EXHIBIT 10.20
PSC 02-05
STATE OF NEW MEXICO
HUMAN SERVICES DEPARTMENT
MEDICAID MANAGED CARE SERVICES AGREEMENT
This agreement ("Agreement") between the New Mexico Human Services Department
("HSD") and Lovelace Community Health Plan of Albuquerque, New Mexico,
("CONTRACTOR"), specifies the terms and conditions under which the CONTRACTOR
shall provide Medicaid managed care services for HSD's Medical Assistance
Division ("MAD").
The term of this Agreement shall be from July 1, 2001 and shall expire June 30,
2003, unless amended, or terminated pursuant to its terms. Pursuant to the
Request for Proposals ("RFP"), HSD and the CONTRACTOR mutually may extend this
Agreement for two additional one-year terms, or a single additional two-year
term. In no circumstance shall the Agreement exceed a total of four years in
duration. This Agreement shall not become effective until approved in writing by
the Department of Finance and Administration and the United States Department of
Health and Human Services' Health Care Financing Administration ("HCFA"). The
New Mexico Attorney General's Office must also review this agreement for legal
form and sufficiency.
The term day(s) refers to calendar days, unless otherwise specified. The first
day is excluded and the last day is included. Timelines or due dates falling on
a weekend or state or federal holiday shall be extended to the first business
day after the weekend or holiday.
The terms "contract" and "agreement" are used interchangeably throughout this
document.
ARTICLE 1 - RECITALS
1.1 All services provided pursuant to this Agreement are subject to the
Procurement Code and 1 NMAC 5.2 unless specifically provided otherwise
herein.
1.2 All services purchased under this Agreement shall be subject to the
following provisions for administration of the Medicaid program, which
are incorporated herein by reference:
(1) The MAD program eligibility and provider policy manuals,
including all updates, revisions, substitutions and
replacements;
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(2) Title XIX and Title XXI of the Social Security Act and Code of
Federal Regulations Title 42 Parts 430 to end, as revised from
time to time;
(3) The RFP; all RFP Amendments; CONTRACTOR Questions and HSD's
Answers; and HSD written Clarifications;
(4) The CONTRACTOR'S Best and Final Offer;
(5) The CONTRACTOR'S Proposal (including any and all written
materials presented in the orals portion of the procurement)
where not inconsistent with this Agreement and subsequent
amendments to this Agreement;
(6) All applicable statutes, regulations and rules implemented by
the Federal Government, the State of New Mexico ("State"), and
HSD, concerning Medicaid services, managed care organizations,
health maintenance organizations, fiscal and fiduciary
responsibilities applicable under the Insurance Code of New
Mexico, NMSA 1978 Sections 59A-1-1 et. seq., and any other
applicable laws; to this effect, the CONTRACTOR is put on
notice that regulations have been promulgated by the federal
government implementing the Balanced Budget Act. The effective
date of these regulations has been delayed until June 18,
2001, with the possibility of another extension. However, the
CONTRACTOR and its subcontractors shall comply with these
regulations, if not repealed, as of their effective date.
(7) The HSD's MAD Policy Manual, including all updates and
revisions thereto, or substitutions and replacements thereof,
duly adopted in accordance with applicable law. All defined
terms used within the Agreement shall have the meanings given
them in the Policy Manual; and
(8) All applicable statutes, regulations and rules implemented by
the Federal Government, the State of New Mexico, and HSD
concerning State Children's Health Insurance Program
("SCHIP").
1.3 HSD is responsible for administering New Mexico's Medicaid program. Due
to increasing budgetary constraints, HSD shall require that most
Medicaid recipients enroll with managed care organizations ("MCOs").
HSD plans to execute agreements with managed care organizations which
meet the requirements specified under the terms of this Agreement and
the RFP.
1.4 HSD shall award risk-based contracts to the CONTRACTORS with statutory
authority to enter into capitated agreements, assume risk and that meet
applicable requirements and/or standards delineated under state and
federal law.
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1.5 The CONTRACTOR possesses the required authorization and expertise to
meet the terms of this Agreement.
1.6 The CONTRACTOR shall be National Committee for Quality Assurance
("NCQA") accredited, or in active pursuit of accreditation by July 1,
2001. "Active pursuit" is defined as having applied for accreditation.
NOW, THEREFORE, in consideration of the mutual promises contained herein, HSD
and the CONTRACTOR agree as follows:
ARTICLE 2 - SCOPE OF WORK
The CONTRACTOR shall perform professional services including, but not
necessarily limited to, the following:
2.1 PROGRAM ADMINISTRATION
(1) Member Services
HSD shall implement procedures governing the following
activities by the CONTRACTOR or entities acting on behalf of
the CONTRACTOR: Development of information and educational
media; Provision of materials explaining the enrollment
options and process to potential members; and provision of
informational presentations to eligible members, members,
member advocates and other interested parties.
The CONTRACTOR shall have a member services function that
coordinates communication with members and acts as a member
advocate. There should be sufficient staff to allow members to
resolve problems or inquiries.
A. Policies and Procedures:
The CONTRACTOR shall have and comply with written
policies and procedures regarding the treatment of
minors; those adults who are in the custody of the
State; those children and adolescents who are under
the jurisdiction of the Children, Youth, and Families
Department (CYFD); and any individual who is unable
to exercise rational judgment or give informed
consent, under applicable federal and state laws and
New Mexico Medicaid Regulations.
i. The CONTRACTOR shall have and comply with
written policies
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and procedures that describe a process to
detect, measure, and eliminate operational
bias or discrimination against enrolled
Medicaid members by the CONTRACTOR or its
providers.
ii. The CONTRACTOR shall maintain and comply
with written policies and procedures to
ensure that its providers and their
facilities are in compliance with the
Americans with Disabilities Act ("ADA").
iii. The CONTRACTOR shall maintain and comply
with written policies and procedures
regarding members' and/or legal guardians'
right to select a primary care provider.
iv. The CONTRACTOR shall perform an initial
assessment of member's health care needs
within 90 days of the date of a member's
enrollment. A member is considered to be
enrolled for the purpose of this sub-section
at the time the member is considered locked
in the CONTRACTOR'S MCO. The initial
assessment shall, at a minimum, include the
distribution of an appropriate form to
members and the clinical review of any form
returned by members. The form, if mailed to
a member, shall include a pre-addressed
return postage paid envelope.
v. The CONTRACTOR shall provide potential and
enrolled members with a directory to include
MCO addresses and telephone numbers, (and
primary care and specialty provider lists
and relevant phone numbers) and the
identity, location, phone number and
qualifications to include area of specialty,
board certification and any areas of special
expertise that would be helpful to
individuals deciding to enroll with the
CONTRACTOR, for each primary care and
specialty provider. At the option of the
CONTRACTOR, the directory may be limited to
primary care and self-refer providers.
vi. The CONTRACTOR shall provide potential and
enrolled members a list of all items and
services that are available to members
covered either directly or through a method
of referral and/or prior authorization.
vii. The CONTRACTOR'S written policies and
procedures shall be made available upon
request to members and their representatives
for review during normal business hours.
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B. Member Education
Medicaid recipients shall be educated about their
rights, responsibilities, service availability, and
administrative roles under the managed care system.
Member education is initiated when they become
eligible for Medicaid and is augmented by information
provided by HSD and the CONTRACTOR.
C. Initial Information
The education of the member is initiated when the
member becomes eligible for Medicaid. HSD distributes
information about Medicaid managed care and the
enrollment process.
D. MCO Enrollment Information
Once a member is determined to be an MCO mandatory
member, HSD provides specific information about
services included in the benefit packages, MCOs from
which the member can choose, and enrollment of the
member(s).
E. Member Handbook
i. The CONTRACTOR shall maintain written
policies and procedures governing the
development and distribution of marketing
materials for members.
ii. The CONTRACTOR is responsible for providing
members with a member handbook. The
CONTRACTOR shall provide periodic updates to
the handbook as needed explaining changes in
all policies and procedures that affect the
member.
iii. The CONTRACTOR shall send a provider
directory and member handbook to enrollees
or potential enrollees requesting a copy and
as requested by HSD. The CONTRACTOR shall
direct a person requesting a member handbook
or a provider directory to an internet site.
However, a specific request for a printed
document shall be met. The CONTRCTOR shall
provide a one page, two-sided summary of its
benefits which may be distributed by HSD at
its discretion.
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iv. Member handbooks shall be made available in
formats other than written English, (e.g.
Braille), if in the CONTRACTOR'S or HSD's
determination five percent of the
CONTRACTOR'S Salud! members are conversant
only in those other languages or formats. In
addition, such language used shall be
prepared in a manner which is clear and
understandable to an individual who has
completed no more than the sixth grade. The
handbook shall include:
a) Limitations to the receipt of care
from non-participating providers;
b) Coordination of care by PCPs;
c) The CONTRACTOR demographic
information including the
organization's toll-free member
phone number;
d) Services for which prior
authorization or a referral is
required, and the method of
obtaining both;
e) The provider list, including phone
numbers, addresses and type of
service designations which need not
physically be a part of the
handbook;
f) Notice to members on both the
internal and HSD grievance and
appeal processes;
g) Information on how to obtain
services;
h) The members' rights and
responsibilities;
i) Information on obtaining care in
emergency or urgent conditions;
(j) The CONTRACTOR'S operating rules as
required by NCQA;
(k) Information on accessing behavioral
health or other specialty services,
including but not limited to EPSDT,
and family planning services,
including a discussion of member's
rights to self refer to in-plan and
out-of-plan
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family planning providers;
(l) Information on the member's right
to terminate enrollment and the
process for voluntarily
disenrolling from the plan; and
(m) Other information determined by the
State to be essential during the
member's initial contact with the
CONTRACTOR.
F. Second Opinions
i. The CONTRACTOR shall provide members with
the option of receiving a second opinion
from another provider participating with the
CONTRACTOR when members need additional
information regarding recommended treatment
or when requested care has been denied by
the provider.
ii. The CONTRACTOR may select the provider
giving the second opinion, in accordance
with a method established by the CONTRACTOR
to equitably distribute these duties,
provided that the provider selected
practices in an area that provides expertise
appropriate to the member's specific
treatment or condition.
G. Maintenance of Toll-Free Line
The CONTRACTOR shall maintain one or more toll-free
telephone line(s) which is accessible twenty-four
(24) hours a day, seven (7) days a week, to
facilitate member access to qualified clinical staff.
MCO Members may also leave a voice mail message to
obtain the CONTRACTOR'S policy information, and /or
to register grievances with the CONTRACTOR. The phone
call shall be returned the next business day by an
appropriate CONTRACTOR staff person.
H. Member Notification
i. The CONTRACTOR shall adopt written policies
and procedures to require prompt
notification of abnormal results of
diagnostic laboratory, diagnostic imaging,
and other testing and, if clinically
indicated, to notify the member of a
scheduled follow-up visit. This shall be
documented in the member's record.
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ii. At the request of a member, the CONTRACTOR
shall provide information to the member on
options for private health insurance when
the member's enrollment is terminated due to
loss of Medicaid eligibility. This shall be
documented in the member's records
maintained by the CONTRACTOR.
I. Benefit Information
i. The CONTRACTOR shall provide in English and
Spanish each member and/or legal guardian
with written information about benefits,
including:
a) Benefits and services, including
preventive services, included in,
and excluded from, coverage;
b) Any special benefit provisions that
may apply to services obtained
outside the CONTRACTOR'S system;
c) Any restrictions on benefits that
apply to services obtained outside
the CONTRACTOR'S service area; and
d) The following information regarding
the member's rights of access to,
and coverage of, emergency
services, both inside and outside
of the CONTRACTOR'S network:
1. That both in-network and
out-of-network emergency
services are a covered
benefit;
2. That emergency services
are defined as covered
inpatient and outpatient
services furnished by a
qualified Medicaid
provider that are
necessary to evaluate or
stabilize an emergency
condition;
3. That an emergency
condition is a medical
condition manifesting
itself by acute symptoms
of sufficient severity
(including severe pain)
such that a prudent
layperson, who possesses
an average knowledge of
health and medicine, could
reasonably expect the
absence of immediate
medical attention to
result in placing the
individual's health (or
with respect to a pregnant
woman, the health of the
woman or her unborn child)
in serious jeopardy,
serious impairment to body
function or serious
dysfunction of any bodily
organ or part;
4. That the CONTRACTOR shall
not retroactively deny a
claim for an emergency
screening examination
because the condition,
which appeared to be an
emergency medical
condition under the
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prudent layperson standard
(defined in (3) above),
turned out to be
non-emergency in nature;
and
5. That the CONTRACTOR does
not require prior
authorization for
emergency services
rendered in or out of
network with all emergency
services reimbursed at the
in network rate.
ii. The CONTRACTOR shall provide each member
with written information in English or
Spanish, as appropriate, that instructs
members about how to obtain primary and
specialty care, including:
a) A list of providers, by provider
type and specialty, available
through the CONTRACTOR and how to
access them; such list, at the
option of the CONTRACTOR, may be
limited to primary care providers
and those providers to whom members
may self-refer, including, but not
limited to, family planning
providers, point-of-entry
behavioral health providers, urgent
and emergency care providers, IHS
and other Native American
providers, and pharmacies. Upon
request, the CONTRACTOR shall
provide information on the
participation status of any
provider;
b) The means for obtaining more
information about providers who
participate in the MCO;
c) The means for obtaining primary
care services;
d) The means for obtaining specialty
care, behavioral health services
and hospital services;
e) The means for obtaining care after
normal office hours;
f) The means for obtaining emergency
care, including the CONTRACTOR'S
policy on when to directly access
emergency care or use 911 services;
g) The means for obtaining care and
coverage when out of the
CONTRACTOR'S service area;
h) The means by which the CONTRACTOR
shall notify members affected by
the termination or change in any
benefit, service or service
delivery office/site.
iii. The CONTRACTOR shall provide each member
and/or legal guardian with written policies
and procedures in English and Spanish and
procedures concerning:
a) Its policy on freedom of provider
choice;
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b) Changing assigned providers, if
applicable;
c) Accessing the toll-free phone
lines;
d) Filing a grievance and/or appeal;
e) The procedure for appealing a
decision that adversely affects the
member's coverage, benefits, or
other relationship with the
CONTRACTOR; and
f) All other policies and procedures
regarding member rights and
responsibilities.
iv. The CONTRACTOR shall provide affected
members and/or legal guardians with updated
information within 30 days of any material
change.
J. Member Identification Card
The CONTRACTOR shall issue a member identification
card within thirty (30) days of enrollment to each
member. The card shall be substantially the same as
the card issued to commercial enrollees. The card may
not contain information which identifies the member
as a Medicaid recipient, other than designations
which are commonly used by the CONTRACTOR to identify
for providers the members' benefits, or copayments,
such as group or plan numbers.
K. Members' Patient Bill of Rights and Responsibilities
The CONTRACTOR shall be required to comply with the
MAD regulation on Patient Bill of Rights. The
CONTRACTOR shall provide each member with written
information, in English or Spanish, as appropriate,
found in the MAD patient Bill of Rights pursuant to
MAD 606.7.6 and 606.1.2.3.
i. Members and/or legal guardians have a right
to obtain equitable treatment, with respect
and recognition of the member's dignity and
need for privacy.
ii. Members have a right to receive health care
services in a non-discriminatory fashion.
a) Members and, as appropriate, their
families and/or legal guardians
have a right to participate with
practitioners in decision making
regarding all aspects of their
health care, including development
of the treatment plan. The policy
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shall contain procedures for
obtaining informed consent.
b) The policy shall ensure that
legally determined surrogate
decision makers shall be involved,
as appropriate, to facilitate care
decisions.
iii. Members and/or legal guardians have a right
and the means to voice complaints or file
grievances and appeals about the care
provided by the CONTRACTOR.
iv. Members and/or legal guardians have a right
and the means to be able to choose from
among the available providers within the
limits of the plan network and its referral
and prior authorization requirements.
v. Members have a right to formulate advance
directives consistent with Federal and State
laws and regulations.
vi. Members have a right to have access to their
medical records in accordance with the
applicable Federal and State laws and
regulations.
vii. Members and/or legal guardians, to the
extent possible, have a responsibility to
provide information that the CONTRACTOR, its
practitioners, and providers need in order
to care for them.
viii. Members and/or legal guardians, to the
degree possible, have a responsibility to
participate in understanding their health
problems and developing mutually agreed upon
treatment goals.
ix. Members and/or legal guardians have a
responsibility to follow the plans and
instructions for care that they have agreed
upon with their practitioners.
x. Members and/or legal guardians have a
responsibility to keep, reschedule, or
cancel a scheduled appointment rather than
to simply fail to keep it.
L. Consumer Advisory Board
i. The CONTRACTOR shall establish a Consumer
Advisory Board representing both physical
and behavioral health members. The
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board shall include regional representation,
including members, advocates and providers.
ii. The Consumer Advisory Board shall serve to
advise the CONTRACTOR on issues concerning
service delivery and quality, member rights
and responsibilities, the process for
resolving member grievances, and the needs
of the groups they represent as they pertain
to Medicaid managed care. The Board shall
meet on at least a quarterly basis in the
state's regions. The CONTRACTOR is
responsible for keeping a written record of
the board meetings.
iii. The CONTRACTOR'S Consumer Advisory Board
shall maintain documentation of all attempts
to invite and include its members in its
meetings. The Board roster and minutes shall
be made available to HSD upon request.
iv. The Consumer Advisory Board shall advise HSD
in writing ten (10) days in advance of all
meetings to be held. HSD reserves the right
to attend and observe the meetings of the
Board at its discretion.
v. The Consumer Advisory Board shall consist of
a fair representation of the CONTRACTOR'S
members in terms of race, gender and New
Mexico geographic areas.
vi. The CONTRACTOR shall send the CONTRACTOR'S
representatives to attend at least two
statewide consumer meetings to help ensure
that member issues are being heard and
addressed.
M. Standards for Utilization Management (UM)
i. The CONTRACTOR'S Utilization Management (UM)
Program shall properly manage the use of
limited resources, maximize the
effectiveness of care by evaluating clinical
appropriateness, and authorize the type and
volume of services through fair, consistent
and culturally competent decision making to
assure equitable access to care and to a
successful link between care and outcomes;
ii. The CONTRACTOR shall define in writing the
UM program structure and accountability
mechanisms;
iii. The CONTRACTOR senior management and the
CONTRACTOR Medical Director or the
CONTRACTOR'S Internal Quality
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Management and Improvement ("QI") program
shall annually evaluate and approve or
revise the UM program;
iv. The CONTRACTOR shall define all services
which require prior authorization;
v. The CONTRACTOR shall develop and implement
written policies and procedures for review
of utilization decisions to ensure their
basis in sound clinical evidence and that
conform to medical necessity criteria;
vi. The CONTRACTOR shall ensure the involvement
of appropriate, practicing practitioners in
the development of UM procedures;
vii. The CONTRACTOR shall comply with NCQA
Standards for Utilization Management and
follow NCQA timeliness standards for
routine, urgent and emergent situations. The
decision-making timeframes should
accommodate the clinical urgency of the
situation and not delay the provision of
services to members for lengthy periods of
time;
viii. The CONTRACTOR shall approve or deny
services for routine/nonurgent, urgent care
requests within the timeframes stated in
regulation. These required timeframes are
not to be affected by "pend" decision;
ix. The CONTRACTOR shall evaluate member and
provider satisfaction with the utilization
process;
x. The CONTRACTOR shall ensure that UM
functions are appropriately implemented,
monitored and professionally managed;
xi. The CONTRACTOR shall submit quarterly to HSD
in a format to be determined by HSD after
consultation with the CONTRACTOR, a job
description and the qualifications of each
individual behavioral health UM staff who
makes behavioral health determinations; and
xii. The CONTRACTOR shall provide to HSD ad hoc
reports about service utilization upon
request by HSD.
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N. Denials
i. The CONTRACTOR shall clearly document in
English or Spanish, as appropriate, on a
form agreed to by HSD, and communicate in
writing the reasons for each denial. A
"denial" is defined as a refusal by the
CONTRACTOR to authorize a service requested
or recommended by the member's health care
provider.
ii. The CONTRACTOR shall provide in writing the
reason for a denial of service coverage to
the requesting practitioner and the affected
member. There shall be established and well
publicized internal and accessible grievance
and appeals mechanism for both providers and
members; the notification of a denial shall
include a description of how to file a
grievance and notice of appeal.
iii. The CONTRACTOR shall recognize that a
utilization review decision resulting from a
Fair Hearing conducted by the designated HSD
official is final and shall be honored by
the CONTRACTOR, unless the CONTRACTOR
successfully appeals the Fair Hearing
decision in a court of competent
jurisdiction.
iv. The CONTRACTOR shall evaluate member and
provider satisfaction with the UM process as
a part of its member satisfaction survey
while maintaining the federal and state
confidentiality requirements of surveyed
participants.
v. The CONTRACTOR shall forward survey results
to HSD. HSD shall have access to the
CONTRACTOR'S UM review documentation.
(2) Standards for Internal Quality Management and Improvement
A. The CONTRACTOR shall have Quality Improvement (QI)
Programs based on a model of continuous quality
improvement. The QI programs shall encompass
physical, mental and behavioral health. The ultimate
responsibility for QI is with the CONTRACTOR and
shall not be delegated to subcontractors. The QI
structures and procedures shall be clearly defined
with responsibilities appropriately assigned.
B. The CONTRACTOR shall produce and deliver to HSD and
the CONTRACTOR'S members, upon request, an annually
evaluated and updated program description. The QI
program description shall contain a
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work plan, or schedule of activities to be reviewed
quarterly and to include:
i. Objectives, scope, and planned projects or
activities for the year;
ii. Planned monitoring of previously identified
issues, including tracking of issues over
time; and
iii. Planned evaluation of the QI program.
C. The CONTRACTOR shall designate a physician and a
behavioral health care practitioner with primary
responsibility for the implementation of the QI
program.
D. The CONTRACTOR shall establish a committee to oversee
and implement QI requirements and such requirements
shall address:
i. QI Program and Policy;
ii. QI Committee and Policy;
iii. Annual QI Workplan and Evaluation;
iv. Confidentiality Policy and Procedures;
v. Medical Records Documentation Policy and
Procedures;
vi. Policy and Procedures for working with high
need members;
vii. Member Satisfaction Surveys;
viii. Disease Management Protocols and Procedures;
and
ix. Policy and Procedures for Continuity and
Coordination of Care.
E. The CONTRACTOR shall every two years, appropriately
update and disseminate evidence-based practice
guidelines for providing services for acute and/or
chronic conditions, both physical and behavioral,
relevant to enrolled membership. The QI program shall
be approved by HSD prior to implementation.
F. Quality Management/Quality Improvement Program
(QM/QI)
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i. The CONTRACTOR shall have a QM/QI program,
including goals; objectives; structure;
policies; and authorities that shall result
in continuous quality improvement in the
physical, mental and behavioral health care;
ii. The CONTRACTOR shall have a QI work plan
that includes immediate objectives for each
contract period and long term objectives for
the entire contract period. This work plan
shall contain the scope of the objectives,
activities planned; timeframe and other
relevant information;
iii. The CONTRACTOR shall evaluate the overall
effectiveness of its QI program and
demonstrate improvements in the quality of
clinical care and the quality of service to
its members;
iv. The CONTRACTOR shall have a process for
exchanging information throughout the
CONTRACTOR'S organization;
v. The CONTRACTOR shall have written policies
and procedures for medical records
documentation;
vi. The CONTRACTOR shall have disease management
protocols and procedures;
vii. The CONTRACTOR shall have policies and
procedures for working with high need
members;
viii. The CONTRACTOR shall have written policies
and procedures for conducting member and
provider surveys;
ix. The CONTRACTOR shall have written policies
and procedures for continuity and
coordination of care; and
x. The CONTRACTOR shall have written policies
and procedures on confidentiality, including
a provision that all materials concerning
the care and treatment of members shall be
made available to HSD.
G. QI Projects and Reviews
The CONTRACTOR shall:
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i. Be responsible to demonstrate to HSD that
the results of QI projects and reviews are
used to improve the quality of service
coverage and delivery with appropriate
individual practitioners and institutional
providers. When the CONTRACTOR determines
that there are provider performance
problems, the CONTRACTOR is responsible to
take and document appropriate action.
ii. Ensure that the QI program is applied to the
entire range of health services provided
through the CONTRACTOR by assuring that all
major population groups, care settings, and
service types are included in the scope of
the review. A major population group is one
which represents at least ten percent of a
CONTRACTOR'S enrollment.
H. Continuous Quality Improvement
The CONTRACTOR shall ensure that management is based
on principles of Continuous Quality Improvement/Total
Quality Management (CQI/TQM), including, the
recognition that opportunities for improvement are
unlimited that the QI process shall be data driven,
requiring continual measurement of clinical and
non-clinical effectiveness and programmatic
improvements of clinical and non-clinical processes
driven by such measurements; requiring re-measurement
of effectiveness and continuing development and
implementation of improvements as appropriate; and
shall rely on customer input.
I. QI Program Effectiveness Evaluation
The CONTRACTOR shall annually evaluate the overall
effectiveness of its QI program and demonstrate
improvements in the quality of clinical care and the
quality of service to its members. The CONTRACTOR
shall submit its written evaluation of the QI program
to HSD. This evaluation shall include at least the
following:
i. A description of completed and ongoing QI
activities;
ii. Trending of measures to assess performance
in quality of clinical care and quality of
service;
iii. An analysis of whether there have been
demonstrated improvements in the quality of
clinical care and quality of service; and
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iv. An evaluation of the overall effectiveness
of the QI program.
J. Delegation
HSD reserves the right to approve and disapprove any
delegated subcontract templates.
The CONTRACTOR shall:
i. Have a written document (Agreement), signed
by both parties, that describes the
responsibilities of the CONTRACTOR and the
delegate; the delegated activities; the
frequency of reporting (if applicable) to
the CONTRACTOR ; the process by which the
CONTRACTOR evaluates the delegate; and the
remedies, including revocation of the
delegation, available to the CONTRACTOR if
the delegate does not fulfill its
obligation;
ii. Have written policies and procedures to
ensure that the delegated agency meets all
standards of performance mandated by HSD for
the SALUD! program;
iii. Have written policies and procedures for the
oversight of the delegated agency's
performance of the delegated functions;
iv. Have written policies and procedures to
ensure consistent statewide application of
all utilization management criteria when
utilization management is delegated;
v. Include in its agreement with the delegate
whether the CONTRACTOR or the delegate shall
oversee the performance of the subdelegate
to ensure that there is a mutually agreed
document in place for any subdelegated
functions;
vi. Be ultimately accountable for all delegated
activities and may not under any
circumstances abrogate any responsibility
for decisions made by a delegate regarding
delegated functions;
vii. Provide a list of all delegates to HSD;
viii. Ensure that it notifies HSD of any proposed
new agreement for delegation at least thirty
(30) calendar days prior to the proposed
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beginning date of the Agreement or any
material changes to existing Agreements; and
ix. Not delegate quality oversight, utilization
management, prevention, education, outreach,
grievance, internal hearings, appeals, data
collection, or claims payment for behavioral
health services.
K. Clinical Performance
The CONTRACTOR shall identify and monitor on an
on-going basis indicators of clinical performance;
and, implement activities designed to improve the
process of providing a clinical service;
L. Member Satisfaction Survey
As part of its QI Program, the CONTRACTOR shall
conduct at least one annual survey of member
satisfaction with the CONTRACTOR, which shall be
designed by the CONTRACTOR with input from the
Consumer Advisory Board and which shall assess member
satisfaction with the quality, availability, and
accessibility of care. The survey shall provide a
statistically valid sample of all CONTRACTOR members,
including members who have requested to change
his/her primary care provider (PCP) and all members
who have voluntarily disenrolled from the CONTRACTOR.
The member survey shall address member receipt of
educational materials, and use and usability of the
provided education materials. The CONTRACTOR'S survey
shall address the satisfaction of members with
serious/chronic care conditions. The CONTRACTOR shall
follow all federal and state confidentiality
requirements in conducting this survey with members.
