to IHS at any time. Native
American Title XXI members must make a choice prior to being determined
eligible.
7. MAINSTREAMING OF AHCCCS MEMBERS
To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative
action so that members are provided covered services without regard to payer
source, race, color, creed, sex, religion, age, national origin, ancestry,
marital status, sexual preference, genetic information, or physical or mental
handicap, except where medically indicated. Contractors must take into account a
member's culture, when addressing members and their concerns, and must take
reasonable steps to encourage subcontractors to do the same. The Contractor must
make interpreters available for members to ensure appropriate delivery of
covered services.
Examples of prohibited practices include, but are not limited to, the following:
a. Denying or not providing a member any covered service or access to an
available facility.
b. Providing to a member any covered service which is different, or is
provided in a different manner or at a different time from that
provided to other members, other public or private patients or the
public at large except where medically necessary.
c. Subjecting a member to segregation or separate treatment in any manner
related to the receipt of any covered service; restricting a member in
any way in his or her enjoyment of any advantage or privilege enjoyed
by others receiving any covered service.
d. The assignment of times or places for the provision of services on the
basis of the race, color, creed, religion, age, sex, national origin,
ancestry, marital status, sexual preference, income status, AHCCCS
membership, or physical or mental handicap of the participants to be
served.
If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care
(i.e. the terms of the subcontract act to discourage the full utilization of
services by some members), the Contractor will be in default of its contract.
If the Contractor identifies a problem involving discrimination by one of its
providers, it shall promptly intervene and implement a corrective action plan.
Failure to take prompt corrective measures may place the Contractor in default
of its contract.
8. MEMBER INFORMATION
All informational materials prepared by the Contractor shall be approved by
AHCCCSA prior to distribution to members. The reading level and name of the
evaluation methodology used should be included.
- - All materials shall be translated when the Contractor is aware that a language
is spoken by 3,000 or 10% (whichever is less) of the Contractor's members who
also have Limited English Proficiency (LEP) in that language.
- - All vital materials shall be translated when the Contractor is aware that a
language is spoken by 1,000 or 5% (whichever is less) of the Contractor's
members who also have LEP in that language. Vital materials must include, at a
minimum, notices for denials, reductions, suspensions or terminations of
services, vital information from the member handbooks and consent forms.
22
- - All written notices informing members of their right to interpretation and
translation services in a language shall be translated when the Contractor is
aware that 1,000 or 5% (whichever is less) of the Contractor's members speak
that language and have LEP.
When there are program or service site changes, notification shall be provided
to the affected members at least 14 days before implementation. The Contractor
shall review and update the Member Handbook at least once a year. The Handbook
must be submitted to AHCCCSA Office of Managed Care for approval by Sept. 1 of
each contract year, or within four weeks of receiving the annual renewal
amendment, whichever is later.
The Contractor shall make every effort to ensure that all information prepared
for distribution to members is written at a 4th grade level.
The Contractor shall produce and provide the following printed information to
each member or family within 10 days of receipt of notification of the
enrollment date:
I. A Member Handbook which, at a minimum, shall include the following
items that are also listed in the Office of Managed Care, Operations
Policy #404, Member Information Policy:
a. A table of contents.
b. A general description of how managed care works, particularly
in regards to member responsibilities, appropriate utilization
of services and the PCP's role as gatekeeper of services.
c. A description of all available covered services and an
explanation of any service limitations or exclusions from
coverage and a notice stating that the Contractor will be
liable only for those services authorized by the Contractor.
The description should include a brief explanation of the
Contractor's approval and denial process.
d. Information on what to do when family size changes.
e. How to obtain a PCP.
f. How to change PCPs.
g. How to make, change and cancel appointments with a PCP or
dentist.
h. List of applicable copayments (including a statement that care
will not be denied due to lack of copayment). The member
handbook must clearly state that members cannot be billed for
covered services (other than applicable copayments), what to
do if they are billed, and under what circumstances a member
may be billed for non-covered services.
i. Dual eligibility (i.e. Medicare and Medicaid); services
received in and out of the Contractor's network; copayments.
See Section D, Paragraph 41, Medicare Services and Cost
Sharing.
j. The process of referral to specialists and other providers,
including access to behavioral health services provided by the
ADHS RBHA system.
k. How to contact Member Services and a description of its
function.
l. What to do in case of an emergency and instructions for
receiving advice on getting care in case of an emergency. In a
life-threatening situation, the member handbook should
instruct members to use the emergency medical services (EMS)
available and/or activate EMS by dialing 9-1-1. The handbook
should contain information on proper emergency service
utilization.
m. How to obtain emergency transportation and medically necessary
transportation.
n. EPSDT services. A description of the purpose and benefits of
EPSDT services, including the required components of EPSDT
screenings and the provision of all medically necessary
services to treat a physical or mental illness discovered by
the screenings. Screenings include a comprehensive history and
developmental/behavioral health screening, comprehensive
unclothed physical examination, appropriate vision testing,
hearing testing, laboratory tests, dental screening and
immunizations.
o. Maternity and family planning services.
p. Description of covered behavioral health services and how to
access these services.
q. Description of all covered dental services and how to access
these services.
r. Out of county/out of state moves.
s. Grievance and request for hearing procedures, including a
clear explanation of the members right to file a grievance and
request for hearing and to appeal any decision that affects
the member's receipt of covered services.
t. Contributions the member can make towards his/her own health,
member responsibilities, appropriate and inappropriate
behavior, and any other information deemed essential by the
Contractor or AHCCCS. This
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shall include a statement that the member is responsible for
protecting his or her ID card and that misuse of the card,
including loaning, selling or giving it to others could result
in loss of the members eligibility and/or legal action. A
sentence shall be included that stresses the importance of
members keeping, not discarding, the swipe ID card.
u. How to access after-hours care (urgent care).
v. Advance directives for adults.
w. Use of other sources of insurance. See Section D, Paragraph
40, Coordination of Benefits.
x. The last revision date.
y. Member's notification rights and responsibilities under AAC
R9-22, Article 13 and AHCCCS policy.
z. A description of Fraud and Abuse including instructions on how
to report suspected fraud or abuse. This shall include a
statement that misuse of a member's identification card,
including loaning, selling or giving it to others could result
in loss of the member's eligibility and/or legal action
against the member
aa. A statement that informs the member of their right to request
information on whether or not the health plan has Physician
Incentive Plans (PIP) that affect the use of referral
services, the right to know the types of compensation
arrangements the plan uses, the right to know whether
stop-loss insurance is required and the right to a summary of
member survey results (in accordance with PIP regulation).
bb. Members right to be treated fairly regardless of race,
religion, sex, age or ability to pay.
cc. Instructions for obtaining culturally competent materials,
including translated member materials.
dd. A description of the criteria and procedures for requesting a
health plan change.
ee. Information regarding prenatal HIV testing and counseling
services.
ff. Members have a right to know of providers who speak languages
other than English.
II. A list of the names, telephone numbers and service site addresses of
PCPs available for selection by the member and a description of the
selection process. Upon request by the member, the Contractor must make
information available regarding provider qualifications.
Regardless of the format chosen by the Contractor, the member handbook must be
printed in a type style and size, which can easily be read by members with
varying degrees of visual impairment. At a minimum, the member handbook shall
also contain the following language regarding questions, problems, grievances
and requests for hearings (Ref. AHCCCS Rule R9-22-518 and R9-31-518):
Q. What if I have any questions, problems or complaints about
[Contractor's name]?
A. If you have a question or problem, please call _________ and ask to
talk to a Member Representative. They are there to help you.
A. If you have a specific complaint about your medical care, the Member
Representative will help you.
Q. What if I'm not happy with the help given to me by the Member
Representative?
A. If you are unhappy with the answer you receive, you can tell the Member
Representative you want to file a written or oral grievance. The
grievance must be filed not later than 60 days after the date of the
action, decision, or incident.
A. [Contractor's name] will make a final decision for grievances within 30
days of receiving your written or oral grievance. A letter will be
mailed to you stating the health plan's decision and the reason for the
decision. The letter will tell you how you can appeal the decision if
you are still unhappy. You must let the health plan know you want to
appeal the decision letter.
A. If you are appealing the health plan's decision, [Contractor's name]
will send your request for appeal to the AHCCCSA. You will receive
information from AHCCCSA on how your appeal will be handled. AHCCCSA
will then decide if the health plan's decision was correct under the
circumstances.
9. MEMBER SURVEYS
AHCCCSA may periodically conduct a survey of a representative sample of the
Contractor's membership. AHCCCSA will design a questionnaire to assess
accessibility, availability and continuity of care with PCPs; communication
between members and the Contractor; and general member satisfaction with the
AHCCCS program. To ensure comparability of results, the questions to the members
will be the same for all contractors. AHCCCSA will consider suggestions from the
Contractor for questions to be included in each survey. The results of these
surveys will become public information and available to all interested parties
upon request. In addition, unless waived by AHCCCSA, the Contractor shall
perform its own annual general or focused member survey. All such contractor
surveys must be approved in advance by AHCCCSA.
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10. MARKETING
The Contractor shall submit all proposed marketing and outreach materials and
events that will involve the general public to the AHCCCS Marketing Committee
for prior approval in accordance with the AHCCCS Health Plan Marketing Policy.
The Contractor must have signed contracts with PCPs, specialists, dentists, and
pharmacies in order for them to be included in marketing materials.
11. ANNUAL ENROLLMENT CHOICE
AHCCCSA conducts an Annual Enrollment Choice (AEC) for members on their annual
anniversary date. AHCCCSA may hold an open enrollment on a limited basis as
deemed necessary. During AEC, members may change contractors subject to the
availability of other contractors within their Geographic Service Area. Members
are mailed a printed enrollment form and may choose a new contractor by
contacting AHCCCSA to complete the enrollment process. If the member does not
participate in the AEC, no change of contractor will be made (except for
approved changes under the Change of Plan Policy) during the new anniversary
year. This holds true if the Contractor's contract is renewed and the member
continues to live in the Contractor's service area. The Contractor shall comply
with the Office of Managed Care Member Transition for Annual Enrollment Choice
and Other Plan Changes policy.
12. TRANSITION OF MEMBERS
The Contractor shall comply with the AMPM, and the Office of Managed Care Member
Transition for Annual Enrollment Choice and Other Plan Changes standards for
member transitions between health plans or GSAs, to or from an ALTCS program
contractor, IHS, a PL 93-638 tribal entity, and upon termination or expiration
of a contract. The Contractor shall develop and implement policies and
procedures, which comply with AHCCCS medical policy to address transition of:
1. Members with significant medical conditions such as a high-risk
pregnancy or pregnancy within the last 30 days, the need for organ or
tissue transplantation, chronic illness resulting in hospitalization or
nursing facility placement, etc.;
2. Members who are receiving ongoing services such as dialysis, home
health, chemotherapy and/or radiation therapy or who are hospitalized
at the time of transition;
3. Members who have received prior authorization for services such as
scheduled surgeries, out-of-area specialty services, nursing home
admission;
4. Prescriptions, DME and medically necessary transportation ordered for
the transitioning member by the relinquishing contractor; and
5. Medical records of the transitioning member (the cost of reproducing
and forwarding medical records shall be the responsibility of the
relinquishing AHCCCS contractor).
When relinquishing members, the Contractor is responsible for timely
notification of the receiving contractor regarding pertinent information related
to any special needs of transitioning members. The Contractor, when receiving a
transitioning member with special needs, is responsible to coordinate care with
the relinquishing contractor in order that services not be interrupted, and for
providing the new member with health plan and service information, emergency
numbers and instructions of how to obtain services.
In the event the contract, or any portion thereof, is terminated for any reason,
or expires, the Contractor shall assist AHCCCSA in the transition of its members
to other contractors, and shall abide by standards and protocols set forth
above. In addition, AHCCCSA reserves the right to extend the term of the
contract on a month-to-month basis to assist in any transition of members. The
Contractor shall make provision for continuing all management and administrative
services until the transition of all members is completed and all other
requirements of this contract are satisfied. The Contractor shall be responsible
for providing all reports set forth in this contract and necessary for the
transition process and shall be responsible for the following:
a. Notification of subcontractors and members.
b. Payment of all outstanding obligations for medical care rendered to
members.
c. Until AHCCCSA is satisfied that the Contractor has paid all such
obligations, the Contractor shall provide the following reports to
AHCCCSA:
d. A monthly claims aging report by provider/creditor including IBNR
amounts;
e. A monthly summary of cash disbursements;
f. Copies of all bank statements received by the Contractor.
g. Such reports shall be due on the fifth day of each succeeding month for
the prior month.
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h. In the event of termination or suspension of the contract by AHCCCSA,
such termination or suspension shall not affect the obligation of the
Contractor to indemnify AHCCCSA for any claim by any third party
against the State or AHCCCSA arising from the Contractor's performance
of this contract and for which the Contractor would otherwise be liable
under this contract.
i. Any dispute by the Contractor with respect to termination or suspension
of this contract by AHCCCSA shall be exclusively governed by the
provisions of Section E, Paragraph 26, Disputes.
j. Any funds advanced to the Contractor for coverage of members for
periods after the date of termination shall be returned to AHCCCSA
within 30 days of termination of the contract.
13. STAFF REQUIREMENTS AND SUPPORT SERVICES
The Contractor shall have in place the organization, management and
administrative systems capable of fulfilling all contract requirements. For the
purposes of this contract, the Contractor shall not employ or contract with any
individual that has been debarred, suspended or otherwise lawfully prohibited
from participating in any public procurement activity. At a minimum, the
following staff is required.
a. A full-time ADMINISTRATOR/CEO/COO who is available at all times to
fulfill the responsibilities of the position and to oversee the entire
operation of the health plan. The Administrator shall devote sufficient
time to the Contractor's operations to ensure adherence to program
requirements and timely response to AHCCCS Administration.
b. A MEDICAL DIRECTOR who shall be an Arizona-licensed physician. The
Medical Director shall be actively involved in all-major clinical
programs and QM/UM components of the Contractor's health plan. The
Medical Director shall devote sufficient time to Contractor's health
plan to ensure timely medical decisions, including after-hours
consultation as needed.
c. A CHIEF FINANCIAL OFFICER/CFO who is available at all times to fulfill
the responsibilities of the position and to oversee the budget and
accounting systems implemented by the Contractor.
d. A QUALITY MANAGEMENT/UTILIZATION MANAGEMENT COORDINATOR who is an
Arizona-licensed registered nurse, physician or physician's assistant.
e. A MATERNAL HEALTH/EPSDT COORDINATOR who shall be an Arizona-licensed
registered nurse, physician or physician's assistant; or have a
Master's degree in health services, public health or health care
administration or other related field.
f. A BEHAVIORAL HEALTH COORDINATOR who shall be a behavioral health
professional as described in Health Services Rule R9-20. The Behavioral
Health Coordinator shall devote sufficient time to ensure that the
Contractor's behavioral health referral and coordination activities are
implemented per AHCCCSA requirements.
g. PRIOR AUTHORIZATION STAFF to authorize medical care 24 hours per day, 7
days per week. This staff shall include an Arizona-licensed registered
nurse, physician or physician's assistant.
h. CONCURRENT REVIEW STAFF to conduct inpatient concurrent review. This
staff shall consist of an Arizona-licensed registered nurse, physician,
physician's assistant or an Arizona-licensed practical nurse
experienced in concurrent review and under the direct supervision of a
registered nurse, physician or physician's assistant.
i. MEMBER SERVICES MANAGER AND STAFF to coordinate communications with
members and act as member advocates. There shall be sufficient Member
Service staff to enable members to receive prompt resolution to their
problems, and to meet the Contractor's standards for telephone
abandonment rates and telephone hold times.
j. PROVIDER SERVICES MANAGER AND STAFF to coordinate communications
between the Contractor and its subcontractors. There shall be
sufficient Provider Services staff to enable providers to receive
prompt resolution to their problems or inquiries.
k. A CLAIMS ADMINISTRATOR AND CLAIMS PROCESSORS to ensure the timely and
accurate processing of original claims, claims correction letters,
re-submissions and overall adjudication of claims.
1. ENCOUNTER PROCESSORS to ensure the timely and accurate processing and
submission to AHCCCSA of encounter data and reports.
m. A GRIEVANCE COORDINATOR who will manage and adjudicate member and
provider grievances.
n. CLERICAL AND SUPPORT STAFF to ensure appropriate functioning of the
Contractor's operation.
The Contractor shall inform AHCCCSA, Office of Managed Care, in writing and
provide a resume within seven days of staffing changes in the following key
positions:
Administrator Member Services Manager
Medical Director Provider Services Manager
Chief Financial Officer Claims Administrator
Maternal Health/EPSDT Coordinator Quality Management/Utilization Management
Grievance Coordinator Coordinator
Behavioral Health Coordinator
26
The Contractor shall ensure that all staff has appropriate training, education,
experience and orientation to fulfill the requirements of the position. See the
AMPM, Chapter 600 for specific position requirements.
14. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS
The Contractor shall develop and maintain written policies, procedures and job
descriptions for each functional area of its health plan, consistent in format
and style. The Contractor shall maintain written guidelines for developing,
reviewing and approving all policies, procedures and job descriptions. All
policies and procedures shall be reviewed at least annually to ensure that the
Contractor's written policies reflect current practices. Reviewed policies shall
be dated and signed by the Contractor's appropriate manager, coordinator,
director or administrator. All medical and quality management policies must be
approved and signed by the Contractor's Medical Director. Job descriptions shall
be reviewed at least annually to ensure that current duties performed by the
employee reflect written requirements.
15. ADVANCE DIRECTIVES
The Contractor shall maintain policies and procedures addressing advanced
directives for adult members that specify:
a. Each contract or agreement with a hospital, nursing facility, home
health agency, hospice or organization responsible for providing
personal care must comply with federal and State law regarding advance
directives for adult members. Requirements include:
(1) Maintaining written policies that address the rights of adult
members to make decisions about medical care, including the
right to accept or refuse medical care, and the right to
execute an advance directive. If the agency/organization has a
conscientious objection to carrying out an advance directive,
it must be explained in policies. (A health care provider is
not prohibited from making such objection when made pursuant
to A.R.S. ss. 36-3205.C.1.)
(2) Provide written information to adult members regarding each
individual's rights under State law to make decisions
regarding medical care, and the health care provider's written
policies concerning advance directives (including any
conscientious objections).
(3) Documenting in the member's medical record whether or not the
adult member has been provided the information and whether an
advance directive has been executed.
(4) Not discriminating against a member because of his or her
decision to execute or not execute an advance directive, and
not making it a condition for the provision of care.
(5) Providing education to staff on issues concerning advance
directives including notification of direct care providers of
services, such as home health care and personal care, of any
advanced directives executed by members to whom they are
assigned to provide services.
b. Contractors shall encourage subcontracted PCPs to comply with the
requirements of subparagraph a. (2) through (5) above. Contractors
shall also encourage health care providers specified in subparagraph a.
to provide a copy of the member's executed advanced directive, or
documentation of refusal, to the member's PCP for inclusion in the
member's medical record.
16. PERFORMANCE STANDARDS
All Performance Standards described below apply to Title XIX, Title XXI, and
state-only member populations. Effective October 1, 2001, AHCCCS requires
Contractors to implement the Quality Improvement System for Managed Care
(QISMC). AHCCCS will work with the Contractors to develop quality improvement
projects that will meet the QISMC guidelines. Compliance with this requirement
is a part of the Operational and Financial Review.
Contractors must meet AHCCCS stated Minimum Performance Standards. However, it
is equally important that Contractors continually improve their performance
indicator outcomes from year to year, as defined by QISMC. Contractors shall
strive to meet the ultimate standard, or Benchmark, established by AHCCCS.
Any statistically significant drop in the Contractor's performance level for any
indicator must be explained by the Contractor in its annual quality management
program evaluation. If a Contractor has a significant drop in any indicator
without a justifiable explanation, it will be required to submit a corrective
action plan and may be subject to sanctions.
27
AHCCCS has established three levels of performance:
- - MINIMUM PERFORMANCE STANDARD -- A Minimum Performance Standard is the
minimally expected level of performance by the Contractor. If a
Contractor does not achieve this standard for two consecutive years,
the Contractor will be required to submit a corrective action plan and
may be subject to sanctions. If the rate for any indicator declines to
a level below the AHCCCS Minimum Performance, the Contractor will be
required to submit a corrective action plan and may be subject to
sanctions.
- - GOAL -- A Goal is a reachable standard for a given performance
indicator for the Contract Year. If the Contractor has already met or
exceeded the AHCCCS Minimum Performance Standard for any indicator, the
Contractor must strive to meet the CYE 2002 Goal for the indicator(s).
- - BENCHMARK -- A Benchmark is the ultimate standard to be achieved.
Contractors that have already achieved or exceeded the Goal for any
performance indicator must strive to meet the Benchmark for the
indicator(s). Contractors that have achieved the Benchmark are expected
to maintain this level of performance for future years.
A Contractor that has not shown demonstrable and sustained improvement toward
meeting AHCCCS Performance Standards shall develop a corrective action plan. The
corrective action plan must be received by the Office of Medical Management
within 30 days of receipt of notification from AHCCCS. This plan must be
approved by AHCCCS prior to implementation. AHCCCS may conduct one or more
follow-up onsite reviews to verify compliance with a corrective action plan.
Failure to achieve adequate improvement may result in sanction imposed by
AHCCCS.
PERFORMANCE INDICATORS: For CYE 2001, the Contractor shall comply with AHCCCS
quality management requirements to improve performance for all AHCCCS
established performance indicators. Complete descriptions of these indicators
can be found in the Technical Specifications section of the most recently
published Health Plan Performance Standards Results and Analysis documents for
perinatal, pediatric and adult/adolescent services. For CYE 2002, the indicator
for postpartum visits has been eliminated as a contractual performance standard.
The Contractor shall continue to monitor rates for postpartum visits and
implement interventions as necessary to improve or sustain its rates. This
activity will be monitored by AHCCCS during the annual Operational and Financial
Review.
In addition, AHCCCS has established standards for the following indicators:
EPSDT PARTICIPATION: The Contractor shall take affirmative steps to increase
member participation in the EPSDT program. The participant rate is the number of
children younger than 21 years receiving at least one medical screen during the
contract year, compared to the number of children expected to receive at least
one medical screen. The number of children expected to receive at least one
medical screen is based on the AHCCCS EPSDT periodicity schedule and the average
period of eligibility.