The CONTRACTOR shall:
i. Use the CAHPS 2.0H Adult and Child survey
Instruments (most current version) to assess
member satisfaction as part of the HEDIS
requirements and report the results of the
CAHPS survey to HSD.
ii. Disseminate results of the member
satisfaction survey to practitioners,
providers, HSD and members.
iii. Participate in the design of a separate
annual member satisfaction survey to be
conducted by an independent entity
determined by HSD. The survey itself shall
not be the financial responsibility of
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the CONTRACTOR.
iv. Follow NCQA guidelines for the conduct of
Provider Satisfaction surveys; cooperate
with HSD in conducting provider satisfaction
survey, including making available a
current, unduplicated provider file(s)
available to HSD or its EQRO upon request;
conduct a provider satisfaction survey, at
least annually, of all in-network providers;
and report information from this survey to
HSD annually; and, include the results in
the QI/QM Effectiveness Evaluation into the
QI/QM plan for the upcoming contract year.
(HSD will work towards reducing the
administrative burden of this requirement on
providers by combining surveys or conducting
one survey. However, until such is
accomplished, the CONTRACTOR must comply
with this requirement as stated.)
M. External Quality Review
i. HSD shall retain the services of an external
quality review organization in accordance
with the Social Security Act, Section 1902
(a) (30) [C], and the CONTRACTOR shall
cooperate fully with that organization and
prove to that organization the CONTRACTOR'S
adherence to HSD's quality standards as set
forth in MAD Policy Section 606.7. HSD shall
also contract with an external review
organization to audit a statistically valid
sample of the CONTRACTOR behavioral health
UM decisions including authorizations,
reductions, terminations and denials. This
audit is intended to determine if authorized
service levels are appropriate with respect
to accepted standards of clinical care. The
CONTRACTOR shall cooperate fully with that
organization.
ii. The CONTRACTOR shall participate in various
other tasks identified by HSD that shall
enable HSD to gauge performance in a variety
of areas, i.e., care coordination, treatment
of special populations and behavioral health
care delivery.
iii. The CONTRACTOR shall utilize technical
assistance and guidelines offered by the
EQRO, unless otherwise agreed upon by HSD
and the CONTRACTOR.
iv. The external quality review organization
retained by HSD shall not be a competitor of
the CONTRACTOR.
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N. Publication
At its discretion, HSD shall release all aggregate
results of the QI/audit functions to the public and
to the Federal Government.
(3) Performance Indicators
A. Performance Improvement Projects (PIPs) are one of
the tools that HSD has chosen to use to measure a
CONTRACTOR'S ability to identify problematic areas
within its operations and take actions which shall
improve its performance in those focus areas.
Examples of these include but, are not limited to,
administrative functions (telephone response rates),
utilization management (timeliness of Prior
Authorizations), access to care, preventive care
(improvement of EPSDT screening rates), and care
coordination.
B. The CONTRACTOR shall:
i. Participate in six (6) PIPs per year chosen
by HSD in consultation with the CONTRACTOR.
Three (3) PIPs shall relate to behavioral
health;
ii. Adhere to timely and accurate collection of
baseline project indicator data (physical
health, behavioral health, administrative),
which shall show the CONTRACTOR'S
performance rate for those indicators
identified for improvement by HSD;
iii. Identify specific interventions that the
CONTRACTOR intends to use to improve
performance in a given area;
iv. Demonstrate improvement in each quality
indicator within each calendar year of the
contract; and
v. Perform subsequent measurement and written
assessment of the ongoing effectiveness of
named interventions.
C. Critical Indicators Report
The CONTRACTOR shall:
i. Track, analyze, and report to HSD monthly,
certain indicators identified specific to
behavioral or physical health that shall
enable
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HSD to determine potential problems areas
within quality of care, access, or service
delivery;
ii. Collect the requested data monthly, perform
analysis on the data for the purpose of
determining completeness and validity, and
report results to HSD monthly;
iii. Analyze the data, including the
identification of any significant trends;
and
iv. Address all negative trends in the analysis
and develop appropriate CQI initiatives.
Examples of negative trends may include
involuntary hospitalizations, decrease in
EPSDT screens, high infant mortality or an
increase in suicides or suicide attempts.
(4) Standards for Access
A. The CONTRACTOR shall ensure the Salud! member
caseload of any PCP does not exceed fifteen hundred
(1,500) enrollees.
B. The CONTRACTOR shall provide to members and providers
clear instructions on how to access services,
including those that require prior approval or
referral.
C. The CONTRACTOR shall meet time and distance standards
for PCPs and pharmacies as determined by HSD or as
described in MAD Policy 606.7.9.3. The CONTRACTOR
shall have systems to track and report this data and
such data shall be available to HSD upon request.
D. The CONTRACTOR shall meet provider appointment and
pharmacy in-person prescription fill time standards
as described in MAD Policy 606.7.9.4; shall approve
or deny requests for DME within seven (7) working
days of the initial request. Members shall be able to
obtain prescribed medical supplies and
non-specialized DME within 24 hours, when needed on
an urgent basis. All new, customized, made-to-measure
equipment shall be delivered within 150 days of the
request date. All repairs or modifications shall be
delivered within 60 days of the request date.
E. The CONTRACTOR shall provide Geo-Access or equivalent
reports quarterly to HSD on the CONTRACTOR'S network
capacity of behavioral health providers and
facilities.
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i. Routine and non-specialized supplies
The CONTRACTOR shall:
a) Ensure supplies are delivered
consistent with clinical need;
b) Have an emergency response plan for
medical equipment or supplies
needed on an emergent basis;
c) Ensure that members and/or their
family receive adequate instruction
on use of the supplies or
equipment;
d) Be able to deliver the
transportation benefit statewide;
e) Have a sufficient transportation
network available to meet the
transportation needs of members.
This includes requiring an
appropriate number of handivans for
members who are wheelchair or
ventilator-dependent or have other
equipment needs;
f) Require that all transportation
vehicles be equipped with a
communication device for use in
case of an emergency;
g) Allow the member to self refer for
behavioral health and substance
abuse services, family planning,
vision and dental services without
approval from a PCP; and
h) Allow a newly enrolled woman in her
third trimester of pregnancy to
continue to see her established
obstetrical provider.
i) Have CPR certified drivers to
transport members whose clinical
needs dictate.
F. Emergency Conditions
The CONTRACTOR shall:
i. Provide services for emergency and urgent
conditions, including emergency
transportation anywhere within the United
States;
ii. Ensure that there is no clinically
significant delay caused by the CONTRACTOR
utilization control measures; and
iii. Ensure that members have access to the
nearest appropriately designated Trauma
Center according to established emergency
Medical Services triage and transportation
protocols.
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G. Non-Emergency Access Standards
The CONTRACTOR shall comply with the following
non-emergency access standards for outpatient
appointments:
i. For routine, symptomatic,
recipient-initiated, outpatient appointments
for primary preventive medical care the
request-to-appointment time shall be no
greater than 30 days, unless the member
requests a later time.
ii. For routine, symptomatic,
recipient-initiated, outpatient appointments
for non-urgent primary medical care, the
request-to-appointment time shall be no
greater than 14 days, unless the member
requests a later time.
iii. For non-urgent behavioral health care, the
request-to-appointment time shall be no
greater than 14 days, unless the member
requests a later time.
iv. Primary medical, including behavioral
health, and dental care outpatient
appointments for urgent conditions shall be
available within 24 hours.
v. For specialty outpatient referral and/or
consultation appointments, including
behavioral health, the
request-to-appointment time shall be
consistent with the clinical urgency but no
greater than 21 days, unless the member
requests a later time.
vi. For outpatient scheduled appointments the
time the member is seen shall not be more
than 30 minutes after the scheduled time
unless the member is late.
vii. For routine outpatient diagnostic
laboratory, diagnostic imaging, and other
testing appointments, the
request-to-appointment time shall be
consistent with the clinical urgency but no
greater than 14 days unless the member
requests a later time.
viii. For urgent outpatient diagnostic laboratory,
diagnostic imaging, and other testing,
appointments availability shall be
consistent with the clinical urgency but no
greater than 48 hours.
ix. The timing of scheduled follow-up outpatient
visits with
- 24 -
practitioners shall be consistent with the
clinical need.
H. The CONTRACTOR shall ensure that PCP and pharmacy
availability meet specified geographic access
standards based on the county of residence: 90% of
members residing in urban counties shall travel no
longer than 30 miles to receive pharmacy and PCP
availability; 90% of members residing in rural
counties shall travel no longer than 45 miles to
receive pharmacy and PCP availability; and 90% of
members residing in frontier counties shall travel no
longer than 60 miles to receive pharmacy and PCP
availability. The CONTRACTOR shall ensure that
members have access to pharmacy availability within
24 hours of discharge from a hospital, urgent care
facility or emergency room.
(5) Referral and Coordination
The CONTRACTOR shall have and comply with written policies and
procedures for the coordination of care. The CONTRACTOR'S
policies and procedures shall ensure that referrals including
referrals to the following providers: other specialists,
out-of-network providers, and all publicly supported providers
for medically necessary services are available to members. The
CONTRACTOR'S referral process shall be effective and efficient
and not present an impediment to timely receipt of services
(6) General Care Coordination Requirements
A. The CONTRACTOR shall:
i. Provide statewide care coordination, either
directly or through subcontractors, for
SALUD! Members with multiple and complex
special physical, mental and behavioral
health care needs.
ii. Provide as part of their care coordination
program, the six targeted case management
programs included in the SALUD! Benefit
package, on a statewide basis, and be held
accountable for delivering these services
according to MAD policy.
iii. Develop and implement written policies and
procedures, approved by HSD, which govern
how members with multiple and complex
special physical, mental and behavioral
health care needs shall be identified.
iv. Develop and implement written policies and
procedures, approved
- 25 -
by HSD, governing how care coordination
shall be provided for members. These shall
address the development of member's
individual treatment plan, based on a
comprehensive assessment of the goals,
capacities and medical condition of the
member, and the needs and goals of the
family; and criteria for evaluating a
member's response to care and revising the
plan, as indicated. A member and family
shall be involved in the development of the
treatment plan, as appropriate. A member or
family shall have a right to refuse care
coordination or case management.
v. Develop and implement policies and
procedures which define care coordination,
including the targeted case management
programs, according to MAD policy on each;
specify that care coordinators/case managers
shall meet with members on a regular,
face-to-face basis, as is indicated.
Telephonic contacts alone do not meet the
requirements of the six specific case
management programs, or of care coordination
services.
vi. Specify how care coordination shall be
supported by an internal information system.
vii. Develop and implement policy and procedures
to establish working relationships between
care coordinators and providers.
viii. Continue to work with the Medicaid in the
Schools (MITS) program providers to identify
and coordinate with the child's SALUD!
primary care provider (PCP).
B. Specific Coordination Requirements
i. Initial Written Referral Report. A written
report of the outcome of any referral,
containing sufficient information to
coordinate the member's care, shall be
forwarded to the PCP by the behavioral
health provider within seven (7) calendar
days after the screening and evaluation
visit.
ii. Ongoing Reporting. While the member is
receiving services from a behavioral health
provider, the behavioral health provider
shall keep the member's PCP informed of drug
therapy; laboratory and radiology results;
sentinel events such as hospitalization,
emergencies, incarceration, discharge from a
psychiatric hospital or from behavioral
health services; and transitions in level of
care.
- 26 -
The PCP shall keep the behavioral health
provider informed of drug therapy;
laboratory and radiology results; medical
consultations; and sentinel events such as
hospitalization and emergencies.
iii. Behavioral Health Referral Policies and
Procedures. The CONTRACTOR shall develop and
implement written policies and procedures
that allow members access to behavioral
health services without first going through
the PCP. These policies and procedures shall
accord timely access to behavioral health
services. The CONTRACTOR shall notify
members of their rights to access behavioral
health services without a referral. The
CONTRACTOR shall notify members of their
rights to access behavioral health services
without a referral.
iv. Psychiatric Consultation. A psychiatrist
shall be available to the PCP to assist with
pharmacotherapy and diagnostic evaluations.
v. Physical Health Consultation and Treatment.
The CONTRACTOR shall have and comply with
written policies and procedures governing
referrals from behavior health providers for
physical health consultation and treatment.
vi. Coordination With Waiver Programs. The
CONTRACTOR shall provide all covered
benefits to members who are waiver
participants. There are four Home and
Community-Based Waiver programs: the
Developmentally Disabled Waiver, the
Disabled and Elderly Waiver, the Medically
Fragile Waiver and the AIDS Waiver. An
integral part of each waiver is the
provision of case management. The CONTRACTOR
shall coordinate closely with the Waiver
case manager to ensure that case information
is shared, necessary services are provided
and are not duplicative. HSD shall monitor
utilization to ensure that the CONTRACTOR
provides to members who are waiver
participants all benefits included in the
CONTRACTOR benefit package.
vii. Coordination of Services with Children,
Youth and Families Department (CYFD). The
CONTRACTOR shall have written policies and
procedures requiring coordination with the
CYFD Protective Services and Juvenile
Justice Divisions to ensure that members
receive medically necessary services
regardless of the member's custody status.
These policies and procedures shall
- 27 -
specifically address compliance to the
following sections of the New Mexico
Children's Code: Section 32A-2-21
(Disposition of a mentally disordered or
developmentally disabled child in a
delinquency proceeding); Section 32A-3A-5
(Plan for family services/ family needs
assessment and referral); Section 32A-3B-17
(Disposition of developmentally disabled or
mentally disordered child in a proceeding
under the Family in Need of Services Act);
Section 32A-4-3 (Duty to report child abuse
and child neglect and penalty); Section
32A-4-14 (Change in placement); Section
32A-4-23 (Disposition of a mentally
disordered or developmentally disabled child
in a proceeding under the Abuse and Neglect
Act.); and Article 6, Children's Mental
Health and Developmental Disabilities. If
Child Protective Services (CPS), Juvenile
Justice or Adult Protective Services (APS)
has an open case on a member, the CYFD
social worker or Juvenile Probation Officer
assigned to the case shall be involved in
the assessment and treatment plan, including
decisions regarding the provision of
services for the member. The CONTRACTOR
shall designate a single contact point for
these cases.
viii. Coordination of Services with Schools. The
CONTRACTOR shall have and implement written
policies and procedures regarding
coordination with the schools for those
members receiving services excluded from
managed care as specified in the
Individualized Education Program (IEP) or
Individualized Family Service Program
(IFSP). The CONTRACTOR shall provide the
names of the members' PCPs to schools
participating in the Medicaid in the Schools
(MITS) program.
(7) Selection or Assignment to a Primary Care Provider (PCP)
The CONTRACTOR shall maintain and comply with written policies
and procedures governing the process of member selection of a
PCP and requests for change.
A. Initial Enrollment. At the time of enrollment the
CONTRACTOR shall ensure that each member has the
freedom to choose a PCP within a reasonable distance
from the member's place of residence. The process
whereby a CONTRACTOR assigns members to PCPs shall
include at least the following features: The
CONTRACTOR shall provide the member with the means
for selecting a PCP within five (5) business days of
enrollment. The CONTRACTOR shall offer freedom of
choice to
- 28 -
members in making a PCP selection. If a member does
not select a PCP within a reasonable period of
enrollment, the CONTRACTOR shall make the assignment
and notify the member in writing of his/her PCP's
name, location, and office telephone number, while
providing the member with an opportunity to select a
different PCP if he/she is dissatisfied with the
assignment. The CONTRACTOR shall assign a PCP based
on factors such as patient age, residence, and if
known, current provider relationships.
B. Subsequent Change in PCP Initiated by Member. Members
may initiate a PCP change at any time, for any
reason. The request can be made in writing or by
telephone. Any change in PCP shall be effective as of
the first of the month following the month in which
the request was received.
C. Subsequent Change in PCP Initiated by the CONTRACTOR
The CONTRACTOR may initiate a PCP change for a member
under the following circumstances:
i. The member and the CONTRACTOR agree that
assignment to a different PCP in the
CONTRACTOR'S provider network is in the
member's best interest, based on the
member's medical condition;
ii. A member's PCP ceases to participate in the
CONTRACTOR'S network;
iii. A member's behavior toward the PCP is such
that it is not feasible to safely or
prudently provide medical care and the PCP
has made all reasonable efforts to
accommodate the member; or
iv. A member has initiated legal actions against
the PCP.
D. In instances where a PCP has been terminated, the
CONTRACTOR shall allow affected members to select
another PCP or make an assignment within fifteen (15)
days of the termination effective date.
E. PCP Lock In. HSD shall allow the CONTRACTOR to
require that a member see a certain PCP when
identification of utilization of unnecessary services
indicates a need to provide case continuity. Prior to
placing the member on PCP lock in, the CONTRACTOR
shall inform the member of the intent to lock in,
including the reasons for imposing the PCP lock in.
The CONTRACTOR'S grievance procedure shall be made
available to any member being designated for PCP lock
in. The
- 29 -
CONTRACTOR shall document review of the PCP.
The PCP lock in shall be reviewed and documented by
the CONTRACTOR and approved by HSD at least every six
months. The member shall be removed from PCP lock in
when the CONTRACTOR has determined that the
utilization problems have been solved and that
recurrence of the problems are judged to be
improbable. HSD shall be notified of all lock in
removals.
2.2 ENROLLMENT
(1) Maximum Medicaid Enrollment
HSD and the CONTRACTOR may mutually agree in writing to
establish a maximum Medicaid enrollment level for Medicaid
beneficiaries, which may vary throughout the terms of the
Agreement. The maximum Medicaid Enrollment also may be
established by HSD on a statewide or county-by- county basis
based on the capacity of the CONTRACTOR'S provider network, or
to ensure that the CONTRACTOR has capacity for statewide
Medicaid enrollment. Subsequent to the establishment of this
limit, if the CONTRACTOR wishes to change its maximum
enrollment level, the CONTRACTOR shall notify HSD in writing
ninety (90) days prior to the desired effective date of the
change. HSD shall approve all requests for changing maximum
enrollment levels before implementation. Should a maximum
enrollment level be reduced to below the actual enrollment
level, HSD may disenroll members to establish compliance with
the new limit.
(2) Enrollment Requirements
As required by 42 C.F.R. 434.25, the CONTRACTOR shall accept
eligible individuals, in the order in which they apply:
A. Without restriction, unless authorized by the HCFA
Regional Administrator;
B. Up to the limits established pursuant to the
Agreement;
C. All enrollments shall be voluntary, and the
CONTRACTOR shall not discriminate against eligible
individuals on the basis of health status or need for
health services.
D. The CONTRACTOR shall assume responsibility for all
covered medical conditions of each member inclusive
of pre-existing conditions as of the effective date
of enrollment.
- 30 -
(3) Eligibility
A. HSD shall determine eligibility for enrollment in the
managed care program. All Medicaid eligible members
are required to participate in the Medicaid managed
care program except for the following:
i. Members eligible for both Medicaid and
Medicare, i.e. dual eligibles;
ii. Institutionalized members i.e., those
residing for greater than thirty (30) days
in nursing facilities;
iii. Members residing in intermediate care
facilities for the mentally retarded;
iv. Members participating in the Health
Insurance Premium (HIPP) Program;
v. Children and adolescents in out-of-state
foster care or adoption placement; and
vi. Native Americans who have the option to
voluntarily enroll with the CONTRACTOR.
(4) HSD Exemptions
HSD shall grant exemptions to mandatory enrollment based upon
criteria established by HSD. A member or his or her
representative, parent, or legal guardian shall submit such
requests in writing to HSD, including a description of the
special circumstances justifying an exemption. Requests are
evaluated by HSD clinical staff and forwarded to the MAD
Medical Director or his/her designee for final determination.
(5) Special Situations
A. Newborn Enrollment
Newborns are automatically eligible for a period of
one (1) year and are immediately enrolled with the
mother's MCO. If the child's mother is not a member
at the time of the birth, in a hospital or at home,
then the child is enrolled during the next applicable
enrollment cycle. The
- 31 -
CONTRACTOR is not responsible for care of a child
hospitalized during enrollment, until discharge
except for newborns born to enrolled mothers.
B. Hospitalized Members.
A member who is hospitalized at the time he/she first
enrolls with the CONTRACTOR may enroll with the
CONTRACTOR. However, the CONTRACTOR shall not be
responsible for the costs of such hospitalization,
except newborns born to a member mother, until the
member is discharged from the hospital. Instead, HSD
shall pay the appropriate provider(s), on a
fee-for-service basis, all provider-submitted claims
related to a member who is hospitalized in a general
acute care, rehabilitation or freestanding
psychiatric hospital at the time such member enrolls
with the CONTRACTOR, until such time as the member is
discharged from the hospital.
C. Members in Placement in Residential Treatment
Centers.
If a child or adolescent becomes Medicaid eligible
while residing in an accredited or non-accredited
residential treatment center, they shall be
immediately eligible for enrollment.
D. Members in Treatment Foster Care Placements.
If a child or adolescent was residing in a treatment
foster care placement at the time managed care
enrollment began, they shall be exempt from enrolling
in an MCO until they are discharged from treatment
foster care.
E. Native Americans
i. Native Americans shall have the option to
participate in managed care and be enrolled
with the CONTRACTOR to receive medical care
through Indian Health Services (IHS), tribal
provider, and/or other non-Native American
provider, or to not participate in managed
care and continue to receive medical care.
If a Native American member voluntarily
chooses to enroll with the CONTRACTOR, the
enrollment process is initiated.
ii. The CONTRACTOR shall make good faith efforts
to contract with the appropriate urban
Indian clinics tribally owned health
centers, and IHS facilities for the
provision of medically necessary services.
- 32 -
iii. The CONTRACTOR shall ensure that translation
services are reasonably available when
needed, both in providers' offices and in
contacts with the CONTRACTOR.
iv. The CONTRACTOR shall ensure adequate medical
transportation for Native American members
residing in rural and remote areas.
v. The CONTRACTOR shall ensure that culturally
appropriate materials are reasonably
available to Native Americans.
F. Members Placed in Nursing Facilities:
A member placed in a nursing facility for what is
expected to be a long term or permanent placement the
CONTRACTOR remains responsible for the member until
the member is disenrolled by HSD.
G. Members Receiving Hospice Services
Members who have elected and are receiving hospice
services at the time of enrollment shall be exempt
from enrolling in an MCO unless they revoke their
hospice election.
(6) Enrollment Process for Members
Current members may request a change in MCOs during the first
eighty five (85) days of a twelve (12) month enrollment
period.
A. Minimum Selection Period
A new member shall have at least fourteen (14)
calendar days from the date of eligibility to select
an MCO from the provided information. The new member
can select anytime during this selection period. If a
selection is not made during this selection period,
HSD shall assign the new member to an MCO.
B. Begin Date of Enrollment
Enrollment generally shall begin the first day of the
first full month following selection or assignment.
If the selection or assignment is made after the 25th
day of the month and before the first full day of the
next month, the enrollment shall begin on the first
day of the second full month after the selection or
assignment.
- 33 -
C. Member Switch
A current CONTRACTOR member has the opportunity to
change MCOs during the first eighty-five (85) days of
a twelve (12) month period. HSD shall notify the
CONTRACTOR members of their opportunity to select a
new CONTRACTOR provider. A member is limited to one
eighty-five day switch period per CONTRACTOR. After
exercising the switching rights, and returning to a
previously selected CONTRACTOR, the member shall
remain with the CONTRACTOR until his/her lock-in
period expires before being permitted to switch
CONTRACTORS.
D. Mass Transfer Process
The mass transfer process is initiated when HSD
determines that the transfer of MCO members from one
MCO to another is appropriate.
i. Triggering Mass Transfer Process. The mass
transfer process may be triggered by two
situations: maintenance change, i.e.,
changes in CONTRACTOR identification number
or CONTRACTOR name; and significant change
in the CONTRACTOR contracting status
including, but not limited to, loss of
licensure, substandard care, fiscal
insolvency or significant loss in network
providers.
ii. Effective Date of Mass Transfer. The change
in enrollment initiated by the mass transfer
begins with the first day of the month
following the identification of the need to
transfer the CONTRACTOR members.
iii. Member Selection Period. Following a mass
transfer, the CONTRACTOR members are given
an opportunity to select a different
CONTRACTOR.
E. Transition of Care
i. The CONTRACTOR shall develop a detailed plan
that addresses the clinical transition
issues and transfer of potentially large
numbers of members into their organization.
This plan shall include how the CONTRACTOR
proposes to identify members currently
receiving services;
ii. The CONTRACTOR shall develop a detailed plan
for the
- 34 -
transition of an individual member, which
includes member and provider education about
the CONTRACTOR, and the CONTRACTOR process
to assure any existing treatment plans are
revised as necessary;
iii. The member's current MCO shall be able to
identify members and provide necessary data
and information to the future MCO for
members switching plans, either individually
or in large numbers to avoid unnecessary
delays in treatment that could be
detrimental to the member;
iv. The CONTRACTOR shall honor all prior
approvals granted by HSD through its
CONTRACTOR for the first thirty days of
enrollment or until the CONTRACTOR has made
other arrangements for the transition of
services. Providers associated with these
services shall be reimbursed by the
CONTRACTOR;
v. The CONRACTOR shall adhere to the New Mexico
Children's Code NMSA 1978 Section 32A-3B-9
relating to notification of the child's
guardian ad litem, parent, guardian or legal
custodian 10 days prior to a change in
placement for members currently receiving
behavioral health services requiring a level
of care determination, unless an emergency
situation requires moving the child prior to
sending notice;
vi. The current CONTRACTOR shall reimburse the
providers and facilities approved by HSD, if
a donor organ becomes available during the
first thirty days of enrollment and
transplant services have been prior approved
by HSD;
vii. The CONTRACTOR shall fill prescriptions for
drug refills for the first thirty days or
until the CONTRACTOR has made other
arrangements, for newly enrolled managed
care members;
viii. The CONTRACTOR shall pay for DME costing
$2000 or more, approved by the CONTRACTOR
but delivered after disenrollment;
ix. The CONTRACTOR shall be responsible for
covered medical services provided to the
member for any month they receive a
capitation payment, even if the member has
lost Medicaid eligibility;
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x. The CONTRACTOR is responsible for payment of
all inpatient services until discharge from
the hospital or transfer to a different
level of care, if the member is hospitalized
at the time of exemption or switch
enrollment;
xi. The CONTRACTOR is responsible for payment
until disenrollment, if an enrollment member
is placed in a nursing facility or
intermediate care facility for the mentally
retarded as a long term or permanent
placement; and
xii. The CONTRACTOR shall ensure the transition
of care requirements outlined above can be
met with both individual and mass enrollment
into and out of their organization.
(7) Member Disenrollment
A. CONTRACTOR Requests for Disenrollment
Member disenrollment shall only be considered in rare
circumstances. The CONTRACTOR may request that a
particular member be disenrolled. Disenrollment
requests shall be submitted in writing to HSD. The
request and supporting documentation shall meet
requirements specified by HSD. If the disenrollment
request is granted the CONTRACTOR retains
responsibility for the member's care until such time
as the member is enrolled with a new CONTRACTOR. If a
request for disenrollment is approved the member
shall not be re-enrolled with the CONTRACTOR for a
period of time to be determined by HSD. Conditions
that may permit lock-out or disenrollment are:
i. The CONTRACTOR demonstrates that it has made
a good faith effort to accommodate the
member but such efforts have been
unsuccessful;
ii. The conduct of the member is such that it is
not feasible safe or prudent to provide
medical care subject to the terms of the
contract;
iii. The CONTRACTOR has offered to the member in
writing the opportunity to utilize the
grievance procedures;
iv. The CONTRACTOR shall not terminate
enrollment because of an
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adverse change in the member's health. The
CONTRACTOR shall provide adequate
documentation that terminations are proper
and not due to an adverse change in the
member's health; and
v. The CONTRACTOR has received threats or
attempts of intimidation from the member to
the CONTRACTORS, providers or its own staff.
B. Member Initiated Disenrollment
A Medicaid member who is required to participate in
managed care may request to be disenrolled from the
CONTRACTOR "for cause" at anytime, even during a
lock-in period. This request shall be submitted in
writing to HSD for review. HSD shall complete the
review and furnish a written decision to the member
and the CONTRACTOR in a timely manner. Members who
voluntarily enroll may choose to disenroll at any
time.
C. HSD Initiated Disenrollment
HSD may initiate disenrollment in three
circumstances:
i. If a member loses Medicaid eligibility;
ii. If the member is re-categorized into a
Medicaid coverage category not included in
the managed care initiative; or
iii. The CONTRACTOR'S enrollment maximum is
reduced to below contract levels. After HSD
becomes aware of, or is alerted to, the
existence of one of the reasons listed
above, HSD shall immediately notify the
member or family and the CONTRACTOR and
shall update the enrollment roster.
2.3 PROVIDERS
The CONTRACTOR shall establish and maintain a comprehensive network of
providers capable of serving all members who enroll in the MCO.
Pursuant to Section 1932(b)(7) of the Social Security Act, the
CONTRACTOR shall not discriminate against providers with respect to
participation, reimbursement, or indemnification for any provider
acting within the scope of that provider's license or certification
under applicable state law solely on the basis of the provider's
license or certification.
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(1) Required Policies and Procedures
A. The CONTRACTOR shall maintain written policies and
procedures on provider recruitment and termination of
provider participation with the CONTRACTOR. HSD shall
have the right to review these policies and
procedures upon demand. The recruitment policies and
procedures shall describe how a CONTRACTOR responds
to a change in the network that affects access and
its ability to deliver services in a timely manner.
B. The CONTRACTOR shall require that each physician
providing services to Medicaid members has a unique
identifier in accordance with the provisions of
Section 1173(b) of the Social Security Act. The
CONTRACTOR shall annually develop and implement a
training plan to educate providers and their staff on
selected managed care or the CONTRACTOR processes and
procedures. The plan shall be submitted to HSD for
review and approval on or before July of each year.
(2) General Information Submitted to HSD
The CONTRACTOR shall maintain an accurate list of all active
PCPs, specialists, hospitals, and other providers
participating or affiliated with the CONTRACTOR. The
CONTRACTOR shall submit the list to HSD on a monthly basis and
include a clear delineation of all additions and terminations
that have occurred the prior month. The CONTRACTOR shall
report quarterly the capacity of each contracted behavioral
health provider to take new Medicaid clients and to serve
current clients. The CONTRACTOR'S contracts with providers
must include language stating that the MCO contractors will
report any changes in their capacity to take new Medicaid
clients or serve current clients.
(3) The Primary Care Provider (PCP)
The PCP shall be a medical provider participating with the
CONTRACTOR who has the responsibility for supervising,
coordinating, and providing primary health care to members,
initiating referrals for specialist care, and maintaining the
continuity of the member's care. The CONTRACTOR shall
distribute information to the network providers that explains
the Medicaid-specific policies and procedures relating to PCP
responsibilities. The CONTRACTOR is prohibited from excluding
providers as primary care providers based on the proportion of
high-risk patients in their caseloads.
(4) Primary Care Responsibilities
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A. The CONTRACTOR shall ensure that the following
primary care responsibilities are met by the PCP, or
in another manner. The CONTRACTOR shall provide
twenty-four (24) hour, seven (7) day a week access;
and ensure coordination and continuity of care with
providers who participate with the CONTRACTOR network
and with providers outside the CONTRACTOR network
according to the CONTRACTOR policy; and, ensuring
that the member receives appropriate prevention
services for their age group.
B. The CONTRACTORS are prohibited from excluding
providers as primary care providers based on the
proportion of high-risk patients in their caseloads.
C. The CONTRACTOR shall have a formal process for
provider education regarding SALUD!, the conditions
of participation in the network and the provider's
responsibilities to the CONTRACTOR and its members.
HSD shall be provided documentation upon request that
such provider education is being conducted.
(5) CONTRACTOR Responsibility for PCP Services
A. The CONTRACTOR shall retain responsibility for
monitoring PCP activities to ensure compliance with
the CONTRACTOR and HSD policies. The CONTRACTOR shall
educate PCPs about special populations and their
service needs. The CONTRACTOR shall ensure that PCPs
successfully identify and refer patients to specialty
providers as medically necessary.
B. The CONRACTOR shall have an internal provider appeals
process.
(6) Specialty Providers
The CONTRACTOR shall contract with a sufficient number of
specialists with the applicable range of expertise to ensure
that the needs of CONTRACTOR members shall be met within the
CONTRACTOR network of providers. The CONTRACTOR shall also
have a system to refer members to providers who are not
affiliated with the MCO network if providers with the
necessary qualifications or certifications do not participate
in the network.
(7) Provider to Member Ratios and Access Requirements
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The CONTRACTOR shall ensure that member caseload of any PCP in
its network does not exceed fifteen hundred (1,500) of its
members. Exceptions to this limit may be made with the consent
of HSD. Reasons for exceeding the limit may include continuing
established care, assigning of a family unit or the
availability of mid-level clinicians in the practice which
expands the capacity of the PCP.
(8) Geographic Access Requirements
The minimum number of primary care providers from which to
choose and the distances to those providers shall vary by
county based on whether the county is urban, rural or frontier
as defined. Urban counties are: Bernalillo, Los Alamos, Santa
Fe, and Dona Ana. Frontier counties are: Catron, Harding,
DeBaca, Union, Guadalupe, Hidalgo, Socorro, Mora, Sierra,
Lincoln, Torrance, Colfax, Quay, San Miguel, and Cibola. Rural
counties are those which are not listed as urban or frontier.
The standards are as follows: 90 percent of urban residents
shall travel no longer than 30 miles to see a PCP; 90 percent
of rural residents shall travel no longer than 45 miles to see
a PCP; and 90 percent of frontier residents shall travel no
longer than 60 miles to see a PCP.
(9) Federally Qualified Health Centers ("FQHCs")
A. Federally Qualified Health Centers (FQHCs) are
federally-funded Community Health Centers, Migrant
Health Centers and Health Care for the Homeless
Projects that receive grants under sections 329, 330
and 340 of the US Public Health Services Act. Current
federal regulations {SSA 1902(a)(13)(E)} specify that
states shall guarantee access to FQHCs and RHCs under
Medicaid managed care programs; therefore the
CONTRACTOR shall provide access to FQHCs and RHCs to
the extent that access is required under federal law.
B. The CONTRACTOR shall contract with as many FQHCs and
RHCs as necessary to permit beneficiaries access to
participating FQHCs and RHCs without having to travel
a significant distance. At least one FQHC shall
specialize in provider health care for the homeless
in Bernalillo County. At least one FQHC shall be with
one urban Indian FQHC in Bernalillo County.
C. The CONTRACTOR shall contract with FQHCs and RHCs in
accordance with the 30 minute travel time standards
for routinely used delivery sites. A CONTRACTOR with
an FQHC or RHC on its panel that has no capacity to
accept new patients shall not satisfy these
requirements unless
- 40 -
there exist no other FQHCs or RHCs in the area.
D. The CONTRACTOR shall offer FQHCs and RHCs terms and
conditions, including reimbursement, that are at
least equal to those offered to other providers of
comparable services.
E. If the CONTRACTOR cannot satisfy the standard for
FQHC and RHC access at any time while the CONTRACTOR
holds a Medicaid contract, the CONTRACTOR shall allow
its members to seek care from non-contracting FQHCs
and RHCs and shall reimburse these providers at the
Medicaid fee schedule.
(10) University of New Mexico Health Sciences Center
The CONTRACTOR shall contract with the University of New
Mexico Health Sciences Center for specialty services provided
by Carrie Tingley Hospital and the University of New Mexico
Hospital including transplants, neonatal, burn and trauma,
level I trauma center, and other specialized pediatric
services, not otherwise available, provided that in the event
the CONTRACTOR and University of New Mexico Health Sciences
Center cannot reach agreement as to reimbursement for services
that the CONTRACTOR shall agree to pay Medicaid
fee-for-service rates for the services in question.
(11) Local Department of Health Offices
A. The CONTRACTOR shall contract with public health
providers for services as described in Section
MAD-606.A.6., BENEFITS PACKAGE, and those defined as
public health services under State law, NMSA 1978
Sections 24-1-1, et. seq.
B. The CONTRACTOR shall contract with local and district
public health offices for family planning services.
C. The CONTRACTOR may contract with local and district
health offices for other clinical preventive services
not otherwise available in the community such as
prenatal care or prenatal case management.
(12) Children's Medical Services (CMS)
The CONTRACTOR shall contract with CMS to administer outreach
clinics at sites throughout the State. The clinics offer
pediatric sub-specialty services in
- 41 -
local communities which include cleft palate, neurology,
endocrine, and asthma and pulmonary.
(13) Shared Responsibility between the CONTRACTOR and Public Health
Offices
A. The CONTRACTOR shall coordinate with the public
health offices regarding the following services:
i. Sexually transmitted disease services
including screening, diagnosis, treatment,
follow-up and contact investigations;
ii. HIV prevention counseling, testing, and
early intervention;
iii. Tuberculosis screening, diagnosis, and
treatment;
iv. Disease outbreak prevention and management
including reporting according to state law
requirements, responding to epidemiology
requests for information, and coordination
with epidemiology investigations and
studies;
v. Referral and coordination to ensure maximum
participation in the Supplemental Food
Program for Women, Infants, and Children
(WIC);
vi. Health education services for individuals
and families with a particular focus on
injury prevention including car seat use,
domestic violence, and lifestyle issues
including tobacco use, exercise, nutrition,
and substance use;
vii. Development and support for family support
programs such as home visiting programs for
families of newborns and other at-risk
families and parenting education; and
viii. Participation and support for local health
councils to create healthier and safer
communities with a focus on coordination of
efforts such as DWI councils, maternal and
child health councils, tobacco coalitions,
safety counsel, safe kids and others.
(14) School-Based Providers
The CONTRACTOR shall participate in the School Based Health
Clinic Project.
- 42 -
(15) Indian Health Services (IHS) & Tribal Health Centers
A. The CONTRACTOR shall allow members who are Native
American to seek care from any IHS, Tribal Provider
or Urban Indian Program Provider defined in the
Indian Health Care Improvement Act (25 U.S.C. 1601 et
seq.) whether or not the provider participates in the
CONTRACTOR provider network.
B. The CONTRACTOR shall not prevent members who are IHS
beneficiaries from seeking care from IHS, Tribal or
Urban Indian Providers, and network providers due to
their status as Native Americans.
C. The CONTRACTOR shall track IHS expenditures by
members for those Native Americans who voluntarily
enroll in the MCO. The CONTRACTOR shall reimburse
these providers.
D. The CONTRACTOR shall track reimbursement to these
providers by member.
(16) Family Planning Services and Providers
A. Federal law prohibits restricting access to family
planning services for Medicaid recipients. The
CONTRACTOR shall implement written policies and
procedures defining how members are educated about
their right to family planning services, freedom of
choice, and methods of accessing such services.
B. The CONTRACTOR shall give each member, including
adolescents, the opportunity to use his or her own
primary care provider or go to any family planning
center for family planning services without requiring
a referral. Clinics and providers, including those
funded by Title X of the Public Health Service Act,
shall be reimbursed by the CONTRACTOR for all family
planning services regardless of whether they are a
participating or non-participating provider. Unless
otherwise negotiated, the CONTRACTOR shall reimburse
providers of family planning services at the Medicaid
rate.
C. Non-participating providers are responsible for
keeping family planning information confidential in
favor of the individual patient even if the patient
is a minor. The CONTRACTOR is not responsible for the
confidentiality of medical records maintained by
non-participating
- 43 -
providers.
D. Family planning services are defined as the
following:
i. Health Education and counseling necessary to
make informed choices and understand
contraceptive methods;
ii. Limited history and physical examination;
iii. Laboratory tests if medically indicated as
part of decision making process for choice
of contraceptive methods;
iv. Diagnosis and treatment of sexually
transmitted diseases (STDs) if medically
indicated;
v. Screening, testing and counseling of at-risk
individuals for human immunodeficiency virus
(HIV) and referral for treatment;
vi. Follow-up care for complications associated
with contraceptive methods issued by the
family planning provider;
vii. Provision of, but not payment for,
contraceptive pills;
viii. Provision of devises/supplies;
ix. Tubal legations;
x. Vasectomies; and
xi. Pregnancy testing and counseling
E. If a non-participating provider of family planning
services detects a problem outside of the scope of
services listed above, the provider should refer the
member back to the CONTRACTOR. The CONTRACTOR is not
under any HSD initiated obligation to reimburse
non-participating family planning providers for
non-emergent services outside the scope of these
defined services.
(17) Behavioral Health Care
A. The CONTRACTOR shall:
- 44 -
i. Deliver all behavioral health services
through direct contracts with individual
behavioral health provider groups. All
administrative functions associated with
behavioral health shall be retained and
integrated within the CONTRACTOR;
ii. Minimize the administrative costs associated
with the delivery of behavioral health care;
iii. Build a statewide behavioral health provider
network that ensures access to all levels of
behavioral health services, across a
continuum from the most to the least
restrictive setting. The network shall be
sufficient to ensure that the standards in
MAD Policy 606 for access to care providers
who want to refer members for behavioral
health care and vice versa;
iv. Develop and implement written policies and
procedures for members on how to access
behavioral health services without a
referral along with written policies and
procedures for primary care and other
specialty care providers who want to refer
members for behavioral health care and vice
versa;
v. Develop and implement written policies and
procedures for coordination of physical and
behavioral health services, monitoring its
implementation;
vi. Develop and distribute a provider manual,
which includes a specific section on
behavioral health; and
vii. Develop procedures for communicating
regularly with behavioral health providers
on issues related to provision of services.
B. Behavioral Health Clinical Practice Guidelines and
Utilization Management
i. The CONTRACTOR shall develop and implement
written behavioral health clinical practice
guidelines for major behavioral health
diagnoses for children, youth and adult
populations. These guidelines shall be based
upon the MAD regulation definition of
medical necessity, professionally accepted
standards of practice, and national
guidelines, and with input from the
CONTRACTOR'S practitioners. Behavioral
health clinical practice guidelines and
utilization management criteria shall be
- 45 -
applied consistently across the state.
ii. The CONTRACTOR shall provide care
coordination for members with multiple and
complex special physical, mental,
neurobiological, emotional and/or behavioral
health care needs on an as needed basis,
depending upon the clinical profile of the
patient. The CONTRACTOR shall have written
policies and procedures, approved by HSD,
which govern how members with these multiple
and complex needs will be identified and how
these specific care coordination services
will be provided.
iii. The CONTRACTOR shall reevaluate the
behavioral health clinical practice
guidelines at least every two years, with
input from the CONTRACTOR'S clinical
providers. Any updates should be
communicated to providers.
iv. The CONTRACTOR shall ensure the continuity
and coordination of a member's medical and
behavioral health care among practitioners
treating the same member.
v. The CONTRACTOR shall affect a smooth
transition in situations when a network
provider leaves the network.
vi. The CONTRACTOR shall collect and report
longitudinal data, on a quarterly basis for
two (2) years, for all Medicaid SALUD!
children and youth to age 21 accessing
treatment foster care (TCI I and II);
residential treatment centers (RTCs) and
inpatient psychiatric hospitalization. This
data shall track individual members,
including the child or adolescent's actual
length of stay and disposition after
discharge for data elements that are
mutually agreed to in writing by HSD and the
CONTRACTOR. The data shall be analyzed by
the CONTRACTOR and used to evaluate the
appropriateness of care and to identify any
trends, including, but not limited to,
premature discharges, as evidenced by
readmissions to either TFC, RTC and/or
inpatient psychiatric hospitalization.
vii. The CONTRACTOR shall collect and report on a
quarterly basis key variables of program
performance related to behavioral health
services. Key variables will be determined
in consultation with the CONTRACTOR and
stakeholders.
C. Behavioral Health Care Coordination
- 46 -
The CONTRACTOR shall provide care coordination for
members with multiple and complex special physical,
mental, neurobiological, emotional and/or behavioral
health care needs on an as needed basis, depending
upon the clinical profile of the member. The
CONTRACTOR shall have written policies and
procedures, approved by HSD, which govern how members
with these multiple and complex needs shall be
identified and how these specific care coordination
services shall be provided.
(18) Standards For Provider Credentialing and Recredentialing
A. Individual Providers
At the time of credentialing, the CONTRACTOR shall
comply with all requirements in the MAD Policy
Manual, which include the requirement to verify from
primary sources that at a minimum the provider has:
i. A current valid license to practice;
ii. Clinical privileges in good standing at the
institution designated by the practitioner
as the primary admitting facility, if
applicable;
iii. A valid DEA or CDS certificate, if
applicable;
iv. Graduation from an accredited professional
school/program and/or highest training
program applicable to the academic or
professional degree, discipline, and
licensure of the practitioner;
v. Board certification if the practitioner
states that he/she is board certified in a
specialty on the application;
vi. Current, adequate malpractice insurance, in
accordance with the CONTRACTOR'S
requirements, if applicable;
vii. The absence of a prohibitive history of
professional liability claims that resulted
in settlements or judgments paid by or on
behalf of the practitioner; and
viii. Not been barred from participation based on
existing Medicare or Medicaid sanctions.
(19) Organizational Providers
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A. The CONTRACTOR shall have written policies and
procedures for the initial and ongoing assessment of
all organizational providers with which it intends to
contract or with which it is contracted. Providers
include, but are not limited to hospitals; home
health agencies; nursing facilities; free-standing
surgical centers; ambulatory psychiatric and
addiction disorder residential treatment centers,
clinics, and other facilities; 24-hour programs
included in the continuum of behavioral care, such as
behavioral units of general hospitals; and
freestanding psychiatric hospitals.
B. The CONTRACTOR shall confirm that the provider is in
good standing with State and Federal regulatory
bodies, including HSD;
C. The CONTRACTOR shall confirm that the provider has
been reviewed and approved by an accrediting body
(Accredited Residential Treatment Centers shall be
accredited by the JCAHO, and other behavioral care
providers shall be accredited by the Council on
Accreditation of Rehabilitation Facilities (CARF) or
the Council on Accreditation (COA) for
child/adolescent providers); or
D. The CONTRACTOR shall develop and implement standards
of participation that demonstrates the provider is in
compliance with provider participation requirements
under federal laws and regulations, if the provider
has not been approved by an accrediting body.
(20) Recredentialing
The CONTRACTOR shall formally recredential its network
providers at least every two years.
(21) Primary Source Verification
A. HSD shall have the right to name a single primary
source verification entity to be used by the
CONTRACTOR and its subcontractors in its provider
credentialing process. All CONTRACTORS shall use one
standardized credentialing form except that at its
discretion the CONTRACTOR may use its own
credentialing system for credentialing of staff-model
providers. HSD shall have the right to mandate a
standard credentialing application to be used by the
CONTRACTOR and its subcontractors in its provider
credentialing process. The form shall meet NCQA
standards.
- 48 -
B. The CONTRACTOR shall provide to HSD copies of all
Medicaid provider specific forms used in its health
system operations and credentialing/recredentialing
process for prior approval. The forms shall be user
friendly. The CONTRACTOR shall participate in a
workshop to consolidate and standardize forms across
all plans and for its credentialing/recredentialing
processes/applications.
C. The CONTRACTOR shall maintain relatively low
administrative expenses and reduce administrative
burden and use current technology to minimize
administrative burdens for subcontracted and provider
staff.
2.4 BENEFITS/SERVICES
The CONTRACTOR shall be required to provide a comprehensive coordinated
and fully integrated system of health care services. The CONTRACTOR
does not have the option of deleting benefits from the Medicaid defined
benefit package. The following services are included in the covered
benefit package of this Agreement:
(1) Inpatient Hospital Services
The benefit package includes hospital inpatient acute care,
procedures, and services asset forth in MAD Program Manual
section MAD-721, HOSPITAL SERIVCES. The CONTRACTOR shall
comply with the maternity length of stay in the Health
Insurance and Portability Act of 1996. Coverage for a hospital
stay following a normal vaginal delivery may generally not be
limited to less than 48 hours for both the mother and newborn
child. Health coverage for a hospital stay in connection with
childbirth following a cesarean section may generally not be
limited to less than 96 hours for both mother and newborn
child.
(2) Transplant Services
The benefit package includes transplantation services. The
following transplants are covered in the benefit package:
heart transplants, lung transplants, heart-lung transplants,
liver transplants, kidney transplants, autologous bone marrow
transplants, allegoric bone marrow transplants and corneal
transplants, as detailed in MAD Program Manual Section
MAD-764, TRANSPLANT SERVICES, Section MAD-765, EXPERIMENTAL OR
INVESTIGATIONAL PROCEDURES, TECHNOLOGIES, OR NON-DRUG
THERAPIES.
(3) Hospital Outpatient Service
- 49 -
The benefit package includes hospital outpatient services for
preventive, diagnostic, therapeutic, rehabilitative, or
palliative medical services as set forth in MAD Program Manual
Section MAD-721.61, OUTPATIENT COVERED SERVICES.
(4) Case Management Services
The benefit package includes case management services as set
forth in the MAD Program Manual Sections MAD 771-772, MAD 774-
775, and MAD-744, including, Case Management Services for
Adults With Developmental Disabilities as set forth in the MAD
Program Manual Section MAD-771, CASE MANAGEMENT SERVICES FOR
ADULTS WITH DEVELOPMENTAL DISABILITIES; Case Management
Services for Pregnant Women and Their Infants as set forth in
MAD Program Manual Section MAD-772, CASE MANAGEMENT SERVICES
FOR PREGNANT WOMEN AND THEIR INFANTS; Case Management Services
for Traumatically Brain Injured Adults set forth in the MAD
Program Manual Section MAD-774, CASE MANAGED SERVICES FOR
TRAUMATICALLY BRAIN INJURED ADULTS. Case management services
for children up to the age of three (3) as set forth in MAD
Program Manual Section MAD-775, CASE MANAGEMENT SERVICES FOR
CHILDREN UP TO AGE THREE; Case Management Services for The
Medically at Risk as set forth in MAD Program Manual Section
MAD-744, EPSDT CASE MANAGEMENT. The benefit package does not
include Case Management provided to DD children age 0 -3 who
are receiving early intervention services, or case management
provided by the Children, Youth and Families Department
defined as child protective services management.
(5) Emergency Services
A. The benefit package includes services meeting the
definition of emergency services. Emergency Services
shall be provided in accordance with MAD-606.A.7.
QUALITY MANAGEMENT.
B. Reimbursement for Emergency Services
i. The CONTRACTOR shall ensure that acute
general hospitals are reimbursed for
emergency services which they are required
to provide because of federal mandates such
as the "anti-dumping" law in the Omnibus
Budget Reconciliation Act of 1989. P.L.
101-239 and 42 U.S.C. section 1395 dd (1867
of the Social Security Act).
- 50 -
ii. The CONTRACTOR shall pay for both the
services involved in the screening
examination and the services required to
stabilize the patient, if the screening
examination leads to a clinical
determination by the examining physician
that an actual emergency medical condition
exists.
iii. The CONTRACTOR is required to pay for all
emergency services which are medically
necessary until the clinical emergency is
stabilized. This includes all treatment that
may be necessary to assure, within
reasonable medical probability, that no
material deterioration of the patient's
condition is likely to result from or occur
during discharge of the patient or transfer
of the patient to another facility.
iv. If the screening examination leads to a
clinical determination by the examining
physician that an actual emergency medical
condition does not exist, then the
determining factor for payment liability is
whether the member had acute symptoms of
sufficient severity at the time of
presentation. In these cases, the CONTRACTOR
shall review the presenting symptoms of the
member and shall pay for all services
involved in the screening examination where
the present symptoms (including severe pain)
were of sufficient severity to have
warranted emergency attention under the
prudent layperson standard. If the member
believes that a claim for emergency services
has been inappropriately denied by the
CONTRACTOR, the member may seek recourse
through the CONTRACTOR or HSD appeal.
v. When the member's primary care physician or
other CONTRACTOR representative instructs
the member to seek emergency care in network
or out-of-network, the CONTRACTOR is
responsible for payment, at the in network
rate, for the medical screening examination
and for other medically necessary emergency
services intended to stabilize the patient
without regard to whether the member meets
the prudent layperson standard.
vi. The CONTRACTOR must be in compliance with
Medicare Part C regulations for coordinating
post-stabilization care.
(6) Physical Health Services
- 51 -
The benefit package includes primary (including those provided
in school-based settings) and specialty physical health
services provided by a licensed practitioner performed within
the scope of practice as defined by State Law and set forth in
MAD Program Manual Section MAD-711, MEDICAL SERVICES
PROVIDERS; Section MAD-718.1, MIDWIFE SERVICES; Section
MAD-718.2, PODIATRY SERVICES; Section MAD-712, RURAL HEALTH
CLINIC SERVICES; and Section MAD-713, FEDERALLY QUALIFIED
HEALTH CENTER SERVICES.
(7) Laboratory Services
The benefit package includes all laboratory services provided
according to the applicable provisions of CLIA as set forth in
MAD Program Manual Section MAD-751, LABORATORY SERVICES.
(8) Diagnostic Imagining and Therapeutic Radiology Services
The benefit package includes medically necessary diagnostic
imaging and radiology services as set forth in MAD Program
Manual Section 752, DIAGNOSTIC IMAGINING AND THERAPEUTIC
RADIOLOGY SERVICES.
(9) Anesthesia Services
The benefit package includes anesthesia and monitoring
services necessary for performance of surgical or diagnostic
procedures as set forth in MAD Program Manual Section MAD-714,
ANESTHESIA SERVICES.
(10) Vision Services
The benefit package includes vision services as set forth in
MAD Program Manual Section MAD-715, VISION CARE SERVICES.
(11) Audiology Services
The benefit package includes audiology services as set forth
in MAD Program Manual Section MAD-755, HEARING AIDS AND
RELATED EVALUATION.
(12) Dental Services
The benefit package includes dental services as set forth in
MAD Program Manual Section MAD-716, DENTAL SERVICES.
- 52 -
(13) Dialysis Services
The benefit package includes medically necessary dialysis
services as set forth in MAD Program Manual Section MAD-761,
DIALYSIS SERVICES. Dialysis providers shall assist members in
applying for and pursuing final Medicare eligibility
determination.
(14) Pharmacy Services
A. The benefit package includes all pharmacy and related
services, as set forth in MAD MAD-753 PHARMACY
SERVICES. The CONTRACTOR formulary shall use the
following guidelines: (i) There is at least one
representative drug for each of the categories in the
First Data Bank Blue Book; (ii) Generic substitution
shall be based on AB Rating and/or clinical need;
(iii) For a multiple source brand name product within
a therapeutic class, the CONTRACTOR may select a
representative drug; (iv) The formulary shall follow
the HCFA special guidelines relating to drugs used to
treat HIV infection; (v) The formulary shall include
coverage of certain OTC drugs when prescribed by a
licensed practitioner; and (vi) The CONTRACTOR shall
implement an appeals process for practitioners who
think that an exception to the formulary shall be
made for an individual member.
B. Drug Utilization Review Program
The CONTRACTOR shall maintain written policies and
procedures governing its drug utilization review
(DUR) program, in compliance with any applicable
Federal Medicaid law.
(15) Durable Medical Equipment and Medical Supplies
The benefit package includes the purchase, delivery,
maintenance and repair of equipment, oxygen and oxygen
administration equipment, nutritional products, disposable
diapers, and disposable supplies essential for the use of the
equipment as set forth in MAD Program Manual Section MAD-754,
DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLIES.
(16) EPSDT Services
The benefit package includes the delivery of the Federally
mandated Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) services as set in forth MAD Program Manual
Section MAD-740, EPSDT SERVICES.
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A. EPSDT Private Duty Nursing
The benefit package includes private duty nursing for
the EPSDT population as set forth in MAD Program
Manual Section MAD-746.3, EPSDT PRIVATE DUTY NURSING
SERVICE. The services shall either be delivered in
the member's home or the school setting.
B. EPSDT Personal Care
The CONTRACTOR shall pay for medically necessary
personal care services furnished to eligible members
under twenty-one (21) years of age as part of EPSDT.
42 CFR Section 440.167, MAD 746.5.
C. Tot-to-Teen Health Checks
The CONTRACTOR shall adhere to the periodicity
schedule and to ensure that eligible members receive
EPSDT screens (Tot-to-Teen Health Checks) including:
(i) Education of and outreach to members regarding
the importance of the health checks; (ii) Development
of a proactive approach to ensure that the services
are received by the members; (iii) Facilitation of
appropriate coordination with school-based providers;
(iv) Development of a systematic communication
process with CONTRACTOR'S participating providers
regarding screens and treatment coordination with
special emphasis on the behavioral health needs of
the members; (v) Processes to document, measure, and
assure compliance with the periodicity schedule; and
(vi) Development of a proactive process to ensure the
appropriate follow-up evaluation, referral, and/or
treatment, especially early intervention for mental
health conditions, vision and hearing screening and
current immunizations.