PEDIATRIC IMMUNIZATIONS: The Contractor shall ensure members under age 21
receive age-appropriate immunizations as specified in the AMPM
The Contractor shall participate in an annual immunization audit based on random
sampling to assess and verify the immunization status of two-year-old members.
AHCCCS will provide the Contractor the selected sample, specifications for
conducting the audit, the AHCCCSA reporting requirements, and technical
assistance. The Contractor shall identify each child's PCP, conduct the
assessment, and report to AHCCCS in the required format all immunization data
for the two-year-old children sampled. If medical records are missing for more
that 5 percent of the sample group, the Contractor is subject to sanctions by
AHCCCSA. An External Quality Review Organization (EQRO) may conduct a study to
validate the Contractor's reported rates.
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The following table identifies the Minimum Performance Standards, Goals and
Benchmarks for each indicator:
BENCHMARK*
CYE 02 MINIMUM CYE 02 (HEALTH PEOPLE
PERFORMANCE STANDARD GOAL GOALS)
-------------------- ------ --------------
Performance Indicator
Immunization of two-year-olds 3 antigen
series (4:3:1) 78% 82% 90%
Immunization of two-year-olds 5 antigen
series (4:3:1:2:3) 67% 73% 90%
Immunizations of two-year-olds
DtaP 4 doses 82% 85% 90%
Polio 4 doses 88% 90% 90%
MMR 1 dose 88% 90% 90%
Hib 2 doses 85% 90% 90%
HBV 3 doses 81% 87% 90%
Varicella 1 dose 73% 80% 90%
Dental visits 45% 55% 90%
Well-child Visits 15 Months 58% 64% 90%
Well-child Visits 3-6 Years 48% 64% 80%
EPSDT Participation 58% 80% 80%
Children's Access to PCP's 77% 80% 95%
Cervical Cancer Screening (3-yr period) ** 57% 60% 85%
Breast Cancer Screening 55% 60% 60%
Adolescent Well-care Visits 48% 49% 50%
Adult Ambulatory/Preventive Care 78% 80% 95%
Low Birth Weight 8.5% 7.5% 5%
Initiation of Prenatal Care 59% 65% 90%
*Benchmarks for each performance indicator are based on Healthy People 2000 and
2010 goals for health promotion and disease prevention, as determined by the
U.S. Department of Health and Human Services.
**AHCCCS reported an overall three-year rate for cervical cancer screening,
consistent with HEDIS methodology, for CYE 1999. Results were not calculated for
individual Health Plans. AHCCCS will develop a methodology for compiling a
three-year rate for individual Health Plans for CYE 2000 and use this rate in
the future.
ACCESS TO CARE: During the contract year AHCCCSA will pursue the feasibility of
developing and establishing baseline information for two new measures: Provider
Turnover and Availability of Language Interpretation Services.
17. QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)
QUALITY MANAGEMENT (QM): The Contractor shall provide quality medical care to
members, regardless of payer source or eligibility category. The Contractor
shall execute processes to assess, plan, implement and evaluate quality
management and improvement activities, as specified in the AMPM, Chapter 900,
that include at least the following:
- - Conducting Quality Improvement Projects (QIPs);
- - QM monitoring and evaluation activities;
- - Credentialing and recredentialing processes;
- - Investigation, analysis, tracking and trending of quality of care
issues, abuse and/or complaints; and
- - AHCCCS mandated performance indicators.
The Contractor shall submit, within timelines specified in Attachment F, a
written QM plan that addresses its strategies for quality improvement and
conducting the quality management activities described in this section. Although
the Contractor is no longer required to conduct two clinical studies during each
contract year, the Contractor shall conduct quality improvement projects as
required by the AMPM, Chapter 900.
The Contractor may combine its plan for quality improvement and quality
management activities with the plan that addresses utilization management as
described below.
UTILIZATION MANAGEMENT (UM): The Contractor shall execute processes to assess,
plan, implement and evaluate utilization management activities, as specified in
the AMPM, Chapter 1000 that include at least the following:
- - Prior authorization;
- - Concurrent review;
- - Continuity and coordination of care;
- - Monitoring and evaluation of over and/or under utilization of services;
29
- - Evaluation of new medical technologies, and new uses of existing
technologies; and
- - Development and/or adoption of practice guidelines.
The Contractor shall maintain a written UM plan that addresses its plan for
monitoring UM activities described in this section. The plan must be submitted
for review by AHCCCS OMM within timelines specified in Attachment F.
18. PHYSICIAN INCENTIVES
The Contractor must comply with all applicable physician incentive requirements
and conditions defined in 42 CFR 417.479. These regulations prohibit physician
incentive plans that directly or indirectly make payments to a doctor or a group
as an inducement to limit or refuse medically necessary services to a member.
The Contractor is required to disclose all physician incentive agreements to
AHCCCSA and to AHCCCS members who request them.
The Contractor shall not enter into contractual arrangements that place
providers at significant financial risk as defined in CFR 417.479 unless
specifically approved in advance by the Office of Managed Care. In order to
obtain approval, the following must be submitted to the Office of Managed Care
45 days prior to the implementation of the contract:
1. A complete copy of the contract
2. A plan for the member satisfaction survey
3. Details of the stop-loss protection provided
4. A summary of the compensation arrangement that meets the substantial
financial risk definition..
The Contractor shall disclose to AHCCCSA the information on physician incentive
plans listed in 42 CFR 417.479(h)(1) through 417.479(I) upon contract renewal,
prior to initiation of a new contract, or upon request from AHCCCSA or CMS.
Please refer to the "Physician Incentive Guidelines" in the Bidder's Library for
details on providing required disclosures.
19. APPOINTMENT STANDARDS
For purposes of this section, "urgent" is defined as an acute, but not
necessarily life-threatening disorder, which, if not attended to, could endanger
the patient's health. The Contractor shall have procedures in place that ensure
the following standards are met:
a. Emergency PCP appointments - same day of request
b. Urgent care PCP appointments - within two days of request
c. Routine care PCP appointments - within 21 days of request
For SPECIALTY REFERRALS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of referral
b. Urgent care appointments - within three days of referral
c. Routine care appointments - within 30 days of referral
For DENTAL APPOINTMENTS, the Contractor shall be able to provide:
a. Emergency appointments - within 24 hours of request
b. Urgent appointments - within three days of request
c. Routine care appointments - within 45 days of request
For maternity care, the Contractor shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within three days of request
d. High risk pregnancies - within three days of identification
of high risk by the Contractor or maternity
care provider, or immediately if an
emergency exists
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If a member needs non-emergent medically necessary transportation, the
Contractor shall require its transportation provider to schedule the
transportation so that the member arrives no sooner than one hour before the
appointment; does not have to wait more than one hour after making the call to
be picked up; nor have to wait for more than one hour after conclusion of the
appointment for transportation home.
The Contractor shall actively monitor the adequacy of its appointment processes
and reduce the unnecessary use of alternative methods such as emergency room
visits. The Contractor shall actively monitor and ensure that a member's waiting
time for a scheduled appointment at the PCP's or specialist's office is no more
than 45 minutes, except when the provider is unavailable due to an emergency.
The Contractor shall have written policies and procedures about educating its
provider network regarding appointment time requirements. The Contractor must
assign a specific staff member or unit within its organization to monitor
compliance with appointment standards, and shall require a corrective action
plan when appointment standards are not met. Appointment standards shall be
included in the Provider Manual.
20. REFERRAL PROCEDURES AND STANDARDS
The Contractor shall have adequate written procedures regarding referrals to
specialists, to include, at a minimum, the following:
a. Use of referral forms clearly identifying the Contractor
b. A system for resolving disputes regarding the referrals
c. Having a process in place that ensures the member's PCP receives all
specialist and consulting reports and a process to ensure PCP follow-up
of all referrals including EPSDT referrals for behavioral health
services
d. A referral plan for any member who is about to lose eligibility and who
requests information on low-cost or no-cost health care services
e. Referral to Medicare HMO including payment of copayments
The Contractor shall comply with all applicable physician referral requirements
and conditions defined in Sections 1903(s) and 1877 of the Social Security Act.
Upon finalization of the regulations, the Contractor shall comply with all
applicable physician referral requirements and conditions defined in 42 CFR Part
411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act
prohibits physicians from making referrals for designated health services to
health care entities with which the physician or a member of the physician's
family has a financial relationship. Designated health services include:
Clinical laboratory services
Physical therapy services
Occupational therapy services
Radiology services
Radiation therapy services and supplies
Durable medical equipment and supplies
Parenteral and enteral nutrients, equipment and supplies
Prosthetics, orthotics and prosthetic devices and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services
21. PROVIDER MANUAL
The Contractor shall develop, distribute and maintain a provider manual. The
Contractor shall ensure that each contracted provider is issued a copy of the
provider manual and is encouraged to distribute a provider manual to any
individual or group that submits claim and encounter data. The Contractor
remains liable for ensuring that all providers, whether contracted or not, meet
the applicable AHCCCS requirements such as covered services, billing, etc. At a
minimum, the Contractor's provider manual must contain information on the
following:
a. Introduction to the Contractor which explains the Contractor's
organization and administrative structure
b. Provider responsibility and the Contractor's expectation of the
provider
c. Overview of the Contractor's Provider Service department and function
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d. Listing and description of covered and non-covered services,
requirements and limitations including behavioral health services
e. Emergency room utilization (appropriate and non-appropriate use of the
emergency room)
f. EPSDT Services - screenings include a comprehensive history,
developmental/behavioral health screening, comprehensive unclothed
physical examination, appropriate vision testing, hearing testing,
laboratory tests, dental screenings and immunizations
g. Dental services
h. Maternity/Family Planning services
i. The Contractor's policy regarding PCP assignments
j. Referrals to specialists and other providers, including access to
behavioral health services provided by the ADHS/RBHA system.
k. Grievance and request for hearing rights
1. Billing and encounter submission information
-indicate which form UB92, HCFA 1500, or Form C is to be used
for services
-indicate which fields are required for a claim to be
considered acceptable by the Contractor. A completed sample
of each form shall be included
m. Contractor's written policies and procedures which affect the
provider(s) and/or the provider network
n. Claims re-submission policy and procedure
o. Reimbursement, including reimbursement for dual eligibles (i.e.
Medicare and Medicaid) or members with other insurance
p. Explanation of remittance advice
q. Prior authorization and notification requirements
r. Claims medical review
s. Concurrent review
t. Fraud and Abuse
u. Formularies (with updates and changes provided in advance to providers,
including pharmacies)
v. AHCCCS appointment standards
w. Americans with Disabilities Act (ADA) requirements and Title VI, as
applicable
x. Eligibility verification
y. Cultural competency information, including notification about Title VI
of the Civil Rights Act of 1964. Providers should also be informed of
how to access interpretation services to assist members who speak a
language other the English or who use sign language.
22. PRIMARY CARE PROVIDER STANDARDS
The Contractor shall include in its provider network a sufficient number of PCPs
to meet the requirements of this contract. Health care providers designated by
the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic
physicians who generally specialize in family practice, internal medicine,
obstetrics, gynecology, or pediatrics; certified nurse practitioners or
certified nurse midwifes; or physician's assistants.
The Contractor shall assess the PCP's ability to meet AHCCCS appointment
availability and other standards, when determining the appropriate number of its
members to be assigned to a PCP. The Contractor should also consider the PCP's
total panel size (i.e. AHCCCS and non-AHCCCS patients) when making this
determination. AHCCCS members shall not comprise the majority of a PCP's panel
of patients. AHCCCSA shall inform the Contractor when a PCP has a panel of more
that 1,800 AHCCCS members (assigned by a single or multiple contractors), to
assist in the assessment of the size of their panel. This information will he
provided on a quarterly basis. The Contractor will adjust the size of a PCP's
panel, as needed, for the PCP to meet AHCCCS standards.
The Contractor shall have a system in place to monitor and ensure that each
member is assigned to an individual PCP and that the Contractor's data regarding
PCP assignments is current. The Contractor is encouraged to assign members with
complex medical conditions, who are age 12 and younger, to Board Certified
pediatricians. PCP's with assigned members diagnosed with AIDS or as HIV
positive shall meet criteria and standards set forth in the AHCCCS Medical
Policy Manual.
To the extent required by this contract, the Contractor shall offer members
freedom of choice in selecting a PCP. When a new member has been assigned to the
Contractor, the Contractor shall inform the member in writing of his enrollment
and of his PCP assignment within 10 days of the Contractor's receipt of
notification of assignment by AHCCCSA. The Contractor shall include with the
enrollment notification a list of all the Contractor's available PCPs and the
process for changing the PCP
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assignment, should the member desire to do so. The Contractor shall confirm any
PCP change in writing to the member. Members may make both their initial PCP
selection and any subsequent PCP changes either verbally or in writing.
At a minimum, the Contractor shall hold the PCP responsible for the following
gatekeeping activities:
a. Supervision, coordination and provision of care to each assigned member
b. Initiation of referrals for medically necessary specialty care
c. Maintaining continuity of care for each assigned member
d. Maintaining the member's medical record, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services.
The Contractor shall establish and implement policies and procedures to monitor
PCP gatekeeping activities and to ensure that PCPs are adequately notified of,
and receive documentation regarding, specialty and referral services provided to
assigned members by specialty physicians, dentists and other health care
professionals. Contractor policies and procedures shall be subject to approval
by AHCCCSA, Office of Managed Care, and shall be monitored through operational
audits. PCPs and specialists who provide inpatient services to the Contractor's
members shall have admitting and treatment privileges in a minimum of one
general acute care hospital that is located within the Contractor's service
area.
23. OTHER PROVIDER STANDARDS
The Contractor shall develop and implement policies and procedures to:
a. Recruit sufficient specialty physicians, dentists, health care
professionals, health care institutions and support services to meet
the medical needs of its members.
b. Monitor the adequacy, accessibility and availability of its provider
network to meet the needs of its members, including the provision of
care to members with limited proficiency in English.
Contractor policies shall be subject to approval by AHCCCSA, Office of Managed
Care, and shall be monitored through operational audits.
For specialty services, the Contractor shall ensure that:
a. PCP referral shall be required for specialty physician services, except
that women shall have direct access to GYN providers without a referral
for preventive and routine services. Any waiver of this requirement by
the Contractor must be approved in advance by AHCCCSA.
b. Specialty physicians shall not begin a course of treatment for a
medical condition other than that for which the member was referred,
unless approved by the member's PCP.
c. The specialty physicians shall provide to the member's PCP complete
documentation of all diagnostic services including copies: of test
results; if applicable; treatment services provided; and the resulting
outcome for each.
The Contractor shall ensure that a maternity care provider is designated for
each pregnant member for the duration of her pregnancy and postpartum care and
that maternity services are provided in accordance with the AMPM. The Contractor
may include in its provider network the following maternity care providers:
a. Arizona licensed allopathic and/or osteopathic physicians who are
general practitioners or specialize in family practice or obstetrics
b. Certified nurse midwives
c. Licensed midwives.
Members may choose, or be assigned, a PCP who provides obstetric care (physician
or certified nurse midwife). Such assignment shall be consistent with the
freedom of choice requirements for selecting health care professionals while
ensuring that the continuity of care is not compromised. Members who choose to
receive maternity services from a licensed midwife shall also be assigned to a
PCP for medical care as primary care is not within the scope of practice for
licensed midwives.
All physicians and certified nurse midwives who perform deliveries shall have OB
hospital privileges. Licensed midwives perform deliveries only in the member's
home. Labor and delivery services may also be provided in the member's home by
physicians, certified nurse practitioners and certified nurse midwives who
include such services within their practice.
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24. NETWORK DEVELOPMENT
The Contractor shall develop and maintain a provider network that is sufficient
to provide all covered services to AHCCCS members. It shall ensure covered
services are provided promptly and are reasonably accessible in terms of
location and hours of operation. There shall be sufficient personnel for the
provision of covered services, including emergency medical care on a
24-hour-a-day, 7-days-a-week basis. The proposed network shall be sufficient to
provide covered services within designated time and distance limits. For
Maricopa and Pima Counties only, this includes a network such that 95% of its
members residing within the boundary area of metropolitan Phoenix and Tucson do
not have to travel more than 5 miles to see a PCP or pharmacy. 95% of its
members residing outside the boundary area must not have to travel more than 10
miles to see such providers. See Attachment B, Minimum Network Requirements, for
details on network requirements by Geographic Service Area. Also see Section D,
Paragraph 35, Hospital Subcontracting and Reimbursement, for details on changes
in hospital subcontracting effective October 1, 2001.
Under the Balanced Budget Act of 1997, the Contractor shall not discriminate
with respect to participation in the AHCCCS program, reimbursement or
indemnification against any provider based solely on the provider's type of
licensure or certification. This provision, however, does not prohibit the
Contractor from limiting provider participation to the extent necessary to meet
the needs of the Contractor's members. This provision also does not interfere
with measures established by the Contractor to control costs consistent with its
responsibilities under this contract.
25. NETWORK MANAGEMENT
The Contractor shall have policies and procedures in place that pertain to all
service specifications described in the AMPM, Chapters 300, 600 and 900. In
addition, the Contractor shall have policies on how the Contractor will:
a. Communicate with the network regarding contractual and/or program
changes and requirements
b. Monitor and control network compliance with policies and rules of
AHCCCSA and the Contractor, including compliance with all policies and
procedures related to the grievance process and ensuring the member's
care is not compromised during the grievance process.
c. Evaluate the quality of services delivered by the network
d. Provide or arrange for medically necessary covered services should the
network become temporarily insufficient within the contracted service
area
e. Monitor network capacity to ensure that there are sufficient providers
to handle the volume of members
f. Ensure service accessibility, including monitoring appointment
procedures standards, appointment waiting times, and service provision
standards
All material changes in the Contractor's provider network must be approved in
advance by AHCCCSA, Office of Managed Care. A material change is defined as one,
which affects, or can reasonably be foreseen to affect, the Contractor's ability
to meet the performance and network standards as described in this contract. The
Office of Managed Care must be notified of planned material changes in the
provider network before the change process has begun, for example before issuing
a 60-day termination notice to a provider. The notification shall be made within
one working day if the change is unexpected. AHCCCSA will assess proposed
changes in the Contractor's provider network for potential impact on members'
health care and provide a written response to the Contractor within 14 days of
receipt of request. For emergency situations, AHCCCSA will expedite the approval
process.
The Contractor shall notify AHCCCSA, Office of Managed Care, within one working
day of any unexpected changes that would impair its provider network. This
notification shall include (1) information about how the change will affect the
delivery of covered services, and (2) the Contractor's plans for maintaining the
quality of member care if the provider network change is likely to result in
deficient delivery of covered services.
26. FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)
The Contractor is encouraged to use FQHCs in Arizona to provide covered services
and must comply with the federal mandates. Under the Benefits Improvement and
Protection Act of 2000 (BIPA). AHCCCSA is required to reimburse FQHCs the
difference between the Contractor's reimbursement to the FQHC, and what the FQHC
would have received under the Medicaid Prospective Payment System (PPS). This
requirement replaces the supplemental payment methodology that began October 1,
1997. AHCCCSA and its contractors are required to comply with this legislation.
34
AHCCCSA and the FQHCs have agreed that AHCCCSA will reimburse the FQHCs $1.75
per member per month for Title XIX members only. This payment methodology was
implemented effective January 1, 2001. To comply with BIPA requirements, AHCCCSA
will establish a baseline rate. After a baseline rate is established, AHCCCSA
will adjust the payment rate annually in accordance with annual inflation
trends.
Contractors are required to submit member month information for Title XIX
members, including Title XIX Waiver members, for each FQHC on a quarterly basis
to AHCCCS Office of Managed Care. AHCCCSA will perform periodic audits of the
member month information submitted. Contractors should refer to the Office of
Managed Care's policy on FQHC reimbursement for further guidance. The following
FQHCs are currently recognized by CMS:
Canyonlands Community Health Care
Chiricahua Community Health Centers, Inc.
Clinica Adelante, Inc.
Desert Senita Community Health Center
El Rio Health Center
Inter-Tribal Health Care Center
Marana Health Center
Mariposa Community Health Center, Inc.
Mountain Park Health Center
Native American Community Health Center, Inc.
Native Americans for Community Action Family Health Center
North Country Community Health Center
Sun Life Family Health
Center Sunset Community Health Center (formerly Valley Health
Center, Inc.)
United Community Health Center, Inc.
Any other clinics that subsequently become FQHC's will be subject to the
reimbursement methodology described above.
27. PROVIDER REGISTRATION
The Contractor shall ensure that all of its subcontractors register with AHCCCSA
as an approved service provider and receive an AHCCCS Provider ID Number. A
Provider Participation Agreement must be signed by each provider who does not
already have a current AHCCCS ID number. The original shall be forwarded to
AHCCCSA. This provider registration process must be completed in order for the
Contractor to report services a subcontractor renders to enrolled members and
for the Contractor to be paid reinsurance.
28. PROVIDER AFFILIATION TRANSMISSION
The Contractor shall submit information quarterly regarding its provider
network. This information shall be submitted in the format described in the
Provider Affiliation Transmission User Manual on October 15, January 15, April
15, and July 15 of each contract year. The Manual may be found in the Bidder's
Library.
29. PERIODIC REPORT REQUIREMENTS
AHCCCSA, under the terms and conditions of its CMS grant award, requires
periodic reports, encounter data, and other information from the Contractor. The
submission of late, inaccurate, or otherwise incomplete reports shall constitute
failure to report subject to the penalty provisions described in this contract.
Standards applied for determining adequacy of required reports are as follows:
a. Timeliness: Reports or other required data shall be
received on or before scheduled due dates.
b. Accuracy: Reports or other required data shall be
prepared in strict conformity with appropriate authoritative
sources and/or AHCCCS defined standards.
c. Completeness: All required information shall be fully
disclosed in a manner that is both responsive and pertinent to
report intent with no material omissions.
AHCCCS requirements regarding reports, report content and frequency of
submission of reports are subject to change at any time during the term of the
contract. The Contractor shall comply with all changes specified by AHCCCSA.