(17) Services Provided in Schools
The benefit package includes services provided in schools
excluding those specified in the Individual Education Plan
(IEP) or the Individualized Family Services Plan (IFSP) as set
forth in the MAD Program Manual Section MAD-747, SCHOOL-BASED
SERVICES FOR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE.
(18) Nutritional Services
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The benefit package includes nutritional services furnished to
pregnant women and children as set forth in MAD Program Manual
Section MAD-758, NUTRITIONAL SERVICES.
(19) Home Health Services
The benefit package includes home health services as set forth
in MAD Program Manual Section MAD-768, HOME HEALTH SERVICES.
The CONTRACTOR shall coordinate Home Health and the Home and
Community-Based Waiver programs if a member is eligible for
both Home Health and Waiver Services.
(20) Hospice Services
The benefit package includes hospice services as set forth in
MAD Program Manual Section MAD- 763, HOSPICE CARE SERVICES.
(21) Ambulatory Surgical Services
The benefit package includes surgical services rendered in an
ambulatory surgical center setting as set forth in MAD Program
Manual Section MAD- 759, AMBULATORY SURGICAL CENTER SERVICES.
(22) Rehabilitation Services
The benefit package includes inpatient and outpatient hospital
and outpatient physical, occupational, and speech therapy
services as set forth in MAD Program Manual Section MAD-767,
REHABILITATION SERVICES and licensed speech and language
pathology services furnished under the EPSDT program as set
forth in MAD Program Manual Section MAD-746.4, LICENSED SPEECH
AND LANGUAGE PATHOLOGISTS. The CONTRACTOR shall coordinate
rehabilitation services and Home and Community-Based Waiver
programs if a member is eligible for both rehabilitation
services and Waiver Services.
(23) Reproductive Health Services
The benefit package includes reproductive health services as
set forth in MAD Program Manual Section MAD-762, REPRODUCTIVE
HEALTH SERVICES. The CONTRACTOR shall provide Medicaid members
with sufficient information to allow them to make informed
choices including: the types of family planning services
available; the member's right to access these services in a
timely and confidential manner; and the freedom to choose a
qualified family planning
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provider who participates in the CONTRACTOR network or from a
provider who does not participate in the CONTRACTOR network.
(24) Pregnancy Termination Procedures
The benefit package includes services for the termination of
pregnancy and/or pre- or post-decision counseling or
psychological services as set forth in MAD Program Manual
Section MAD-766, PREGNANCY TERMINATION PROCEDURES.
(25) Transportation Services
The benefit package includes transportation service such as
ground ambulance, air ambulance, taxicab and/or handivan,
commercial bus, commercial air, meal, and lodging services as
indicated for medically necessary physical and behavioral
health services as set forth in MAD Program Manual Section
MAD-756, TRANSPORTATION SERVICES. Pursuant to NMSA 1978
Section 65-2-97.F and applicable rules and interpretations of
these laws by the State Public Regulation Commission, rates
paid by the CONTRACTOR to transportation providers are not
subject to and are exempt from New Mexico State Public
Regulation Commission approved tariffs.
(26) Prosthetics and Orthotics
The benefit package includes prosthetic and orthotic services
as set forth in the MAD Program Manual Section MAD-757,
PROSTHETICS AND ORTHOTICS.
(27) Behavioral Health Services Included in the Benefit Package for
Adults and Children
A. Inpatient Hospital Services
The benefit package includes inpatient hospital
psychiatric services provided in general hospital
units and/or PPS-Exempt Units in a general hospital
as set forth in the MAD Program Manual Section
MAD-721, HOSPITAL SERVICES,
B. Hospital Outpatient Services
The benefit package includes outpatient psychiatric
and partial hospitalization services provided in
PPS-exempt units of general hospitals as set forth in
the MAD Program Manual Section MAD-722,
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OUTPATIENT PSYCHIATRIC SERVICES AND PARTIAL
HOSPITALIZATION.
C. Outpatient Health Care Professional Services
The benefit package includes outpatient health care
services as set forth in the MAD Program Manual
Section MAD-717, PSYCHIATRIC AND PSYCHOLOGICAL
SERVICES and MAD-746.2 LICENSED MASTERS LEVEL
INDEPENDENT SOCIAL WORKER.
(28) Behavioral Health Services Included only in the Benefit
Package for Children
A. The benefit package includes prevention, screening,
diagnostics, ameliorative services, and other
medically necessary behavioral health care and
substance abuse treatment or services for Medicaid
members under twenty-one (21) years of age whose need
for behavioral health services is identified during
an Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) screen.
B. All behavioral health care services shall be provided
in accordance with the New Mexico Children's Code.
The services include:
i. Inpatient Hospitalization in Free Standing
Psychiatric Hospitals: The benefit package
includes inpatient services in free standing
psychiatric hospitals as set forth in the
MAD Program Manual Section MAD-742.1,
INPATIENT PSYCHIATRIC CARE IN FREESTANDING
PSYCHIATRIC HOSPITALS.
ii. Accredited Residential Treatment Center
Services: The benefit package includes
accredited residential treatment services as
set forth in the MAD Program Manual Section
MAD-742.2, ACCREDITED RESIDENTIAL TREATMENT
CENTER SERVICES.
iii. Non-Accredited Residential Treatment
Centers: The benefit package includes
residential treatment services as set forth
in the MAD Program Manual Section MAD-742.3,
NON-ACCREDITED RESIDENTIAL TREATMENT CENTERS
AND GROUP HOMES.
iv. Outpatient and Partial Hospitalization
Services in Freestanding Psychiatric
Hospital: The benefit package includes
outpatient and
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partial hospitalization services provided in
freestanding psychiatric hospitals as set
forth in the MAD Program Manual Section
MAD-742.4 OUTPATIENT AND PARTIAL
HOSPITALIZATION SERVICES IN FREESTANDING
PSYCHIATRIC HOSPITALS.
v. Day Treatment Services: The benefit package
includes day treatment services as set forth
in the MAD Program Manual Section MAD-745.3,
DAY TREATMENT SERVICES.
vi. Behavior Management Skills Development
Services (BMSDS): The benefit package
includes behavior management services as set
forth in the MAD Program Manual Section
MAD-745.2, BEHAVIOR MANAGEMENT SKILLS
DEVELOPMENT SERVICES.
vii. School-Based Services: The benefit package
includes counseling, evaluation, and therapy
furnished in a school-based setting but not
specified in the Individual Education Plan
(IEP) or the Individualized Family Services
Plan (IFSP) as set forth in the MAD Program
Manual Section MAD-747, SCHOOL-BASED
SERVICES FOR RECIPIENTS UNDER TWENTY-ONE
YEARS OF AGE.
viii. Case Management Services for The Medically
at Risk: Case management services for
individuals who are under twenty-one (21)
who are medically at risk as set forth in
MAD Program Manual Section MAD-744, EPSDT
CASE MANAGEMENT.
ix. Treatment Foster Care Services: Treatment
Foster Care services as set forth in MAD
Program Manual Section MAD-745.1, TREATMENT
FOSTER CARE.
(29) Behavioral Health Services Included only in the Benefit
Package for Adults
A. Psychosocial Rehabilitation
The benefit package includes psychosocial
rehabilitation services as set forth in the MAD
Program Manual Section MAD-737, MENTAL HEALTH
REHABILITATION.
B. Case Management Services for the Chronically Mentally
Ill
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The benefit package includes case management services
as set forth in the MAD Program Manual Section
MAD-773, CASE MANAGEMENT SERVICES FOR THE CHRONICALLY
MENTALLY ILL.
(30) Health Education and Preventive Care
A. The CONTRACTOR shall provide a continuous program of
health education without cost to members. Such a
program may include publications (e.g., brochures,
newsletters), media (e.g., films, videotapes),
presentations (seminars, lunch-and-learn sessions)
and classroom instruction.
B. The CONTRACTOR shall provide programs of wellness
education. Additional programs may be provided which
address the social and physical consequences of
high-risk behaviors.
C. The CONTRACTOR shall make preventive services
available to members. The CONTRACTOR shall
periodically remind and encourage their members to
use benefits including physical examinations which
are available and designed to prevent illness (e.g.
HIV counseling and testing for pregnant women).
(31) Advance Directives
A. The CONTRACTOR shall implement written policies and
procedures with respect to advance directives that
address the following requirements:
i. The CONTRACTOR shall provide written
information to adult members concerning
their rights to accept or refuse medical or
surgical treatment and to formulate advance
directives, and the MCO's policies and
procedures with respect to the
implementation of such rights;
ii. The CONTRACTOR shall document in the
member's medical record whether or not the
member has executed an advanced directive;
iii. The CONTRACTOR shall prohibit discrimination
in the provision of care or in any other
manner discriminating against a member based
on whether the member has executed an
advance directive;
iv. The CONTRACTOR shall ensure compliance with
requirements of
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Federal and State laws respecting advance
directives; and
v. The CONTRACTOR shall provide education for
staff and the community on issues concerning
advance directives.
(32) Experimental Technology
The CONTRACTOR shall not deem a technology or its application
experimental, investigational or unproven and deny coverage
unless that technology or its application fulfills the
definition of "experimental, investigational or unproven"
contained in the MAD Program Policy Manual, Section 765,
EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES, TECHNOLOGIES OR
THERAPIES.
(33) Standards for Preventive Health Services
A. Unless a member refuses offered services, and such
refusal is documented, the CONTRACTOR shall provide,
to the extent possible, the services described in
this section. Member refusal is defined to include
both failure to consent, and refusal to access care.
B. Preventive health services shall include:
i. Immunizations: The CONTRACTOR shall ensure
that, within six months of enrollment,
members are immunized and current according
to the type and schedule provided by the
most current version of the Recommendations
of the Advisory Committee on Immunization
Practices, Centers for Disease Control and
Prevention, Public Health Service,
Department of Health and Human Services.
This may be done by providing the necessary
immunizations or by verifying the
immunization history by a method deemed
acceptable by the ACIP. "Current" is defined
as no more that four months overdue.
ii. Screens: The CONTRACTOR shall ensure that,
to the extent possible, within six months of
enrollment or within six months of a charge
in the standard, asymptomatic members
receive and are current for at least the
following preventative screening services.
Current is defined as no more than four
months overdue. The CONTRACTOR shall require
its providers to perform the appropriate
interventions based on the results of the
screening.
a) Screening for Breast Cancer.
Females aged 50-69 years
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who are not at high risk for breast
cancer shall be screened annually
with mammography and a clinical
breast examination.
b) Screening for Cervical Cancer.
Female members with a cervix shall
receive Papanicolaou (Pap) testing
starting at the onset of sexual
activity, but at least by 18 years
of age, and every three years
thereafter until reaching 65 years
of age if prior testing has been
consistently normal and the member
has been confirmed to be not at
high risk. If the member is at high
risk, the frequency shall be at
least annual.
c) Screening for Colorectal Cancer.
All members aged 50 years and older
at normal risk for Colorectal
cancer shall be screened with
annual fecal occult blood testing
or sigmoidoscopy at a periodicity
determined by the CONTRACTOR.
d) Blood Pressure Measurement. Members
of all ages shall receive a blood
pressure measurement as medically
indicated.
e) Serum Cholesterol Measurement. All
enrolled men aged 35-65 years and
women aged 45-65 years who are at
normal risk for coronary heart
disease shall receive serum
cholesterol measurement every five
years. Those members with multiple
risk factors shall also receive
HDL-C measurement.
f) Screening for Obesity. All members
shall receive annual body weight
and height measurements to be used
in conjunction with a calculation
of the Body Mass Index or reference
to a table of recommended weights.
g) Screening for Elevated Lead Levels.
All members aged 9-15 months
(ideally 12 months) shall receive a
blood lead measurement at least
once.
h) Screening for Diabetes. All members
shall receive a fasting or two-hour
post-prandial serum glucose
measurement at least once.
i) Screening for Tuberculosis. Members
shall receive a tuberculin skin
test based on the level of
individual risk for development of
the infection.
j) Screening for Rubella. All enrolled
women of childbearing ages shall be
screened for rubella susceptibility
by history of vaccination or by
serology at their first clinical
encounter in an office setting.
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k) Screening for Visual Impairment.
All members aged 3-4 years shall be
screened at least once for
amblyopia and strabismus by
physical examination and a stereo
acuity test.
l) Screening for Hearing Impairment.
All members aged 50 and beyond
shall be routinely screened for
hearing impairment by questioning
them about their hearing.
m) Screening for Problem Drinking and
Substance Abuse. All adolescent and
adult members shall be screened at
least once by a careful history of
alcohol use and/or the use of a
standardized screening
questionnaire such as the Alcohol
Use Disorders Identification Test
(AUDIT) or the four question CAGE
instrument and the Substance Abuse
Screening and Severity Inventory
(SASSI). The frequency of screening
shall be determined by the results
of the first screen and other
clinical indications.
n) Prenatal Screening. All pregnant
members shall be screened for
preeclampsia, D (Rh)
Incompatibility, Down syndrome,
neural tube defects, and
hemoglobinopathies, vaginal and
rectal Group B Streptococcal
infection, and counsel and offer
testing for HIV.
o) Newborn Screening. At a minimum,
all newborn members shall be
screened for phenylketonuria,
congenital hypothyroidism,
galactosemia, and any other
congenital disease or condition
specified in accordance with the
Department of Health regulation 7
NMAC 30.6.
p) During an encounter with a primary
care provider, a behavioral health
screen shall occur.
q) The CONTRACTOR shall ensure that
clinically appropriate follow-up
and/or intervention is performed
when indicated by the screening
results and that this is done using
the guidance provided in the Guide
to Clinical Preventive Services,
Report of the U.S. Preventive
Services Task Force, Second
Edition, Shalliams and Wilkins,
1996.
iii. Tot-to-Teen Health checks: The CONTRACTOR
shall operate a Tot-to-Teen Health check
Program for members up to 21 years of age to
ensure the delivery of the Federally
mandated Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) services.
Within six months of enrollment the
CONTRACTOR shall endeavor to ensure that
eligible members (up to age 21) are current
according to screening schedule in EPSDT
services MAD-740.
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iv. The CONTRACTOR shall provide to applicable
asymptomatic members counseling on the
following unless recipient refusal is
documented: to prevent tobacco use, to
promote physical activity, to promote a
healthy diet, to prevent osteoporosis and
heart disease in menopausal women citing the
advantages and disadvantages of calcium and
hormonal supplementation, to prevent motor
vehicle injuries, to prevent household and
recreational injuries, to prevent dental and
periodontal disease, to prevent HIV
infection and other sexually transmitted
diseases, and to prevent unintended
pregnancies.
v. The CONTRACTOR shall provide a toll-free
health advisor telephone hotline which shall
provide at least the following:
a) General health information on
topics appropriate to the various
Medicaid populations, including
those with severe and chronic
conditions;
b) Clinical assessment and triage to
evaluate the acuity and severity of
the member's symptoms and make the
clinically appropriate referral;
and
c) Prediagnostic and post-treatment
health care decision assistance
based on symptoms.
vi. The CONTRACTOR shall have a written family
planning policy. This policy shall ensure
that members of the appropriate age of both
sexes who seek Family Planning services
shall be provided with counseling pertaining
to the following: methods of contraception;
evaluation and treatment of infertility; HIV
and other sexually transmitted diseases and
risk reduction practices; options for
pregnant members who do not wish to keep a
child; and options for pregnant members who
may wish to terminate the pregnancy.
vii. The CONTRACTOR shall operate a proactive
prenatal care program to promote early
initiation and appropriate frequency of
prenatal care consistent with the standards
of the American College of Obstetrics and
Gynecology. The program shall include at
least the following:
a) Educational outreach to all members
of child-bearing ages;
b) Prompt and easy access to
obstetrical care including
providing an office visit with a
practitioner within three
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weeks of having a positive
pregnancy test (laboratory or home)
unless earlier care is clinically
indicated;
c) Risk assessment of all pregnant
members to identify high risk cases
for special management;
d) Counseling which strongly advises
voluntary testing for HIV;
e) Case management services to address
the special needs of members who
have a high risk pregnancy
especially if risk is due to
psychosocial factors such as
substance abuse or teen pregnancy;
f) Screening for determination of need
for a post-partum home visit; and
g) Coordination with other services in
support of good prenatal care
including transportation and other
community services and referral to
an agency which dispenses free or
reduced price baby car seats.
2.5 CULTURALLY COMPETENT SERVICES
(1) The CONTRACTOR shall develop and implement a Cultural
Competency/Sensitivity Plan, through which the CONTRACTOR
shall ensure that it provides, both directly and through its
health care providers and subcontractors, culturally competent
services to its SALUD! members.
(2) The CONTRACTOR shall phase-in the cultural competency plan
over the first two years of the contract according to the
following process:
A. Year 1, and no later than July 1, 2002
The CONTRACTOR shall:
i. Develop a Cultural Competency Plan that
describes how the CONTRACTOR shall ensure
that services provided are culturally
competent.
ii. Develop written policies and procedures that
implement the Cultural Competency Plan and
ensure that culturally competent services
are provided by the CONTRACTOR both directly
and through its health care providers and
subcontractors.
iii. Target cultural competency training to
primary care providers, care
coordinators/case mangers, home health care
staff and licensed
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masters and doctoral level mental health and
substance abuse professionals.
iv. Develop and implement a plan for
interpretive services and written materials
to meet the needs of consumers and their
decision-makers whose primary language is
not English, using qualified medical
interpreters, if available.
v. Identify community advocates and agencies
that could assist non-English and
limited-English speaking individuals and/or
that provider other culturally appropriate
and competent services, which include
methods for outreach and referral.
B. Year 2, and no later than July 1, 2003
The CONTRACTOR shall:
i. Incorporate cultural competence into
treatment planning, utilization management
and quality improvement.
ii. Identify resources and interventions for
high risk health conditions found in certain
cultural groups.
iii. Develop and incorporate contract language
specific to cultural competency requirements
for inclusion in contracts between the
CONTRACTOR and providers and subcontractors.
2.6 CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)
(1) General Requirements
CSHCN applies to individuals, under 21 years of age, who have
or are at an increased risk for a chronic physical ,
developmental, or behavioral or emotional condition, and who
also require health and related services of a type or amount
beyond that required by children generally. The guiding
principle for this definition is that the children shall be at
individual risk and have a functional need. The primary
purpose of the definition is to identify CSHCN so that the
CONTRACTOR can facilitate access to appropriate services. The
definition also allows for a flexible targeting of individuals
based on clinical justification and discharging them when
special services are no longer needed.
A. CONTRACTOR Requirements:
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i. The CONTRACTOR shall include in its member
services handbook a description of providers
and programs available to children with
special health care needs.
ii. The CONTRACTOR shall identify from among its
members children with special health care
needs, using the proposed definition and
criteria for identification.
B. Criteria that the CONTRACTOR shall use in identifying
CSHCN, include:
i. Children who are eligible for SSI as
disabled under Title XVI;
ii. Children identified in the DOH Title V
Children's Medical Services program;
iii. Children participating in the Home and
Community Based Waivers;
iv. Children receiving foster care or adoption
assistance support through Title IV-E;
v. Other children in foster care or out-of-home
placement; and
vi. Children who are described in the
Individuals with Disabilities Education Act;
and other children who, by merit of a
clinical assessment, should be included.
C. SALUD! Enrollment for CSHCN
The CONTRACTOR shall have written policies and
procedures to facilitate a smooth transition of a
member to another CONTRACTOR, when a member chooses
and is approved to switch to another CONTRACTOR.
(2) Parent/Child Information and Education
A. The CONTRACTOR shall develop and distribute, as
appropriate, information and materials specific to
the needs of CSHCN members and their caregivers. This
includes information, such as a list of items and
services that are in SALUD! and those that are carved
out, how to plan for and arrange transportation, how
to access behavioral health care without
- 66 -
going through the PCP, how the parent or legal
guardian should present a child for care in an
emergency room unfamiliar with the child's special
health care needs, and the availability of a care
coordinator. This information could be included in a
special member handbook on CSHCN or in an insert to
the member handbook.
B. The CONTRACTOR shall make available health education
programs to assist the child's caregiver(s) in
understanding CSHCN and how to cope with the
day-to-day stress of caring the child.
C. The CONTRACTOR shall provide a list of key CONTRACTOR
CSHCN resource people and their phone numbers.
D. The CONTRACTOR shall designate a single entity that a
parent or provider can call for information during
the enrollment process and after becoming a member.
(3) Choice of Specialist as Primary Care Provider (PCP)
The CONTRACTOR shall develop and implement written policies
and procedures governing the process for member selection of a
PCP, including the right to choose a specialist as a PCP, if
warranted and agreed upon by the specialist provider.
(4) Specialty Providers for CSHCN
The CONTRACTOR shall have enough specialty providers to ensure
timely access to necessary specialty care, consistent with
SALUD! access appointment standards for clinical urgency.
(5) Transportation
A. The CONTRACTOR shall have written policies and
procedures in place to ensure that the appropriate
level of transportation is arranged based on the
member's clinical condition.
B. The CONTRACTOR shall have past member and service
data available at the time services are requested to
expedite appropriate arrangements.
C. The CONTRACTOR shall ensure that CPR-certified
drivers transport CSHCN whose clinical need dictates.
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D. The CONTRACTOR shall have written policies and
procedures to ensure that transportation type is
clinically appropriate, including access to
non-emergency ground ambulance carriers.
E. The CONTRACTOR shall develop and implement written
policies and procedures to ensure that members can
access and receive authorization for needed
transportation services under certain unusual
circumstances without the usual advance notification.
F. The CONTRACTOR shall develop and implement a written
policy regarding the transportation of minors if a
parent or legal guardian shall not be in attendance
to ensure the minor's safety.
G. The CONTRACTOR shall distribute clear and detailed
written information to CSHCN and their families on
how to obtain transportation services and also make
this information available to network providers.
(6) Care Coordination for CSHCN
A. The CONTRACTOR shall have written policies and
procedures for identifying CSHCN who could benefit
from care coordination and ensuring that those
children have access to care coordination.
B. The CONTRACTOR shall have written policies and
procedures for accessing care coordination.
C. The CONTRACTOR shall have written policies and
procedures for the development, implementation and
periodic evaluation of a child's treatment plan.
These policies and procedures shall address the
involvement of parent(s) and legal guardians, as well
as the child, in decisions about the child's care and
development and implementation of the treatment plan.
The caregivers of CSHCN and the children themselves,
where indicated, shall be full participants in
setting and achieving their own goals related to the
child's health.
D. The CONTRACTOR shall have written policies and
procedures for educating parent(s), legal guardians
and children that care coordination is available and
when it may be appropriate to their needs.
E. The CONTRACTOR shall have written policies and
procedures for educating providers about the
availability of care coordination, its value as a
resource in caring for the child, and how to access
it.
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(7) Emergency, Inpatient and Outpatient Ambulatory Surgery
Hospital Requirements for CSHCN
A. The CONTRACTOR shall develop and implement written
policies and procedures for educating caregivers of
CSHCN with complicated clinical histories on how to
utilize emergency room care, including what clinical
history to present when emergency care or inpatient
admission are needed for their child.
B. The CONTRACTOR shall develop and implement written
policies and procedures governing how coordination
with the PCP and hospitalists shall occur when a
child with a special health care need is
hospitalized.
C. The CONTRACTOR shall develop and implement written
policies and procedures to ensure that the ER
physician has access to the child's medical history.
D. The CONTRACTOR shall develop and implement written
policies and procedures for obtaining any necessary
referrals from PCPs for hospitals that require
in-house staff to examine or treat members having
outpatient or ambulatory surgical procedures
performed.
(8) Rehabilitation Therapy Services (Physical, Occupational,
Speech Therapy) for CSHCN
A. The CONTRACTOR shall develop and implement therapy
clinical practice guidelines specific to the chronic
or long term conditions of their CSHCN population,
including the use of a home therapy program and
involvement of a caretaker in the treatment plan, and
based on Medicaid managed care policy on medical
necessity.
B. The CONTRACTOR shall be informed about and coordinate
with other therapy services being delivered by:
Special Rehabilitation Services, the Home and
Community Based Waiver programs or by the schools to
avoid unnecessary duplication.
C. The CONTRACTOR shall involve families of members,
physicians and therapy providers to identify issues
that should be addressed in developing the new
criteria.
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D. The CONTRACTOR shall develop and implement
utilization prior approval and continued stay
criteria, including timeframes, that are appropriate
to the chronicity of the member's status and
anticipated development process.
(9) Durable Medical Equipment (DME) and Supplies
A. Subject to any requirements to procure a physician's
order to provide supplies to members, the CONTRACTOR
shall develop and implement a process to permit
members utilizing supplies on an ongoing basis to
submit a list of supplies monthly. The CONTRACTOR
shall contact the member's legal guardian when
requested supplies cannot be delivered (require
back-ordering, etc.) and make other arrangements,
consistent with clinical need.
B. The CONTRACTOR shall develop and implement a system
for monitoring compliance with standards for DME and
medical supplies, and instituting corrective action,
if the provider is out of compliance.
C. The CONTRACTOR shall have an emergency response plan
for DME and medical supplies needed on an emergent
basis.
(10) Clinical Practice Guidelines for Provision of Care to CSHCN
The CONTRACTOR shall develop clinical practice guidelines,
practice parameters and/or other specific criteria that
consider the needs of CSHCN and provide guidance in the
provision of acute and chronic medical and behavioral health
care services to this population. The guidelines should be
professionally accepted standards of practice and national
guidelines.
(11) Utilization Management (UM) for Services to CSHCN
The CONTRACTOR shall develop written policies and procedures
to exclude from prior authorization any item or service
enumerated in the child's treatment plan, and/or extend the
authorization periodicity, for services provided for a chronic
condition. There should be a process for review and periodic
update of the treatment plan, as indicated.
(12) Consumer Surveys Specific to CSHCN
The CONTRACTOR shall add questions about children with special
health care needs to their HEDIS CAHPS 2.04 survey.
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(13) CSHCN Performance Improvement Project
The CONTRACTOR shall perform a performance improvement project
specific to CSHCN.
2.7 SERVICES EXCLUDED FROM THE BENEFIT PACKAGE
(1) The following services are not included in the benefit
package. Reimbursement for these services shall be made by HSD
on a fee-for-service basis:
A. Services provided in nursing facilities or hospital
swing beds to members residing over thirty (30)
continuous days or on a permanent basis as set forth
in MAD Program Manual Section MAD- 731, NURSING
FACILITIES, and MAD-723, SWING BED HOSPITAL SERVICES.
B. Services provided in intermediate care facilities for
the mentally retarded as set forth in MAD Program
Manual Section MAD-732, INTERMEDIATE CARE FACILITY
FOR THE MENTALLY RETARDED;
C. Services provided pursuant to the Home and
Community-Based Services Waiver programs as set forth
in MAD Program Manual Sections MAD-733, HOME AND
COMMUNITY-BASED SERVICES WAIVERS;
D. Emergency services to undocumented aliens as set
forth in MAD Program Manual Section MAD-769,
EMERGENCY SERVICES FOR UNDOCUMENTED ALIENS;
E. Experimental or investigational procedures,
technologies or non-drug therapies as set forth in
MAD Program Manual Section MAD-765, EXPERIMENTAL OR
INVESTIGATIONAL PROCEDURES, TECHNOLOGIES OR NON-DRUG
THERAPIES;
F. Special Rehabilitation Services at set forth in MAD
Program Manual Section MAD-743, SPECIAL
REHABILITATION SERVICES;
G. Case management provided by the Children Youth and
Families Department defined as child protective
services case management and as detailed in MAD
Program Manual section MAD-744, EPSDT CASE
MANAGEMENT;
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H. Case management provided by the Children Youth and
Families Department as detailed in the Medical
Assistance Manual Section MAD-776, ADULT PROTECTIVE
SERVICES CASE MANAGEMENT.
I. Case management provided by Children, Youth and
Families Department as detailed in the Medical
Assistance Manual Section MAD-778, CASE MANAGEMENT
SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION
AND PAROLE OFFICERS.
J. Services provided in the schools and specified in the
Individualized Education Program (IEP) or
Individualized Family Service Plan (IFSP), as
detailed in the medical assistance manual Section MAD
747, SCHOOL BASED SERVICES FOR RECIPIENTS UNDER
TWENTY-ONE YEARS OF AGE.