35
The Contractor shall be responsible for continued reporting beyond the term of
the contract. For example, processing claims and reporting encounter data will
likely continue beyond the term of the contract because of lag time in filing
source documents by subcontractors.
The Contractor shall comply with all financial reporting requirements contained
in the Reporting Guide for Acute Health Care Contractors with the Arizona Health
Care Cost Containment System, a copy of which may be found in the Bidder's
Library. The required reports, which are subject to change during the contract
term, are summarized in Attachment F, Periodic Report Requirements.
30. DISSEMINATION OF INFORMATION
Upon request, the Contractor shall assist AHCCCSA in the dissemination of
information prepared by AHCCCSA or the federal government to its members. The
cost of such dissemination shall be borne by the Contractor. All advertisements,
publications and printed materials that are produced by the Contractor and refer
to covered services shall state that such services are funded under contract
with AHCCCSA.
31. REQUESTS FOR INFORMATION
AHCCCSA may, at any time during the term of this contract, request financial or
other information from the Contractor. Upon receipt of such requests for
information, the Contractor shall provide complete information as requested no
later than 30 days after the receipt of the request unless otherwise specified
in the request itself.
32. OPERATIONAL AND FINANCIAL READINESS REVIEWS
AHCCCSA may conduct Operational and Financial Readiness Reviews on all
successful offerors and will, subject to the availability of resources, provide
technical assistance as appropriate. The Readiness Reviews will be conducted
prior to the start of business. The purpose of Readiness Reviews is to assess
new contractors' readiness and ability to provide contract services to members
at the start of the contract year and current contractors' readiness to expand
to new geographic service areas. A new contractor will be permitted to commence
operations only if the Readiness Review factors are met to AHCCCSA's
satisfaction.
33. OPERATIONAL AND FINANCIAL REVIEWS
In accordance with CMS requirements, AHCCCSA will conduct regular Operational
and Financial Reviews for the purpose of (but not limited to) ensuring
operational and financial program compliance. The Reviews will identify areas
where improvements can be made and make recommendations accordingly, monitor the
Contractor's progress towards implementing mandated programs and provide the
Contractor with technical assistance if necessary. The Contractor shall comply
with all other medical audit provisions as required by AHCCCS Rule R9-22-521 and
R9-31-521.
The type and duration of the Operational and Financial Review will be solely at
the discretion of AHCCCSA. Except in cases where advance notice is not possible
or advance notice may render the review less useful, AHCCCSA will give the
Contractor at least three weeks advance notice of the date of the on-site
review. In preparation for the on-site Operational and Financial Reviews, the
Contractor shall cooperate fully with AHCCCSA and the AHCCCSA Review Team by
forwarding in advance such policies, procedures, job descriptions, contracts,
logs and other information that AHCCCSA may request. The Contractor shall have
all requested medical records on-site. Any documents not requested in advance by
AHCCCSA shall be made available upon request of the Review Team during the
course of the review. The Contractor personnel, as identified in advance shall
be available to the Review Team at all times during AHCCCSA on-site review
activities. While on-site, the Contractor shall provide the Review Team with
workspace, access to a telephone, electrical outlets and privacy for
conferences. Certain documentation submission requirements may be waived at the
discretion of AHCCCSA if the Contractor has obtained accreditation from NCQA,
JCAHO or any other nationally recognized accrediting body. The Contractor must
submit the entire accreditation report to AHCCCSA for such waiver consideration.
The Contractor will be furnished a copy of the Operational and Financial Review
Report and given an opportunity to comment on any review findings prior to
AHCCCSA publishing the final report. Operational and Financial Review findings
may be used in the scoring of subsequent bid proposals by that Contractor.
Recommendations made by the Review Team to bring the Contractor into compliance
with federal, State, AHCCCS, and/or RFP requirements must be implemented by the
Contractor. AHCCCSA may conduct a follow-up Operational and Financial Review to
determine the Contractor's progress in
36
implementing recommendations and achieving program compliance. Follow-up reviews
may be conducted at any time after the initial Operational and Financial Review.
AHCCCSA may conduct an Operational and Financial Review in the event the
Contractor undergoes a merger, reorganization, change in ownership or makes
changes in three or more key staff positions within a 12-month period.
34. CLAIMS PAYMENT SYSTEM
The Contractor shall develop and maintain a claims payment system capable of
processing, cost avoiding and paying claims in accordance with ARS 36-2904(H)
and (K), AHCCCS Rules R9-22-705, and R9-22-709, a copy of which may be found in
the Bidder's Library. In the absence of a subcontract provision to the contrary,
claims submission deadlines shall be calculated from the date of service or the
effective date of eligibility posting, whichever is later. Remittance advices
accompanying the Contractor's payments to providers must contain, at a minimum,
adequate descriptions of all denials and adjustments, the reasons for such
denials and adjustments, the amount billed, the amount paid, and grievance and
request for hearing rights. The Contractor's claims payment system, as well as
its prior authorization and concurrent review process, must minimize the
likelihood of having to recoup already-paid claims. Any recoupment in excess of
$50,000 per provider within a contract year must be approved in advance by
AHCCCSA, Office of Managed Care.
In accordance with the Balanced Budget Act of 1997, unless a subcontract
specifies otherwise, the Contractor shall ensure that 90% of all clean claims
are paid within 30 days of receipt of the clean claim and 99% are paid within 90
days of receipt of the clean claim.
During the term of this contract, AHCCCSA anticipates requiring all health plans
to use a standardized electronic format for electronic claims processing between
the plan and its providers. AHCCCSA plans to require the formats outlined in the
Technical Interface Guidelines under Claims Processing, which is the format
adopted by CMS FFS providers and their billing agents who submit claims
electronically to AHCCCS. The form UB-92 and 1500 layouts will be supplemented
by a Form C layout. All formats are subject to changes as required by federal
law. Reasonable implementation timeframes will be negotiated with each plan.
35. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT
MARICOPA AND PIMA COUNTIES ONLY: Legislation authorizes the Hospital
Reimbursement Pilot Program (Pilot), which is effective from October 1, 2001,
through September 30, 2003. The Pilot as defined by AHCCCS Rule R9-22-718
requires hospital subcontracts to be negotiated between health plans in Maricopa
and Pima counties and hospitals to establish reimbursement levels, terms and
conditions. Subcontracts shall be negotiated by the Contractor and hospitals to
cover operational concerns, such as timeliness of claims submission and payment,
payment of discounts or penalties, legal resolution, which may, as an option,
include establishing arbitration procedures. These negotiated subcontracts shall
remain under close scrutiny by AHCCCSA to ensure availability of quality
services within specific service districts, equity of related party interests,
reasonableness of rates. The general provisions of this program encompass acute
care hospital services and outpatient hospital services that result in an
admission. The Contractor shall submit all hospital subcontracts and any
amendments to AHCCCSA, Office of Managed Care, for prior approval. For
non-emergency patient-days, the Contractor shall ensure that at least 65% of its
members use contracted hospitals. AHCCCSA reserves the right to subsequently
adjust the 65% standard. Further, if in AHCCCSA's judgement the number of
emergency days at a particular non-contracted hospital becomes significant,
AHCCCSA may require a subcontract at that hospital.
ALL COUNTIES EXCEPT MARICOPA AND PIMA: The Contractor shall reimburse hospitals
for member care in accordance with AHCCCS Rule R9-22-705. The Contractor is
encouraged to obtain contracts with hospitals in all GSA's and must submit
copies of these contracts, including amendments, to AHCCCSA, Office of Managed
Care, at least seven days prior to the effective dates thereof.
The Contractor may conduct prepayment and postpayment medical reviews of all
hospital claims including outlier claims. Erroneously paid claims are subject to
recoupment. If the Contractor fails to identify lack of medical necessity
through concurrent review and/or prepayment medical review, lack of medical
necessity identified during postpayment medical review shall not constitute a
basis for recoupment by the Contractor. This prohibition does not apply to
recoupments that are a result of an AHCCCS reinsurance audit. See also Section
D, Paragraph 34, Claims Payment System. For a more complete description of the
guidelines for hospital reimbursement, please consult the Bidder's Library for
applicable statutes and rules.
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FOR OUT-OF-STATE HOSPITALS: The Contractor shall reimburse out-of-state
hospitals in accordance with AHCCCS Rule R9-22-705.
36. NURSING FACILITY REIMBURSEMENT
The Contractor shall not deny nursing facility services if the nursing facility
is unable to obtain prior authorization in situations where acute care
eligibility and ALTCS eligibility overlap and the member is enrolled with an
AHCCCS acute care contractor. In such situations, the Contractor shall impose
reasonable authorization requirements. The Contractor's payment responsibility
described above applies only in situations where the nursing facility has not
been notified in advance of the member's enrollment with an AHCCCS acute care
contractor. To further illustrate, when ALTCS eligibility overlaps AHCCCS acute
care enrollment, the acute care enrollment takes precedence. Although the member
could be ALTCS eligible for this time period, there is no ALTCS enrollment that
occurs on the same days as AHCCCS acute enrollment. The Contractor is
responsible for payment of services while the member is enrolled with the
Contractor. The Contractor is not responsible for the full 90 days per contract
year of nursing facility coverage if ALTCS enrollment occurs before the 90 days
has ended.
The Contractor shall provide medically necessary nursing facility services for
any member who has a pending ALTCS application, who is currently residing in a
nursing facility and is eligible for services provided under this contract. If
the member becomes ALTCS eligible and is enrolled with an ALTCS Program
Contractor before the end of the maximum 90 days per contract year of nursing
facility coverage, the Contractor is only responsible for nursing facility
coverage during the time the member is enrolled with the Contractor. Nursing
facility services covered by a third party insurer (including Medicare) while
the member is enrolled with the Contractor shall be applied to the 90 day per
contract year limitation.
The Contractor shall notify the Assistant Director of the Division of Member
Services in writing, when a member has been residing in a nursing facility for
75 days. This will allow AHCCCSA time to follow-up on the status of the ALTCS
application process and to prepare for potential fee-for-service coverage if the
stay goes beyond the 90-day per contract year maximum.
37. COMPENSATION
The method of compensation under this contract will be Prior Period Coverage
(PPC) capitation, prospective capitation, delivery supplement, hospitalized
supplement for Title XIX Waiver members, HIV-AIDS supplement, reinsurance (PPC
and prospective), and third party liability, as described and defined within
this contract and appropriate laws, regulations or policies.
Subject to the availability of funds, AHCCCSA shall make payments to the
Contractor in accordance with the terms of this contract provided that the
Contractor's performance is in compliance with the terms and conditions of this
contract. Payment must comply with requirements of A.R.S. Title 36. AHCCCSA
reserves the option to make payments to the Contractor by wire or National
Automated Clearing House Association (NACHA) transfer and will provide the
Contractor at least 30 days notice prior to the effective date of any such
change.
Where payments are made by electronic funds transfer, AHCCCSA shall not be
liable for any error or delay in transfer nor indirect or consequential damages
arising from the use of the electronic funds transfer process. Any charges or
expenses imposed by the bank for transfers or related actions shall be borne by
the Contractor. Except for adjustments made to correct errors in payment, and as
otherwise specified in this section, any savings remaining to the Contractor as
a result of favorable claims experience and efficiencies in service delivery at
the end of the contract term may be kept by the Contractor.
All funds received by Contractor pursuant to this contract shall be separately
accounted for in accordance with generally accepted accounting principles.
Except for funds received from the collection of permitted copayments and
third-party liabilities, the only source of payment to Contractor for the
services provided hereunder is the Arizona Health Care Cost Containment System
Fund. An error discovered by the State with or without an audit in the amount of
fees paid to Contractor will be subject to adjustment or repayment by Contractor
making a corresponding decrease m a current Contractor's payment or by making an
additional payment by AHCCCSA to the Contractor.
No payment due the Contractor by AHCCCSA may be assigned by the Contractor. Ths
section shall not prohibit AHCCCSA at its sole option from making payment to a
fiscal agent hired by Contractor.
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The Contractor or its subcontractors shall collect any required copayment from
members but service will not be denied for inability to pay the copayment.
Except for permitted copayments, the Contractor or its subcontractors shall not
bill or attempt to collect any fee from, or for, a member for the provision of
covered services. Any required copayments collected shall belong to the
Contractor or its subcontractors.
PRIOR PERIOD COVERAGE (PPC) CAPITATION: The Contractor will be paid capitation
for all PPC member months., including partial member months. This capitation
includes the cost of providing medically necessary covered services to members
during prior period coverage. The PPC capitation rates will be set by AHCCCSA
and will be paid to the Contractor along with the prospective capitation
described below. Contractors will not receive PPC capitation for newborns of
members who were enrolled at the time of delivery.
RECONCILIATION OF PPC COSTS TO REIMBURSEMENT: For CYE `02 and `03, a full
reconciliation to 0% profit or loss will be done by AHCCCSA for all eligibility
groups, except for the Title XIX Waiver Group. Only the retro period is eligible
for this reconciliation. AHCCCSA will reimburse the health plans 100% of any
excess reasonable costs as determined by reported encounters, and all profits
will be recouped. Refer to the Office of Managed Care's PPC Reconciliation
Policy for further details of the reconciliation process.
RISK SHARING FOR TITLE XIX WAIVER MEMBERS: For CYE' 02 and CYE' 03, AHCCCSA will
reconcile the contractor's PPC and prospective medical cost expenses (net of
reinsurance, excluding administrative and non-operating expenses) to PPC
capitation, prospective capitation, and hospitalized supplements (net of
administration) paid to the Contractor during the year. This reconciliation will
limit the Contractor's losses to 2% and profits to 4%. Any losses in excess of
2% will be reimbursed to the Contractor, and likewise, profits in excess of 4%
will be recouped. Encounter data will be used to determine medical expenses.
The Contractor may choose to elect an alternative risk sharing methodology on
October 1, 2001 for CYE `02. In this alternative risk sharing methodology,
AHCCCSA will recoup profits in excess of 1% and reimburse losses in excess of
1%. Refer to the Title XIX Waiver Reconciliation Policy for details of the
reconciliation process.
DELIVERY SUPPLEMENT: When the Contractor has an enrolled woman who delivers
during a prospective enrollment period, the Contractor will be entitled to a
supplemental payment. Supplemental payments will not apply to women who deliver
in a prior period coverage time period. AHCCCSA reserves the right at any time
during the term of this contract to adjust the amount of this payment for women
who deliver at home.
HIV-AIDS SUPPLEMENT: On a quarterly basis, AHCCCSA shall utilize encounters to
determine the number of members receiving approved HIV/AIDS drugs and calculate
the amount of the supplemental payment. The rate of reimbursement for this
separate per member per month payment is specified in Section B and is subject
to review during the term of the contract. AHCCCSA reserves the right to recoup
any amounts paid for ineligible members as determined through an encounter data
review as well as an associated penalty for incorrect encounter reporting.
Refer to the Office of Managed Care's HIV/AIDS supplemental payment and review
policies for further details and requirements.
38. CAPITATION ADJUSTMENTS
INCENTIVE FUND: AHCCCSA may retain a specified percentage of capitation
reimbursement in order to distribute to Contractors based on their performance
measure outcomes. AHCCCSA will notify Contractors 60 days prior to a new
contract year if this methodology will be implemented and will provide details
of the reimbursement methodology at that time.
CAPITATION ADJUSTMENTS: Except for changes made specifically in accordance with
this contract, the rates set forth in Section B shall not be subject to
re-negotiation or modification during the contract period. AHCCCSA may, at its
option, review the effect of a program change and determine if a capitation
adjustment is needed. In these instances the adjustment will be prospective with
assumptions discussed with the Contractor prior to modifying capitation rates.
The Contractor may request a review of a program change if it believes the
program change was not equitable; AHCCCSA will not unreasonably withhold such a
review.
If the Contractor is in any manner in default in the performance of any
obligation under this contract, AHCCCSA may, at its option and in addition to
other available remedies, adjust the amount of payment until there is
satisfactory resolution of the
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default. The Contractor shall reimburse AHCCCSA and/or AHCCCSA may deduct from
future monthly capitation for any portion of a month during which the Contractor
was not at risk due to, for example:
a. death of a member
b. member's incarceration (not eligible for AHCCCS benefits from the date
of incarceration)
c. duplicate capitation to the same contractor
d. adjustment based on change in member's contract type
If a member is enrolled twice with the same contractor, recoupment will be made
as soon as the double capitation is identified. AHCCCSA reserves the right to
modify its policy on capitation recoupments at any time during the term of this
contract.
39. REINSURANCE
REGULAR ACUTE PROSPECTIVE REINSURANCE: Reinsurance is a stop-loss program
provided by AHCCCSA to the Contractor for the partial reimbursement of covered
inpatient facility medical services incurred for a member with an acute medical
condition beyond an annual deductible (AHCCCS Rule R9-22-503 and R9-31-503). Per
diem rates paid for nursing facility services, including room and board,
provided in lieu of hospitalization for up to 90 days in any contract year shall
be eligible for reinsurance coverage. Refer to the AHCCCS Re insurance Claims
Processing Manual for further details on the Reinsurance Program.
AHCCCSA is self-insured for the reinsurance program. The program is
characterized by an initial deductible level and a subsequent coinsurance
percentage. The coinsurance percent is the rate at which AHCCCSA will reimburse
the Contractor for inpatient covered services incurred above the deductible.
Prospective reinsurance coverage applies to prospective enrollment periods. The
deductible level is based on the Contractor's statewide AHCCCS acute care
enrollment (not including SOBRA Family Planning Extension services) as of
October 1st each contract year for all rate codes and counties, as shown in the
following table. These deductible levels are subject to change by AHCCCSA during
the term of this contract. Any change would have a corresponding impact on
capitation rates.
Prospective Reinsurance PPC Reinsurance
TITLE XIX NON-TXIX
STATEWIDE PLAN WAIVER WAIVER
ENROLLMENT GROUP COINSURANCE DEDUCTIBLE COINSURANCE
- ---------- --------- ----------- ---------- -----------
0-19,999 $20,000 75% $5,000 100%
20,000-49,999 $35,000 75% $5,000 100%
50,000 and over $50,000 75% $5,000 100%
A Contractor whose enrollment qualifies for the $35,000 or $50,000 deductible
level may, prior to the start of the contract period, elect one of the lower
deductible levels indicated in the above table. Contractors may riot elect to
increase their deductible level. If a Contractor's actual deductible is $35,000
or $50,000, AHCCCSA will increase the Contractor's capitation rate awarded by
defined amounts for each capitation risk group. These specific capitation
adjustments are available from the Office of Managed Care.
PRIOR PERIOD COVERAGE REINSURANCE: A separate reinsurance deductible and
coinsurance percentage will apply during prior period coverage. As noted in the
table above, all Contractors, regardless of enrollment, will be subject to a
$5,000 deductible level. The coinsurance percentage for the prior period
coverage reinsurance is 100%. Expenses incurred during prior period coverage
will not apply toward the prospective reinsurance thresholds. Effective October
1, 2001, the Title XIX Waiver Group will no longer be eligible for prior period
coverage reinsurance.
AHCCCSA will use inpatient encounter data to determine prospective and prior
period coverage reinsurance benefits. Reimbursement for these reinsurance
benefits will be made to the Contractor each month. AHCCCSA will also provide
for a reconciliation of reinsurance payments in the case where encounters used
in the calculation of reinsurance benefits are subsequently adjusted or voided.
Effective October 1, 1998, when a member changes Contractors within a contract
year, for reinsurance purposes, all eligible inpatient costs incurred for that
member will follow the member to the receiving health plan. Therefore, all
submitted encounters from the health plan the member is leaving (for dates of
service within the current contract year) will be applied
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toward the receiving health plan's deductible level. For further details
regarding this policy and other reinsurance policies refer to the AHCCCS
Reinsurance Claims Processing Manual.
Medical review on prospective and prior period coverage reinsurance cases will
be determined based on statistically valid retrospective random sampling.
AHCCCSA, Office of Medical Management, will generate the sampling and will
notify the Contractor of documentation needed for the retrospective medical
review process to occur at the Contractor's offices. Reinsurance consideration
will be given to inpatient facility contracts, and hearing decisions rendered by
the Office of Legal Assistance. Pre-hearing and/or hearing penalties
discoverable during the review process will not be reimbursed under reinsurance.
A recoupment of reinsurance reimbursements made to the Contractor will occur
based on the results of the medical review sampling. The results of the medical
review sampling will be separately extrapolated to the entire prospective and
prior period coverage reinsurance reimbursement populations in the review time
frame for the Contractor. AHCCCSA will give the Contractor at least 45 days
advance notice of any on-site review. The Contractor shall have all requested
medical records on-site. Any documents not requested in advance by AHCCCSA shall
be made available upon request of the Review Team during the course of the
review. The Contractor representative shall be available to the Review Team at
all times during AHCCCSA on-site review activities. While on-site, the
Contractor shall provide the Review Team with workspace, access to a telephone,
electrical outlets and privacy for conferences. The Contractor will be furnished
a copy of the Reinsurance Review Report within 60 days of the onsite review and
given an opportunity to comment on any review findings.
CATASTROPHIC REINSURANCE: The reinsurance program also includes a special
Catastrophic Reinsurance program. This program encompasses members diagnosed
with hemophilia, von Willebrand's Disease, and Gaucher's Disease. This program
also covers members who are eligible to receive covered major organ and tissue
transplantation including bone marrow, heart, heart/lung, lung, liver, kidney,
and other organ transplantation. For additional detail and restrictions refer to
the AHCCCS Reinsurance Claims Processing Manual and the AMPM. There are no
deductibles for catastrophic reinsurance cases. All catastrophic claims are
subject to medical review by AHCCCSA.
The Contractor shall notify AHCCCSA, Office of Medical Management, Reinsurance
Unit, of cases identified for catastrophic non-transplant reinsurance coverage
within 30 days of (a) initial diagnosis, (b) enrollment with the Contractor, and
(c) the beginning of each contract year. Catastrophic reinsurance will be paid
for a maximum 30-day retroactive period from the date of notification to
AHCCCSA.
HEMOPHILIA: When a member is identified as being catastrophically eligible by
AHCCCSA due to the specific diagnosis of hemophilia (ICD9 codes 286.0, 286.1,
286.2), all medically necessary covered services provided during the contract
year shall be eligible for reimbursement at 85% of the Contractor's paid amount.
VON WILLEBRAND'S DISEASE: Catastrophic reinsurance coverage is available for all
members diagnosed with von Willebrand's Disease who are non-DDAVP responders and
dependent on Plasma Factor VIII. The Contractor must promptly notify AHCCCS
Office of Medical Management Reinsurance Unit after diagnosis. All medically
necessary covered services provided during the contract year shall be eligible
for reimbursement at 85% of the Contractor's paid amount.
GAUCHER'S DISEASE: Catastrophic reinsurance is available for members diagnosed
with Gaucher's Disease classified as Type I and are dependent on enzyme
replacement therapy. All medically necessary covered services provided during
the contract year shall be eligible for reimbursement at 85% of the Contractor's
paid amount.
TRANSPLANTS: Bone grafts and cornea transplantation services are not eligible
for catastrophic reinsurance coverage but are eligible under the regular
(non-catastrophic) reinsurance program. Refer to the AMPM, Chapter 300 for
covered services for organ and tissue transplants. Catastrophic reinsurance
coverage for transplants is limited to 85% of the AHCCCS contract amount for the
transplantation services rendered, or 85% of the Contractor's paid amount,
whichever is lower. The AHCCCS contracted transplantation rates may be found in
the Bidder's Library. When a member is referred to a transplant facility for an
AHCCCS-covered organ transplant, the Contractor shall notify AHCCCSA, Office of
Medical Management.
Encounter data will not be used to determine catastrophic reinsurance benefits
for transplants. However, this does not relieve the Contractor of the
responsibility for submitting encounters for all catastrophic reinsurance
services.
Effective October 1, 2000, Contractors will be reimbursed 100% for medically
necessary expenses provided in a contract year, after a catastrophic reinsurance
case reaches $650,000. This additional reimbursement will limit a Contractor's
medical expenses to $97,500 per catastrophic reinsurance case.
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All reinsurance claims must be submitted within fifteen months after the date of
service, or date of eligibility posting, whichever is later.
40. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as
a source of payment for covered services only after all other sources of payment
have been exhausted. The two methods used in the coordination of benefits are
cost avoidance and postpayment recovery. The Contractor shall use these methods
as described in A.A.C. R9-22-10. See Section D, Paragraph 41, Medicare Services
and Cost Sharing.
COST AVOIDANCE: The Contractor shall cost-avoid all claims or services that are
subject to third-party payment and may deny a service to a member if it knows
that a third party (i.e. other insurer) will provide the service. However, if a
third-party insurer (other than Medicare) requires the member to pay any
copayment, coinsurance or deductible, the Contractor is responsible for making
these payments, even if the services are provided outside of the Contractor's
network. The Contractor's liability for coinsurance and deductibles is limited
to what the Contractor would have paid for the entire service pursuant to a
written contract with the provider or the AHCCCS fee-for-service rate, less any
amount paid by the third party. (The Contractor must decide whether it is more
cost-effective to provide the service within its network or pay coinsurance and
deductibles for a service outside its network. For continuity of care, the
Contractor may also choose to provide the service within its network.) If the
Contractor refers the member for services to a third-party insurer (other than
Medicare), and the insurer requires payment in advance of all copayments,
coinsurance and deductibles, the Contractor must make such payments in advance.
If the Contractor knows that the third party insurer will neither pay for nor
provide the covered service, and the service is medically necessary, the
Contractor shall not deny the service nor require a written denial letter. If
the Contractor does not know whether a particular service is covered by the
third party, and the service is medically necessary, the Contractor shall
contact the third party and determine whether or not such service is covered
rather than requiring the member to do so. (See also Section D, Paragraph 41,
Medicare Services and Cost Sharing.)
The requirement to cost-avoid applies to all AHCCCS covered services. For
prenatal care and preventive pediatric services, AHCCCS may require the
Contractor to provide such service and then coordinate payment with the
potentially liable third party ("pay and chase"). In emergencies, the Contractor
shall provide the necessary services and then coordinate payment with the
third-party payer. The Contractor shall also provide medically necessary
transportation so the member can receive third-party benefits. Further, if a
service is medically necessary, the Contractor shall ensure that its cost
avoidance efforts do not prevent a member from receiving such service and that
the member shall not be required to pay any coinsurance or deductibles for use
of the other insurer's providers.
POSTPAYMENT RECOVERIES: Postpayment recovery is necessary in cases where the
Contractor was not aware of third-party coverage at the time services were
rendered or paid for, or was unable to cost-avoid. The Contractor shall identify
all potentially liable third parties and pursue reimbursement from them except
in the circumstances below. The Contractor shall not pursue reimbursement in the
following circumstances unless the case has been referred to the Contractor by
AHCCCSA or AHCCCSA'S authorized representative:
Uninsured/underinsured motorist insurance Restitution Recovery
First-and third-party liability insurance Worker's Compensation
Tortfeasors, including casualty Estate recovery
Special Treatment Trusts recovery
The Contractor shall report any cases involving the above circumstances to
AHCCCSA's authorized representative should the Contractor identify such a
situation. See AHCCCS Rule R9-22-1002 and R9-3l-1002. The Contractor shall
cooperate with AHCCCSA's authorized representative in all collection efforts. In
joint cases involving both AHCCCS fee-for-service or reinsurance and the
Contractor, AHCCCSA's authorized representative is responsible for performing
all research, investigation and payment of lien-related costs, subsequent to the
referral of any and all relevant case information to AHCCCSA's authorized
representative by the Contractor. AHCCCSA's authorized representative is also
responsible for negotiating and acting in the best interest of all parties to
obtain a reasonable settlement in joint cases and may compromise a settlement in
order to maximize overall reimbursement, net of legal and other costs. For total
plan cases involving only payments from the Contractor, the Contractor is
responsible for performing all research, investigation, the filing of liens and
payment of lien filing fees and other related costs. The Contractor shall use
the cover sheet as prescribed by AHCCCS when filing liens.
The Contractor may retain up to 100% of its third-party collections if all of
the following conditions exist:
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a. Total collections received do not exceed the total amount of the
Contractor's financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service,
reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law
REPORTING. The Contractor may be required to report case level detail of
third-party collections and cost avoidance, including number of referrals on
total plan cases. In addition, upon AHCCCSA's request, the
Contractor shall provide an electronic extract of the Casualty cases, including
open and closed cases. Data elements include, but are not limited to: the
member's first and last name; AHCCCS ID; date of incident; claimed amount;
paid/recovered amount; and case status. The AHCCCSA TPL Section shall provide
the format and reporting schedule for this information to the Contractor. The
Contractor shall notify AHCCCSA's authorized representative within five working
days of the identification of a third-party liability case with retnsurance.
Failure to report reinsurance cases may result in one of the remedies specified
in Paragraph 60 (Sanctions) of Section D. The Contractor shall communicate any
known change in health insurance information, including Medicare, to AHCCCS
Administration, Division of Member Services, not later than 10 days from the
date of discovery using the AHCCCS Third-Party Coverage Form found in the
Bidder's Library.
AHCCCSA will provide the Contractor, on an agreed upon schedule, with a complete
file of all third-party coverage information (other than Medicare) for the
purpose of updating the Contractor's files. The Contractor shall notify AHCCCSA
of any known changes in coverage within deadlines and in a format prescribed by
AHCCCSA.
TITLE XXI (KIDSCARE): Eligibility for KidsCare benefits requires that the
applicant/member not be enrolled with or entitled to any other health insurance
benefits. If the Contractor becomes aware of any such potential coverage, the
Contractor shall notify AHCCCSA immediately. The Contractor shall follow the
same cost avoidance and postpayment recovery practices for the KidsCare
population as it does for the Title XIX population, and shall maintain a
reporting system which allows Title XIX and KidsCare information to be reported
separately.
CONTRACT TERMINATION: Upon termination of this contract, the Contractor will
complete the existing third party liability cases or make any necessary
arrangements to transfer the cases to AHCCCSA's authorized TPL representative.
41. MEDICARE SERVICES AND COST SHARING
AHCCCS has members enrolled who are eligible for both Medicaid and Medicare.
These members are referred to as "dual eligible". Generally, Contractors are
responsible for payment of Medicare coinsurance and/or deductibles for covered
services provided to dual eligible members. However, there are different cost
sharing responsibilities that apply to dual eligible members based on a variety
of factors. The Contractor is responsible for adhering to the cost sharing
responsibilities presented in the AHCCCS Medicare Cost Sharing policy. Effective
10/1/97, the Contractor shall have no cost sharing obligation if the Medicare
payment exceeds what the Contractor would have paid for the same service of a
non-Medicare member.
42. COPAYMENTS
The Contractor is responsible for the collection of copayments from members in
accordance with AHCCCS Rule R9-22-711 and R9-31-711. The Contractor may not
collect copayments for family planning and EPSDT services.
43. RECORDS RETENTION
The Contractor shall maintain books and records relating to covered services and
expenditures including reports to AHCCCSA and working papers used in the
preparation of reports to AHCCCSA. The Contractor shall comply with all
specifications for record keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as required by AHCCCS Rules
and policies. Records shall include but not be limited to financial statements,
records relating to the quality of care, medical records, prescription files and
other records specified by AHCCCSA.
The Contractor agrees to make available at its office at all reasonable times
during the term of this contract and the period set forth in paragraphs a. and
b. below any of its records for inspection, audit or reproduction by any
authorized representative of AHCCCSA, State or Federal government.
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The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this contract except as provided
in paragraphs a. and b. below:
If this contract is completely or partially terminated, the records relating to
the work terminated shall be preserved and made available for a period of five
years from the date of any such termination. Records which relate to grievances,
disputes, litigation or the settlement of claims arising out of the performance
of this contract, or costs and expenses of this contract to which exception has
been taken by AHCCCSA, shall be retained by the Contractor for a period of five
years after the date of final disposition or resolution thereof.
44. MEDICAL RECORDS
The member's medical record is the property of the provider who generates the
record. Each member is entitled to one copy of his or her medical record free of
charge. The Contractor shall have written policies and procedures to maintain
the confidentiality of all medical records. AHCCCSA shall be afforded access to
all members' medical records whether electronic or paper within 20 working days
of receipt of request.
The Contractor is responsible for ensuring that a medical record is established
when information is received about a member. If the PCP has not yet seen the
member, such information may be kept temporarily in an appropriately labeled
file, in lieu of actually establishing a medical record, but must be associated
with the member's medical record as soon as one is established.
The Contractor shall have written policies and procedures for the maintenance of
medical records so that those records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of
information.
The Contractor shall have written standards for documentation on the medical
record for legibility, accuracy and plan of care which comply with the AMPM.
The Contractor shall have written plans for providing training and evaluating
providers' compliance with the Contractor's medical records standards. Medical
records shall be maintained in a detailed and comprehensive manner which
conforms to good professional medical practice, permits effective professional
medical review and medical audit processes, and which facilitates an adequate
system for follow-up treatment. Medical records must be legible, signed and
dated.
When a member changes PCPs, his or her medical records or copies of medical
records must be forwarded to the new PCP within 10 working days from receipt of
the request for transfer of the medical records.
AHCCCSA is not required to obtain written approval from a member before
requesting the member's medical record from the PCP or any other agency. The
Contractor may obtain a copy of a member's medical records without written
approval of the member if the reason for such request is directly related to the
administration of the AHCCCS program.
Information related to fraud and abuse may be released so long as protected
HIV-related information is not disclosed. (A.R.S. ss. 36-6641)
45. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS
The Contractor shall not, without the prior approval of AHCCCSA, make any
advances to a related party or subcontractor. The Contractor shall not, without
similar prior approval, make any distribution, loan or loan guarantee to any
entity, including another fund or line of business within its organization. All
investments, other than investments in U.S. Government securities or
Certificates of Deposit, also require AHCCCSA pnor approval. (See the Reporting
Guide for Acute Care Contractors for alternatives to the prior approval of
individual investments.) All requests for prior approval are to be submitted to
the Office of Managed Care.
46. ACCUMULATED FUND DEFICIT
The Contractor and its owners shall fund any accumulated fund deficit through
capital contributions in a form acceptable to AHCCCSA within 30 days after
receipt by AHCCCSA of the final audited financial statements, or as otherwise
requested by AHCCCSA. AHCCCSA may, at its option, impose enrollment caps in any
or all GSA's as a result of an accumulated deficit, even if unaudited.
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47. DATA EXCHANGE REQUIREMENT
The Contractor is authorized to exchange data with AHCCCSA relating to the
information requirements of this contract and as required to support the data
elements to be provided AHCCCSA in the format specified in the AHCCCS Technical
Interface Guidelines which is available in the Bidder's Library. The information
so recorded and submitted to AHCCCSA shall be in accordance with all procedures,
policies, rules, or statutes in effect during the term of this contract. If any
of these procedures, policies, rules, regulations or statutes are hereinafter
changed both parties agree to conform to these changes following appropriate
notification to both parties by AHCCCSA.
The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to
any error, omission, deletion, or erroneous insert caused by
Contractor-submitted data. Any data that does not meet the standards required by
AHCCCSA shall not be accepted by AHCCCSA.
The Contractor is responsible for identifying any inconsistencies immediately
upon receipt of data from AHCCCSA. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary
adjustments to correct its records at its own expense.
The Contractor shall accept from AHCCCSA original evidence of eligibility and
enrollment in a form appropriate for electronic data exchange. Upon request by
AHCCCSA, the Contractor shall provide to AHCCCSA updated date-sensitive PCP
assignments in a form appropriate for electronic data exchange.
The Contractor shall be provided with a Contractor-specific security code for
use in all data transmissions made in accordance with contract requirements.
Each data transmission by the Contractor shall include the Contractor's security
code. The Contractor agrees that by use of its security code, it certifies that
any data transmitted is accurate and truthful, to the best of the Contractor's
knowledge. The Contractor further agrees to indemnify and hold harmless the
State of Arizona and AHCCCSA from any and all claims or liabilities, including
but not limited to consequential damages, reimbursements or erroneous billings
and reimbursements of attorney fees incurred as a consequence of any error,
omission, deletion or erroneous insert caused by the Contractor in the submitted
input data. Neither the State of Arizona nor AHCCCSA shall be responsible for
any incorrect or delayed payment to the Contractor's AHCCCS services providers
(subcontractors) resulting from such error, omission, deletion, or erroneous
input data caused by the Contractor in the submission of AHCCCS claims.
The publication AHCCCS Contracted Health Plan Technical Interface Guidelines
describes the specific technical and procedural requirements for interfaces
between AHCCCS and the Contractor and its subcontractors. The Contractor is
responsible for complying with all technical requirements as stated in this
manual as well as any subsequent changes to the manual. A copy may be found in
the Bidder's Library.
The costs of software changes are included in administrative costs paid to the
Contractor. There is no separate payment for software changes. A PMMIS systems
contact will be assigned after contract award. AHCCCSA will work with the health
plans as they evaluate Electronic Data Interchange options.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA): The Contractor
shall comply with the Administrative Simplification requirements of Subpart F of
the HIPPA of 1996 (Public Law 107-191, 110 Statutes 1936) and all federal
regulations implementing that Subpart that are applicable to the operations of
the Contractor by the dates required by the implementing federal regulations.
Failure to comply with the requirements of this paragraph constitute grounds for
the termination of this contract.
CONTRACT TERMINATION FOR FAILURE TO COMPLY WITH HIPAA: The Contractor shall
notify AHCCCS no later than one hundred and twenty (120) days prior to any
required compliance date if the Contractor is unwilling to or anticipates that
it will be unable to comply with any of the requirements of the preceding
paragraph. Receipt by AHCCCS of a notice of anticipated inability of
unwillingness to comply as required by this paragraph constitute grounds for the
termination of this contract.
48. ENCOUNTER DATA REPORTING
The accurate and timely reporting of encounter data is crucial to the success of
the AHCCCS program. AHCCCSA uses encounter data to pay reinsurance benefits, set
fee-for-service and capitation rates, determine disproportionate share payments
to hospitals, and to determine compliance with performance standards. The
Contractor shalt submit encounter data to AHCCCSA for all covered services for
which the Contractor incurred a financial liability, including services provided
during prior period coverage. This requirement is a condition of the CMS grant
award.
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Encounter data must be provided to AHCCCSA by electronic media and must be
submitted in the PMMIS AHCCCSA supplied formats. Formatting and specific
requirements for encounter data are described in the AHCCCS Encounter Reporting
User Manual and the AHCCCS Technical Interface Guidelines, copies of which may
be found in the Bidder's Library. The Encounter Submission Requirements are
included herein as Attachment I.
An Encounter Submission Tracking Report must be maintained and made available to
AHCCCSA upon request. The Tracking Report's purpose is to link each claim to an
adjudicated or pended encounter returned to the Contractor. Further information
regarding the Encounter Submission Tracking Report may be found in The Encounter
User's Manual.
49. MONTHLY ROSTER RECONCILIATION
AHCCCSA produces daily roster updates identifying new members and changes to
members' demographic, eligibility and enrollment data, which the Contractor
shall use to update its member records. The daily roster which is run prior to
the monthly roster is referred to as the "last daily" and will contain all rate
code changes made for the prospective month, as well as any new enrollments and
disenrollments.
The monthly roster is generally produced two days before the end of every month.
The roster will identify the total active population for the Contractor as of
the first day of the next month. This roster contains the information used by
AHCCCSA to produce the monthly capitation payment for the next month. The
Contractor will reconcile their member files with the AHCCCS monthly roster.
After reconciling the monthly roster information, the Contractor resumes posting
daily roster updates beginning with the last two days of the month. The last two
daily rosters are different from the regular daily rosters in that they pay
and/or recoup capitation into the next month.
Refer to the AHCCCS Contracted Health Plan Technical Interface Guidelines
available in the Bidder's Library for additional information.
50. TERM OF CONTRACT AND OPTION TO RENEW
The initial term of this contract shall be 10/1/97 through 9/30/98. In addition,
AHCCCSA reserves the sole option to extend the term of the contract. Legislation
was passed that allows AHCCCSA the right to extend the contract in excess of
five years. As a result of this legislation, AHCCCSA is exercising it's right to
extend the contract to 9/30/03. The new contract cycle will be effective
10/01/03. All contract extensions shall be through contract amendment. If, in
conjunction with a contract extension, AHCCCSA elects to increase the capitation
rate for any new category, such increase will not exceed in aggregate the
inflation rate recognized by the Arizona Legislature.
If the Contractor has been awarded a contract in more than one GSA, each such
contract will be considered separately renewable. AHCCCSA may renew the
Contractor's contract in one GSA but not in another. In addition, if the
Contractor has had significant problems of non-compliance in one GSA, it may
result in the capping of the Contractor's enrollment in another. Further,
AHCCCSA may require a contractor to renew all GSA's, or may terminate remaining
GSA's if the Contractor does not agree to renew all GSA's.
When AHCCCSA issues an amendment to extend the contract, the provisions of such
extension will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the extension amendment has not been signed by the
Contractor, unless within that time the Contractor notifies AHCCCSA in writing
that it refuses to sign the extension amendment. If the Contractor provides such
notification, AHCCCSA will initiate contract termination proceedings.
CONTRACTOR'S NOTICE OF INTENT NOT TO RENEW: If the Contractor chooses not to
renew this contract, the Contractor may be liable for certain costs associated
with the transition of its members to a different health plan. If the Contractor
provides AHCCCSA written notice of its intent not to renew this contract at
least 180 days before its expiration, this liability for transition costs may be
waived by AHCCCSA.
51. SUBCONTRACTS
The Contractor shall be legally responsible for contract performance whether or
not subcontracts are used. No subcontract shall operate to terminate the legal
responsibility of the Contractor to assure that all activities carried out by
the subcontractor
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conform to the provisions of this contract. Subject to such conditions, any
function required to be provided by the Contractor pursuant to this contract may
be subcontracted to a qualified person or organization. All such subcontracts
must be in writing. See policy on claims processing by subcontracted providers
in the Bidder's Library.
All subcontracts entered into by the Contractor are subject to prior review and
approval by AHCCCSA, Contracts and Purchasing, and shall incorporate by
reference the terms and conditions of this contract. The following subcontracts
shall be submitted to AHCCCSA Contracting Office for prior approval at least 30
days prior to the beginning date of the subcontract:
a. Automated data processing
b. Third-party administrators
c. Management Services (See also Section D, Paragraphs 53 & 54)
d. Model subcontracts
e. Capitated or other risk subcontracts requiring claims processing by the
subcontractor must be submitted to AHCCCSA, Office of Managed Care.
The Contractor shall maintain a fully executed original of all subcontracts,
which shall be accessible to AHCCCSA within two working days of request by
AHCCCSA. A subcontract is violable and subject to immediate cancellation by
AHCCCSA in the event any subcontract pertinent to "a" through "e" above is
implemented without the prior written approval of AHCCCSA. All subcontracts
shall comply with the applicable provisions of Federal and State laws,
regulations and policies.
The Contractor shall not include covenant-not-to-compete requirements in its
provider agreements. Specifically, the Contractor shall not contract with a
provider and require that the provider not provide services for any other AHCCCS
contractor.
The Contractor must enter into a written agreement with any provider the
Contractor reasonably anticipates will be providing services on its behalf more
than 25 times during the contract year. Exceptions to this requirement include
the following:
a. If a provider who provides services more than 25 times during the
contract year refuses to enter into a written agreement with the
Contractor, the Contractor shall submit documentation of such refusal
to AHCCCS Office of Managed Care within seven days of its final attempt
to gain such agreement.
b. If a provider performs emergency services such as an emergency room
physician or an ambulance company, a written agreement is not required.