2.8 ENHANCED BENEFITS/SERVICES
The CONTRACTOR shall provide a schedule for implementing enhanced
services pursuant to the CONTRACTOR'S proposal. The schedule shall
include identification of enhanced services that are already part of
the benefit package. All enhancements shall be identifiable and
measurable through the use of unique payment and/or processing codes,
which shall be part of the encounter data submitted to HSD, unless the
enhanced benefits offered by the CONTRACTOR do not generate claim or
encounter data.
2.9 GRIEVANCE
The member, guardian of the member for minors, or representative of the
member has the right to file a grievance if he/she is dissatisfied with
the services rendered by the CONTRACTOR. This includes but is not
limited to dissatisfaction with direct service provider(s),
appropriateness of services rendered, timeliness of services rendered,
availability of services, delivery of services, prescription of
services, denial, reduction, and/or termination of services,
disenrollment, or any other performance that is considered
unsatisfactory. A participating provider also has the right to file a
grievance with the CONTRACTOR if the provider is dissatisfied with the
CONTRACTOR'S decision to terminate, suspend, reduce, or not provide
services to a member. The CONTRACTOR shall implement written policies
and procedures describing how the member and provider register a
grievance with the CONTRACTOR and how the CONTRACTOR resolves a given
type of grievance.
(1) CONTRACTOR Grievance Hearing Policies and Procedures
A. The CONTRACTOR shall establish and implement written
policies and
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procedures for resolution of grievances, including
internal CONTRACTOR hearings which shall include at
minimum:
i. The procedures for notifying members of the
right to file a grievance and to request a
hearing using the CONTRACTOR'S hearing
process and provide members written notice
of adverse actions as described in the
Medical Assistance Division Program Manual;
ii. The name of specific individual(s)
designated as the MCO Medicaid member
grievance coordinator with the authority to
administer the policies and procedures for
grievance resolution, to review
patterns/trends in grievances and to
initiate corrective action;
iii. The policies and procedures for a toll-free
telephone line for members to register a
grievance with the CONTRACTOR;
iv. The specific policies and procedures
detailing how a thorough investigation of
the grievance, using applicable statutory,
regulatory, and contractual provisions, is
conducted; The CONTRACTOR shall have
physician involvement in reviewing
medically-related grievances. The CONTRACTOR
shall offer to meet with the member during
the formal grievance process;
v. The investigation and final CONTRACTOR
decision for grievances filed by Medicaid
members and providers shall be completed
within thirty (30) calendar days of the
receipt of the grievance with a report in
writing stating the resolution of the
grievance to HSD, the grievant, and involved
parties. The CONTRACTOR shall implement
policies and procedures for an expedited or
emergency alternative appeal process for
quality of care and level of care/placement
issues, and for cases where the health
and/or welfare of the member is immediately
at risk; The expedited or emergency process
shall result in a timely resolution such
that a reasonable person would believe that
a prevailing member would be able to realize
the full benefit of a decision in his or her
favor;
vi. The procedures for maintaining a file of all
grievances that contain sufficient
information to identify the grievance, the
date the grievance was received, the nature
of the grievance, notice to the
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grievant of receipt of a grievance, all
correspondence between affected parties, the
date the grievance is resolved, the means of
grievance resolution, and notices of final
decision to affected parties and all other
pertinent information. Documentation
regarding the grievance shall be made
available to the grievant, if requested;
vii. Specific policies and procedures detailing
how confidential information gathered or
learned during the investigation or
resolution of a grievance is to be
maintained, including the confidentiality of
the member's status as a Medicaid member and
status as a grievant; and
viii. A statement that the member shall not be
subject to retaliation for filing a
grievance.
(2) Accessibility of Grievance Files
All grievance files shall be maintained in a secure,
designated area and be accessible to HSD upon request, for
review. Grievance files shall be retained for six (6) years
following the final decision, HSD or judicial appeal, or
closure of a grievance case file.
(3) Information Distribution
The CONTRACTOR shall have the following responsibilities with
regard to the distribution of information:
A. Member Notice With Initial Enrollment
Upon enrollment, the CONTRACTOR shall provide
members, at no cost, with a member information sheet
or handbook which provides information on how they
and/or their representative(s) can file a grievance
and about the grievance resolution process. The
member information shall also advise members of their
right to file a request for an administrative hearing
with HSD Hearings Bureau, without first utilizing the
CONTRACTOR'S grievance process, in those instances in
which Medicaid benefits are terminated, suspended,
reduced or not-provided. The information shall meet
the standards for communication specified in Section
MAD-606.7, QUALITY MANAGEMENT, Standards for Member
Communication.
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B. The CONTRACTOR may not establish time limits of less
than one year from the date of occurrence for the
member to file a formal grievance.
i. Method of Obtaining Hearing and the Right to
Representation: The information shall
include the method by which a hearing may be
obtained and the right to
self-representation or the use of a
spokesperson or legal counsel.
ii. Non-Disclosure of Information. The member
information shall include a statement that
information about the grievance is not
disclosed without the member's permission
unless disclosure is required by law.
iii. Non-Retaliation. The information shall
include a statement which verifies that the
member shall not be subjected to retaliation
for filing a grievance.
(4) Provider Receipt of Grievance Policies and Procedures
The CONTRACTOR shall provide a copy of its policies and
procedures for grievance resolution to all service providers
in the CONTRACTOR network.
(5) Acknowledgment When Grievance Filed
Within five (5) working days of receipt of the grievance, the
CONTRACTOR shall provide the grievant with written notice that
the grievance has been received and the expected date of its
resolution.
(6) Notice to Member or Provider of Final Decision
The CONTRACTOR shall mail a copy of its final written decision
to HSD, the member or provider to the address on file and all
those parties affected by the decision. The final decision
shall include and describe at least the following:
A. The nature of the grievance;
B. A statement of the action the CONTRACTOR intends to
take;
C. A statement describing the reasons for the
CONTRACTOR'S action;
D. Specific references and citations to applicable
Medicaid and the CONTRACTOR'S policies and
procedures, if any, that support the
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action;
E. The member's right to request an administrative
hearing, if not already requested, to appeal the
CONTRACTOR'S decision to the HSD Hearings Bureau
within thirty (30) calendar days of the final
CONTRACTOR'S decision to terminate, suspend, reduce,
or not provide a benefit to the member; and
F. The statement that the member's request for an
administrative hearing which is received by HSD
within ten (10) calendar days of the CONTRACTOR'S
final decision stays the enforcement of the
CONTRACTOR'S decision to discontinue services
currently provided, but does not require the
CONTRACTOR to initiate any treatment or services or
to increase the level of any current treatment or
services.
(7) Notice to HSD
If a request for an administrative hearing to appeal the
CONTRACTOR'S final decision is received, an official record of
the grievance and copy of the final CONTRACTOR'S decision
shall be provided to the HSD Hearings Bureau by the CONTRACTOR
within five (5) working days of HSD's request for such
information.
(8) Administrative Hearings
Members may file a request for an administrative hearing
through the HSD Hearings Bureau without first availing
themselves of the CONTRACTOR'S grievance process when the
final decision rendered by the CONTRACTOR is to terminate,
suspend, reduce, or not-provide benefit(s) to a member.
(9) Quarterly Reports
The CONTRACTOR shall provide a quarterly report to HSD of all
grievances received from or about Medicaid members, by the
CONRACTOR or its subcontractors. The report shall include
patient details according to the format in Guidance Memo #62.
(10) Hearing Report
The CONTRACTOR shall provide a monthly report of all internal
CONTRACTOR hearings filed and their disposition.
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2.10 FIDUCIARY RESPONSIBILITIES
(1) Solvency Requirements and Risk Protections
A CONTRACTOR that contracts with HSD for the provision of
services shall comply with and is subject to all applicable
State and Federal laws and regulations including those
regarding solvency and risk standards. In addition to
requirements imposed by State or Federal law, the CONTRACTOR
shall be required to meet specific Medicaid financial
requirements and to present to HSD or its agent any
information and records deemed necessary to determine its
financial condition. The response to requests for information
and records shall be delivered to HSD, at no cost to HSD, in a
reasonable time from the date of request or as specified
herein.
(2) Reinsurance
The CONTRACTOR shall have and maintain adequate protections
against financial loss due to outlier (catastrophic) cases and
member utilization that is greater than expected. The
CONTRACTOR shall submit to HSD such documentation as is
necessary to prove the existence of this protection, which may
include policies and procedures of reinsurance.
(3) Third Party Liability
The CONTRACTOR is responsible for identification of other
third party coverage of members and coordination of benefits
with applicable third parties. The CONTRACTOR shall inform HSD
of any member who has other health care coverage. The
CONTRACTOR shall provide documentation to HSD enabling HSD to
pursue its rights under State and Federal law. Documentation
includes payment information on enrolled members as requested
by HSD, Third Party Liability Unit of the MAD, to be delivered
within 20 business days from receipt of the request. Other
documentation to be provided by the CONTRACTOR includes a
quarterly listing of potential accident and personal injury
cases to be pursued by HSD that are known to the CONTRACTOR.
The CONTRACTOR and HSD shall jointly develop and agree upon a
reporting format to carry out the requirement of this
subsection. However, if an agreed upon format cannot be
developed HSD retains the right to make a final determination
of the reporting format.
(4) Fidelity Bond Requirement
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The CONTRACTOR shall maintain in force a fidelity bond in the
amount specified under the Insurance Code, NMSA 1978 Sections
59A-1-1, et. seq..
(5) Net Worth Requirement
The CONTRACTOR shall at all times be in compliance with the
net worth requirements in the Insurance Code.
(6) Solvency Cash Reserve Requirement
A. The CONTRACTOR shall have sufficient reserve funds
available to ensure that the provisions of services
to Medicaid members is not at risk in the event of
the CONTRACTOR insolvency. The CONTRACTOR shall
comply with all state and federal laws and
regulations regarding solvency, risk, audit and
accounting standards.
B. Per Member Cash Reserve
The CONTRACTOR shall maintain three (3) percent of
the monthly capitated payments per member with an
independent trustee during each month of the first
year of the Agreement. The CONTRACTOR shall maintain
this cash reserve for the duration of the Agreement.
HSD shall adjust this cash reserve requirement
annually, or as needed, based on the number of the
CONTRACTOR'S members. Each CONTACTOR shall maintain
its own cash reserve account. This account may be
accessed solely for payment for services to that
CONTRACTOR'S members in the event that the CONTRACTOR
becomes insolvent. Money in the reserve account
remains the property of the CONTRACTOR and any
interest earned (even if retained in the account)
shall be the property of the CONTRACTOR.
(7) Inspection and Audit for Solvency Requirements
The CONTRACTOR shall meet all requirements for licensure
within the State with respect to inspection and auditing of
financial records. The CONTRACTOR shall also cooperate with
HSD or its designee, and provide all financial records
required by HSD or its designee so that they may inspect and
audit the CONTRACTOR'S financial records at least annually or
at HSD's discretion.
(8) Timely Payments
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A. The CONTRACTOR shall make timely payments to both its
contracted and non-contracted providers. The
CONTRACTOR shall promptly pay for all covered
emergency services, including medically necessary
testing to determine if a medical emergency exists,
that are furnished by providers that do not have
arrangements with the CONTRACTOR. This includes all
covered emergency services provided by a
nonparticipating provider, including those when the
time required to reach the CONTRACTOR'S facilities or
the facilities of a provider with which the
CONTRACTOR has contracted, would mean risk of
permanent damage to the member's health. The
CONTRACTOR shall pay 90 percent of all clean claims
from practitioners who are in individual or group
practice or who practice in shared health facilities
within 30 days of date of receipt, and shall pay 99
percent of all such clean claims within 90 days of
receipt. A "clean claim" means a manually or
electronically submitted claim from a participating
provider that: contains substantially all the
required data elements necessary for accurate
adjudication without the need for additional
information from outside of the health plan's system;
it includes a claim with errors originating in the
states' system. It does not include a claim from a
provider who is under investigation for fraud or
abuse, or a claim under review for medical necessity,
is not materially deficient or improper, including
lacking substantiating documentation currently
required by the health plan; or has no particular or
unusual circumstances requiring special treatment
that prevent payment from being made by the health
plan within thirty days of the date of receipt if
submitted electronically or forty-five days if
submitted manually.
(9) Insurance
A. The CONTRACTOR, its successors and assignees shall
procure and maintain such insurance as is required by
currently applicable federal and state law and
regulation. Such insurance shall include, but not be
limited to, the following:
i. Liability insurance for loss, damage, or
injury (including death) of third parties
arising from acts and omissions on the part
of the CONTRACTOR, its agents and employees;
ii. Workers compensation;
iii. Unemployment insurance, and;
iv. Reinsurance.
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v. Automobile insurance to the extent
applicable to CONTRACTOR'S operations.
B. The CONTRACTOR shall provide HSD with documentation
that the above specified insurance has been obtained;
and the CONTRACTOR'S subcontractors shall provide the
same documentation to the CONTRACTOR
(10) The CONTRACTOR shall have and maintain adequate protections
against financial loss due to outlier (catastrophic) cases and
member utilization that is greater than expected. The
CONTRACTOR shall submit to HSD such written documentation as
is necessary to show the existence of this protection, which
may include policies and procedures of reinsurance.
2.11 FRAUD AND ABUSE
(1) The CONTRACTOR shall have written policies and procedures to
address prevention, detection, preliminary investigation,
reporting of potential and actual Medicaid fraud and abuse;
(2) The CONTRACTOR shall have a comprehensive internal program to
prevent, detect, preliminarily investigate and report
potential and actual program violations to help recover funds
misspent due to fraudulent actions;
(3) The CONTRACTOR shall have specific controls for prevention
such as claim edits, post processing, review of claims,
provider profiling and credentialing; prior authorizations,
utilization/quality management and relevant provisions in the
plan's contracts with its providers and subcontractors.
(4) The CONTRACTOR shall cooperate with the Medicaid Fraud Control
Unit (MFCU) and other investigatory agencies as mutually
agreed to by the parties in writing;
(5) The CONTRACTOR shall have systems that can monitor service
utilization and encounters for fraud and abuse;
(6) The CONTRACTOR shall immediately report to HSD any activity
giving rise to a reasonable suspicion of fraud and abuse
including aberrant utilization derived from provider
profiling. The CONTRACTOR shall promptly conduct a preliminary
investigation and report the results of the investigation to
HSD as
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defined by the CONTRACTOR in consultation with HSD and the
Medicaid Fraud Control Unit (MFCU). A formal investigation
shall not be conducted by the CONTRACTOR but the full
cooperation of the CONTRACTOR as mutually agreed to in writing
between the parties during the investigation will be required.
(7) The CONTRACTOR shall not use its organization's determination
as to whether questionable patterns in provider profiles are
acceptable or not, as a basis to withhold this information
from HSD.
2.12 REPORTING
The CONTRACTOR shall provide to HSD managerial, financial, and
utilization and quality reports. The content, format, and schedule for
submission shall be determined by HSD in advance for the financial
reporting period and shall conform to reasonable industry, and/or HCFA
standards. HSD may also require the CONTRACTOR to submit non-routine ad
hoc reports, provided that HSD shall pay the CONTRACTOR to produce any
non-routine ad hoc reports that require a significant amount of time,
resources or effort on the part of the CONTRACTOR.
(1) Reporting Standards
Reports submitted by the CONTRACTOR to HSD shall meet the
following standards:
A. Reports or other required data shall be received on
or before scheduled due dates;
B. Reports or other required data shall be prepared in
strict conformity with appropriate authoritative
sources and/or HSD defined standards; and
C. All required information shall be fully disclosed in
a manner that is both responsive and pertinent to
report intent with no material omission.
D. The submission of late, inaccurate, or otherwise
incomplete reports constitutes failure to report. In
such cases, a penalty may be assessed by HSD.
E. Possibility for Change. HSD requirements regarding
reports, report content, and frequency of submission
are subject to change at any time during the term of
the managed care contract. The CONTRACTOR shall
comply with all changes specified by HSD.
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(2) Monitoring of Grievance Resolution
The CONTRACTOR shall submit a Quarterly Grievance Report to
HSD using the Quarterly Grievance Report format no later than
forty-five (45) days from the end of the quarter.
(3) Financial Reporting
A. The CONTRACTOR shall submit annual audited financial
statements including but not limited to its Income
Statement, Statement of Changes in Financial
Condition or cash flow, and Balance Sheet and shall
include an audited schedule of Salud! revenues and
expenses including a breakout of the Salud!
behavioral health revenue and expenses. The result of
the CONTRACTOR'S annual audit and related management
letters shall be submitted no later than one hundred
fifty (150) days following the close of the
CONTRACTOR'S fiscal year. The audit shall be
performed by an independent Certified Public
Accountant. The CONTRACTOR shall submit for
examination any other financial reports requested by
HSD and related to the CONTRACTOR'S solvency or
performance of this Agreement.
B. The CONTRACTOR and its subcontractors shall maintain
their accounting systems in accordance with statutory
accounting principles, generally accepted accounting
principles, or other generally accepted system of
accounting . The accounting system shall clearly
document all financial transactions between the
CONTRACTOR and its subcontractors, and the CONTRACTOR
and HSD. These transactions shall include but are not
limited to claim payments, refunds, and adjustments
of payments.
C. The CONTRACTOR and its subcontractors shall make
available to HSD and any other authorized State or
Federal agency, any and all financial records
required to examine the compliance by the CONTRACTOR
insofar as those records are related to CONTRACTOR'S
performance under this Agreement.. For the purpose of
examination, review, and inspection of its records,
the CONTRACTOR and its subcontractors shall provide
HSD access to its facilities.
D. The CONTRACTOR and its subcontractors shall retain
all records and reports relating to agreements with
HSD for a minimum of six (6) years from the date of
final payment. In cases involving incomplete audits
and/or unresolved audit findings, administrative
sanctions, or litigation, the minimum six (6) year
retention period shall begin when such actions
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are resolved.
E. The CONTRACTOR shall submit records involving any
business restructuring when changes in ownership
interest of 5% or more have occurred. These records
shall include, but are not limited to, an updated
list of names and addresses of all persons or
entities having ownership interest of 5% or more.
These records shall be provided no later than sixty
(60) days following the change of ownership.
F. The following table gives an overview of the
reporting requirements the HSD has established to
monitor and examine CONTRACTOR for solvency and
compliance with Federal requirements for financial
stability. These requirements shall enable HSD or its
designee to determine if changes have occurred which
affect an MCO and its subcontractors financial
condition. The CONTRACTOR'S required level of
reinsurance, fidelity bond, or insurance and solvency
cash reserves may change with changes to the MCO net
worth or other financial condition.
G. Behavioral Health Reporting
(1) Submit monthly behavioral health UM reports
to HSD, in a format to be determined by HSD
after consultation with the CONTRACTOR.
These monthly reports will include the
following categories: total number of UM
reductions of care, total number of
terminations of care, the total of clinical
denials of care and total number of
administrative denials for all prior
approved behavioral health services;
(2) Submit a monthly behavioral health
utilization report to HSD, in a format to be
determined by HSD after consultation with
the CONTRACTOR, identifying the actual
Medicaid clients impacted by any of the
reporting elements above, including each
client's name, social security number, date
of request, date of UM determinations,
service requested, and final UM
determination.
(3) The CONTRACTOR shall collect and report on a
quarterly basis key variables of program
performance related to behavioral health
services. Key variables will be determined
in consultation with the CONTRACTOR and
stakeholders.
H. Financial Reporting Requirements:
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DEFINITION FREQUENCY OBJECTIVE DUE DATE
---------- --------- --------- --------
Calendar year Independently Audited Annual Examine for Solvency and HCFA June 1
Financial Statements Compliance
Calendar Year Medicaid Specific Annual Examine for Solvency and HCFA June 1
Behavioral Health Schedule of Revenue Compliance
and Expenses
Calendar Year Medicaid Specific Annual Examine for Solvency and HCFA June 1
Audited Schedule of Revenue and Compliance
Expenses
MCO Quarterly Department of Insurance Quarterly DOI Quarterly Statements 45 days from end of
Unaudited Statements Qtr
Department of Insurance Annual Annual DOI Annual Statement March 1
Statement including all supporting
schedules (Medicaid specific included)
Department of Insurance Reports Quarterly Examine for Solvency and HCFA 45 days from end of
Compliance Quarter, March 1 for
Annual Statement
Claims Aging Quarterly Examine for Solvency and HCFA 30 days from end of
Compliance Qtr
Expenditure by Category of Services Quarterly Determine Cost Efficiency 30 days from end of
for hospital, pharmacy, behavioral Qtr
health, physician, dental,
transportation and other
Expenditure of services to FQHC's. Quarterly Enable HSD to make wraparound 30 days from end of
payments to FQHC's Qtr
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Expenditures of services to RHC's Quarterly Enable HSD to make wraparound 30 days from end of
payments to RHC's Qtr
Expenditures specifically made to Quarterly Enable HSD to reconcile the 30 days from end of
IHS, tribal 638 and urban Indian payments made by the Qtr
providers. CONTRACTOR to IHS, tribal 638,
and urban Indian providers
against the supplemental
capitation payments made by
HSD to the CONTRACTOR
Analysis of Benefit Coordination Quarterly Rate payment and Cost 30 days from end of
savings of MCO by rate cell Efficiency Qtr
Identify the Fidelity Bond or Annual Examine for Solvency and HCFA Initially and upon
Insurance Protection by Amount of Compliance renewal
Coverage in relation to Annual
Payments. Identify MCO Directors,
Officers Employees or Partners.
Analysis of Stop-loss protection Quarterly and Examine for Solvency, Rate 30 days from end of
with Detail of Panel Composition Annually Payment, and HCFA Compliance Qtr
Including Rules Regarding
Physician Incentives
Reinsurance Policy Annual Assess Solvency and HCFA Initially and upon
Compliance renewal
Cash Reserve Statement Quarterly Examine for Solvency and HCFA 30 days from end of
Compliance Qtr
(4) Automated Reporting
A. The CONTRACTOR is required to submit data to HSD. HSD
shall define
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the format and data elements after having consulted
with the CONTRACTOR on the definition of these
elements.
B. The CONTRACTOR is responsible for identifying any
inconsistencies immediately upon discovery. If any
unreported inconsistencies are subsequently
discovered, the CONTRACTOR shall make the necessary
adjustments at its own expense.
C. HSD, in conjunction with its fiscal agent, intends to
implement electronic data interchange standards for
transactions related to managed health care. The
CONTRACTOR shall work with HSD to develop the
technical components of such an interface.
(5) Encounters
HSD maintains oversight responsibility for evaluating and
monitoring the volume, timeliness, and quality of encounter
data submitted by the CONTRACTOR. If the CONTRACTOR elects to
contract with a third party Contractor to process and submit
encounter data, the CONTRACTOR remains responsible for the
quality, accuracy, and timeliness of the encounter data
submitted to HSD. HSD shall communicate directly with the
CONTRACTOR any requirements and/or deficiencies regarding
quality, accuracy and timeliness of encounter data, and not
with the third party Contractor. The CONTRACTOR shall submit
encounter data to HSD in accordance with the following:
A. Encounter Submission Media
The CONTRACTOR shall provide encounter data to HSD by
electronic media, such as magnetic tape or direct
file transmission. Paper submission is not permitted.
B. Encounter Submission Time Frames
The CONTRACTOR shall submit encounters to HSD within
90 days of the date of service or discharge,
regardless of whether the encounter is from a
subcontractor or subcapitated arrangement. Encounters
which do not clear edit checks shall be returned to
the CONTRACTOR for correction and resubmission. The
CONTRACTOR shall correct and resubmit the encounter
data to HSD.
C. Encounter Data Elements
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Encounter data elements are based on the
Medicaid-Medicare Common Data Initiative (McData Set)
which is a minimum core data set for states and MCOs
developed by HCFA and HSD for use in managed care.
HSD may increase or reduce or make mandatory or
optional, data elements as it deems necessary.
D. Encounter Data Formats
The CONTRACTOR shall submit encounter data to HSD
using the following formats:
i. HCFA 1500 Encounter Format - This format is
used to report individual medical services
such as physician visits, nursing visits,
surgical procedures, anesthesia services,
laboratory test, radiology services, home
and community based services, therapy
procedures, durable medical equipment,
supplies and transportation services.
Services shall be reported through the use
of HCFA Common Procedure Coding System
(HCPCS) codes (level 1, 2, or 3).
ii. UB92 Encounter Format - This encounter
format is primarily used to report facility
services such as inpatient or outpatient
hospital, dialysis, and institutional
services.
iii. New Mexico Drug Form Encounter Format - This
format is used to report pharmacy items
provided to enrolled Medicaid Managed Care
members.
iv. ADA Dental Claim Encounter Format - This
encounter format is used to report dental
services provided to enrolled Medicaid
Managed Care members.
v. Turn Around Document (TAD) - This encounter
format is used to report long term care and
residential care stays.
(6) Disease Reporting
The CONTRACTOR shall ensure that its providers comply with the
disease reporting required by the A New Mexico Regulations
Governing the Control of Disease and Conditions of Public
Health Significance, 1980".
(7) HEDIS
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The CONTRACTOR shall participate in the most current HEDIS
reporting system; submit a copy of the HEDIS data in
accordance with the NCQA requirement; and submit a final audit
report to HSD along with the HEDIS data submission tool. The
HEDIS compliance audit will be at the expense of the
CONTRACTOR.
(8) MHSIP
The CONTRACTOR shall report MHSIP data annually to HSD;
utilize a standardized format for data submission, designed by
HSD in consultation with the CONTRACTOR; pull a statistically
valid sample from which to collect MHSIP data; and train its
staff in the collection and reporting of MHSIP data and in
survey conduct.
(9) Health Management Systems Reports
The CONTRACTOR shall identify the number of adult Severely
Disabled Mentally Ill (SDMI) and Severely Emotionally
Disturbed Children (SED) and Chronic Substance Abuse (CSA)
members served and report the following adverse events
involving SDMI, SED, and CSA members to the HSD on a quarterly
basis: suicides, other deaths, attempted suicides, involuntary
hospitalizations, detentions for protective custody, and
detention for alleged criminal activity.
(10) Provider Network Reports
The CONTRACTOR shall notify HSD within five (5) working days
of any unexpected changes to the composition of its provider
network that negatively affects member access or the
CONTRACTOR'S ability to deliver all services included in the
benefit package in a timely manner. Any anticipated material
changes in the CONTRACTOR'S provider network shall be reported
to HSD in writing when the CONTRACTOR knows of the anticipated
change or within thirty (30) calendar days, whichever comes
first. The notice submitted to HSD shall include the following
information: Nature of the change; Information about how the
change affects the delivery of covered services or access to
the services; and the CONTRACTOR'S plan for maintaining the
access and quality of member care.
2.13 SYSTEM REQUIREMENTS
(1) The CONTRACTOR'S Management Information System (MIS) shall be
capable of accepting, processing, maintaining and reporting
specific information necessary
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to the administration of the SALUD! Program by June 1, 2001.
The CONTRACTOR'S MIS shall the following requirements.
(2) System Hardware, Software and Information Systems
Requirements: The CONTRACTOR is required to maintain system
hardware, software, and information systems (IS) resources
sufficient to provide the capability to:
A. Accept, transmit, maintain, and store electronic data
and enrollment roster files;
B. Conduct automated claims processing;
C. Estimate the number of records to be received from
providers and subcontractors, monitor, and transmit
electronic encounter data to HSD according to
encounter data submission standards;
D. Transmit data electronically over a Bulletin Board
System and via internet;
E. Disseminate enrollment information to providers
within five (5) business days of receipt of the
information;
F. Maintain a website for dispersing information to
providers and members, and be able to receive
comments electronically;
G. Have the systems capability to receive data elements
associated with identifying members who are receiving
ongoing services under fee-for-service Medicaid or
from another CONTRACTOR;
H. Have systems capability to transmit to HSD or another
CONTRACTOR data elements associated with their
members who have been receiving ongoing services
within their organization; and
I. Maintain a system backup and recovery plan.
(3) Provider Network Information Requirements: The CONTRACTOR'S
provider network capabilities shall include, but not be
limited to:
A. Maintaining complete provider information for all
providers contracted with the CONTRACTOR and its
subcontractors and any other non-contracted providers
who have provided services to date;
B. Transmitting a Provider Network File to HSD on a
monthly basis, no later
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than the 28th day of each month, to include all
contracted providers, non-contracted providers who
have provided service to date, providers who have
applied for contract and are pending, providers whose
application has been denied, and providers who have
been terminated from contract. The file is a general
replacement file each month with no deletions from
the file until 3 years past the date of the
provider's termination or denied status. Once a
provider is shown on the file, the provider should
continue to be reported regardless of whether any
encounters are reported for that provider or not;
C. Providing a complete and accurate designation of each
provider according to the data elements and
definitions included in the SALUD! Systems Manual;
and
D. Providing automated access to members and providers
of a member's PCP assignment.
(4) Claims Processing Requirements: The CONTRACTOR and any of its
subcontractors or providers paying their own claims are
required to maintain claims processing capabilities to
include, but not be limited to:
A. Accepting National Standard Formats for electronic
claims submission. In the event that final HIPAA
regulations change any formats or data required on
the standardized formats, the CONTRACTORS shall be
required to adapt their systems accordingly;
B. Assigning unique identifiers for all claims received
from providers;
C. Standardizing protocols for the transfer of claims
information between the CONTRACTOR and its
subcontractors/providers, audit trail activities, and
the communication of data transfer totals and dates;
D. Meeting both state and federal standards for
processing claims;
E. Generating remittance advice to providers;
F. Participating in a joint committee for standardizing
coding where national coding systems do not apply;
G. Accepting from providers and subcontractors national
standard codes and, where these codes don't apply,
acceptance of state-assigned codes that have been
approved by the HSD joint committee for
standardization;
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H. Editing claims to ensure providers licensed to render
the services being billed are submitting services,
that services are appropriate in scope and amount,
and that enrollees are eligible to receive the
service; and
I. Developing and maintaining an electronic billing
system for all providers submitting bills directly to
the CONTRACTOR within six months of the inception of
the Agreement. Require all subcontractor benefit
managers to meet the same deadline.
(5) Member Information Requirements: The CONTRACTOR'S member
information requirements shall include, but not be limited to:
A. Accepting, maintaining and transmitting member
information:
B. Monitoring newborns to ensure minimal lapse in time
between the infant's birth and their determination of
Medicaid eligibility. The CONTRACTOR shall submit
electronic claims for newborn capitations until the
MMIS is capable of issuing the capitations
automatically. The anticipated date for this
capability is October 1, 2001, after which the
CONTRACTOR shall only be responsible for submitting
capitation claims in unusual circumstances, such as
to correct a previously unidentified problem.
Retroactive capitations shall only be issued for the
first three months of life, during which time the
mother's MCO shall cover the services of the newborn.
After the time, if that newborn has not appeared on a
roster for the CONTRACTOR, the CONTRACTOR shall not
be responsible for the continuing health care for the
child. However, the parent or guardian may choose a
different MCO for the newborn as early as the second
month of life. In such a case, the MCO of the mother
is only entitled to the capitation for the birth
month;
C. Generating member information to providers within
five (5) business days of receipt of the enrollment
roster from HSD;
D. Using all four occurrences of the Medicaid member ID
number sent to the CONTRACTOR on the enrollment
roster to ensure the CONTRACTOR can differentiate
between a change in an existing client's Medicaid
member ID number and a new client. These numbers
needs to be available to staff to be used as a cross
reference when providers or others submit a number
other than the number maintained by the CONTRACTOR as
the primary number and as a means to update the
member's ID number when eligibility changes
necessitate a change to the number;
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E. Maintaining a special medical status identifier on
their system's database consistent with HSD's for
this field. This requirement also applies to any
subcontractor who maintains a copy of the member
rosters for the purpose of distributing eligibility
or roster information to providers or verifying
member eligibility;
F. Meeting federal HCFA standards for release of member
information (applies to subcontractors as well).
Standards are specified in the SALUD! Systems Manual
and at 42 CFR 431.306(b);
G. Track changes in the members' category of eligibility
to ensure appropriate services are covered and
appropriate application of co-pays;
H. Maintaining accurate member eligibility and
demographic data,
I. Providing automated access to providers regarding
member eligibility and PCP assignment. The CONTRACTOR
shall provide an automated voice response system for
providers to verify eligibility and PCP assignment;
J. Making member enrollment and PCP assignment
information available for electronic verification
systems, including swipe card systems; and
K. Providing daily electronic transmission to HSD of
member enrollment and PCP assignment.
(6) Encounter and Provider Network Reporting Requirements: The
CONTRACTOR has a responsibility for the following Encounter
and Provider Network File Submission and Reporting
capabilities to include, but not be limited to:
A. Submitting to HSD encounters, according to the
specifications included in the SALUD! Systems Manual,
within 90 days of the date of service or discharge,
regardless of whether the encounter is from a
subcontractor or subcapitated arrangement;
B. Submitting encounter files that have an error rate of
no more than five percent;
C. Submitting corrections to any encounters that are
rejected by HSD as exceeding by HSD the five percent
error threshold within 30 days of the rejection;
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D. Submitting adjustments/voids to encounters that have
previously been accepted by HSD within 30 days of the
adjustment or void of claim;
E. Including written contractual requirements for
subcontractors or providers that pay their own claims
to submit encounters to the CONTRACTOR on a timely
basis to ensure that the CONTRACTOR can submit
encounters to HSD within 90 days of the date of
service or discharge;
F. Editing encounters prior to submission to prevent or
decrease submission of duplicate encounters,
encounters from providers not on the CONTRACTOR'S
provider network file, and other types of encounter
errors;
G. Having a formal monitoring and reporting system to
reconcile submissions and resubmission of encounter
data between the CONTRACTOR and HSD to assure
timeliness of submissions, resubmissions and
corrections and completeness of data. The CONTRACTORS
shall be required to report the status of their
encounter data submissions overall on a form
developed by HSD;
H. Having a formal monitoring and reporting system to
reconcile submissions and resubmissions of encounter
data between the CONTRACTORS and their subcontractors
or providers who pay their own claims to assure
timeliness and completeness of their submission of
encounter data to the CONTRACTORS;
I. Complying with the most current federal standards for
encryption of any data that is transmitted via the
internet (also applies to subcontractors). A summary
of the current HCFA guidelines is included in the
SALUD! Systems Manual;
J. Complying with HCFA standards for electronic
transmission, security, and privacy, as may be
required by HIPAA (also applies to subcontractors);
and
K. Reporting all data noted as "required" in the
encounter formats provided in the Systems Manual.
ARTICLE 3 - LIMITATION OF COST
The total amount payable by HSD to all CONTRACTORS executing Agreements with HSD
to perform services shall be less than the upper payment limit established under
the terms of the
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1915(b) waiver for Medicaid managed care. In no event shall capitation fees or
other payments provided for in the Agreement exceed the payment limits set forth
in 42 C.F.R Section 447.361 and 447.362. In no event shall HSD pay twice for the
provision of services.
ARTICLE 4 - HSD RESPONSIBILITY
4.1 HSD shall:
(1) Establish and maintain Medicaid eligibility information and
transfer eligibility information to assure appropriate
enrollment in and assignment to the CONTRACTOR. On the
CONTRACTOR'S request, this information shall be transferred
electronically. The CONTRACTOR shall have the right to rely on
eligibility and enrollment information transmitted to the
CONTRACTOR by HSD.
(2) Support implementation deadlines by providing technical
information at the required level of specificity in a timely
fashion.
(3) Provide the CONTRACTOR with enrollment information concerning
each Medicaid member enrolled with the CONTRACTOR, including
the member's name and social security number, the member's
address, the member's date of birth and gender, the
availability of third party coverage, and the member's rate
category.
(4) Compensate the CONTRACTOR as specified in Article 5 -
Compensation and Payment Reimbursement for Managed Care.
(5) Provide a mechanism for fair/administrative hearings to review
denials and Utilization Management decisions made by the
CONTRACTOR.
(6) Monitor the effectiveness of the CONTRACTOR'S Quality
Assurance Program.
(7) Review the CONTRACTOR'S grievance files as necessary.
(8) Establish requirements for review and make decisions
concerning the CONTRACTOR'S requests for disenrollment.
(9) Determine the period of time within which a member cannot be
reenrolled in a CONTRACTOR that successfully has requested
his/her disenrollment.
(10) Provide mandatory Medicaid enrollees with specific information
about services, benefits, and MCOs from which to choose and
member enrollment.
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(11) Have the right to receive solvency and reinsurance information
from the CONTRACTOR, and to inspect the CONTRACTOR'S financial
records as frequently as necessary, but at least annually.
(12) Have the right to receive all information regarding third
party liability from the CONTRACTOR so that it may pursue its
rights under State and Federal law.
(13) Review the CONTRACTOR'S policies and procedures concerning
Medicaid fraud and abuse until they are deemed acceptable.
(14) Provide the content, format and schedule for the CONTRACTOR'S
report submission.
(15) Inspect, examine, and review the CONTRACTOR'S financial
records as necessary to assure compliance with all applicable
State and Federal laws and regulations.
(16) Monitor encounter data submitted by the CONTRACTOR and shall
provide data elements for reporting.
(17) Provide the CONTRACTOR with specifications related to data
reporting requirements.
(18) Amend its fee-for-service and other provider agreements, as
necessary, to encourage health care providers paid by HSD to
enter into contracts with the CONTRACTOR at the applicable
Medicaid reimbursement rate for the provider, absent other
negotiated arrangements. The applicable Medicaid reimbursement
rate is defined to exclude disproportionate share and medical
education payments.
(19) Establish maximum enrollment levels to ensure that all MCOs
maintain statewide enrollment capacity.
4.2 HSD and/or its fiscal agent shall implement electronic data interchange
standards for transactions related to managed health care.
4.3 Performance by the CONTRACTOR shall not be contingent upon time
availability of HSD personnel or resources with the exception of
specific responsibilities stated in the RFP and the normal cooperation
that can be expected in such a contractual Agreement. The CONTRACTOR'S
access to HSD personnel shall be granted as freely as possible.
However, the competency/sufficiency of HSD staff shall not be reason
for relieving the CONTRACTOR of any responsibility for failing to meet
required deadlines or producing
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unacceptable deliverables. To the extent the CONTRACTOR is unable to
perform any obligation or meet any deadline under this Agreement
because of the failure of HSD to perform its specific responsibilities
under the Agreement, the CONTRACTOR'S performance shall be excused or
delayed, as appropriate. The CONTRACTOR shall provide HSD written
notice as soon as possible, but in no event later than the expiration
of any deadline or date for performance, that identifies the specific
responsibility that HSD has failed to meet, as well as the reason HSD's
failure impacts the CONTRACTOR'S ability to meet its performance
obligations under the Agreement.
ARTICLE 5 - COMPENSATION & PAYMENT REIMBURSEMENT
FOR MANAGED CARE
5.1 Subject to Article 8, ENFORCEMENT, HSD shall pay the monthly rates
shown below, for each member, in full consideration of all the work to
be performed by the CONTRACTOR under this Agreement. The monthly rate
for each member is based on the age, gender, and eligibility category
of the member. To the extent, if any, it is determined by the
appropriate taxing authority that the performance of this Agreement by
the CONTRACTOR is subject to taxation, the amounts paid by HSD to the
CONTRACTOR under this Agreement, shall include such tax(es). The
CONTRACTOR is responsible for reporting and remitting all applicable
taxes to the appropriate taxing agency.
5.2 The monthly rate set forth below shall be subject to renegotiation
during the Agreement if HSD determines that it is necessary due to
change in Federal or State law or in the appropriations made available
for these tasks as set forth in Article 14, Appropriations, and Article
12, Contract Modification.
5.3 Payment for Services
(1) HSD shall pay a capitated amount to the CONTRACTOR for the
provision of the managed care benefit package at the rates
specified below. The monthly rate for each member is based on
a combination of the age, gender and eligibility category of
the member. The combinations are grouped into twenty-nine (29)
rate cells. Medicaid members shall be held harmless against
any liability for debts of a CONTRACTOR that were incurred
within the Agreement in providing covered services to the
Medicaid member.
(2) HSD shall pay each CONTRACTOR an additional payment for each
Native American identified in HSD's system. This additional
payment is to be used to cover medical costs of Native
Americans provided at Indian Health Service; tribal 638 and
defined urban Indian providers. The Native American payment
amount is
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established by HSD and is fully reimbursed to the CONTRACTOR.
The supplemental payment amounts are subject to revision based
upon an actuarial review. These payments are cost neutral to
the CONTRACTOR. Any payment made beyond the amount of the
supplemental capitation shall be reimbursed by HSD. Any
payment made by HSD that is not expended shall be recouped
from the CONTRACTOR.
(3) Medicaid and SCHIP members shall be held harmless against any
liability for debts of the CONTRACTOR which were incurred
within the Agreement in providing health care to the Medicaid
or SCHIP member, excluding any members liability for
copayments or member's liability for an overpayment resulting
from benefits paid pending the results of a fair hearing. The
CONTRACTOR has no obligation to continue to see members for
treatment if the member fails to meet copayment obligations.
5.4 Payment on Risk Basis
The CONTRACTOR is at risk of incurring losses if its expenses for
providing the managed care benefit package exceeds its capitation
payment. HSD shall not provide a retroactive payment adjustment to the
CONTRACTOR to reflect the cost of services actually furnished by the
CONTRACTOR. The CONTRACTOR may retain its profits.
5.5 Changes in the Capitation Rates
(1) The capitation rates shall remain in effect as referenced in
Attachments A and B for the first twenty-four (24) months for
the effective date of this Agreement. Capitation rates may be
reviewed if this Agreement is extended with the CONTRACTOR
pursuant to this Agreement. Upon mutual Agreement of the
CONTRACTOR and HSD, the capitation rates may be adjusted based
on factors such as changes in the scope of work, a Native
American MCO is established or a Navajo Medicaid Agency
created, HCFA requires a modification of the state's waiver or
new or amended federal or state laws or regulations are
implemented, inflation, significant changes in the demographic
characteristics of the member population, or the
disproportionate enrollment selection of the CONTRACTOR by
members in certain rate cohorts. Any changes to the rates
shall be modified pursuant to Articles 12 (Contract
Modification) and 37 (Amendments) of this agreement.
(2) HSD shall compensate the CONTRACTOR for work performed under
this Agreement at the following rates shown on Attachments A
and B.
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(3) The CONTRACTOR shall obtain reinsurance for coverage of
members as required by this Agreement. However, the CONTRACTOR
remains ultimately liable to HSD for the services rendered
under the terms of this Agreement. The CONTRACTOR shall
provide a copy of its proposed reinsurance agreement with its
response to the RFP.
5.6 Procedures
(1) HSD shall distribute an aggregate amount to the CONTRACTOR for
all members enrolled with the CONTRACTOR on or before the
second Friday of each month.
(2) Until a newborn receives a separate member identifier from
HSD, the CONTRACTOR shall submit a payment request to HSD for
the newborn member. HSD shall pay the CONTRACTOR the monthly
rate for the newborn after receipt and verification of the
claim by HSD.
(3) HSD shall make a full monthly payment to the CONTRACTOR for
the month in which the member's enrollment is terminated. The
CONTRACTOR shall be responsible for covered medical services
provided to the member in any month for which HSD paid the
CONTRACTOR for the member's care under the terms of this
Agreement.
(4) HSD shall recoup payments for members who are incorrectly
enrolled with more than one CONTRACTOR; payments made for
members who die prior to the enrollment month for which
payment was made; and/or payments for members whom HSD later
determines were not eligible for Medicaid during the
enrollment month for which payment was made. Notwithstanding
the foregoing, HSD shall not have the right to recoup a
payment made to the CONTRACTOR if either the CONTRACTOR
(and/or its subcontractors) provided any health care services
to the member during the relevant period of time or more than
twenty-four months have elapsed since the payments were made.
(5) With the exception of newborns born while the mother is an
enrolled member, HSD is responsible for payment of all
inpatient facility and professional services provided from the
date of admission until the date of discharge, if a member is
hospitalized at the time of enrollment.
(6) If the member is hospitalized at the time of disenrollment,
the CONTRACTOR shall be responsible for payment of all covered
inpatient facility and professional services from the date of
admission to the date of discharge. The CONTRACTOR shall be
responsible for coverage of such services until the member is
discharged from the hospital. The CONTRACTOR shall be
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responsible for ensuring proper transition of care if the
reason for disenrollment is the member's selection of a
different CONTRACTOR.
(7) If a member is in a nursing home at the time of disenrollment,
the CONTRACTOR shall be responsible for payment of all covered
services until the date of discharge or the time the nature of
the member's care ceases to be subacute or skilled nursing
care, whichever first occurs. The CONTRACTOR shall be
responsible for ensuring proper transition of care if the
reason for disenrollment is the member's selection of a
different MCO.
(8) On a periodic basis, HSD shall provide the CONTRACTOR with
coordination of benefits information for enrolled members. The
CONTRACTOR shall:
A. Not refuse or reduce services provided under this
Agreement solely due to the existence of similar
benefits provided under other health care contracts.
B. Attempt to recover any third-party resources
available to Medicaid recipients (42 C.F.R. 433
Subpart D) and shall make all records pertaining to
Third Party Collections (TPL) for members available
to HSD for audit and review. HSD shall have the right
to claim any TPL collections generated by these
activities.
C. Notify HSD as set forth below when the CONTRACTOR
learns (not identified in enrollment roster) that a
member has TPL for medical care:
i. Within fifteen (15) working days when a
member is verified as having dual coverage
under its managed care organization.
ii. Within sixty (60) calendar days when a
member is verified as having coverage with
any other managed care organization or
health carrier.
D. Communicate and ensure compliance with the
requirements of this section by subcontractors that
provide services under the terms of this Agreement.
E. Members shall not be charged for services covered
under the terms of this Agreement, except as provided
in the MAD Provider Policy Manual Section MAD-701.7,
ACCEPTANCE OF RECIPIENT OR THIRD PARTY PAYMENTS.
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F. Payments provided for under this Agreement shall be
denied for new members when, and for so long as,
payment for those members is denied under 42 CFR
Section 434.67(e).
5.7 Special Payment Requirements
This section lists special payment requirements by provider type:
(1) Reimbursement of Federally Qualified Health Centers (FQHCs)
FQHCs are reimbursed at 100 percent of reasonable cost under a
Medicaid fee-for-service or managed care program. The FQHC can
waive its right to reasonable cost and elect to receive the
rate negotiated with the CONTRACTOR. During the course of the
contract negotiations with the CONTRACTOR, the FQHC shall
state explicitly that it elects to receive 100 percent of
reasonable costs or waive this requirement.
(2) Reimbursement for Providers Furnishing Care to Native
Americans
If an Indian Health Service (IHS), or tribal 638 provider
delivers services to the CONTRACTOR member who is a Native
American, the CONTRACTOR shall reimburse the provider at the
rate currently established for the IHS facilities or
Federally-leased facilities by the Office of Management (OMB),
or Medicaid, or at a fee negotiated between the provider and
the CONTRACTOR.
(3) Reimbursement for Family Planning Services
The CONTRACTOR shall reimburse out-of-network family planning
providers for provision of services to CONTRACTOR members at a
rate which at a minimum equals the applicable Medicaid
fee-for-service rate appropriate to the provider type.
(4) Reimbursement for Women in the Third Trimester of Pregnancy
If a pregnant woman in the third trimester of pregnancy has an
established relationship with an obstetrical provider and
desires to continue that relationship, and the provider is not
participating with the CONTRACTOR, the CONTRACTOR shall
reimburse the nonparticipating provider at the applicable
Medicaid fee-for-service rate appropriate to the provider
type.
5.8 Reimbursement for Emergency Services
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(1) The CONTRACTOR shall ensure that acute general hospitals are
reimbursed for emergency services which they provide because
of federal mandates such as the "anti-dumping" law in the
Omnibus Budget Reconciliation Act of 1989, P.L. 101-239 and 42
U.S.C. section 1395 dd (1867 of the Social Security Act).
(2) If the screening examination leads to a clinical determination
by the examining physician that an actual emergency medical
condition exists, the CONTRACTOR shall pay for both the
services involved in the screening examination and the
services required to stabilize the patient.
(3) The CONTRACTOR is required to pay for all emergency services
which are medically necessary until the clinical emergency is
stabilized. This includes all treatment that may be necessary
to assure, within reasonable medical probability, that no
material deterioration of the patient's condition is likely to
result from, or occur, during discharge of the patient or
transfer of the patient to another facility.
(4) If the screening examination leads to a clinical determination
by the examining physician that an actual emergency medical
condition does not exist, then the determining factor for
payment liability is whether the member had acute symptoms of
sufficient severity at the time of presentation. In these
cases, the CONTRACTOR shall review the presenting symptoms of
the member and shall pay for all services involved in the
screening examination where the present symptoms (including
severe pain) were of sufficient severity to have warranted
emergency attention under the prudent layperson standard. If
the member believes that a claim for emergency services has
been inappropriately denied by the CONTRACTOR, the member may
seek recourse through the CONTRACTOR or HSD appeal process.
(5) When the member's primary care physician or other CONTRACTOR
representative instructs the member to seek emergency care in
network or out of network, the CONTRACTOR is responsible for
payment at the in network rate, for the medical screening
examination and for other medically necessary emergency
services, intended to medically stabilize the patient without
regard to whether the member meets the prudent layperson
standard.
ARTICLE 6 - CONTRACT ADMINISTRATOR
The Contract Administrator is, and his/her successor shall be, designated by the
Secretary of HSD. HSD shall notify the CONTRACTOR of any changes in the identity
of the Contract Administrator. The Contract Administrator is empowered and
authorized as the agent of HSD to represent HSD in all matters related to this
Agreement except those reserved to other HSD personnel by the Agreement.
Notwithstanding the above, the Contract Administrator does not
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have the authority to amend the terms and conditions of this Agreement. All
events, problems, concerns or requests affecting this Agreement shall be
reported by the CONTRACTOR to the Contract Administrator
ARTICLE 7 - CONTRACTOR PERSONNEL
7.1 The CONTRACTOR warrants and represents that it shall assign sufficient
employees to the performance of this Agreement to meet all aspects of
its performance as represented by the CONTRACTOR to HSD in its
proposal.
7.2 Replacement of any CONTRACTOR personnel shall be with personnel of
equal ability, experience, and qualifications.
7.3 HSD reserves the right to require the CONTRACTOR to make changes in its
staff assignments if the assigned staff is/are not, in the opinion of
HSD, meeting the needs of Medicaid members or the needs of HSD in
implementing and enforcing the terms of this Agreement, provided that
such CONTRACTOR staff changes shall comport with the CONTRACTOR'S
personnel policies.
7.4 The CONTRACTOR may not have an employment, consulting or other
agreement with a person who has been convicted of crimes specified in
Section 1128 of the Social Security Act for the provision of items and
services that are significant and material to the entity's obligations
under the Agreement.
7.5 The CONTRACTOR shall submit to HSD on a quarterly basis a brief job
description and the qualifications of each individual behavioral health
UM staff.
ARTICLE 8 - ENFORCEMENT
8.1 HSD Sanctions
(1) Unless otherwise required by law, the level or extent of
sanctions shall be based on the frequency or pattern of
conduct, or the severity or degree of harm posed to (or
incurred by) members or to the integrity of the Medicaid
program.
(2) If the Secretary of HSD or his/her designee determines, after
notice and opportunity by the CONTRACTOR to be heard in
accordance with Article 15, that the CONTRACTOR or any agent
or employee of the CONTRACTOR, or any persons with an
ownership interest in the CONTRACTOR, or related party of the
CONTRACTOR, has failed to comply with any applicable law,
regulation, term of this Agreement, policy, standard, rule, or
for other good cause, the Secretary of HSD may impose any or
all of the following in accordance with applicable law:
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A. Plans of Correction. The CONTRACTOR shall be required
to provide to HSD, within fourteen (14) days, a plan
of correction to remedy any defect in its
performance.
B. Directed Plans of Correction. The CONTRACTOR shall be
required to provide to HSD, within fourteen (14)
days, a plan of correction as directed by HSD.
C. Civil or administrative monetary penalties may be
imposed to the extent authorized by federal or state
law.
i. HSD retains the right to apply progressively
strict sanctions against the CONTRACTOR,
including an assessment of a monetary
penalty against the CONTRACTOR, for failure
to perform in any contract areas.
ii. Unless otherwise required by law, the level
of extent of sanctions shall be based on the
frequency or pattern of conduct, or the
severity or degree of harm posed to or
incurred by members or to the integrity of
the Medicaid program. HSD shall impose
liquidated damages consistent with letter J
of this Article.
iii. A monetary penalty, depending upon the
severity of the infraction. Penalty
assessments shall range, up to five (5)
percent of the CONTRACTOR'S Medicaid
capitation payment in the month in which the
penalty is assessed.
iv. Any withholding of capitation payments in
the form of a penalty assessment does not
constitute just cause for the CONTRACTOR to
interrupt services provided to members.
v. All other administrative, contractual or
legal remedies available to HSD shall be
employed in the event that the CONTRACTOR
violates or breaches the terms of the
Agreement.
D. Adjustment of Automated Assignment Formula: HSD may
selectively assign members who have not selected a
CONTRACTOR to an alternative CONTRACTOR in response
to the CONTRACTOR'S failure to fulfill its duties.
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E. Suspension of New Enrollment: HSD may suspend new
enrollment to the CONTRACTOR.
F. Appointment of a State Monitor: Should HSD be
required to appoint a State monitor to assure the
CONTRACTOR'S performance, the CONTRACTOR shall bear
the reasonable cost of the State intervention.
G. Payment Denials. HSD may deny payment for all members
or deny payment for new members.
H. Rescission: HSD may rescind marketing consent.
I. Actual Damages: HSD may assess to the CONTRACTOR
actual damages to HSD or its members resulting from
the CONTRACTOR'S non-performance of its obligations.
J. Liquidated Damages: HSD may pursue liquidated damages
in an amount equal to the costs of obtaining
alternative health benefits to the member in the
event of the CONTRACTOR'S non-performance. The
damages shall include the difference in the capitated
rates that would have been paid to the CONTRACTOR and
the rates paid to the replacement health plan. The
State may withhold payment to the CONTRACTOR for
liquidated damages until such damages are paid in
full.
K. Removal: HSD may remove members with third party
coverage from enrollment with the CONTRACTOR.
L. Temporary Management: HSD may appoint temporary
management to oversee the operations of the
CONTRACTOR upon a finding by the Secretary of HSD
that there is continued egregious behavior by the
CONTRACTOR, there is a substantial risk to the health
of the members, or to assure the health of the
CONTRACTOR'S members while there is an orderly
termination or reorganization of the CONTRACTOR'S
organization or improvements are made to remedy the
identified violations. The Secretary of HSD shall not
allow the removal of the temporary management until
it determines that the CONTRACTOR has the capability
to ensure that the violation shall not reoccur. The
CONTRACTOR does not have the right to a
predetermination hearing prior to the appointment of
temporary management.
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M. Terminate Enrollment: HSD may permit members enrolled
with the CONTRACTOR to terminate enrollment without
cause and notify such members of the right to
terminate enrollment.
N. Impose Penalty: HSD may impose an administrative
penalty of not more than five thousand dollars
($5,000) each for engaging in any practice described
in Section B of the Medicare Provider Act.
O. Intermediate Sanctions: HSD may issue an intermediate
sanction in the form of administrative order
requiring the CONTRACTOR to cease or modify any
specified conduct or practice engaged in by it or its
employees, subcontractors, or agents to fulfill its
contractual obligations in the manner specified in
the order, provide any services that have been denied
or take steps to provide or arrange for the provision
of any services that it has agreed or is otherwise
obligated to make available.
P. Suspension: HSD may suspend the Agreement.
Q. Termination: HSD may terminate the Agreement.
8.2 Federal Sanctions
(1) Section 1903 (m)(5)(A) and (B) of the Social Security Act
vests the Secretary of HHS with the authority to deny Medicaid
payments to a health plan for members who enroll after the
date on which the health plan has been found to have committed
one of the violations set forth in the Agreement. State
payments for the CONTRACTOR'S members are automatically denied
whenever, and for so long as, federal payment for such members
has been denied as a result of the commission of such
violations. The following violations can trigger denial of
payment pursuant to section 1903(m)(5) of the Social Security
Act:
A. Substantial failure to provide required medically
necessary items or services when the failure has
adversely affected (or has substantial likelihood of
adversely affecting) a member;
B. Imposition of premiums on Medicaid members in excess
of permitted premiums;
C. Discrimination among Medicaid beneficiaries with
respect to enrollment, re-enrollment, or
disenrollment on the basis of Medicaid beneficiaries'
health status or requirements for health care
services;
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D. Misrepresentation or falsification of certain
information; or
E. Failure to cover emergency services under Section
1932(b)(2) of the Social Security Act when the
failure affects (or has a substantial likelihood of
adversely affecting) a member.