These and any other exceptions to this requirement must be approved by AHCCCS
Office of Managed Care. Each subcontract must contain verbatim all the
provisions of Attachment A, Minimum Subcontract Provisions. In addition, each
subcontract must contain the following:
a. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor.
b. Identification of the name and address of the subcontractor.
c. Identification of the population, to include patient capacity, to be
covered by the subcontractor.
d. The amount, duration and scope of medical services to be provided, and
for which compensation will be paid.
e. The term of the subcontract including beginning and ending dates,
methods of extension, termination and renegotiation.
f. The specific duties of the subcontractor relating to coordination of
benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and
other third-party liability coverage and to seek such Medicare or third
party liability payment before submitting claims to the Contractor.
h. A description of the subcontractor's patient, medical and cost record
keeping system.
i. Specification that the subcontractor shall cooperate with quality
assurance programs and comply with the utilization control and review
procedures specified in 42 CFR Part 456, as implemented by AHCCCSA.
j. A provision stating that a merger, reorganization or change in
ownership of a subcontractor that is related to or affiliated with the
Contractor shall require a contract amendment and prior approval of
AHCCCSA.
k. Procedures for enrollment or re-enrollment of the covered population
(may also refer to the Provider Manual).
1. A provision that the subcontractor shall be fully responsible for all
tax obligations, Worker's Compensation Insurance, and all other
applicable insurance coverage obligations which arise under this
subcontract, for itself and its employees, and that AHCCCSA shall have
no responsibility or liability for any such taxes or insurance
coverage.
m. A provision that the subcontractor must obtain any necessary
authorization from the Contractor or AHCCCSA for services provided to
eligible and/or enrolled members.
n. A provision that the subcontractor must comply with encounter reporting
and claims submission requirements as described in the subcontract.
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52. SPECIALTY CONTRACTS
AHCCCSA may at any time negotiate or contract on behalf of the Contractor and
AHCCCSA for specialized hospital and medical services. AHCCCSA will consider
existing Contractor resources in the development and execution of specialty
contracts. AHCCCSA may require the Contractor to modify its delivery network to
accommodate the provisions of specialty contracts. Specialty contracts shall
take precedence over and supersede existing and future subcontracts for services
that are subject to specialty contracts. AHCCCSA may consider waiving this
requirement in particular situations if such action is determined to be in the
best interest of the State; however, in no case shall reimbursement exceed that
payable under the relevant AHCCCSA specialty contract.
During the term of specialty contracts, AHCCCSA may act as an intermediary
between the Contractor and specialty contractors to enhance the cost
effectiveness of service delivery. AHCCCSA reserves the right to make direct
payments to specialty contractors on behalf of the Contractor. Adjudication of
claims related to such payments provided under specialty contracts shall remain
the responsibility of the Contractor. AHCCCSA may provide technical assistance
prior to the implementation of any specialty contracts.
AHCCCSA shall provide at least 60 days advance written notice to the Contractor
prior to the implementation of any specialty contract.
53. MANAGEMENT SERVICES SUBCONTRACTORS
All proposed management services subcontracts and/or corporate cost allocation
plans must be approved in advance by AHCCCSA Contracting Office as described in
Section D, Paragraph 51, Subcontracts. Cost allocation plans must be submitted
with the proposed management fee agreement. AHCCCSA reserves the right to
perform a thorough review of actual management fees charged and/or corporate
allocations made. If the fees or allocations actually paid out are determined to
be unjustified or excessive, amounts may be subject to repayment to the
Contractor, the Contractor may be placed on monthly financial reporting, and/or
financial sanctions may be imposed.
54. MANAGEMENT SERVICES SUBCONTRACTOR AUDITS
All management services subcontractors that have oversight responsibilities for
the Contractor's program operations (such as third-party administrators) are
required to have an annual financial audit. A copy of this audit shall be
submitted to AHCCCSA, Office of Managed Care, within 120 days of the
subcontractor's fiscal year end.
If services billed by a consultant or actuary are less than $50,000, AHCCCSA
will waive the requirement for an audit of that consultant or actuary.
55. MINIMUM CAPITALIZATION REQUIREMENTS
In order to be considered for contract award, the Offeror must meet a minimum
capitalization requirement for each GSA bid. The capitalization requirement for
both new and continuing offerors must be met within 15 days after contract
award.
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Minimum capitalization requirements by GSA are as follows:
Capitalization Requirement Capitalization Requirement
GSA #2 Yuma $1,400,000
GSA #4 Mohave, La Paz 1,150,000
GSA #6 Yavapai, Coconino 1,250,000
GSA #8 Pinal, Gila 1,450,000
GSA #10 Pima 1,250,000
GSA #12 Maricopa 2,500,000
GSA #14 Graham, Greenlee 350,000
GSA #16 Apache, Navajo 650,000
GSA #18 Cochise, Santa Cruz 1,450,000
NEW OFFERORS: To be considered for a contract award in a given GSA or group of
GSA's, a new offeror must meet the minimum capitalization requirements listed
above. The capitalization requirement is subject to a $5,000,000 ceiling
regardless of the number of GSA's awarded. This requirement is in addition to
the Performance Bond requirements defined in Paragraphs 56 and 57 below and must
be met with cash with no encumbrances, such as a loan subject to repayment. The
capitalization requirements may be applied toward meeting the equity per member
requirement (see Section D, Paragraph 58, Financial Viability Criteria) and is
intended for use in operations of the Contractor.
CONTINUING OFFERORS: Continuing offerors that are bidding a county or GSA that
they are currently servicing must meet the equity per member standard (see
Section D, Paragraph 58, Financial Viability Criteria) for their current
membership. Continuing offerors that do not meet the equity standard must fund
through capital contribution the necessary amount to meet this requirement.
Continuing offerors that are bidding a new GSA must provide the additional
capitalization for the new GSA they are bidding. (See the table of requirements
by GSA above). Continuing offerors will not be required to provide additional
capitalization if they currently meet the equity per member standard with their
existing membership and their excess equity is sufficient to cover the proposed
additional members, or they have at least $5,000,000 in equity.
56. PERFORMANCE BOND OR BOND SUBSTITUTE
The Contractor shall be required to provide a performance bond of standard
commercial scope issued by a surely company doing business in this State, an
irrevocable letter of credit, or a cash deposit ("Performance Bond") to AHCCCSA
for as long as the Contractor has AHCCCS-related liabilities of $50,000 or more
outstanding, or 15 months following the effective date of this contract,
whichever is later, to guarantee: (1) payment of the Contractor's obligations to
providers, non-contracting providers, and non-providers; and (2) performance by
the Contractor of its obligations under this contract. The Performance Bond
shall be in a form acceptable to AHCCCSA as described in the AHCCCS Performance
Bond policy available in the Office of Managed Care.
In the event of a default by the Contractor, AHCCCSA shall, in addition to any
other remedies it may have under this contract, obtain payment under the
Performance Bond or substitute security for the purposes of the following:
a. Paying any damages sustained by providers, non-contracting providers
and nonproviders by reason of a breach of the Contractor's obligations
under this contract,
b. Reimbursing AHCCCSA for any payments made by AHCCCSA on behalf of the
Contractor, and
c. Reimbursing AHCCCSA for any extraordinary administrative expenses
incurred by reason of a breach of the Contractor's obligations under
this contract, including, but not limited to, expenses incurred after
termination of this Contract for reasons other than the convenience of
the State by AHCCCSA.
In the event AHCCCSA agrees to accept substitute security in lieu of the
Performance Bond, irrevocable letter of credit or cash deposit, the Contractor
agrees to execute any and all documents and perform any and all acts necessary
to secure and enforce AHCCCSA's security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings
pursuant to the Arizona Uniform Commercial Code. In the event such substitute
security is agreed to and accepted by AHCCCSA, the Contractor acknowledges that
it has granted AHCCCSA a security interest in such substitute security to secure
performance of its obligations under this contract. The Contractor is solely
responsible for establishing the credit-worthiness of all forms of substitute
security. AHCCCSA may, after written notice to the Contractor, withdraw its
permission for substitute security, in which case the Contractor shall provide
AHCCCSA with a form of security described above. The Contractor may not change
the amount, duration or scope of the performance bond without prior written
approval from AHCCCSA, Office of Managed Care.
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The Contractor shall not leverage the bond for another loan or create other
creditors using the bond as security.
57. AMOUNT OF PERFORMANCE BOND
The initial amount of the Performance Bond shall be equal to 110% of the total
capitation payment expected to be paid in the month of October 1997, or as
determined by AHCCCSA. The total capitation amount shall include SOBRA
supplemental payments. This requirement must be satisfied by the Contractor not
later than 15 days after notification by AHCCCSA of the amount required.
Thereafter, AHCCCSA shall evaluate the enrollment statistics of the Contractor
on a monthly basis. If there is an increase in capitation payment that exceeds
10% of the performance bond amount, AHCCCSA may require an increase in the
amount of the Performance Bond. The Contractor shall have 15 days following
notification by AHCCCSA to increase the amount of the Performance Bond. The
Performance Bond amount that must be maintained after the contract term shall be
sufficient to cover all outstanding liabilities and will be determined by
AHCCCSA. The Contractor may not change the amount of the performance bond
without prior written approval from AHCCCSA, Office of Managed Care.
58. FINANCIAL VIABILITY STANDARDS/PERFORMANCE GUIDELINES
AHCCCSA has established the following financial viability standards/performance
guidelines. On a quarterly basis, AHCCCSA will review the following ratios with
the purpose of monitoring the financial health of the Contractor. The two
Financial Viability Standards, the Current Ratio and Equity per Member, are the
standards that best represent the financial solvency of the Contractor.
Therefore, the Contractor must comply with these two financial viability
standards.
AHCCCSA will also monitor the Medical Expense Ratio, the Administrative Cost
Percentage, and the RBUC's Days Outstanding. These guidelines are analyzed as
part of AHCCCSA's due diligence in financial statement monitoring. Sanctions
will not be imposed if the Contractor does not meet these performance
guidelines. However, if a critical combination of the Financial Viability
Standards and Performance Guidelines are not met, additional monitoring, such as
monthly reporting, may be required.
FINANCIAL VIABILITY STANDARDS:
CURRENT RATIO Current assets* divided by current
liabilities. "Current assets" includes any
long-term investments that can be converted
to cash within 24 hours without significant
penalty (i.e., greater than 20%). Standard:
At least 1.00
*if current assets includes a receivable
from a parent company, the parent company
must have liquid assets that support the
amount of the intercompany loan.
EQUITY PER MEMBER Equity*, less on-balance sheet performance
bond, divided by the number of non- SOBRA
Family Planning Extension Services members
enrolled at the end of the period. Standard.
At least $150 (Failure to meet this standard
may result in an enrollment cap being
imposed in any or all contracted GSAs.)
*for purposes of this measurement, the
equity to be measured must be supported by
unencumbered current assets.
PERFORMANCE GUIDELINES:
MEDICAL EXPENSE RATIO Total medical expenses (net of reinsurance,
TPL, HIV/AIDS Supplement) divided by total
capitation + Delivery Supplement. Standard:
At least 85%
ADMINISTRATIVE COST PERCENTAGE Total administrative expenses (excluding
income taxes), divided by total capitation +
Delivery Supplement + TPL + reinsurance +
HIV/AIDS Supplement. Standard: No more
than 10%
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59. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP
A proposed merger, reorganization or change in ownership of the Contractor
health plan shall require prior approval of AHCCCSA and a subsequent contract
amendment. The Contractor must submit a detailed merger, reorganization and/or
transition plan to AHCCCSA Contracting Office for AHCCCSA review. The purpose of
the plan review is to ensure uninterrupted services to members, evaluate the new
entity's ability to support the provider network, ensure that services to
members are not diminished and that major components of the organization and
AHCCCS programs are not adversely affected by such merger, reorganization or
change in ownership.
60. SANCTIONS
AHCCCSA may impose sanctions, suspend, deny, refuse to renew, or terminate this
contract or any related subcontracts in accordance with AHCCCS Rules R9-22-606
and the terms of this contract and applicable federal or State law and
regulations. Written notice will be provided to the Contractor specifying the
sanction to be imposed, the grounds for such sanction and either the length of
suspension or the amount of capitation prepayment to be withheld. The Contractor
may appeal the decision to impose a sanction in accordance with AHCCCS Rule
R9-22-804.
In lieu of the above remedies, AHCCCSA may, at its option, impose partial or
full enrollment caps on the Contractor. Among the contract violations that may
result in an enrollment cap are, but are not limited to, the following:
a. Marketing violations
b. Failure to meet AHCCCS Financial Viability Standards
c. Material deficiency in the Contractor's provider network
d. Quality of care and quality management issues
e. Failure to meet AHCCCS encounter standards
CURE NOTICE PROCESS: Prior to the imposition of a sanction for non-compliance,
AHCCCSA may provide a written cure notice to the Contractor regarding the
details of the non-compliance. The cure notice will specify the period of time
during which the Contractor must bring its performance back into compliance with
contract requirements. If, at the end of the specified time period, the
Contractor has complied with the cure notice requirements, AHCCCSA will take no
further action. If, however, the Contractor has not complied with the cure
notice requirements, AHCCCSA will proceed with the imposition of sanctions.
61. AUTO-ASSIGNMENT ALGORITHM
Members who do not exercise their right to choose and don't have family
continuity, are assigned to Contractors through an auto-assignment algorithm.
The algorithm is a mathematical formula used to distribute members to the
various Contractors in a manner that is predictable and consistent with AHCCCSA
goals. The algorithm favors those Contractors with lower capitation rates. For
further details on the AHCCCS Auto-Assignment Algorithm, refer to Attachment G.
AHCCCSA may change the algorithm at any time during the term of the contract and
frequently does so in response to Contractor-specific issues of non-compliance
(e.g. imposition of an enrollment cap). The Contractor should consider this in
preparing its response to this RFP. AHCCCSA is not obligated to adjust for any
financial impacts this may have on the Contractor.
62. GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS
The Contractor shall have in place a written grievance and request for hearing
process for members and providers which defines and explains their rights
regarding any adverse action by the Contractor. The Contractor shall provide the
appropriate personnel to establish, implement and maintain the necessary
functions related to grievances, requests for hearing, and denials and
reductions of services. Refer to Attachment H for Grievance and Request for
Hearing Process and Standards and Paragraph 5, Denials and Reductions of
Services.
The grievance and request for hearing process shall be in accordance with
applicable federal and state laws, AHCCCS rules and policies, including, but not
limited to R9-22-Article 8, R9-31-Article 8 and the Members Rights and
Responsibilities Policy. The Contractor must ensure that the Contractor's
grievance and request for hearing policies include processing procedures and
documentation requirements. The Contractor must ensure that it provides written
information to both members and providers which clearly explains the grievance
and request for hearing process.
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The Contractor shall be responsible to provide the necessary professional,
paraprofessional, and clerical services for the representation of the Contractor
in all issues relating to grievances, denials and reductions of services and any
other matters arising under this contract which rise to the level of
administrative hearing or a judicial proceeding.
63. QUARTERLY GRIEVANCE REPORT
The Contractor shall submit a Quarterly Grievance Report to AHCCCSA, Office of
Legal Assistance, using the Quarterly Grievance Report Format on file in the
Bidder's Library. The Quarterly Grievance Report must be received by the
AHCCCSA, Office of Legal Assistance, no later than 45 days from the end of the
quarter.
64. KIDSCARE
On November 1, 1998, AHCCCSA implemented a Title XXI Children's Health Insurance
Program, referred to as "KidsCare". KidsCare provides health care coverage
statewide to eligible children under age 19 and is provided through the existing
AHCCCS health plans, state employee HMOs that elect to participate at the
beginning of a contract cycle, and tribal facilities or Indian Health Service
for Native Americans who elect to receive services through them.
The KidsCare service package is established by the legislature and approved by
CMS through the State Plan. Capitation rates payable to the Contractor for
KidsCare members will be set by AHCCCSA in conjunction with an independent
actuary.
KidsCare members in families with gross household income over 150% and up to
200% of the federal poverty limit shall pay a premium to AHCCCSA. The premium
amount shall be based on the number of members in the household and the gross
family income in accordance with 9 A.A.C., Article 14.
TITLE XVI PARENT/GUARDIAN HEALTH INSURANCE COVERAGE: A.R.S. ss.36-2984 mandates
that the Contractor offer health insurance coverage to the parent(s) or legal
guardian(s) of a child who is eligible for Title XXI. The Contractor shall
establish rates for this coverage, which must be approved by AHCCCSA, Office of
Managed Care, prior to implementation. Title XXI funds or any other federal or
state funds shall not be used to subsidize family coverage. The full cost of the
premium shall be paid by the parent or legal guardian who elects this coverage.
The Contractor may include provisions for pre-existing conditions and any other
medical underwriting considerations that are necessary to protect it from
adverse risk. For further information, refer to the Title XXI Parent/Guardian
Health Insurance Coverage Guidelines on file in the Bidder's Library.
65. PENDING LEGISLATIVE ISSUES
In addition to the requirements described in this RFP, there are several
legislative issues that will have an impact on services provided by the
Contractor on or after October 1, 2001. The following is a brief summary of the
issues.:
BREAST AND CERVICAL CANCER: Legislation was passed to adopt a federal program
that expands Title XIX eligibility to women under the age of 65 who are between
100% and 250% of FPL that have been diagnosed with either breast or cervical
cancer. This program will be implemented early in 2002.
TICKET TO WORK: Legislation was passed to adopt a federal program that expands
Title XIX eligibility to individuals, 16 through 64 years old who meet SSI
eligibility criteria, and whose earned income is at or below 250% FPL. This
program will be implemented early in 2002.
AHCCCS COVERAGE FOR THE PARENTS OF CHILDREN ELIGIBLE FOR KIDSCARE: During the
2001 legislative session, AHCCCS is required to apply for an 1115 Waiver to
cover the parents of children eligible for KidsCare up to 200% of FPL. AHCCCS
will need state match if the waiver is approved, and will seek legislative
expenditure authority. It is anticipated that this program will be effective
October 1, 2002.
In addition to the above pending legislative issues, the final regulations for
the Budget Balanced Act of 1997 have not been finalized. Contractors shall
comply with the BBA regulations upon finalization.
66. SEPARATE INCORPORATION
As specified in A.R.S. ss. 36-2906.01, within 60 days of contract award, a
non-governmental Contractor shall have established a separate corporation for
the purposes of this contract, whose sole activity is the performance of
contract function with
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AHCCCS.
67. CULTURAL COMPETENCY
The Contractor shall have a Cultural Competency Plan that meets the requirements
of the AHCCCS Cultural Competency Policy. The Contractor must identify a staff
member responsible for the cultural competency plan and inform the office of
Managed Care of that person's identity.
68. MEDICAID IN THE PUBLIC SCHOOLS
Pursuant to an Intergovernmental Agreement with the Department of Education, and
a contract with a Third Party Administrator, AHCCCS began paying participating
school districts for specifically identified Medicaid services when provided to
Medicaid-eligible children who are included under the Individuals with
Disabilities Education Act (IDEA). The Medicaid services must be identified in
the member's Individual Education Plan (IEP) as medically necessary for the
child to obtain a public school education. In the first phase of the Medicaid in
the Public Schools (MIPS) program, AHCCCS began reimbursement to school
districts for services provided beginning July 1, 2000. These services included
speech, physical and occupational therapies, nursing services, attendant care
(health aid services provided in the classroom), transportation to and from
school on days when the child receives an AHCCCS-covered MIPS service, and
behavioral health services.
Services provided through MIPS are specifically intended to allow children to
attend school and do not replace medically necessary services provided outside
the educational setting. Thus, the Contractor's determination of whether
services are medically necessary and should be provided to a child shall be made
independently of whether that child also is receiving MIPS services. If a
request is made for services that also are covered under the MIPS program for a
child enrolled with the Contractor, the request shall be evaluated on the same
basis as any request for a covered service.
[END OF SECTION D]
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SECTION E: CONTRACT CLAUSES
1. APPLICABLE LAW
ARIZONA LAW - The law of Arizona applies to this contract including, where
applicable, the Uniform Commercial Code, as adopted in the State of Arizona.
IMPLIED CONTRACT TERMS - Each provision of law and any terms required by law to
be in this contract are a part of this contract as if fully stated in it.
2. AUTHORITY
This contract is issued under the authority of the Contracting Officer who
signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or
materials, directed by an unauthorized state employee or made unilaterally by
the Contractor are violations of the contract and of applicable law. Such
changes, including unauthorized written contract amendments, shall be void and
without effect, and the Contractor shall not be entitled to any claim under this
contract based on those changes.
3. ORDER OF PRECEDENCE
The parties to this contract shall be bound by all terms and conditions
contained herein. For interpreting such terms and conditions the following
sources shall have precedence in descending order: The Constitution and laws of
the United States and applicable federal regulations; the terms of the CMS 1115
waiver for the State of Arizona; the Constitution and laws of Arizona, and
applicable State rules; the terms of this contract, including all attachments
and executed amendments and modifications; AHCCCSA policies and procedures.
4. CONTRACT INTERPRETATION AND AMENDMENT
NO PAROL EVIDENCE - This contract is intended by the parties as a final and
complete expression of their agreement. No course of prior dealings between the
parties and no usage of the trade shall supplement or explain any term used in
this contract.
NO WAIVER - Either party's failure to insist on strict performance of any term
or condition of the contract shall not be deemed a waiver of that term or
condition even if the party accepting or acquiescing in the non-conforming
performance knows of the nature of the performance and fails to object to it.
WRITTEN CONTRACT AMENDMENTS - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the
procurement officer on behalf of the State.
5. SEVERABILITY
The provisions of this contract are severable to the extent that any provision
or application held to be invalid shall not affect any other provision or
application of the contract, which may remain in effect without the invalid
provision, or application.
6. RELATIONSHIP OF PARTIES
The Contractor under this contract is an independent contractor. Neither party
to this contract shall be deemed to be the employee or agent of the other party
to the contract.
7. ASSIGNMENT AND DELEGATION
The Contractor shall not assign any right nor delegate any duty under this
contract without prior written approval of the Contracting Officer, who will not
unreasonably withhold such approval.
8. GENERAL INDEMNIFICATION
The Contractor shall defend, indemnify and hold harmless the State from any
claim, demand, suit, liability, judgment and expense (including attorney's fees
and other costs of litigation) arising out of or relating to injury, disease, or
death of persons or damage to or loss of property resulting from or in
connection with the negligent performance of this contract by the
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Contractor, its agents, employees, and subcontractors or anyone for whom the
Contractor may be responsible. The obligations, indemnities and liabilities
assumed by the Contractor under this paragraph shall not extend to any liability
caused by the negligence of the State or its employees. The Contractor's
liability shall not be limited by any provisions or limits of insurance set
forth in this contract. The State shall reasonably notify the Contractor of any
claim for which it may be liable under this paragraph. The Administration shall
bear no liability for subcontracts that a contractor executes with other parties
for the provision of administrative or management services, medical services or
covered health care services, or for any other purposes.
9. INDEMNIFICATION -- PATENT AND COPYRIGHT
The Contractor shall defend, indemnify and hold harmless the State against any
liability including costs and expenses for infringement of any patent, trademark
or copyright arising out of contract performance or use by the State of
materials furnished or work performed under this contract. The State shall
reasonably notify the Contractor of any claim for which it may be liable under
this paragraph.
10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS
The materials and services supplied under this contract shall comply with all
applicable federal, state and local laws, and the Contractor shall maintain all
applicable licenses and permits.
11. ADVERTISING AND PROMOTION OF CONTRACT
The Contractor shall not advertise or publish information for commercial benefit
concerning this contract without the prior written approval of the Contracting
Officer.
12. PROPERTY OF TILE STATE
Any materials, including reports, computer programs and other deliverables,
created under this contract are the sole property of AHCCCSA. The Contractor is
not entitled to a patent or copyright on those materials and may not transfer
the patent or copyright to anyone else. The Contractor shall not use or release
these materials without the prior written consent of AHCCCSA.
13. THIRD PARTY ANTITRUST VIOLATIONS
The Contractor assigns to the State any claim for overcharges resulting from
antitrust violations to the extent that those violations concern materials or
services supplied by third parties to the Contractor toward fulfillment of this
contract.
14. RIGHT TO ASSURANCE
If AHCCCSA, in good faith, has reason to believe that the Contractor does not
intend to perform or continue performing this contract, the procurement officer
may demand in writing that the Contractor give a written assurance of intent to
perform. The demand shall be sent to the Contractor by certified mail, return
receipt required. Failure by the Contractor to provide written assurance within
the number of days specified in the demand may, at the State's option, be the
basis for terminating the contract.
15. TERMINATION FOR CONFLICT OF INTEREST
AHCCCSA may cancel this contract without penalty or further obligation if any
person significantly involved in initiating, negotiating, securing, drafting or
creating the contract on behalf of AHCCCSA is, or becomes at any time while the
contract or any extension of the contract is in effect, an employee of, or a
consultant to, any other party to this contract with respect to the subject
matter of the contract. The cancellation shall be effective when the Contractor
receives written notice of the cancellation unless the notice specifies a later
time.
16. GRATUITIES
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that employment or a gratuity was offered or made by
the Contractor or a representative of the Contractor to any officer or employee
of the State for the purpose of influencing the outcome of the procurement or
securing the contract, an amendment to the contract, or favorable
55
treatment concerning the contract, including the making of any determination or
decision about contract performance. AHCCCSA, in addition to any other rights or
remedies, shall be entitled to recover exemplary damages in the amount of three
times the value of the gratuity offered by the Contractor.
17. SUSPENSION OR DEBARMENT
The Contractor shall not employ, consult, subcontract or enter into any
agreement for Title XIX services with any person or entity who is debarred,
suspended or otherwise excluded from federal procurement activity. This
prohibition extends to any entity which employs, consults, subcontracts with or
otherwise reimburses for services any person substantially involved in the
management of another entity which is debarred, suspended or otherwise excluded
from federal procurement activity.
The Contractor shall not retain as a director, officer, partner or owner of 5%
or more of the Contractor entity, any person, or affiliate of such a person, who
is debarred, suspended or otherwise excluded from federal procurement activity.
AHCCCSA may, by written notice to the Contractor, immediately terminate this
contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement
activity.
18. TERMINATION FOR CONVENIENCE
AHCCCSA reserves the right to terminate the contract in whole or in part at any
time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, return receipt
requested, to the Contractor of the termination at least 90 days before the
effective date of the termination. In the event of termination under this
paragraph, all documents, data and reports prepared by the Contractor under the
contract shall become the property of and be delivered to AHCCCSA. The
Contractor shall be entitled to receive just and equitable compensation for work
in progress, work completed and materials accepted before the effective date of
the termination.
19. TERMINATION FOR DEFAULT
AHCCCSA reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the
contract or failure to take corrective action as required by AHCCCSA to comply
with the terms of the contract. If the Contractor is providing services under
more than one contract with AHCCCSA, AHCCCSA may deem unsatisfactory performance
under one contract to be cause to require the Contractor to provide assurance of
performance under any and all other contracts. In such situations, AHCCCSA
reserves the right to seek remedies under both actual and anticipatory breaches
of contract if adequate assurance of performance is not received. The
Contracting Officer shall mail written notice of the termination and the
reason(s) for it to the Contractor by certified mail, return receipt requested.
In the event the Contractor requests a hearing prior to termination, AHCCCSA is
required by the Balanced Budget Act of 1997 to oversee the operation of the
Contractor entity through appointment of temporary management prior to the
hearing.
Upon termination under this paragraph, all documents, data, and reports prepared
by the Contractor under the contract shall become the property of and be
delivered to AHCCCSA on demand.
AHCCCSA may, upon termination of this contract, procure, on terms and in the
manner that it deems appropriate, materials or services to replace those under
this contract. The Contractor shall be liable for any excess costs incurred by
AHCCCSA in re-procuring the materials or services.
20. TERMINATION - AVAILABILITY OF FUNDS
Funds are not presently available for performance under this contract beyond the
current fiscal year. No legal liability on the part of AHCCCSA for any payment
may arise under this contract until funds are made available for performance of
this contract.
21. RIGHT OF OFFSET
AHCCCSA shall be entitled to offset against any amounts due the Contractor any
expenses or costs incurred by AHCCCSA concerning the Contractor's non-conforming
performance or failure to perform the contract.
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22. NON-EXCLUSIVE REMEDIES
The rights and the remedies of AHCCCSA under this contract are not exclusive.
23. NON-DISCRIMINATION
The Contractor shall comply with State Executive Order No. 99-4, which mandates
that all persons, regardless of race, color, religion, sex, national origin or
political affiliation, shall have equal access to employment opportunities, and
all other applicable federal and state laws, rules and regulations, including
the Americans with Disabilities Act and Title VI. The Contractor shall take
positive action to ensure that applicants for employment, employees, and persons
to whom it provides service are not discriminated against due to race, creed,
color, religion, sex, national origin or disability.
24. EFFECTIVE DATE
The effective date of this contract shall be the date that the Contracting
Officer signs the award page (page 1) of this contract.
25. INSURANCE
A certificate of insurance naming the State of Arizona and AHCCCSA as the
"additional insured" must be submitted to AHCCCSA within 10 days of notification
of contract award and prior to commencement of any services under this contract.
This insurance shall be provided by carriers rated as "A+" or higher by the A.M.
Best Rating Service. The following types and levels of insurance coverage are
required for this contract:
a. Commercial General Liability: Provides coverage of at least $1,000,000
for each occurrence for bodily injury and property damage to others as
a result of accidents on the premises of or as the result of operations
of the Contractor.
b. Commercial Automobile Liability: Provides coverage of at least
$1,000,000 for each occurrence for bodily injury and property damage to
others resulting from accidents caused by vehicles operated by the
Contractor.
c. Workers Compensation: Provides coverage to employees of the Contractor
for injuries sustained in the course of their employment. Coverage must
meet the obligations imposed by federal and state statutes and must
also include Employer's Liability minimum coverage of $100,000.
Evidence of qualified self-insured status will also be considered.
d. Professional Liability (if applicable): Provides coverage for alleged
professional misconduct or lack of ordinary skills in the performance
of a professional act of service.
The above coverage's may be evidenced by either one of the following:
a. The State of Arizona Certificate of Insurance: This is a form with the
special conditions required by the contract already pre-printed on the
form. The Contractor's agent or broker must fill in the pertinent
policy information and ensure the required special conditions are
included in the Contractor's policy.
b. The Accord form: This standard insurance industry certificate of
insurance does not contain the pine-printed special conditions required
by this contract. These conditions must be entered on the certificate
by the agent or broker and read as follows:
The State of Arizona and Arizona Health Care Cost Containment System are hereby
added as additional insureds. Coverage afforded under this Certificate shall be
primary and any insurance carried by the State or any of its agencies, boards,
departments or commissions shall be in excess of that provided by the insured
Contractor. No policy shall expire, be canceled or materially changed without 30
days written notice to the State. This Certificate is not valid unless
countersigned by an authorized representative of the insurance company.
26. DISPUTES
The exclusive manner for the Contractor to assert any claim, grievance, dispute
or demand against AHCCCSA shall be in accordance with AHCCCS Rule R9-28-804(C).
Pending the final resolution of any disputes involving this contract, the
Contractor shall proceed with performance of this contract in accordance with
AHCCCSA's instructions, unless AHCCCSA specifically, in writing, requests
termination or a temporary suspension of performance.
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27. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS
AHCCCSA may, at reasonable times, inspect the part of the plant or place of
business of the Contractor or subcontractor that is related to the performance
of this contract, in accordance with A.R.S. ss.41-2547.
28. INCORPORATION BY REFERENCE
This solicitation and all attachments and amendments, the Contractor's proposal,
best and final offer accepted by AHCCCSA, and any approved subcontracts are
hereby incorporated by reference into the contract.
29. COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or agency has been employed or retained
to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this
warranty, AHCCCSA shall have the right to annul this contract without liability.
30. CHANGES
AHCCCSA may at any time, by written notice to the Contractor, make changes
within the general scope of this contract. If any such change causes an increase
or decrease in the cost of, or the time required for, performance of any part of
the work under this contract, the Contractor may assert its right to an
adjustment in compensation paid under this contract. The Contractor must assert
its right to such adjustment within 30 days from the date of receipt of the
change notice. Any dispute or disagreement caused by such notice shall
constitute a dispute within the meaning of Section E, Paragraph 26, Disputes,
and be administered accordingly.
When AHCCCSA issues an amendment to modify the contract, the provisions of such
amendment will be deemed to have been accepted 60 days after the date of mailing
by AHCCCSA, even if the amendment has not been signed by the Contractor, unless
within that time the Contractor notifies AHCCCSA in writing that it refuses to
sign the amendment. If the Contractor provides such notification, AHCCCSA will
initiate termination proceedings.
31. TYPE OF CONTRACT
Firm Fixed-Price
32. AMERICANS WITH DISABILITIES ACT
People with disabilities may request special accommodations such as
interpreters, alternative formats or assistance with physical accessibility.
Requests for special accommodations must be made with at least three days prior
notice by calling Michael Veit at (602) 417-4762.
33. WARRANTY OF SERVICES
The Contractor warrants that all services provided under this contract will
conform to the requirements stated herein. AHCCCSA's acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations
under this warranty. In addition to its other remedies, AHCCCSA may, at the
Contractor's expense, require prompt correction of any services failing to meet
the Contractor's warranty herein. Services corrected by the Contractor shall be
subject to all of the provisions of this contract in the manner and to the same
extent as the services originally furnished.
34. NO GUARANTEED QUANTITIES
AHCCCSA does not guarantee the Contractor any minimum or maximum quantity of
services or goods to be provided under this contract.
35. CONFLICT OF INTEREST
The Contractor shall not undertake any work that represents a potential conflict
of interest, or which is not in the best interest of AHCCCSA or the State
without prior written approval by AHCCCSA. The Contractor shall fully and
completely disclose
58
any situation that may present a conflict of interest. If the Contractor is now
performing or elects to perform during the term of this contract any services
for any AHCCCS health plan, provider or Contractor or an entity owning or
controlling same, the Contractor shall disclose this relationship prior to
accepting any assignment involving such party.
36. DISCLOSURE OF CONFIDENTIAL INFORMATION
The Contractor shall not, without prior written approval from AHCCCSA, either
during or after the performance of the services required by this contract, use,
other than for such performance, or disclose to any person other than AHCCCSA
personnel with a need to know, any information, data, material, or exhibits
created, developed, produced, or otherwise obtained during the course of the
work required by this contract. This nondisclosure requirement shall also
pertain to any information contained in reports, documents, or other records
furnished to the Contractor by AHCCCSA.
37. COOPERATION WITH OTHER CONTRACTORS
AHCCCSA may award other contracts for additional work related to this contract
and Contractor shall fully cooperate with such other contractors and AHCCCSA
employees or designated agents, and carefully fit its own work to such other
contractors' work. Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor or by AHCCCSA
employees.
38. ASSIGNMENT OF CONTRACT AND BANKRUPTCY
This contract is voidable and subject to immediate cancellation by AHCCCSA upon
Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or assigning rights or obligations
under this contract without the prior written consent of AHCCCSA.
39. OWNERSHIP OF INFORMATION AND DATA
Any data or information system, including all software, documentation and
manuals, developed by Contractor pursuant to this contract, shall be deemed to
be owned by AHCCCSA. The federal government reserves a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, or otherwise use
and to authorize others to use for federal government purposes, such data or
information system, software, documentation and manuals. Proprietary software
which is provided at established catalog or market prices and sold or leased to
the general public shall not be subject to the ownership or licensing provisions
of this section.
Data, information and reports collected or prepared by Contractor in the course
of performing its duties and obligations under this contract shall be deemed to
be owned by AHCCCSA. The ownership provision is in consideration of Contractor's
use of public funds in collecting or preparing such data, information and
reports. These items shall not be used by Contractor for any independent project
of Contractor or publicized by Contractor without the prior written permission
of AHCCCSA. Subject to applicable state and federal laws and regulations,
AHCCCSA shall have full and complete rights to reproduce, duplicate, disclose
and otherwise use all such information. At the termination of the contract,
Contractor shall make available all such data to AHCCCSA within 30 days
following termination of the contract or such longer period as approved by
AHCCCSA, Office of the Director. For purposes of this subsection, the term
"data" shall not include member medical records.
Except as otherwise provided in this section, if any copyrightable or patentable
material is developed by Contractor in the course of performance of this
contract, the federal government, AHCCCSA and the State of Arizona shall have a
royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or federal
government purposes. Contractor shall additionally be subject to the applicable
provisions of 45 CFR Part 74 and 45 CFR Parts 6 and 8.
40. AHCCCSA RIGHT TO OPERATE CONTRACTOR
If, in the judgment of AHCCCSA, Contractor's performance is in material breach
of the contract or Contractor is insolvent, AHCCCSA may directly operate
Contractor to assure delivery of care to members enrolled with Contractor until
cure by Contractor of its breach, by demonstrated financial solvency or until
the successful transition of those members to other contractors.
If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through
designees appointed by the Director, shall be vested with full and exclusive
power of management and control of the Contractor as necessary to ensure the
uninterrupted
59
care to persons and accomplish the orderly transition of persons to a new or
existing Contractor, or until the Contractor corrects the Contract Performance
failure to the satisfaction of AHCCCS. AHCCCS shall have the power to employ any
necessary assistants, to execute any instrument in the name of the Contractor,
to commence, defend and conduct in its name any action or proceeding in which
the Contractor may be a party.
All reasonable expenses of AHCCCS related to the direct operation of the
Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets
of the Contractor, shall be paid by the Contractor or withheld from payment due
from AHCCCS to the Contractor.
41. AUDITS AND INSPECTIONS
The Contractor shall comply with all provisions specified in applicable AHCCCS
Rule R9-22-519, -520 and -521 and AHCCCS policies and procedures relating to the
audit of Contractor's records and the inspection of Contractor's facilities.
Contractor shall fully cooperate with AHCCCSA staff and allow them reasonable
access to Contractor's staff, subcontractors, members, and records.
At any time during the term of this contract, the Contractor's or any
subcontractor's books and records shall be subject to audit by AHCCCSA and,
where applicable, the federal government, to the extent that the books and
records relate to the performance of the contract or subcontracts.
AHCCCSA and the federal government may evaluate through on-site inspection or
other means, the quality, appropriateness and timeliness of services performed
under this contract.
42. FRAUD AND ABUSE
It shall be the responsibility of the Contractor to report all cases of
suspected fraud and abuse by subcontractors, members or employees. The
Contractor shall provide written notification of all such incidents to AHCCCSA.
The Contractor shall comply with the AHCCCS Health Plans and Program Contractors
Policy for Prevention, Detection and Reporting of Fraud and Abuse which is
available in the Bidder's Library and incorporated herein by reference.
As stated in A.R.S. ss. 13-2310, incorporated herein by reference, any person
who knowingly obtains any benefit by means of false or fraudulent pretenses,
representations, promises or material omissions is guilty of a class 2 felony.
Contractors are required to research potential overpayments identified by a
fraud and abuse investigation or audit conducted by AHCCCSA. After conducting a
cost benefit analysis to determine if such action is warranted, the Contractor
should attempt to recover any overpayments identified due to erroneous, false or
fraudulent billings.
43. LOBBYING
No funds paid to the Contractor by AHCCCSA, or interest earned thereon, shall be
used for the purpose of influencing or attempting to influence an officer or
employee of any federal or State agency, a member of the United States Congress
or State Legislature, an officer or employee of a member of the United States
Congress or State Legislature in connection with awarding of any federal or
State contract, the making of any federal or State grant, the making of any
federal or State loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal or
State contract, grant, loan, or cooperative agreement. The Contractor shall
disclose if any funds other than those paid to the Contractor by AHCCCSA have
been used or will be used to influence the persons and entities indicated above
and will assist AHCCCSA in making such disclosures to CMS.
44. CHOICE OF FORUM
The parties agree that jurisdiction over any action arising out of or relating
to this contract shall be brought or filed in a court of competent jurisdiction
located in the State of Arizona.
[END OF SECTION E]
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ATTACHMENT A
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS
[The following provisions must be included verbatim in every subcontract.]
1. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES
The Arizona Health Care Cost Containment System Administration (AHCCCSA) or the
U.S. Department of Health and Human Services may evaluate, through inspection or
other means, the quality, appropriateness or timeliness of services performed
under this subcontract.
2. RECORDS AND REPORTS
The Contractor shall maintain all forms, records, reports and working papers
used in the preparation of reports, files, correspondence, financial statements,
records relating to quality of care, medical records, prescription files,
statistical information and other records specified by AHCCCSA for purposes of
audit and program management. The Contractor shall comply with all
specifications for record-keeping established by AHCCCSA. All books and records
shall be maintained to the extent and in such detail as shall properly reflect
each service provided and all net costs, direct and indirect, of labor,
materials, equipment, supplies and services, and other costs and expenses of
whatever nature for which payment is made to the Contractor. Such material shall
be subject to inspection and copying by the state, AHCCCSA and the U.S.
Department of Health and Human Services during normal business hours at the
place of business of the person or organization maintaining the records.
The Contractor agrees to make available at the office of the Contractor, at all
times reasonable times, any of its records for inspection, audit or
reproduction, by any authorized representative of the state or federal
governments.
The Contractor shall preserve and make available all records for a period of
five years from the date of final payment under this subcontract except as
provided in paragraphs a. and b. below:
a. If this subcontract is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for
a period of five years from the date of any such termination.
b. Records which relate to disputes, litigation or the settlement of claims
arising out of the performance of this subcontract, or costs and expenses
of this subcontract to which exception has been taken by the state, shall
be retained by the Contractor until such disputes, litigation, claims or
exceptions have been disposed of.
The Contractor shall provide all reports requested by AHCCCSA, and all
information from records relating to the performance of the Contractor which
AHCCCSA may reasonably require. The Contractor reporting requirements may
include, but are not limited to, timely and detailed utilization statistics,
information and reports.
3. LIMITATIONS ON BILLING AND COLLECTION PRACTICES
The Contractor shall not bill, nor attempt to collect payment directly or
through a collection agency from a person claiming to be AHCCCS eligible without
first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered
services. This provision shall not apply to patient contributions to the cost of
services delivered by nursing homes.
4. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES
No payment due the Contractor under this subcontract may be assigned without the
prior approval of AHCCCSA. No assignment or delegation of the duties of this
subcontract shall be valid unless prior written approval is received from
AHCCCSA.
5. APPROVAL OF SUBCONTRACTS, AMENDMENTS OR TERMINATIONS
This subcontract is subject to prior approval by AHCCCSA. The prime contractor
shall notify AHCCCSA in the event of any proposed amendment or termination
during the term hereof. Any such amendment or termination is subject to the
prior approval of AHCCCSA. Approval of the subcontract may be rescinded by the
Director of AHCCCSA for violation of federal or state laws or rules.
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6. WARRANTY OF SERVICES
The Contractor, by execution of this subcontract, warrants that it has the
ability, authority, skill, expertise and capacity to perform the services
specified in this contract.
7. SUBJECTION OF SUBCONTRACT
The terms of this subcontract shall be subject to the applicable material terms
and conditions of the contract existing between the Contractor and AHCCCSA for
the provision of covered services.
8. AWARDS OF OTHER SUBCONTRACTS
AHCCCSA and/or the prime contractor may undertake or award other contracts for
additional or related work to the work performed by the Contractor and the
Contractor shall fully cooperate with such other contractors, subcontractors or
state employees. The Contractor shall not commit or permit any act which will
interfere with the performance of work by any other contractor, subcontractor or
state employee.
9. INDEMNIFICATION BY CONTRACTOR
The Contractor agrees to hold harmless the state, all state officers and
employees, AHCCCSA and other appropriate state agencies, and all officers and
employees of AHCCCSA and all AHCCCS eligible persons in the event of nonpayment
to the Contractor. The Contractor shall further indemnify and hold harmless the
state, AHCCCSA, other appropriate state agencies, AHCCCS contractors, and their
agents, officers and employees against all injuries, deaths, losses, damages,
claims, suits, liabilities, judgments, costs and expenses which may, in any
manner, accrue against the State, AHCCCSA or its agents, officers or employees,
or AHCCCS contractors, through the intentional conduct, negligence or omission
of the Contractor, its agent, officers or employees.
10. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES
The Contractor shall be registered with AHCCCSA and shall obtain and maintain
all licenses, permits and authority necessary to do business and render service
under this subcontract and, where applicable, shall comply with all laws
regarding safety, unemployment insurance, disability insurance and worker's
compensation.
11. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS
The Contractor shall comply with all federal, State and local laws, rules,
regulations, standards and executive orders governing performance of duties
under this subcontract, without limitation to those designated within this
subcontract.