(2) HSD may also deny payment if HSD learns that a CONTRACTOR:
A. Subcontracts with an individual provider, an entity,
or an entity with an individual who is an officer,
director, agent or manager or person with more than
five percent of beneficial ownership of an entity's
equity, that has been convicted of crimes specified
in the Section 1128 of the Social Security Act, or
who has a contractual relationship with an entity
convicted of a crime specified in Section 1128.
(3) HSD shall notify the Secretary of Health and Human Services of
noncompliance with subparagraph A above. HSD may allow
continuance of the Agreement unless the Secretary directs
otherwise but may not renew or otherwise extend the duration
of the existing Agreement with the CONTRACTOR unless the
Secretary provides to HSD and Congress a written statement
describing the compelling reasons that exist for renewing and
extending the Agreement.
(4) This section is subject to the "nonexclusively of remedy"
language.
8.3 Notice and Cure
HSD shall provide reasonable written notice of its decision to impose
sanctions on the CONTRACTOR and, as HSD may deem necessary and proper,
subsequently to members and others who may be directly interested. Such
written notice shall set forth the effective date and the reason(s) for
the sanctions. Prior to imposing sanctions, HSD shall afford the
CONTRACTOR a reasonable opportunity to cure, unless such opportunity
would result in immediate harm to members, or the improper diversion of
Medicaid program funds.
8.4 Non-exclusivity of Remedy
The provisions of this Article supplement, rather than replace, any
other sanctions or remedies available to the HSD under the provisions
of this Agreement or of applicable law or regulations.
8.5 CONTRACTOR'S Incentive Requirements
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HSD shall provide incentives to the CONTRACTOR'S that receive
exceptional grading during the procurement process and for ongoing
performance under the Agreement for quality assurance standards,
performance indicators, enrollment processing, fiscal solvency, access
standards, encounter data submission, reporting requirements, Third
Party Liability collections and marketing plan requirements as
determined by HSD by automatically assigning in greater number to the
CONTRACTOR determined by HSD to warrant greater assignments of such
Medicaid recipients.
ARTICLE 9 - TERMINATION
9.1 All terminations shall be effective at the end of a month, unless
otherwise specified in this Article. This Agreement may be terminated
under the following circumstances:
(1) By mutual written agreement of HSD and the CONTRACTOR upon
such terms and conditions as they may agree;
(2) By HSD for convenience, upon not less than one hundred eighty
(180) days written notice to the CONTRACTOR;
(3) This Agreement shall terminate on the Agreement termination
date. The CONTRACTOR shall be paid solely for services
provided prior to the termination date. The CONTRACTOR is
obligated to pay all claims for all dates of service prior to
the termination date. In the event of the Agreement
termination date or if the CONTRACTOR terminates this
Agreement prior to the Agreement termination date, and, if a
member is hospitalized at the time of termination, the
CONTRACTOR shall be responsible for payment of all covered
inpatient facility and professional services from the date of
admission to the date of discharge. Similarly in the event of
the Agreement termination date or if the CONTRACTOR terminates
this Agreement prior to the Agreement termination date, and, a
member is in a nursing home at the time of termination, the
CONTRACTOR shall be responsible for payment of all covered
services from the date of admission until the date of
discharge or the time the nature of the member's care ceases
to be subacute or skilled nursing care, whichever occurs
first. In the event that HSD terminates this Agreement prior
to the agreement termination date, and, a member is
hospitalized at the time of termination, the CONTRACTOR shall
be responsible for payment of all covered inpatient facility
and professional services from the date of admission to sixty
(60) days after the effective date of termination. Similarly,
in the event that HSD terminates this Agreement prior to the
Agreement termination date, and, a member is in a nursing home
at the time of the effective date of termination, the
CONTRACTOR shall be responsible for payment of all covered
services until sixty (60) days after the
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effective date of termination or the time the nature of the
member's care ceases to be subacute or skilled nursing care,
whichever occurs first;
(4) By HSD for cause upon failure of the CONTRACTOR to materially
comply with the terms and conditions of this Agreement. HSD
shall give the CONTRACTOR written notice specifying the
CONTRACTOR'S failure to comply. The CONTRACTOR shall correct
the failure within thirty (30) days or begin in good faith to
correct the failure and thereafter proceed diligently to
complete or cure the failure. If within thirty (30) days the
CONTRACTOR has not initiated or completed corrective action,
HSD may serve written notice stating the date of termination
and work stoppage arrangements;
(5) By HSD, if required by modification, change, or interpretation
in State or Federal law or HCFA waiver terms, because of court
order, or because of insufficient funding from the Federal or
State government(s), if Federal or State appropriations for
Medicaid managed care are not obtained, or are withdrawn,
reduced, or limited, or if Medicaid managed care expenditures
are greater than anticipated such that funds are insufficient
to allow for the purchase of services as required by this
Agreement. HSD's decision as to whether sufficient funds are
available shall be accepted by the CONTRACTOR and shall be
final;
(6) By HSD, in the event of default by the CONTRACTOR, which is
defined as the inability of the CONTRACTOR to provide services
described in this Agreement or the CONTRACTOR'S insolvency.
With the exception of termination due to insolvency, the
CONTRACTOR shall be given thirty (30) days to cure any such
default, unless such opportunity would result in immediate
harm to members, or the improper diversion of Medicaid program
funds;
(7) By HSD, in the event of notification by the Public Regulation
Commission or other applicable regulatory body that the
certificate of authority under which the CONTRACTOR operates
has been revoked, or that it has expired and shall not be
renewed;
(8) By HSD, in the event of notification that the owners or
managers of the CONTRACTOR, or other entities with substantial
contractual relationship with the CONTRACTOR, have been
convicted of Medicare or Medicaid fraud or abuse or received
certain sanctions as specified in section 1128 of the Social
Security Act;
(9) By HSD, in the event it determines that the health or welfare
of Medicaid members are in jeopardy should the Agreement
continue. For purposes of this
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paragraph, termination of the Agreement requires a finding by
HSD that a substantial number of members face the threat of
immediate and serious harm;
(10) By HSD, in the event of the CONTRACTOR'S failure to comply
with the composition of enrollment requirement contained in 42
C.F.R. Section 434.26 and the Scope of Work. The CONTRACTOR
shall be given fourteen (14) days to cure any such enrollment
composition requirement, unless such opportunity would violate
any federal law or regulation;
(11) By HSD in the event a petition for bankruptcy is filed by or
against the CONTRACTOR;
(12) By HSD if the CONTRACTOR fails substantially to provide
medically necessary items and services that are required under
this Agreement;
(13) By HSD, if the CONTRACTOR discriminates among members on the
basis of their health status or requirements for health
services, including expulsion or refusal to reenroll a member,
except as permitted by this Agreement and federal law, or
engaging in any practice that would reasonably be expected to
have the effect of denying or discouraging enrollment with the
CONTRACTOR by the eligible member or by members whose medical
condition or history indicates a need for substantial future
medical services;
(14) By HSD, if the CONTRACTOR intentionally misrepresents or
falsifies information that is furnished to the Secretary of
Health and Human Services, HSD or Medicaid members, potential
members or health care providers under the Social Security Act
or pursuant to this Agreement;
(15) By HSD, if the CONTRACTOR fails to comply with applicable
physician incentive prohibitions of Section 1903(m)(2)(A)(x)
of the Social Security Act;
(16) By the CONTRACTOR, on at least sixty (60) days prior written
notice in the event HSD fails to pay any amount due the
CONTRACTOR hereunder within thirty (30) days of the date such
payments are due; and
(17) By the CONTRACTOR, on sixty (60) days written notice with
cause, or one hundred eighty (180) days written notice without
cause.
9.2. If HSD terminates this Agreement pursuant to this Article and unless
otherwise specified in this Article, HSD shall provide the CONTRACTOR
written notice of such termination at least sixty (60) days prior to
the effective date of the termination, unless HSD itself receives less
than sixty (60) days notice, in which case HSD shall provide the
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CONTRACTOR with as much notice as possible, but in no event less than
sixty (60) days notice. If HSD determines a reduction in the scope of
work is necessary, it shall notify the CONTRACTOR and proceed to amend
this Agreement pursuant to its provisions.
9.3 By termination pursuant to this Article, neither party may nullify
obligations already incurred for performance of services prior to the
date of notice or, unless specifically Stated in the notice, required
to be performed through the effective date of termination. Any
agreement or notice of termination shall incorporate necessary
transition arrangements.
ARTICLE 10 - TERMINATION AGREEMENT
10.1 When HSD has reduced to writing and delivered to the CONTRACTOR notice
of termination, the effective date, and reasons therefor, if any, HSD,
in addition to other rights provided in this Agreement, may require the
CONTRACTOR to transfer, deliver, and/or make readily available to HSD,
property in which HSD has a financial interest. Prior to invoking the
provisions of this paragraph, HSD shall identify that property in which
it has a financial interest, provided that, subject to HSD's recoupment
rights herein, property acquired with capitation or other payments made
for members properly enrolled shall not be considered property in which
HSD has a financial interest.
10.2 In the event this Agreement is terminated by HSD, immediately as of the
notice date, the CONTRACTOR shall:
(1) Incur no further financial obligations for materials,
services, or facilities under this Agreement, without prior
written approval of HSD.
(2) Terminate all purchase orders or procurements and subcontracts
and stop all work to the extent specified in the notice of
termination, except as HSD may direct for orderly completion
and transition.
(3) Agree that HSD is not liable for any costs of the CONTRACTOR
arising out of termination unless the CONTRACTOR establishes
that the Agreement was terminated due to HSD's negligence,
wrongful act, or breach of the Agreement.
(4) Take such action as HSD may reasonably direct, for protection
and preservation of all property and all records related to
and required by this Agreement.
(5) Cooperate fully in the closeout or transition of any
activities so as to permit continuity in the administration of
HSD programs.
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(6) Allow HSD, its agents and representatives full access to the
CONTRACTOR'S facilities and records to arrange the orderly
transfer of the contracted activities. These records include
the information necessary for the reimbursement of any
outstanding Medicaid claims.
ARTICLE 11 - RIGHTS UPON TERMINATION OR EXPIRATION
11.1 Upon termination or expiration of this Agreement, the CONTRACTOR shall,
upon request of HSD, make available to HSD, or to a person authorized
by HSD, all records and equipment which are the property of HSD.
11.2 Upon termination or expiration, HSD shall pay the CONTRACTOR all
amounts due for service through the effective date of such termination.
HSD may deduct from amounts otherwise payable to the CONTRACTOR monies
determined to be due HSD from the CONTRACTOR. Any amounts in dispute at
the time of termination shall be placed by HSD in an interest-bearing
escrow account with an escrow agent mutually agreed to by HSD and the
CONTRACTOR.
11.3 In the event that HSD terminates the Agreement for cause in full or in
part, HSD may procure services similar to those terminated and the
CONTRACTOR shall be liable to HSD for any excess costs for such similar
services for any calendar month for which the CONTRACTOR has been paid
for providing services to Medicaid members. In addition, the CONTRACTOR
shall be liable to HSD for administrative costs incurred by HSD in
procuring such similar services. The rights and remedies of HSD
provided in this paragraph shall not be exclusive and are in addition
to any other rights and remedies provided by law or under this
contract.
11.4 The CONTRACTOR is responsible for any claims from subcontractors or
other providers, including emergency service providers, for services
provided prior to the termination date. The CONTRACTOR shall promptly
notify HSD of any outstanding claims for which HSD may owe, or be
liable for fee-for-service payment, which are known to the CONTRACTOR
at the time of termination or when such new claims incurred prior to
termination are received.
11.5 Any payments advanced to the CONTRACTOR for coverage of members for
periods after the date of termination shall be promptly returned to
HSD. For termination of an Agreement which occurs mid-month, the
capitation payments for that month shall be apportioned on a daily
basis. The CONTRACTOR shall be entitled to capitation payments for the
period of time prior to the date of termination and HSD shall be
entitled to a refund for the balance of the month. All terminations
shall include a final accounting of capitation payment received and
number of members during the month in which termination is effective.
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11.6 The CONTRACTOR shall ensure the orderly and reasonable transfer of
member care in progress, whether or not those members are hospitalized
or in long-term treatment.
11.7 The CONTRACTOR shall be responsible to HSD for liquidated damages
arising out of CONTRACTOR'S breach of this Agreement.
11.8 In the event HSD proves that the CONTRACTOR'S course of performance has
resulted in reductions in HSD's receipt of federal program funds, as a
Federal sanction, the CONTRACTOR shall remit to HSD, as liquidated
damages, such funds as are necessary to make HSD whole but only to the
extent such damages are caused by the actions of the CONTRACTOR. This
provision is subject to Article 15, Disputes.
ARTICLE 12 - CONTRACT MODIFICATION
12.1 In the event that changes in Federal or State statute, regulation,
rules, policy, or changes in Federal or State appropriation(s) or other
circumstances, require a change in the way HSD manages its Medicaid
program, this Agreement shall be subject to substantial modification by
amendment. Such election shall be effected by HSD sending written
notice to the CONTRACTOR. HSD's decision as to the requirement for
change in the scope of the program shall be final and binding.
12.2 The amendment(s) shall be implemented by Agreement renegotiation in
accordance with Article 37, Amendment. In addition, in the event that
approval of HSD's 1915(b) waiver is contingent upon amendment of this
Agreement, the CONTRACTOR agrees to make any necessary amendments to
obtain such waiver approval. Notwithstanding the foregoing, any
material change in the cost to the CONTRACTOR of providing the services
herein, that is caused by HCFA in granting the waiver, shall be
negotiated and mutually agreed to between HSD and the CONTRACTOR. The
results of the negotiations shall be placed in writing in compliance
with Article 37, (Amendment) of this Agreement.
ARTICLE 13 - INTELLECTUAL PROPERTY
13.1 In the event the CONTRACTOR shall elect to use or incorporate in the
materials to be produced any components of a system already existing,
the CONTRACTOR shall first notify HSD, who after investigation may
direct the CONTRACTOR not to incorporate such components. If HSD shall
not object, and after the CONTRACTOR obtains written consent of the
party owning the same, and furnishing a copy to HSD, the CONTRACTOR may
incorporate such components.
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13.2 The CONTRACTOR warrants that all materials produced hereunder shall not
infringe upon or violate any patent, copyright, trade secret or other
property right of any third party, and the CONTRACTOR shall indemnify
and hold HSD harmless from and against any loss, cost, liability, or
expense arising out of breach or claimed breach of this warranty.
ARTICLE 14 - APPROPRIATIONS
14.1 The terms of this Agreement are contingent upon sufficient
appropriations or authorizations being made by either the Legislature
of New Mexico, Health and Human Services (HHS)/Health Care Financing
Authorities (HCFA), or the U.S. Congress for the performance of this
Agreement. If sufficient appropriations and authorizations are not made
by either the Legislature, HHS/HCFA or the Congress, this Agreement
shall be subject to termination or amendment. HSD's decision as to
whether sufficient appropriations or authorizations exist shall be
accepted by the CONTRACTOR and shall be final and binding. Any changes
to the Scope of Work pursuant to this Section 14.1 shall be in writing
and signed by the parties in accordance with Article 37 (Amendments) of
this Agreement.
14.2 To the extent Health Care Finance Administration, legislation or
Congressional action impact the amount of appropriation available for
performance under this Contract, HSD has the right to amend the Scope
of Work, in its discretion, which shall be effected by HSD sending
written notice to the CONTRACTOR.
ARTICLE 15 - DISPUTES
15.1 The entire agreement shall consist of: (1) this Agreement, including
the Scope of Work, items incorporated by reference in paragraph 1.2.7,
and any amendments; (2) the Request for Proposal, HSD written
clarifications to the Request for Proposal and CONTRACTOR responses to
RFP questions where not inconsistent with the terms of this Agreement
or its amendments; (3) The CONTRACTOR'S Best and Final Offer, and (4)
the CONTRACTOR'S additional responses to the Request for Proposal where
not inconsistent with the terms of this Agreement or its amendments,
all of which are incorporated herein or by reference.
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15.2 In the event of a dispute under this Agreement, various documents shall
be referred to for the purpose of clarification or for additional
detail in the order of priority and significance, specified below:
15.2.1 Amendments to the Agreement in reverse chronological order
followed by;
15.2.2 The Agreement, including items incorporated by reference in
Paragraph 1.2, followed by:
15.2.3 The CONTRACTOR'S Best and Final Offer followed by;
15.2.4 The Request for Proposal, including attachments thereto and
HSD's written responses to written questions and HSD's written
clarifications, and the CONTRACTOR'S response to the Request
for Proposal, including both technical and cost portions of
the response (but only those portions of the CONTRACTOR'S
response including both technical and cost portions of the
response that do not conflict with the terms of this Agreement
and its amendments).
15.3 Dispute Procedures
(1) Any dispute concerning sanctions imposed under this Agreement
shall be reported in writing to the MAD Director within
fifteen (15) days of the date the reporting party received
notice of the sanction. The decision of the Director shall be
delivered to the parties in writing within thirty (30) days
and shall be final and conclusive unless, within fifteen (15)
days from the date of the decision, either party files with
the Secretary of the HSD a written appeal of the decision of
the Director.
(2) Any other dispute concerning performance of the Agreement
shall be reported in writing to the MAD Director within thirty
(30) days of the date the reporting party knew of the activity
or incident giving rise to the dispute. The decision of the
Director shall be delivered to the parties in writing within
thirty (30) days and shall be final and conclusive unless,
within fifteen (15) days from the date of the decision, either
party files with the Secretary of the HSD a written appeal of
the decision of the Director.
(3) Failure to file a timely appeal shall be deemed acceptance of
the Director's decision and waiver of any further claim.
(4) In any appeal under this Article, the CONTRACTOR and the MAD
shall be afforded an opportunity to be heard and to offer
evidence and argument in support
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of their position to the Secretary or his designee. The appeal
is an informal hearing which shall not be recorded or
transcribed, and is not subject to formal rules of evidence or
procedure.
(5) The Secretary or a designee shall review the issues and
evidence presented and issue a determination in writing which
shall conclude the administrative process available to the
parties. The Secretary shall notify the parties of the
decision within thirty (30) days of the notice of the appeal,
unless otherwise agreed to by the parties in writing or
extended by the Secretary for good cause.
(6) Pending decision by the Secretary, both parties shall proceed
diligently with performance of the Agreement, in accordance
with the Agreement.
(7) Failure to initiate or participate in any part of this process
shall be deemed waiver of any claim.
ARTICLE 16 - APPLICABLE LAW
16.1 This Agreement shall be governed by the laws of the State of New
Mexico. All legal proceedings arising from unresolved disputes under
this Agreement shall be brought before the First Judicial District
Court in Santa Fe, New Mexico.
16.2 Each party agrees that it shall perform its obligations hereunder in
accordance with all applicable Federal and State laws, rules and
regulations now or hereafter in effect.
16.3 If any provision of this Agreement is determined to be invalid,
unenforceable, illegal or void, the remaining provisions of this
Agreement shall not be affected, providing the remainder of the
Agreement is capable of performance, the remaining provisions shall be
binding upon the parties hereto, and shall be enforceable, as though
said invalid, unenforceable, illegal, or void provision were not
contained herein.
ARTICLE 17 - STATUS OF CONTRACTOR
17.1 The CONTRACTOR is an independent CONTRACTOR performing professional
services for HSD and is not an employee of the State of New Mexico. The
CONTRACTOR shall not accrue leave, retirement, insurance, bonding, use
of State vehicles, or any other benefits afforded to employees of the
State of New Mexico as a result of this Agreement.
17.2 The CONTRACTOR shall be solely responsible for all applicable taxes,
insurance, licensing and other costs of doing business. Should the
CONTRACTOR default in these
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or other responsibilities, jeopardizing the CONTRACTOR'S ability to
perform services, this Agreement may be terminated immediately upon
written notice.
17.3 The CONTRACTOR shall not purport to bind HSD, its officers or employees
nor the State of New Mexico to any obligation not expressly authorized
herein unless HSD has expressly given the CONTRACTOR the authority to
so do in writing.
ARTICLE 18 - ASSIGNMENT
18.1 With the exception of provider subcontracts or other subcontracts
expressly permitted under this Agreement, the CONTRACTOR shall not
assign, transfer or delegate any rights, obligations, duties or other
interest in this Agreement or assign any claim for money due or to
become due under this Agreement.
ARTICLE 19 - SUBCONTRACTS
19.1 The CONTRACTOR is solely responsible for fulfillment of the Agreement
with HSD. HSD shall make Agreement payments only to the CONTRACTOR.
19.2 The CONTRACTOR shall remain solely responsible for performance by any
subcontractor under such subcontract(s).
19.3 HSD may undertake or award other agreements for work related to the
tasks described in this document or any portion therein if the
CONTRACTOR'S available time and/or priorities do not allow for such
work to be provided by the CONTRACTOR. The CONTRACTOR shall fully
cooperate with such other CONTRACTORS and HSD in all such cases.
19.4 Subcontracting Requirements
(1) Except as otherwise provided in this agreement, the CONTRACTOR
may subcontract to a qualified individual or organization for
the provision of any service defined in the benefit package or
other required MCO function. The CONTRACTOR remains legally
responsible to HSD for all work performed by any
subcontractor. The CONTRACTOR shall submit to HSD boilerplate
contract language and/or sample contracts for various types of
subcontracts during the procurement process. Changes to
contract templates that may materially affect Medicaid members
shall be approved by HSD prior to execution by any
subcontractor.
(2) HSD reserves the right to review and disapprove all
subcontracts and/or any significant modifications to
previously approved subcontracts to ensure
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compliance with requirements set forth in 42 CFR 434.6 or this
Agreement. The CONTRACTOR is required to give HSD prior notice
with regard to its intent to subcontract certain significant
contract requirements as specified herein or in writing by HSD
including, but not limited to, credentialing, utilization
review, and claims processing. HSD reserves the right to
disallow a proposed subcontracting arrangement if the proposed
subcontractor has been formally restricted from participating
in a federal entitlement program (i.e. Medicare, Medicaid) for
other good cause.
(3) The CONTRACTOR shall not contract with an individual provider,
an entity, or an entity with an individual who is an officer,
director, agent or manager or person with more than five
percent of beneficial ownership of an entity's equity, that
has been convicted of crimes specified in the Section 1128 of
the Social Security Act, or who has a contractual relationship
with an entity convicted of a crime specified in Section 1128.
(4) Pursuant to 42 CFR section 417.479(a), no specific payment may
be made directly or indirectly under a physician incentive
plan to a physician or physician group as an inducement to
reduce or limit medically necessary services furnished to an
individual member. The CONTRACTOR shall disclose to HSD the
information on provider incentive plans set forth in 42 CFR
Sections 471.479(h)(1)(ii)-(iv) at the times required by 42
CFR 434.70(a)(3) to allow HSD to determine whether the
incentive plans meet the requirements of 42 CFR 417.479(d)
through (g). The CONTRACTOR shall provide capitation data
required by 42 CFR 479(h)(1)(iv) for the previous calendar
year to HSD by application/CONTRACTOR renewal of each year.
The CONTRACTOR shall provide the information on its physician
incentive plans allowed by 42 CFR Section 417.479(h)(3) to any
Medicaid recipient upon request.
(5) In its subcontracts, the CONTRACTOR shall ensure that
subcontractors agree to hold harmless both the HSD and the
CONTRACTOR'S members in the event that the CONTRACTOR cannot
or shall not pay for services performed by the subcontractor
pursuant to the subcontract. The hold harmless provision shall
survive the effective termination of the CONTRACTOR/
subcontractor contract for authorized services rendered prior
to the termination of the contract, regardless of the cause
giving rise to termination and shall be construed to be for
the benefit of the members.
(6) The CONTRACTOR shall have a written document (agreement),
signed by both parties, that describes the responsibilities of
the CONTRACTOR and the delegate; the delegated activities; the
frequency of reporting (if applicable) to the CONTRACTOR; the
process by which the CONTRACTOR evaluates the
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delegate; and the remedies, including the revocation of
the delegation, available to the MCO if the delegate does not
fulfill its obligations.
(7) The CONTRACTOR shall have policies and procedures to ensure
that the delegated agency meets all standards of performance
mandated by HSD for the SALUD! program. These include, but are
not limited to, use of appropriately qualified staff,
application of clinical practice guidelines and utilization
management, reporting capability, and ensuring members' access
to care;
(8) The CONTRACTOR shall have policies and procedures for the
oversight of the delegated agency's performance of the
delegated functions.
(9) The CONTRACTOR shall have policies and procedures to ensure
consistent statewide application of all utilization management
criteria when utilization management is delegated;
A. Credentialing Requirements: The CONTRACTOR shall
maintain policies and procedures for verifying that
the credentials of all its providers and
subcontractors meet applicable standards as stated in
the Article 2, Scope of Work.
B. Review Requirements: The CONTRACTOR shall maintain a
fully executed original of all subcontracts which are
accessible to HSD upon request.
C. Minimum Requirements: Subcontracts shall contain at
least the following provisions:
i. Subcontracts shall be executed in accordance
with all applicable Federal and State laws,
regulations, policies and procedures and
rules;
ii. Subcontracts shall identify the parties of
the subcontract and their legal basis of
operation in the State of New Mexico;
iii. Subcontracts shall include the procedures
and specific criteria for terminating the
subcontract;
iv. Subcontracts shall identify the services to
be performed by the subcontractor and those
services performed under any other
subcontract(s). Subcontracts shall include
provision(s) describing
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how services provided under the terms of the
subcontract are accessed by members;
v. Subcontracts shall include the reimbursement
rates and risk assumption, if applicable;
vi. Subcontractors shall maintain all records
relating to services provided to members for
a six (6) year period and shall make all
enrollee medical records available for the
purpose of quality review conducted by HSD
or is designated agents both during and
after the contract period;
vii. Subcontracts shall require that member
information be kept confidential, as defined
by Federal and State law;
viii. Subcontracts shall include a provision that
authorized representatives of HSD have
reasonable access to facilities and records
for financial and medical audit purposes
both during and after the contract period;
ix. Subcontracts shall include a provision for
the subcontractor to release to the
CONTRACTOR any information necessary to
perform any of its obligations;
x. The subcontractor shall accept payment from
the CONTRACTOR as payment for any services
included in the benefit package, and cannot
request payment from HSD for services
performed under the subcontract;
xi. If the subcontract includes primary care,
provisions for compliance with PCP
requirements delineated in the primary MCO
contract apply;
xii. The subcontractor shall comply with all
applicable State and Federal statutes, laws,
rules, and regulations;
xiii. Subcontracts shall include provision for
termination for any violation of applicable
HSD, State or Federal requirements;
xiv. The subcontract may not prohibit a provider
or other subcontractor (with the exception
of third party administrators) from entering
into a contractual relationship with another
CONTRACTOR.
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xv. The subcontract may not include any
incentive or disincentive that encourages a
provider or other subcontractor not to enter
into a contractual relationship with another
CONTRACTOR;
xvi. The subcontract cannot contain any gag order
provisions that prohibit or otherwise
restrict covered health professionals from
advising patients about their health status
or medical care or treatment as provided in
Section 1932(b)(3) of the Social Security
act or in contravention of NMSA 1978 Section
59A-57-1 to 57-11, the Patient Protection
Act.
xvii. The subcontract for pharmacy providers shall
include a payment provision consistent with
1978 NMSA Section 27-2-16B unless the
subcontractor provides a voluntary waiver to
any rights under 1978 NMSA Section 27-2-16B
or the CONTRACTOR is notified by HSD that
the provisions of Section 27-2-16B do not
apply to the CONTRACTOR'S subcontract with
the Pharmacies.
ARTICLE 20 - RELEASE
20.1 Upon final payment of the amounts due under this Agreement, the
CONTRACTOR shall release HSD, its officers and employees and the State
of New Mexico from all liabilities and obligations whatsoever under, or
arising from this Agreement. The CONTRACTOR agrees not to purport to
bind the State of New Mexico.
20.2 Payment to the CONTRACTOR by HSD shall not constitute final release of
the CONTRACTOR. Should audit or inspection of the CONTRACTOR'S records
or the CONTRACTOR'S member complaints subsequently reveal outstanding
CONTRACTOR liabilities or obligations, the CONTRACTOR shall remain
liable to HSD for such obligations. Any payments by HSD to the
CONTRACTOR shall be subject to any appropriate recoupment by HSD.
20.3 Notice of any post-termination audit or investigation of complaint by
HSD shall be provided to the CONTRACTOR, and such audit or
investigation shall be initiated in accordance with HCFA requirements.
HSD shall notify the CONTRACTOR of any claim or demand within 30 days
after completion of the audit or investigation or as otherwise
authorized by HCFA. Any payments by HSD to the CONTRACTOR shall be
subject to any appropriate recoupment by HSD in accordance with the
provisions of Article 5 of this Agreement.
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ARTICLE 21 - RECORDS AND AUDIT
21.1 Compensation Records
After final payment under the contract or six (6) years after a pending
audit is completed and resolved, whichever is later, HSD or its
designee shall have the right to audit billings both before and after
payment. The CONTRACTOR shall maintain all necessary records to
substantiate the services it rendered under this Agreement. These
records shall be subject to inspection by HSD, the Department of
Finance and Administration, the State Auditor and/or any authorized
State or Federal entity and shall be retained for six (6) years.
Payment under this Agreement shall not foreclose the right of HSD to
recover excessive or illegal payments as well as interest, attorney
fees and costs incurred in such recovery.
21.2 Other Records
In addition, the CONTRACTOR shall retain all member medical records,
collected data, and other information subject to HSD, State, and
Federal reporting or monitoring requirements for six (6) years after
the contract is terminated under any provisions of Article 11 of this
Agreement or six (6) years after any pending audit is completed and
resolved, whichever is later. These records shall be subject to
inspection by HSD, the Department of Finance and Administration and/or
any authorized State or Federal entity. Payment under this Agreement
shall not foreclose the right of HSD to recover excessive or illegal
payments as well as interest, attorney fees and costs incurred in such
recovery.
21.3 Standards for Medical Records
(1) The CONTRACTOR shall require medical records to be maintained
in a manner on paper and/or in electronic format that is
timely, legible, current, set forth, and organized, and
permits effective and confidential patient care and quality
review.
(2) The CONTRACTOR shall have written medical record
confidentiality policies and procedures that implement the
requirements of State and Federal law and policy and this
Agreement.
(3) The CONTRACTOR shall establish, and shall require its
practitioners to have, an organized medical record keeping
system and standards for the availability of medical records
appropriate to the practice site.
(4) The CONTRACTOR shall include provisions in its contracts with
providers requiring appropriate access to the medical records
of the MCO members for purposes of quality reviews to be
conducted by HSD or agents thereof, and that
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the medical records be available to health care practitioners
for each clinical encounter.
21.4 The CONTRACTOR shall comply with HSD's reasonable requests for records
and documents as necessary to verify that the CONTRACTOR is meeting its
obligations under this Agreement, or for data reporting legally
required of HSD. However, nothing in this Agreement shall require the
CONTRACTOR to provide HSD with information, records, and/or documents
which are protected from disclosure by any law, including, but not
limited to, laws protecting proprietary information as a trade secret,
confidentiality laws, and any applicable legal privileges (including
but not limited to, attorney/client, physician/patient, quality
assurance and peer review), except as may otherwise be required by law
or pursuant to a legally adequate release from the affected member(s).
21.5 The CONTRACTOR shall provide the State of New Mexico, HSD, and any
other legally authorized governmental entity, or their authorized
representatives, the right to enter at all reasonable times the
CONTRACTOR'S premises or other places where work under this contract is
performed to inspect, monitor or otherwise evaluate the quality,
appropriateness, and timeliness of services performed under this
contract. The CONTRACTOR shall provide reasonable facilities and
assistance for the safety and convenience of the persons performing
those duties (e.g. assistance from the CONTRACTOR staff to retrieve
and/or copy materials). HSD and its authorized agents shall schedule
access with the CONTRACTOR in advance within a reasonable period of
time except in case of suspected fraud and abuse. All inspection,
monitoring and evaluation shall be performed in such a manner as not to
unduly interfere with the work being performed under this contract.
21.6 In the event right of access is requested under this section, the
CONTRACTOR or subcontractor shall upon request provide and make
available staff to assist in the audit or inspection effort, and
provide adequate space on the premises to reasonably accommodate the
State or Federal representatives conducting the audit or inspection
effort.
21.7 All inspections or audits shall be conducted in a manner as shall not
unduly interfere with the performance of the CONTRACTOR'S or any
subcontractors activities. The CONTRACTOR shall be given 10 working
days to respond to any findings of an audit before HSD shall finalize
its findings. All information so obtained shall be accorded
confidential treatment as provided in applicable law.
ARTICLE 22 - INDEMNIFICATION
22.1 The CONTRACTOR agrees to indemnify, defend, and hold harmless the State
of New Mexico, its officers, agents and employees from any and all
claims and losses accruing or resulting from any and all CONTRACTOR
employees, agents, or subcontractors, in
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connection with the performance of this Agreement, and from any and all
claims and losses accruing or resulting to any person, association,
partnership, entity, or corporation who may be injured or damaged by
the CONTRACTOR in the performance or failure in performance of this
Agreement. The provisions of this Section 22.1 shall not apply to any
liabilities, losses, charges, costs or expenses caused by, or resulting
from, the acts or omissions of the State of New Mexico, HSD, or any of
its officers, employees, or agents.
22.2 The CONTRACTOR shall at all times during the term of this Agreement,
indemnify and hold harmless HSD against any and all liability, loss,
damage, costs or expenses which HSD may sustain, incur or be required
to pay (1) by reason of any member suffering personal injury, death or
property loss or damage of any kind as a result of the erroneous or
negligent acts or omissions of the CONTRACTOR either while
participating with or receiving care or services from the CONTRACTOR
under this Agreement, or while on premises owned, leased, or operated
by the CONTRACTOR or while being transported to or from said premises
in any vehicle owned, operated, leased, chartered, or otherwise
contracted for or in the control of the CONTRACTOR or any officer,
agent, subcontractor or employee thereof. The provisions of this
Section 22.2 shall not apply to any liabilities, losses, charges, costs
or expenses caused by, or resulting from, the acts or omissions of the
State of New Mexico, HSD, or any of its officers, employees, or agents.
22.3 The CONTRACTOR shall agree to indemnify and hold harmless HSD, its
agents and employees from any and all claims, causes of action, suits,
judgments, losses, or damages, including court costs and attorney fees,
or causes of action, caused by reason of CONTRACTOR'S erroneous or
negligent acts or omissions, including the following:
(1) Any claims or losses attributable to any persons or firm
injured or damaged by erroneous or negligent acts, including
without limitation, disregard of Federal or State Medicaid
regulations or statutes by the CONTRACTOR, its officers,
employees, or subcontractors in the performance of the
Agreement, regardless of whether HSD knew or should have known
of such erroneous or negligent acts; unless the State of New
Mexico, or any of its officers, employees or agents directed
performance of such acts, and
(2) Any claims or losses attributable to any person or firm
injured or damaged by the publication, translation,
reproduction, delivery, performance, use, or disposition of
any data processed under the Agreement in a manner not
authorized by the Agreement or by Federal or State regulations
or statutes, regardless of whether HSD knew or should have
known of such publication, translation, reproduction,
delivery, performance, use, or disposition unless the State of
New Mexico, or any of its officers, employees or agents
directed such publication, translation, reproduction,
delivery, performance, use or disposition.
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(3) The provisions of this Article 22.3 shall not apply to any
liabilities, losses, charges, costs or expenses caused by, or
resulting from, the acts or omissions of the State of New
Mexico, HSD, or any of its officers, employees, or agents.
22.4 The CONTRACTOR, including its subcontractors, agrees that in no event,
including but not limited to nonpayment by the CONTRACTOR, insolvency
of the CONTRACTOR or breach of this Agreement, shall the CONTRACTOR or
its subcontractor bill, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from or have any recourse
against an enrollee or persons (other than the CONTRACTOR) acting on
their behalf for services provided pursuant to this Agreement except
for any MAD population required to make co-payments under Medical
Assistance Division policy. In no case, shall the State, HSD and/or
Medicaid beneficiaries be liable for any debts of the CONTRACTOR.
22.5 The CONTRACTOR agrees that the above indemnification provisions shall
survive the termination of this Agreement, regardless of the cause
giving rise to termination. This provision is not intended to apply to
services provided after this Agreement has been terminated.
ARTICLE 23 - LIABILITY
23.1 The CONTRACTOR shall be wholly at risk for all covered services. No
additional payment shall be made by HSD, nor shall any payment be
collected from an enrollee, except for co-payments authorized by HSD or
State laws or regulation.
23.2 The CONTRACTOR is solely responsible for ensuring that it issues no
payments for services for which it is not liable under this Agreement.
HSD shall accept no responsibility for refunding to the CONTRACTOR any
such excess payments unless the State of New Mexico, or any of its
officers, employees or agents directed such services to be rendered or
payment made.
23.3 The CONTRACTOR, its successors and assignees shall procure and maintain
such insurance and other forms of financial protections as are
identified in this Agreement.
ARTICLE 24 - EQUAL OPPORTUNITY COMPLIANCE
The CONTRACTOR agrees to abide by all Federal and State laws, rules, regulations
and executive orders of the Governor of the State of New Mexico, and the
President of the United States pertaining to equal opportunity. In accordance
with all such laws, rules, and regulations, and executive orders, the CONTRACTOR
agrees to ensure that no person in the United States shall, on the grounds of
race, color, national origin, sex, sexual preference, age, handicap or religion
be excluded from employment with, participation in, be denied the benefit of, or
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otherwise be subjected to discrimination under any program or activity performed
under this Agreement. If HSD finds that the CONTRACTOR is not in compliance with
this requirement at any time during the term of this Agreement, HSD reserves the
right to terminate this Agreement pursuant to Article 9 or take such other steps
it deems appropriate to correct said deficiency.
ARTICLE 25 - RIGHTS TO PROPERTY
All equipment and other property provided or reimbursed to the CONTRACTOR by HSD
is the property of HSD and shall be turned over to HSD at the time of
termination or expiration of this Agreement, unless otherwise agreed in writing.
ARTICLE 26 - ERRONEOUS ISSUANCE OF PAYMENT OR BENEFITS
In the event of an error which causes payment(s) to the CONTRACTOR (or benefits
to others) to be issued in error, the CONTRACTOR shall reimburse the State
within thirty (30) days of written notice of such error for the full amount of
the payment. Interest shall accrue at the statutory rate upon any amounts not
paid and determined to be due after the thirtieth (30th) day following the
notice.
ARTICLE 27 - EXCUSABLE DELAYS
The CONTRACTOR shall be excused from performance hereunder for any period that
it is prevented from performing any services hereunder in whole or in part as a
result of an act of nature, war, civil disturbance, epidemic, court order, or
other cause beyond its reasonable control, and such nonperformance shall not be
a default hereunder or ground for termination of the Agreement.
ARTICLE 28 - MARKETING
28.1 The CONTRACTOR shall maintain written policies and procedures governing
the development and distribution of marketing materials for members;
28.2 HSD shall review and approve the content, comprehension level, and
language(s) of all marketing materials directed at members before use.
Examples include written materials, billboards, and radio, television
advertisements and websites.
(1) The CONTRACTOR shall provide a copy of the CONTRACTOR'S member
handbook to enrollees or potential enrollees requesting a copy
and as requested by HSD..
(2) The CONTRACTOR shall send a provider directory to any person
requesting a copy;
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(3) The CONTRACTOR shall provide a one page, two-sided summary of
its benefits which may be distributed by HSD at its
discretion; and
(4) The CONTRACTOR shall maintain policies and procedures
governing the development and distribution of marketing
materials for members.
28.3 Minimum Marketing and Outreach Requirements: The marketing and outreach
material shall meet the following minimum requirements:
(1) Marketing and/or outreach materials shall meet requirements
for all communication with Medicaid members, as set forth in
Section MAD 606.4.8, MEDICAID MANAGED CARE MARKETING
GUIDELINES.
(2) All marketing and/or outreach materials produced by the
CONTRACTOR under the Medicaid managed care Agreement shall
state that such services are funded pursuant to an Agreement
with the State of New Mexico.
28.4 Marketing and outreach activities not permitted under the Medicaid
Managed Care Agreement:
(1) The following marketing and outreach activities are prohibited
regardless of the method of communication (verbal, written) or
whether the activity is performed by the CONTRACTOR directly,
its participating providers, its subcontractors, or any other
party affiliated with the CONTRACTOR:
A. Asserting or implying that a member shall lose
Medicaid benefits if he/she does not enroll with the
CONTRACTOR or inaccurately depicting the consequences
of choosing a different MCO;
B. Designing a marketing or outreach plan which
discourages or encourages MCO selection based on
health status or risk;
C. Initiating an enrollment request on behalf of a
Medicaid recipient;
D. Making inaccurate, false, materially misleading or
exaggerated statements;
E. Asserting or implying that the CONTRACTOR offers
unique covered services when another MCO provides the
same or similar service;
F. The use of gifts such as diapers, toasters, infant
formula, or other incentives to entice people to join
a specific health plan;
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G. Directly or indirectly conducting door-to-door,
telephonic, or other "cold call" marketing; and
H. Conducting any other marketing activity prohibited by
HSD during the course of this Agreement.
28.5 The CONTRACTOR shall take reasonable steps to prevent subcontractors
and participating providers from committing the acts described herein;
the CONTRACTOR shall be held liable only if it knew or should have
known that its subcontractors or participating providers were
committing the act described herein and did not timely take corrective
actions. HSD reserves the right to prohibit additional marketing
activities at its discretion.
28.6 Marketing Time Frames
The CONTRACTOR may initiate marketing and outreach activities at any
time.
28.7 The Medicaid Managed Care Marketing Guidelines are incorporated into
this Agreement by reference. This Agreement shall incorporate all
revisions to the Guidelines produced during the course of the
Agreement.
28.8 Health Education and Outreach Materials may be distributed to the
CONTRACTOR'S members by mail or in connection with exhibits or other
organized events, including but not limited to health fair, booths at
community events and health plan hosted health improvement events.
Health Education means programs, services or promotions that are
designed or intended to inform the CONTRACTOR'S actual or potential
members about the issues related to health lifestyles, situations that
affect or influence health status or methods or modes of medical
treatment. Outreach is the means of educating or informing the
CONTRACTOR'S actual or potential members about health issues. Health
Education and Outreach materials include but are not limited to general
distribution brochures, member newsletters, posters, member handbooks.
ARTICLE 29 - PROHIBITION OF BRIBES, GRATUITIES & KICKBACKS
29.1 Pursuant to Sections NMSA 1978, Section 13-1-191, 30-24-1 et seq.,
30-41-1, and 30-41-3, the receipt or solicitation of bribes, gratuities
and kickbacks is strictly prohibited.
29.2 No elected or appointed officer or other employee of the State of New
Mexico shall benefit financially or materially from this Agreement. No
individual employed by the State of New Mexico shall be admitted to any
share or part of the Agreement or to any benefit that may arise
therefrom.
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29.3 HSD may, by written notice to the CONTRACTOR, immediately terminate the
right of the CONTRACTOR to proceed under the Agreement if it is found,
after notice and hearing by the Secretary or his duly authorized
representative, 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 of New Mexico with a view toward securing the Agreement or
securing favorable treatment with respect to the award or amending or
making of any determinations with respect to the performing of such
Agreement. In the event the Agreement is terminated as provided in this
section, the State of New Mexico shall be entitled to pursue the same
remedies against the CONTRACTOR as it would pursue in the event of a
breach of contract by the CONTRACTOR and as a penalty in addition to
any other damages to which it may be entitled by law.
ARTICLE 30 - LOBBYING
30.1 The CONTRACTOR certifies, to the best of their knowledge and belief,
that:
(1) No Federal appropriated funds have been paid or shall be paid,
by or on behalf of the CONTRACTOR, to any person for
influencing or attempting to influence an officer or employee
of any agency, a member of Congress, or an employee of a
member of Congress in connection with the awarding of any
Federal contract, the making of any Federal grant, the making
of any Federal loan, the entering into any cooperative
agreement, and the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been
paid or shall be paid to any person for influencing or
attempting to influence an officer or employee of any agency,
member of Congress, an officer or employee of Congress or an
employee of a member of Congress in connection with this
Federal contract, grant, loan, or cooperative agreement, the
CONTRACTOR shall complete and submit Standard Form-LLL
"Disclosure Form to Report Lobbying," in accordance with its
instructions.
30.2 The CONTRACTOR shall require that the language of this certification be
included in the award documents for all subawards at all tiers
(including subcontracts, subgrants, and contracts under grants, loans,
and cooperative agreements) and that all subrecipients shall certify
and disclose accordingly.
30.3 This certification is a material representation of fact upon which
reliance was placed when this transaction was made or entered into.
Submission of this certification is a prerequisite for making or
entering into this transaction imposed under section 1352, title
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31, U.S. Code. Any person who fails to file the required certification
shall be subject to a civil penalty of not less than $10,000 and not
more than $100,000 for such failure.
ARTICLE 31 - CONFLICT OF INTEREST
31.1 The CONTRACTOR warrants that it presently has no interest and shall not
acquire any interest, direct or indirect, which would conflict in any
manner or degree with the performance of services required under this
Agreement, and further warrants that signing of this Agreement shall
not be creating a violation of the Governmental Conduct Act, NMSA 1978
Section 10-16-1 et seq.
31.2 If during the term of this Agreement and any extension thereof the
CONTRACTOR becomes aware of an actual or potential relationship which
may be considered a conflict of interest, the CONTRACTOR shall
immediately notify the Project Manager in writing, Such notification
includes when the CONTRACTOR employs or contracts with a person, on a
matter related to this Agreement, and that person: (1) is a former HSD
employee who has an obligation to comply with NMSA 1978 Section 10-16-1
et. seq., or (2) is a former employee of the Department of Health or
the Children, Youth and Families Department who was substantially and
directly involved in the development or enforcement of this Agreement.
ARTICLE 32 - CONFIDENTIALITY
32.1 Any confidential information, as defined in State or Federal law, code,
rules or regulations or otherwise applicable by the Code of Ethics,
regarding HSD's recipients or providers given to or developed by the
CONTRACTOR and its subcontractors shall not be made available to any
individual or organization by the CONTRACTOR and its subcontractors
without the prior written approval of HSD.
32.2 The CONTRACTOR shall (1) notify HSD promptly of any unauthorized
possession, use, knowledge, or attempt thereof, of HSD's data files or
other confidential information; and (2) promptly furnish HSD full
details of the unauthorized possession, use of knowledge or attempt
thereof, and assist investigating or preventing the recurrence thereof.
32.3 In order to protect the confidentiality of member information and
records:
(1) The CONTRACTOR shall adopt and implement written
confidentiality policies and procedures which conform to
Federal and State laws and regulations.
(2) The CONTRACTOR'S contracts with practitioners and other
providers shall explicitly state expectations about the
confidentiality of member information and records.
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(3) The CONTRACTOR shall afford members and/or legal guardians the
opportunity to approve or deny the release of identifiable
personal information by the CONTRACTOR to a person or agency
outside of the CONTRACTOR, except to duly authorized
subcontractors, providers or review organizations, or when
such release is required by law, State regulation, or quality
standards.
(4) When release of information is made in response to a court
order, the CONTRACTOR shall notify the member and/or legal
guardian of such action in a timely manner.
(5) The CONTRACTOR shall have specific written policies and
procedures that direct how confidential information gathered
or learned during the investigation or resolution of a
grievance is maintained, including the confidentiality of the
member's status as a grievant.
32.4 The CONTRACTOR shall comply with HSD's requests for records and
documents as necessary to verify the CONTRACTOR is meeting its duties
and obligations under this Agreement, or for data reporting legally
required of HSD. Except as otherwise required by law, HSD may not
request from the CONTRACTOR records and documents that go beyond
ensuring that the CONTRACTOR is meeting its duties under this
Agreement, including, where appropriate, records and documents that are
protected by any law, including, but not limited to, laws protecting
proprietary information as a trade secret, confidentiality laws, and
any and all applicable legal privileges (including, but not limited to,
attorney/client, physician/patient, and quality assurance and peer
review).
ARTICLE 33 - COOPERATION WITH MEDICAID FRAUD CONTROL UNIT
33.1 The CONTRACTOR shall immediately report to the New Mexico State
Medicaid Fraud Control Unit (MFCU) of the Attorney General's Office and
HSD any reasonable suspicion or knowledge of fraud and/or abuse,
including but not limited to the false or fraudulent filings of claims
and/or the acceptance of or failure to return monies allowed or paid on
claims known to be false or fraudulent. Where required by law, the
reporting entity shall not attempt to investigate or resolve the
reported suspicion, knowledge or action without informing the MFCU.
33.2 The CONTRACTOR shall cooperate fully in any investigation by the MFCU
or subsequent legal action that may result from such investigation. The
CONTRACTOR and its subcontractors and participating network providers
shall, upon request, make available to the MFCU any and all
administrative, financial and medical records relating to the delivery
of items or services for which HSD monies are expended, unless
otherwise provided by law. In addition, the MFCU shall be allowed to
have access during normal
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business hours to the place of business and all records of the
CONTRACTOR and its subcontractors and participating network providers,
except under special circumstances when after hours access shall be
allowed. Special circumstances shall be determined by the MFCU.
33.3 The CONTRACTOR shall disclose to HSD, the MFCU, and any other state or
federal agency charged with overseeing the Medicaid program, full and
complete information regarding ownership, significant financial
transactions or financial transactions relating to or affecting the
Salud! program and persons related to the CONTRACTOR convicted of
criminal activity related to Medicaid, Medicare, or the federal Title
XX programs.
33.4 Any actual or potential conflict of interest within the CONTRACTOR'S
Salud! program shall be referred by the CONTRACTOR to the MFCU. The
CONTRACTOR also shall refer to the MFCU any instance where a financial
or material benefit is given by any representative, agent or employee
of the CONTRACTOR to HSD or any other party with direct responsibility
for this Agreement. In addition, the CONTRACTOR shall notify the MFCU
if it hires or enters into any business relationship with any person
who, within two years previous to that hiring or contract, was employed
by HSD in a capacity relating to Medicaid or the Salud! program or any
other party with direct responsibility for this Agreement.
33.5 Any recoupment received from the CONTRACTOR by HSD pursuant to the
provisions of Article 8 (Enforcement) of this Agreement herein shall
not preclude the MFCU from exercising its right to criminal
prosecution, civil prosecution, or any applicable civil penalties,
administrative fines or other remedies.
33.6 Upon request to the CONTRACTOR, the MFCU shall be provided with copies
of all grievances and resolutions affecting Medicaid members.
33.7 Should the CONTRACTOR know about or become aware of any investigation
being conducted by the MFCU or HSD, the CONTRACTOR, and its
representatives, agents and employees, shall maintain the
confidentiality of this information.
33.8 The CONTRACTOR shall have in place and enforce policies and procedures
to educate Medicaid members of the existence of, and role of, the MFCU.
33.9 The CONTRACTOR shall have in place and enforce policies and procedures
for the detection and deterrence of fraud. These policies and
procedures shall include specific requirements governing who within the
CONTRACTOR'S organization is responsible for these activities, how
these activities shall be conducted, and how the CONTRACTOR shall
address cases of suspected fraud and abuse.
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33.10 All documents submitted by the CONTRACTOR to HSD, if developed or
generated by the CONTRACTOR, or its agents, shall be deemed to be
certified by the CONTRACTOR as submitted under penalty of perjury.
ARTICLE 34 - WAIVERS
34.1 No term or provision of this Agreement shall be deemed waived and no
breach excused, unless such waiver or consent shall be in writing by
the party claimed to have waived or consented.
34.2 A waiver by either of the parties hereto of a breach of any of the
covenants, conditions, or agreements to be performed by the other shall
not be construed to be a waiver of any succeeding breach thereof or of
any other covenant, condition, or Agreement herein contained.
ARTICLE 35 - PROVIDER AVAILABILITY
All providers owned (wholly or partially) or controlled by the CONTRACTOR, or
any of the CONTRACTOR'S related or affiliated entities, and any and all
providers that own (wholly or partially) or control the CONTRACTOR, shall be
willing to become a network provider for any managed care organization that
contracts with HSD for Medicaid managed care services, to be reimbursed by such
MCO at the then-current and applicable Medicaid reimbursement rate for that
provider type. The Applicable Medicaid reimbursement rate is defined to exclude
disproportionate share and medical education payments.
ARTICLE 36 - NOTICE
36.1 A notice shall be deemed duly given upon delivery, if delivered by
hand, or three days after posting if sent by first class mail, with
proper postage affixed. Notice may also be tendered by facsimile
transmission, with original to follow by first class mail.
36.2 All notices required to be given to HSD under this Agreement shall be
sent to the HSD Contract Administrator or his/her designee at:
Contract Administrator
Human Services Department
P.O. Box 2348
Santa Fe, NM 87504-2348
36.3 All notices required to be given to the CONTRACTOR under this Agreement
shall be sent to:
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Roger Carl, Director of Medicaid
Lovelace Health Plan
4101 Indian School Road, NE
Altura Office Complex
Albuquerque, NM 87110
ARTICLE 37 - AMENDMENTS
This Agreement shall not be altered, changed or amended other than by an
instrument in writing executed by the parties to this Agreement. Amendments
shall become effective and binding when signed by the parties, approved by the
Department of Finance and Administration, and written approvals have been
obtained from any necessary State and Federal agencies. All necessary approvals
shall be attached as exhibits to the Agreement.
ARTICLE 38 - HEADINGS NOT CONTROLLING
Headings used in this Agreement are for reference purposes only and shall not be
deemed a part of the Agreement.
ARTICLE 39 - STATE CHILDREN HEALTH INSURANCE PROGRAM (SCHIP)
39.1 The CONTRACTOR shall enroll as members children who are participants in
SCHIP under Title XXI of the Social Security Act. SCHIP enrollees are
entitled to all of the benefits provided under this Agreement and any
Amendments thereto except that the CONTRACTOR may enforce, against
participants of SCHIP only, any cost sharing requirements approved by
HSD.
39.2 The CONTRACTOR may enforce, against participants of the SCHIP only, any
cost sharing requirements approved by HCFA. All other terms and
conditions of the Agreement and this Amendment shall apply to SCHIP
participants, as they do to Title XIX Medicaid recipients.
ARTICLE 40 - ENTIRE AGREEMENT
This Agreement incorporates all the agreements, covenants, and understandings
between the parties hereto concerning the subject matter hereof, and all such
covenants, agreements and understandings have been merged into this written
Agreement. No prior agreement or understanding, verbal or otherwise, of the
parties or their agents shall be valid or enforceable unless embodied in this
Agreement.
ARTICLE 41 - AUTHORIZATION FOR CARE
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The CONTRACTOR shall, to the extent possible, ensure that administrative burdens
placed on providers are minimized. In furtherance of this objective, the
CONTRACTOR shall provide to HSD, on a quarterly basis, a report of all benefits
and procedures for which the CONTRACTOR or any of its subcontractors require a
prior authorization. This report shall identify, for each such benefit and
procedures, the number of such authorization requests that were made by
providers, and the percentage that were approved and denied.
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IN WITNESS WHEREOF, the parties have executed this Agreement as of the date of
execution by the State Contracts Officer, below.
CONTRACTOR
By: /s/ ILLEGIBLE Date: 5/18/01
------------------------------------
Title: SVP & General Manager
STATE OF NEW MEXICO
By: /s/ Robin Dozier Otten
------------------------------------- Date: May 23, 2001
Robin Dozier Otten, Deputy Secretary
Human Services Department
Approved as to Form and Legal sufficiency:
By: /s/ Rumaldo Armijo Date: 5-22-01
-------------------------------------
Rumaldo Armijo, General Counsel
Human Services Department
OFFICE OF THE ATTORNEY GENERAL
Approved as to Form and Legal sufficiency:
By: /s/ ILLEGIBLE Date: 6-27-01
-------------------------------------
DEPARTMENT OF FINANCE AND ADMINISTRATION
By: /s/ ILLEGIBLE Date: 7-1-01
-------------------------------------
State Contracts Officer
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The records of the Taxation and Revenue Department reflect that the CONTRACTOR
is registered with the Taxation and Revenue Department of the State of New
Mexico to pay gross Receipts and compensating taxes.
TAXATION AND REVENUE DEPARTMENT
ID Number: ILLEGIBLE
By: /s/ Julie Rico Date: 5/24/01
---------------------------
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