12. SEVERABILITY
If any provision of these standard subcontract terms and conditions is held
invalid or unenforceable, the remaining provisions shall continue valid and
enforceable to the full extent permitted by law.
13. VOIDABILITY OF SUBCONTRACT
This subcontract is voidable and subject to immediate termination by AHCCCSA
upon the Contractor becoming insolvent or filing proceedings in bankruptcy or
reorganization under the United States Code, or upon assignment or delegation of
the subcontract without AHCCCSA's prior written approval.
14. CONFIDENTIALITY REQUIREMENT
Confidential information shall be safeguarded pursuant to 42 CFR Part 431,
Subpart F, A.R.S. ss.36-107, 36-2903, 41-1959 and 46-135, and AHCCCS and/or
ALTCS Rules.
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15. GRIEVANCE AND REQUEST FOR HEARING PROCEDURES
Any grievance and request for hearings filed by the Contractor shall be
adjudicated in accordance with AHCCCS Rules. However, on a case by case basis,
the parties may agree to resolve the dispute through binding arbitration.
16. TERMINATION OF SUBCONTRACT
AHCCCSA may, by written notice to the Contractor, terminate this subcontract if
it is found, after notice and hearing by the State, that gratuities in the form
of entertainment, gifts, or otherwise were offered or given by the Contractor,
or any agent or representative of the Contractor, to any officer or employee of
the State with a view towards securing a contract or securing favorable
treatment with respect to the awarding, amending or the making of any
determinations with respect to the performance of the Contractor; provided, that
the existence of the facts upon which the state makes such findings shall be in
issue and may be reviewed in any competent court. If the subcontract is
terminated under this section, unless the prime contractor is a governmental
agency, instrumentality or subdivision thereof, AHCCCSA shall be entitled to a
penalty, in addition to any other damages to which it may be entitled by law,
and to exemplary damages in the amount of three times the cost incurred by the
Contractor in providing any such gratuities to any such officer or employee.
17. PRIOR AUTHORIZATION AND UTILIZATION REVIEW
The prime contractor and Contractor shall develop, maintain and use a system for
Prior Authorization and Utilization Review which is consistent with AHCCCS Rules
and the prime contractor's policies.
18. NON-DISCRIMINATION REQUIREMENTS
If applicable, the Contractor shall comply with:
a. The Equal Pay Act of 1963, as amended, which prohibits sex discrimination
in the payment of wages to men and women performing substantially equal
work under similar working conditions in the same establishment.
b. Title VI of the Civil Rights Act of 1964, as amended, which prohibits the
denial of benefits of, or participation in, contract services on the basis
of race, color, or national origin.
c. Title VII of the Civil Rights Act of 1964, as amended which prohibits
private employers, state and local governments, and educational
institutions from discriminating against their employees and job applicants
on the basis of race, religion, color, sex, or national origin.
d. Title I of the Americans with Disabilities Act of 1990, as amended, which
prohibits private employers and state and local governments from
discriminating against job applicants and employees on the basis of
disability.
e. The Civil Rights Act of 1991, which reverses in whole or in part, several
recent Supreme Court decisions interpreting Title VII.
f. The Age Discrimination in Employment Act (A.R.S. Title 41-1461, et seq.);
which prohibits discrimination based on age.
g. State Executive Order 99-4 and Federal Order 11246 which mandates that all
persons, regardless of race, color, religion, sex, age, national origin or
political affiliation, shall have equal access to employment opportunities.
h. Section 503 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination in the employment or advancement of the employment of
qualified persons because of physical or mental handicap.
i. Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits
discrimination on the basis of handicap in delivering contract services.
19. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION
The Contractor shall comply with all applicable AHCCCS Rules and Audit Guide
relating to the audit of the Contractor's records and the inspection of the
Contractor's facilities. If the Contractor is an inpatient facility, the
Contractor shall file uniform reports and Title XVIII and Title XIX cost reports
with AHCCCSA.
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20. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION
By signing this subcontract, the Contractor certifies that all representations
set forth herein are true to the best of its knowledge.
21. CERTIFICATION OF COMPLIANCE - ANTI-KICKBACK AND LABORATORY TESTING
By signing this subcontract, the Contractor certifies that it has not engaged in
any violation of the Medicare Anti-Kickback statute (42 USC ss.ss. 1320a-76) or
the "Stark I" and "Stark II" laws governing related-entity referrals (PL 101-239
and PL 101-432) and compensation therefrom. If the Contractor provides
laboratory testing, it certifies that it has complied with 42 CFR ss. 411.361
and has sent to AHCCCSA simultaneous copies of the information required by that
rule to be sent to the Health Care Financing Administration.
22. CONFLICT IN INTERPRETATION OF PROVISIONS
In the event of any conflict in interpretation between provisions of this
subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take
precedence.
23. ENCOUNTER DATA REQUIREMENT
If the Contractor does not bill the prime contractor (e.g., Contractor is
capitated), the Contractor shall submit encounter data to the prime contractor
in a form acceptable to AHCCCSA.
24. CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) OF 1988
The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires
laboratories and other facilities that test human specimens to obtain either a
CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the
Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the
requirements of 42 CFR 493, Subpart A.
To comply with these requirements, AHCCCSA requires all clinical laboratories to
provide verification of CLIA Licensure or Certificate of Waiver during the
provider registration process. Failure to do so shall result in either a
termination of an active provider ID number or denial of initial registration.
These requirements apply to all clinical laboratories.
Pass-through billing or other similar activities with the intent of avoiding the
above requirements are prohibited. Prime contractor may not reimburse providers
who do not comply with the above requirements.
25. INSURANCE
[This provision applies only if the Contractor provides services directly to
AHCCCS members]
The Contractor shall maintain for the duration of this subcontract a policy or
policies of professional liability insurance, comprehensive general liability
insurance and automobile liability insurance. The Contractor agrees that any
insurance protection required by this subcontract, or otherwise obtained by the
Contractor, shall not limit the responsibility of Contractor to indemnify, keep
and save harmless and defend the State and AHCCCSA, their agents, officers and
employees as provided herein. Furthermore, the Contractor shall be fully
responsible for all tax obligations, Worker's Compensation Insurance, and all
other applicable insurance coverage, for itself and its employees, and AHCCCSA
shall have no responsibility or liability for any such taxes or insurance
coverage.
26. FRAUD AND ABUSE
If the Contractor discovers, or is made aware, that an incident of potential
fraud or abuse has occurred, the Contractor shall report the incident to the
prime contractor, who shall proceed in accordance with the AHCCCS Health Plans
and Program Contractors Policy for Prevention, Detection and Reporting of Fraud
and Abuse Incidents involving potential member eligibility fraud should be
reported to AHCCCSA, Office of Program Integrity, Member Fraud Unit. All other
incidents of potential fraud should be reported to AHCCCSA, Office of the
Director, Office of Program Integrity. (See AHCCCS Rule R9-22-511.)
A-4
ATTACHMENT B
ATTACHMENT B: MINIMUM NETWORK STANDARDS
(By Geographic Service Area)
INSTRUCTIONS:
Contractors shall have in place an adequate network of providers capable of
meeting contract requirements. The information that follows describes the
minimum network requirements by Geographic Service Area (GSA). In some GSA's
there are required service sites located outside of the geographical boundary of
a GSA. The reason for this relates to practical access to care. In certain
instances, a member must travel a much greater distance to receive services
within their assigned GSA, if the member were not allowed to receive services in
an adjoining GSA or state.
Split zip codes occur in some counties. Split zip codes are those which straddle
two different counties. Enrollment for members residing in these zip codes is
based upon the county and GSA to which the entire zip code has been assigned by
AHCCCS. The Contractor shall be responsible for providing services to members
residing in the entire zip code that is assigned to the GSA for which the
Contractor has agreed to provide services. The split zip codes GSA assignments
are as follows:
SPLIT BETWEEN
ZIP CODE THESE COUNTIES COUNTY ASSIGNED TO ASSIGNED GSA
85220 Pinal and Maricopa Maricopa 12
85242 Pinal and Maricopa Maricopa 12
85292 Gila and Pinal Gila 8
85342 Yavapai and Maricopa Maricopa 12
85358 Yavapai and Maricopa Maricopa 12
85390 Yavapai and Maricopa Maricopa 12
85643 Graham and Cochise Cochise 18
85645 Pima and Santa Cruz Santa Cruz 18
85943 Apache and Navajo Navajo 16
86336 Coconino and Yavapai Yavapai 6
86351 Coconino and Yavapai Coconino 6
86434 Mohave and Yavapai Yavapai
If outpatient specialty services (OB, family planning, and pediatrics) are not
included in the primary care provider contract, at least one subcontract is
required for each of these specialties in the service sites specified. General
surgeons must be available within 50 miles of service sites.
In Tucson (GSA 10) and Metropolitan Phoenix (GSA 12), the Contractor must
demonstrate its ability to provide PCP, dental and pharmacy services so that
members don't need to travel more than 5 miles from their residence.
Metropolitan Phoenix is defined on the Minimum Network Standard page specific to
GSA #6.
At a minimum, the Contractor shall have a physician with admitting and treatment
privileges with each hospital in its network. Contractors in GSA 10 and/or GSA
12 must have at least one hospital contract in each service district. This
requirement is part of the Hospital Subcontracting and Reimbursement Pilot
Program, described more fully in Section D, Paragraph 35, Hospital
Reimbursement. A list of Phoenix and Tucson area hospitals are included.
Provider categories required at various service delivery sites included in the
Service Area Minimum Network Standards are indicated as follows:
H Hospitals
P Primary Care Providers (physicians, certified nurse
practitioners and physician assistants)
D Dentists
PH Pharmacies
B-1
HOSPITALS IN PHOENIX METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
DISTRICT 1
85006 Good Samaritan Regional Medical Center
Phoenix Children's Hospital
St. Luke's Medical Center
85007 Phoenix Memorial Hospital
85008 Maricopa Medical Center
85013 St. Joseph's Hospital & Medical Center
85015 Phoenix Baptist Hospital & Medical Center
85020 John C. Lincoln Hospital -North Mountain
85027 John C. Lincoln Hospital -Deer Valley
DISTRICT 2
85031 Maryvale Hospital Medical Center
85031 Paradise Valley Hospital
85306 Thunderbird Samaritan Medical Center
85308 Arrowhead Community Hospital & Medical Center
85351 Walter O. Boswell Memorial Hospital
85375 Del E. Webb Memorial Hospital
85054 Mayo Clinic Hospital
DISTRICT 3
85201 Mesa General Hospital Medical Center
Mesa Lutheran Hospital
85202 Desert Samaritan Medical Center
85206 Valley Lutheran Hospital
85224 Chandler Regional Hospital
85251 Scottsdale Healthcare- Osborn
85261 Scottsdale Healthcare- Shea
85281 Tempe St. Luke's Hospital
HOSPITALS IN TUCSON METROPOLITAN AREA (BY SERVICE DISTRICT, BY ZIP CODE)
DISTRICT 1
85719 University Medical Center
85741 Northwest Hospital
85745 Carondelet St. Mary's Hospital
DISTRICT 2
85711 Carondelet St. Joseph's Hospital
85712 El Dorado Hospital
Tucson Medical Center
85713 Kino Community Hospital
B-2
Attachment B
Minimum Network Standards
COUNTIES: LA PAZ AND MOHAVE Geographic Service Area 4
HOSPITALS
Bullhead City
Kingman
Lake Havasu City
Parker
St. George, Utah
PRIMARY CARE PROVIDERS [MAP OF KINGMAN, BULLHEAD
Blythe CITY, LAKE HAVASU CITY AND
Bullhead City PARKER]
Colorado City/Hilldale/Knab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah/Mesquite
DENTIST
Blythe
Bullhead City
Colorado City/Hilldale/Kanab, Utah
Kingman
Lake Havasu city
Parker
St. George, Utah/Mesquite
PHARMACIES
Blythe
Bullhead City
Kanab, Utah
Kingman
Lake Havasu City
Parker
St. George, Utah/Mesquite
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-3
Attachment B
Minimum Network Standards
COUNTY: YUMA Geographic Service Area 2
HOSPITALS
Yuma
PRIMARY CARE PROVIDERS
Yuma
Somerton
Wellton
[MAP OF YUMA, SOMERTON AND
WELLTON]
DENTIST
Yuma
PHARMACIES
Yuma
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-4
Minimum Network Standards
COUNTIES: COCONINO AND YAVAPAI Geographic Service Area 6
HOSPITALS
Cottonwood
Flagstaff
Kanab, Utah
Kingman
Page
Payson
Phoenix Wickenburg [MAP OF PAGE, WILLIAMS,
Prescott FLAGSTAFF, SEDONA, COTTONWOOD,
Winslow PRESCOTT VALLEY, CAMP VERDE
AND PRESCOTT]
PRIMARY CARE PROVIDERS
Camp Verde
Cottonwood
Flagstaff
Knab, Utah
Kingman
Page
Payson
Phoenix/Wickenburg
Prescott
Prescott Valley
Sedona
Williams
Winslow
DENTIST
SAME AS PRIMARY CARE
PROVIDERS
PHARMACIES
SAME AS PRIMARY CARE
PROVIDERS
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-5
Minimum Network Standards
COUNTY: MARICOPA Geographic Service Area 12
HOSPITAL
Metropolitan Phoenix*
District 1
Contract Required
District 2
Contract Required
District 3
Contract Required
Wickenburg
Physician(s) w/admit and treatment [MAP OF WICKENBURG, METRO
privileges required PHOENIX,
AVONDALE/GOODYEAR/LITCHFIELD
PRIMARY CARE PROVIDERS PARK/TOLLESON, BUCKEYE AND
Avondale/Goodyear/Litchfield GILA BEND]
Park/Tolleson
Buckeye
Gila Bend
Metropolitan Phoenix*
Queen Creek
Wickenburg
DENTIST
Avondale/Buckeye/Goodyear/Litchfield
Park/Tolleson
Metropolitan Phoenix*
Wickenburg
PHARMACIES
Avondale/Goodyear/Litchfield
Park/Tolleson
Buckeye
Metropolitan Phoenix*
Wickenburg
*For Purposes of this RFP, Metropolitan Phoenix encompasses the following:
Phoenix, Paradise Valley, Cave Creek/Carefree, Fountain Hills, Scottsdale,
Glendale, Sun City/Sun City West, Tempe, Mesa, Gilbert, Chandler, Apache
Junction, Peoria, El Mirage, Guadalupe, Surprise and Youngtown. Within this
area, distance standards must be met as specified in Attachment B.
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-6
Attachment B
Minimum Network Standards
COUNTY: PIMA Geographic Service Area 10
HOSPITAL
Tucson
District 1
Contract Required
District 2
Contract Required
Nogales
Physician(s) w/admit and treatment [MAP OF MARANA, CATALINA, AJO,
privileges required TUSCON AND GREEN VALLEY
CONTINENTAL]
PRIMARY CARE PROVIDERS
Ajo
Catalina
Green Valley/Continental
Nogales
Oro Valley
Tucson
DENTIST
Ajo
Catalina
Green Valley/Continental
Nogales
Oro Valley
Tucson
PHARMACIES
Ajo
Catalina
Green Valley/Continental
Nogales
Oro Valley
Tucson
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-7
Attachment B
Minimum Network Standards
COUNTIES: COCONINO AND YAVAPAI Geographic Service Area 8
HOSPITAL
Casa Grande
Claypool
Mesa
Payson
PRIMARY CARE PROVIDERS
Apache Junction
Casa Grande
Coolidge/Florence [MAP OF PAYSON, CLAYPOOL,
Eloy GLOBE, MIAMI, APACHE JCT,
Globe/Miami/Claypool FLORENCE, KEARNEY, COOLIDGE,
Kearney CASA GRANDE, MAMMOTH, ELOY,
Mammoth/San Manuel/Oracle ORACLE AND SAN MANUEL]
Mesa
Payson
DENTIST
Apache Junction
Casa Grande
Coolidge/Florence
Eloy
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
PHARMACIES
Apache Junction
Casa Grande
Coolidge/Florence
Globe/Miami/Claypool
Kearney
Mammoth/San Manuel/Oracle
Mesa
Payson
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-8
Minimum Network Standards
COUNTIES: APACHE AND NAVAJO Geographic Service Area 16
HOSPITAL
Gallup, NM
Showlow
Springerville
Winslow
PRIMARY CARE PROVIDERS
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside [MAP OF WINSLOW, HOLBROOK,
Snowflake/Taylor SNOWFLAKE/TAYLOR, SHOWLOW,
Springerville/Eager AND PINETOP/LAKESIDE, ST.
St. Johns JOHN'S, SPRINGERVILLE, EAGER]
Winslow
DENTIST
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
PHARMACIES
Gallup, NM
Holbrook
Showlow/Pinetop/Lakeside
Snowflake/Taylor
Springerville/Eager
St. Johns
Winslow
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-9
Minimum Network Standards
COUNTIES: GRAHAM AND GREENLEE Geographic Service Area 14
HOSPITAL
Safford
PRIMARY CARE PROVIDERS
Morenci/Clifton
Safford
DENTIST
Morenci/Clifton
Safford
PHARMACIES
Morenci/Clifton
Safford/Thatcher [MAP OF MORENCI, CLIFTON
THATCHER AND SAFFORD]
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-10
Minimum Network Standards
COUNTIES: COCHISE AND SANTA CRUZ Geographic Service Area 18
HOSPITAL
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Wilcox
PRIMARY CARE PROVIDERS
Benson
Bisbee
Douglas [MAP OF WILLCOX, BENSON,
Nogales SIERRA VISTA, NOGALES, BISBEE
Sierra Vista AND DOUGLAS]
Tucson
Wilcox
DENTIST
Benson/Wilcox
Bisbee
Douglas
Nogales
Sierra Visas
Tucson
PHARMACIES
Benson
Bisbee
Douglas
Nogales
Sierra Vista
Tucson
Wilcox
H=Hospital P=Primary Care Physician D=Dentist Ph=Pharmacy
B-11
ATTACHMENT F Contract/RFP YH8-0001
==============================================================================
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS
The following table is a summary of the periodic reporting requirements for
AHCCCS acute care contractors and is subject to change at any time during the
term of the contract. The table is presented for convenience only and should not
be construed to limit the Contractor's responsibilities in any manner.
"Reporting Guide" refers to the Reporting Guide for Acute Health Care
Contractors with the Arizona Health Care Cost Containment System.
- --------------------------------- ------------------------------- ------------------------------- -------------------------------
REPORT WHEN DUE SOURCE/REFERENCE AHCCCS
CONTACT:
- --------------------------------- ------------------------------- ------------------------------- -------------------------------
Monthly Financial Report 45 days after the end of the Reporting Guide Financial Manager
month, as applicable
Quarterly Financial Report 60 days after the end of each Reporting Guide Financial Manager
quarter
Draft Annual Audit Report 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Draft Management Letter 90 days after the end of each Reporting Guide Financial Manager
fiscal year
Final Annual Audit Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Final Management Letter 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Account's Report on Compliance 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Reconciliation - Annual Audit 120 days after the end of Reporting Guide Financial Manager
and Plan Year-to-Date Financial each fiscal year
Report Information
Financial Disclosure Report 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Annual Analysis of 120 days after the end of Reporting Guide Financial Manager
Profitability by Major Rate each fiscal year
Code (by County)
PPC Lag Schedules 120 days after the end of Reporting Guide Financial Manager
each fiscal year
Physician Incentive Plan (PIP) Annually by October 1st of RFP, Section D, Paragraph 18 Financial Manager
reporting each year
Quarterly FQHC Reports 60 days after the end of each RFP, Section D, Paragraph 26 Financial Manager
quarter
Provider Affiliation 10 business days after the PMMIS Provider-to-Health Plan Health Plan Operations Manager
Transmission beginning of each quarter FTP submission and processing
Corrected Pended Encounter Data Monthly, according to Encounter Manual Encounter Administrator
established schedule
New Day Encounter Data Monthly, according to Encounter Manual Encounter Administrator
established schedule
Medical Records for Data 90 days after the request RFP, Section C, Paragraph 1 Data Validation Manager
Validation received from AHCCCSA
Quarterly Grievance and Appeals 45 days after the end of each RFP, Section D, Paragraph 63 Administrative Assistant
Report quarter
Comprehensive EPSDT Plan Annually on December 1 RFP, Section D, Paragraph 16 OMM MCH Manager
including Dental
EPSDT Progress Report including 15 days after the end of each AMPM, Chapter 400 OMM MCH Manager
Dental - Quarterly Update quarter
F-1
ATTACHMENT F Contract/RFP YH8-0001
==============================================================================
Quarterly Inpatient Hospital 15 days after the end of each State Medicaid Manual and the OMM CMS Administrator
Showing quarter AMPM, Chapter 1000
Quarterly Management/ Annually on November 15th AMPM, Chapter 900 OMM Assistant Medical
Utilization Management Plan Director for Quality
Evaluation and Revision
Monthly Pregnancy Termination End of the month following AMPM, Chapter 400 OMM MCH Manager
Report the pregnancy termination
Maternity Care Plan Annually on December 1st AMPM, Chapter 400 OMM MCH Manager
Semi-annual report of number of 30 days after the end of the AMPM, Chapter 400 OMM MCH Manager
pregnant women who are HIV/AIDS 2nd and 4th quarter of each
positive contract year
Quality Improvement Project Annually on December 15th AMPM, Chapter 900 OMM Assistant Medical
Proposal (initial/baseline year Director for Quality
of the project)
Quality Improvement Project Annually on December 15th AMPM, Chapter 90 OMM Assistant Medical
Interim Report (intervention/ Director for Quality
Measurement year(s) of the
project)
Quality Improvement Project Within 180 days of the end of AMPM, Chapter 900 OMM Assistant Medical
Final Report the project, as defined in Director for Quality
the project proposal approved
by AHCCCS OMM
Provider Fraud/Abuse Report Immediately following AHCCS Internal Audit/Program Office of Program Integrity
discovery Investigation Policy for Manager
Prevention, Detection and
Reporting of Fraud and Abuse
Eligible Person Fraud/Abuse Immediately following AHCCCS Internal Audit/ Office of Program Integrity
Report discovery Program Investigation Policy Manager
for Prevention, Detection and
Reporting of Fraud and Abuse
Non-Transplant Catastrophic Annually, within 30 days of RFP, Section D, Paragraph 39 OMM CMS Reinsurance Manager
Reinsurance covered Diseases the beginning of the contract
year, enrollment to the plan,
and when newly diagnosed.
F-2
ATTACHMENT G Contract/RFP YH8-0001
================================================================================
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM
Members who have the right to choose but do not exercise this right, are
assigned to contractors through an auto-assignment algorithm. The algorithm is a
mathematical formula used to distribute members to the various contractors in a
manner that is predictable and consistent with AHCCCSA goals.
The algorithm employs a data table and a formula to assign cases (a case may be
a member or a household of members) to contractors using the target percentages
developed. The algorithm data table consists of all the zip codes in the state,
all contractors serving each zip code area, and the target percentages by rate
code within each zip code.
The contractor farthest away from its target percentage within a zip code and
rate code, the largest negative difference, is assigned the next case for that
zip code. The equation used is:
(t/T) - P=d
t= The total members assigned to the zip code per rate code category for the
contractor T=The total members assigned to the zip code per rate code category,
all contractors combined P=The target percentage of members for the rate code
for the contractor d=The difference
The algorithm is calculated after each assignment to give a new difference for
each contractor. When more than one contractor has the same difference, and
their differences are greater than all other contractors, the contractor with
the lowest Health Plan I.D. Number will be assigned the case.
All contractors, within a given geographic service area (GSA) and for each rate
code, will have a placement in the algorithm and will receive members
accordingly. A contractor with a more favorable target percentage in the
algorithm will receive proportionally more members. Conversely, a contractor
with a lower target percentage in the algorithm will receive proportionally
fewer members. The algorithm favors contractors with both lower final bids and
awarded rates. The algorithm also favors those contractors with programs that
score higher based on AHCCCSA's evaluation criteria.
DEVELOPMENT OF THE TARGET PERCENTAGES
For the first year of the contract, the algorithm target percentages will be
developed using the methodology described below. However, for subsequent years,
AHCCCS reserves the right to change the algorithm methodology to assure
assignments are made in the best interest of the AHCCS program and the state.
A contractor's placement in the algorithm is based upon the following three
factors which are weighted equally (i.e., 33.33%):
1. The final capitation rate bid submitted by the contractor. Final bids
that are below the bottom of the rate range will be assigned to the
bottom of the rate range for development of the target percentages.
2. The contractor's final awarded rate from AHCCCSA.
3. The contractor's score on the Program component of the proposal.
Points will be assigned to each contractor by rate code by GSA. Based on the
rankings of the final bids submitted and the final awarded rates, each
contractor will be assigned a number of points for each of these two components
separately as follows:
G-1
TABLE FOR FACTORS #1 AND #2
Number of Lowest 2nd Lowest 3rd Lowest 4th Lowest 5th Lowest 6th Lowest 7th Lowest 8th Lowest
Awards in GSA Rate Rate Rate Rate Rate Rate Rate Rate
- --------------- ------------ -------------- -------------- ------------- -------------- -------------- -------------- ------------
2 60 40
3 44 32 24
4 35 28 22 15
5 30 25 20 15 10
6 26 23 19 15 11 6
7 25 20 17 14 11 8 5
8 25 17 15 13 11 8 6 5
Contractors that have equal bids in a GSA for the same rate code will be given
an equal percentage of the points for all of the positions combined.
The third component of the calculation, program scores, will be assigned a
number of points based on where the contractor ranks among the scores. The
higher the score, the more points assigned. For this component, points will be
assigned as follows:
TABLE FOR FACTOR #3
Highest 2nd 3rd 4th 5th 6th 7th 8th
Number of Awards Program Highest Highest Highest Highest Highest Highest Highest
in GSA Score Score Score Score Score Score Score Score
- --------------- -------- -------- ------- ------- ------- ------- ------- ---------
2 60 40
3 44 32 24
4 35 28 22 15
5 30 25 20 15 10
6 26 23 19 15 11 6
7 25 20 17 14 11 8 5
8 25 17 15 13 11 8 6 5
Contractors that have equal program scores will be given an equal percentage of
the points for all of the positions combined.
The points awarded for the three components will be combined as follows to give
the target percentage for each contractor by GSA by rate code.
Final Bid Points + Awarded Bid Points + Program Score Points = TARGET PERCENTAGE
- ------------------------------------------------------------
300
Contractors that have equal bids in a GSA for the same rate code will be given
an equal percentage of the positions combined.
G-2
ATTACHMENT H Contract/RFP YH8-0001
================================================================================
ATTACHMENT H: GRIEVANCE AND REQUEST FOR HEARING PROCESS AND STANDARDS
The Contractor shall have in place a written grievance and request for hearing
policy for members and providers which defines and explains their rights
regarding any adverse action by the Contractor. The Contractor shall also ensure
compliance with the Members' Rights and Responsibilities Policy, as well as
R9-22-Article 13 and R9-31-Article 13. The written grievance and request for
hearing policy shall be in accordance with applicable federal and State laws and
AHCCCS rules and policies including, but not limited to R9-22-Article 8 and
R9-31-Article 8. The grievance and request for hearing policy shall include the
following provisions:
a. The grievance and request for hearing policy shall be provided to
members at the time of enrollment with the Contractor.
b. The grievance and request for hearing policy shall be provided to all
subcontractors at the time of contract. For providers without a
contract, the grievance and request for hearing policy may be mailed
with a remittance advice, provided the remittance is sent within 45
days of receipt of a claim.
c. The grievance and request for hearing policy must specify that all
grievances, with the exception of those challenging claim denials, must
be filed with the Contractor no later than 60 days from the date of the
adverse action. Grievances challenging claim denials must be filed in
writing with the Contractor no later than 12 months from the date of
service, 12 months after the date of eligibility posting or within 60
days after the date of a timely claim submission, whichever is later.
d. Specific individuals are appointed with authority to require corrective
action and with requisite experience to administer the grievance and
request for hearing policy.
e. A log is maintained for all grievances and requests for hearing
containing sufficient information to identify the Complainant, date of
receipt, nature of the grievance and the date the grievance is
resolved. Separate logs must be maintained for provider and member
grievances.
f. Within five working days of receipt, the Complainant is informed by
letter that the grievance has been received.
g. All correspondence must be provided in a second language in accordance
with the Member information standards set forth in Section D, Paragraph
8. In addition, the Contractor must make arrangements to ensure that it
complies with "cultural competency requirements."
h. Each grievance and request for hearing is thoroughly investigated using
the applicable statutory, regulatory, contractual and policy
provisions, ensuring that facts are obtained from all parties.
i. All documentation received and mailed by the Contractor during the
grievance and request for hearing process is dated upon receipt.
j. All grievances and requests for hearing are filed in a secure
designated area and are retained for five years following the
Contractor's decision, the Administration's decision, judicial appeal
or close of the grievance, whichever is later.
k. A copy of the Contractor's decision will be either hand-delivered or
delivered by certified mail to all parties whose interest has been
adversely affected by the decision. The decision shall be mailed to all
other individuals by regular mail. The date of the decision shall be
the date of personal delivery or, if mailed, the postmark date of the
mailing, the postmark date of the mailing. The decision must include
and describe in detail, the following:
1. the nature of the grievance
2. the issues involved
3. the reasons supporting the Contractor's decision, explained in
easy to understand terms for members, including references to
applicable statute, rule, applicable contractual provisions,
policy and procedure
4. the Complainant's right to request a hearing by filing the
request for hearing to the Contractor no later than 30 days
after the date of the Contractor's decision.
l. If the Contractor's decision is appealed and a request for hearing is
filed, the Contractor must ensure that all supporting documentation is
received by the AHCCCSA, Office of Legal Assistance no later than five
working days from the date the Contractor receives the request for
hearing or from the date of the verbal or written request from AHCCCSA,
Office of Legal Assistance. The file sent by the Contractor must
contain a cover letter that includes:
1. Complainant's name
2. Complainant's AHCCCS ID number
3. Complainant's address
4. Complainant's phone number (if applicable)
5. date of receipt of grievance
H-1
ATTACHMENT H Contract/RFP YH8-0001
================================================================================
6. summary of the Contractor's actions undertaken to resolve the
grievance and basis of the determination.
m. The following material shall be included in the file sent by the
Contractor;
1. written request of the Complainant asking for the request for
hearing
2. copies of the entire file which includes the investigations
and /or medical records; and the Contractor's decision
3. other information relevant to the resolution of the grievance
n. The Contractor may attempt to use alternative resolution procedures to
resolve disputes presented to the Contractor verbally or in writing. If
the Contractor elects to use an alternative resolution process, it must
be administered and completed within 10 days from receipt of the
dispute. If the matter is not resolved to the Complainant's
satisfaction within the 10-day time period, the dispute must then be
adjudicated using the grievance and request for hearing standards
referenced above. However, the Contractor must render the written
decision no later than 30 days from the date of the initial filing of
the grievance or dispute unless a longer period was agreed to by the
parties involved.
o. For all disputes where an alternative resolution is proposed, the
Contractor must maintain a separate log, complying with the relevant
paragraphs above.
H-2
ATTACHMENT I Contract/RFP YH8-0001
================================================================================
ATTACHMENT I: ENCOUNTER SUBMISSION REQUIREMENTS
The Contractor will be assessed for noncompliance with encounter submission
requirements. AHCCCSA may also perform special reviews of encounter data, such
as comparing encounter reports to the Contractor's claims files. Any findings of
incomplete or inaccurate encounter data may result in the imposition of
sanctions or requirement of a corrective action plan.
PENDED ENCOUNTER CORRECTIONS
The Contractor must resolve all pended encounters within 120 days of the
original processing date. Sanctions will be imposed according to the following
schedule for each encounter pended for more than 120 days unless the pend is due
to AHCCCSA error:
0 - 120 days 121-180 days 181-240 days 241-360 days 361 + days
No sanction $ 5 per month $ 10 month $ 15 per month $20 per month
"AHCCCSA error" is defined as a pended encouter which (1) AHCCCSA acknowledges
to be the result of its own error, and (2) requires a change to the system
programming, an update to the database reference table, or further research by
AHCCCSA. AHCCCSA reserves the right to adjust the sanction amount if
circumstances warrant.
When the Contractor notifies AHCCCSA in writing that the resolution of a pended
encounter depends on AHCCCSA rather than the Contractor, AHCCCSA will respond in
writing within 30 days of receipt of such notification. The AHCCCSA response
will report the status of each pending encounter problem or issue in question.
Pended encounters will not qualify as AHCCCSA errors if AHCCCSA reviews the
Contractor's notification and asks the Contractor to research the issue and
provide additional substantiating documentation, or if AHCCCSA disagrees with
the Contractor's claim of AHCCCSA error. If a pended encounter being researched
by AHCCCSA is later determined not to be caused by AHCCCSA error, the Contractor
may be sanctioned retroactively.
Before imposing sanctions, AHCCCSA will notify the Contractor in writing of the
total number of sanctionable encounters pended more than 120 days.
Pended encounters shall not be deleted by the Contractor as a means of avoiding
sanctions for failure to correct encounters within 120 days. The Contractor
shall document deleted encounters and shall maintain a record of the deleted
CRNs with appropriate reasons indicated. The Contractor shall, upon request,
make this documentation available to AHCCCSA for review.
ENCOUNTER VALIDATION STUDIES
Per CMS requirement, AHCCCSA will conduct encounter validation studies of the
Contractor's encounter submissions, and sanction the Contractor for
noncompliance with encounter submission requirements. The purpose of encounter
validation studies is to compare recorded utilization information from a medical
record or other source with the Contractor's submitted encounter date. Any and
all covered services may be validated as part of these studies. Encounter
validation studies will be conducted at least yearly.
The following reflects AHCCCA's encounter validation study process and sanction
policy as of 10/1/97. AHCCCSA may revise study methodology, timelines, and
sanction amounts based on agency review or as a result of consultations with
CMS. The Contractor will be notified in writing of any significant change in
study methodology.
AHCCSA will conduct two encounter validation studies. Study "A" examines
non-institutional services (form HCFA 1500 encounters), and Study "B" examines
institutional services (form UB-92 encounters).
AHCCCSA will notify the Contractor in writing of the sanction amounts and of the
selected data needed for encounter validation studies. The Contractor will have
90 days to submit the requested data to AHCCCSA. In the case of medical records
requests, the Contractor's failure to provide AHCCCSA with the records requested
within 90 days may result in a sanction of $1,000 per missing medical record. If
AHCCCSA does not receive a sufficient number of medical records from the
Contractor to select a statistically valid sample for a study, the Contractor
may be sanctioned up to 5% of its annual capitation payment.
I-1
ATTACHMENT I Contract/RFP YH8-0001
================================================================================
The criteria used in encounter validation studies may include timeliness,
correctness, and omission of encounters. These criteria are defined as follows:
Timeliness: The time elapsed between the date of service and the date that the
encounter is received at AHCCCS. All encounters must be received by AHCCCSA no
later than 240 days after the end of the month in which the service was
rendered, or the effective date of enrollment with the Contractor, whichever is
later. For all encounters for which timeliness is evaluated, a sanction per
encounter error extrapolated to the population of encounters may be assessed if
the encounter record is received by AHCCCSA more than 240 days after the date
determined above. It is anticipated that the sanction amount will be $1.00 per
error extrapolated to the population of encounters; however, sanction amounts
may be adjusted if AHCCCSA determines that encounter quality has changed, or if
CMS changes sanction requirements. The Contractor will be notified of the
sanction amount in effect for the studies at the time the studies begin.
Correctness: A correct encounter contains a complete and accurate description of
AHCCS covered services provided to a member. A sanction per encounter error
extrapolated to the population of encounters may be assessed if the encounter is
incomplete or incorrectly coded. It is anticipated that the sanction amount will
be $1.00 per error extrapolated to the population of encounter; however,
sanction amounts may be adjusted if AHCCCS determines that encounter quality has
changed, or if CMS changes sanction requirements. The Contractor will be
notified of the sanction amount in effect for the studies at the time the
studies begin.
Omission of data: An encounter not submitted to AHCCCSA or an encounter
inappropriately deleted from AHCCCSA's pending encounter file or historical
files in lieu of correction of such record. For Study "A" and for Study "B", a
sanction per encounter error extrapolated to the population of encounters may be
assessed for an omission. It is anticipated that the sanction amount will be
$5.00 per error extrapolated to the population of encounters for Study "A" and
$10.00 per error extrapolated to the population of encounters for Study "B";
however, sanction amounts may be adjusted if AHCCCSA determines that encounter
quality has changed, or if CMS changes sanction requirements. The Contractor
will be notified of the sanction amount in effect for the studies at the time
the studies begin.
For encounter validation studies, AHCCCSA will select all approved and pended
encounters to be studied no earlier than 240 days after the end of the month in
which the service was rendered. Once AHCCCSA has selected the Contractor's
encounters for encounter validation studies, subsequent encounter submissions
for the period being studied will not be considered.
AHCCCSA may review all of the Contractor's submitted encounters, or may select a
sample. The sample size, or number of encounters to be reviewed, will be
determined using statistical methods in order to accurately estimate the
Contractor's error rates. Error rates will be calculated by dividing the number
of errors found by the number of encounters reviewed. A 95% confidence interval
will be used to account for limitations caused by sampling. The confidence
interval shows the range within which the true error rate is estimated to be. If
error rates are based on a sample, the error rate used for sanction purposes
will be the lower limit of the confidence interval.
Encounter validation methodology and statistical formulas are provided in the
AHCCCS Encounter Data Validation Technical Document, which is available in the
Bidders Library. This document also provides examples, which illustrate how
AHCCCSA determines study sample sizes, error rates, confidence intervals, and
sanction amounts.
Written preliminary results of all encounter validation studies will be sent to
the Contractor for review and comment. The Contractor will have a maximum of 30
days to review results and provide AHCCCSA with additional documentation that
would affect the final calculation of error rates and sanctions. AHCCCSA will
examine the Contractor's documentation and may revise study results if
warranted. Written final results of the study will then be sent to the
Contractor and communicated to CMS, and any sanctions will be assessed.
The Contractor may file a written challenge to sanctions assessed by AHCCCSA not
more than 35 days after the Contractor receives final study results from
AHCCCSA. Challenges will be reviewed by AHCCCSA and a written decision will be
rendered no later than 60 days from the date of receipt of a timely challenge.
Sanctions shall not apply to encounter errors successfully challenged. A
challenge must be filed on a timely basis and a decision must be rendered by
AHCCCSA prior to filing a grievance and request for hearing pursuant to Article
8 of AHCCCS Rules. Sanction amounts will be deducted from the Contractor's
capitation payment.
I-2
ATTACHMENT I Contract/RFP YH8-0001
================================================================================
ENCOUNTER ADJUSTMENTS
Contractors are required to submit adjusted or voided encounters in the event
that claims are subsequently adjusted or denied after the initial encounter
submission. This includes adjustments for inaccuracies identified by fraud and
abuse audits or investigations conducted by AHCCCSA or the Contractor.
Contractors shall refer to the Encounter User's Manual for further instructions
regarding adjustments to encounters.
I-3
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
CONTRACT AMENDMENT
[AHCCCS LOGO] Page 1 of 3
- ---------------------------- ------------------------- ------------------------------------------ --------------------------
1. AMENDMENT 2. CONTRACT 6. EFFECTIVE DATE OF 4. PROGRAM
NUMBER: NO.: AMENDMENT:
YH8-0001-05 October 1, 2001 OMC
16
- ----------------------------------------------------------------------------------------------------------------------------
5. CONTRACTOR'S NAME AND ADDRESS:
Health Choice Arizona
1600 W. Broadway, Suite 260
Tempe, AZ 85282-1502
- ----------------------------------------------------------------------------------------------------------------------------
6. PURPOSE OF AMENDMENT: To establish new capitation rates and allow the Contractor to elect their risk band method of
the Title XIX Waiver Group.
- ----------------------------------------------------------------------------------------------------------------------------
7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:
A. New Capitation Rates are provided on page two (2) of this amendment; and
B. The Contractor must select one of the two methods of the Title XIX
Waiver Group risk bands. The election form is page three (3) of this
amendment and incorporated by reference herein.
NOTE: PLEASE SIGN AND DATE BOTH AND THEN RETURN ONE TO: MICHAEL VEIT, MD 5700
AHCCCS CONTRACTS AND PURCHASING
701 E JEFFERSON STREET
PHOENIX, AZ 85034
- ----------------------------------------------------------------------------------------------------------------------------
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL
EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
- ----------------------------------------------------------------------------------------------------------------------------
9. SIGNATURE OF AUTHORIZED 10. SIGNATURE OF AHCCCSA CONTRACTING
REPRESENTATIVE: OFFICER:
/s/ Greg Martenson CFO /s/Michael Veit
- ----------------------------------------------------------------------------------------------------------------------------
TYPED NAME:
CAROLYN ROSE MICHAEL VEIT
- ----------------------------------------------------------------------------------------------------------------------------
TITLE: CONTRACTS & PURCHASING
CHIEF EXECUTIVE OFFICER ADMINISTRATOR
- ----------------------------------------------------------------------------------------------------------------------------
DATE: DATE:
9/28/01 9/11/01
- ----------------------------------------------------------------------------------------------------------------------------
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CAPITATION RATE SUMMARY - ACUTE RATES
HEALTH CHOICE ARIZONA
CYE '02 (AS OF 10/01/01)
TANF TANF TANF TANF TANF SSI SSI DELIVERY TITLE XIX HOSPITALIZED
TITLE XIX RATE <1,M/F 1-13,M/F 14-44,F 14-44,M 45+,M/F W/MED W/O MED SFP KICK WAIVER GROUP KICK
- -------------- ------ -------- ------- ------- ------- ----- ------- --- ---- ------------ ----
10 Pima $335.79 $75.04 $131.46 $ 99.61 $271.97 $180.88 $396.01 $18.84 $4,831.84 $321.65 $12,871.62
12 Maricopa $347.38 $76.75 $117.99 $100.83 $280.82 $196.56 $385.26 $19.68 $4,911.82 $314.65 $12,591.60
KIDSCARE KIDSCARE KIDSCARE KIDSCARE DELIVERY
TITLE XXI RATES <1,M/F 1-13,M/F 14-44,F 14-44,M KICK
--------------- -------- -------- -------- -------- ----
10 Pima $270.86 $79.24 $128.04 $80.71 $4,831.84
12 Maricopa $281.63 $82.56 $118.58 $81.01 $4,911.82
TANF TANF TANF TANF TANF SSI SSI TITLE XIX
PPC RATES: <1,M/F 1-13,M/F 14-44,F 14-44,M 45+,M/F W/MED W/O MED WAIVER GROUP
--------- ------ -------- ------- ------- ------- ----- ------- ------------
10 Pima $1,164.82 $32.70 $136.50 $76.91 $180.25 $14.50 $61.79 $234.28
12 Maricopa 1,164.82 $32.70 $136.50 $76.91 $180.25 $14.50 $61.79 $229.19
*Rates have been adjusted for $35,000 Reinsurance Deductible
Page 3 of 3
TITLE XIX WAIVER GROUP RISK BAND
ELECTION FORM
Per Contract YH8-0001, Paragraph 37, Compensation, Risk Sharing for Title XIX
Waiver Members: For CYE '02 and CYE '03, AHCCCSA will reconcile the contractor's
PPC and prospective medical cost expenses to PPC capitation, prospective
capitation, and hospitalized supplements paid to the Contractor during the year.
For CYE '02, the contractor has a choice to elect:
[ ] Default Method: This reconciliation will limit the Contractor's losses
to 2% and profits to 4%. Any losses in excess of 2% will be reimbursed
to the Contractor, and likewise, profits in excess of 1% will be
recouped.
[ ] Alternative Method: This reconciliation will limit the Contractor's
losses to 1% and profits to 1%. Any losses in excess of 1% will be
reimbursed to the Contractor, and likewise, profits in excess of 1%
will be recouped.
- ------------------------------------ -------------------------
Signature Date
- --------------------------------------------------------------------------------
Health Plan
* Please sign and return this form to AHCCCS by December 1, 2001. If not
returned, AHCCCS will assign the Default Method as stated above.