2000 - 2002 MEDICAID HMO CONTRACT
TABLE OF CONTENTS
  AGENCY CORE CONTRACT
  ATTACHMENT 1
10.0 COVERED  SERVICES AND ELIGIBLE RECIPIENTS (All links for Sections 10.0 - 10.10 are accessible from this link only.)
  10.1 General
  10.2 Eligible Recipients
  10.3 Ineligible Recipients
  10.4 Covered Services
  10.5 Optional Services
  10.6 Expanded Services
  10.7 Excluded Services
  10.8 Manner of Service Provision
       10.8.1 Behavioral Health Care
             10.8.1.1 Service  Requirements
            10.8.1.2 Non Covered Services
            10.8.1.3 Care Coordination and Management
            10.8.1.4 Behavioral Clinical Record Requirement
            10.8.1.5 Functional Assessments
            10.8.1.6 Out-of-Plan-Use
            10.8.1.7 Outreach Requirements
            10.8.1.8 Quality Assurance Requirements
            10.8.1.9 Administrative Staff Requirements
            10.8.1.10 Behavioral Health Subcontracts
            10.8.1.11 Management Information System
            10.8.1.12 Monitoring
       10.8.2 Child Health Check-Up
       10.8.3 Dental Services
       10.8.4 Diabetes Supplies and Education
       10.8.5 Family Planning Services
       10.8.6 Frail/Elderly Program
            10.8.6.1 Mandatory Service Requirements
            10.8.6.1.1 Nursing Home Placement
            10.8.6.2 Expanded Supportive Service Requirements
       10.8.7 Freestanding Dialysis Facility Services
       10.8.8 Hearing Services
       10.8.9 Home Health Care Services and Durable Medical Equipment
       10.8.10 Hospital Services
            10.8.10.1 Inpatient
            10.8.10.2 Outpatient
            10.8.10.3 Hospital Ancillary Services
       10.8.11 Immunizations
       10.8.12 Independent Laboratory and Portable X-Ray Services
       10.8.13 Physician Services
       10.8.13.1 Pregnancy Related Requirements
       10.8.14 Prescribed Drug Services
       10.8.15 Therapy Services
       10.8.16 Transportation Services
       10.8.17 Visual Services
  10.9 Quality and Benefit Enhancements
  10.10 Incentive Programs
20.0
 SCOPE OF WORK
 

20.1 Availability/Accessibility of Services
  20.2 Minimum Standards
  20.3 Administration and Management
  20.4 Staff Requirements
  20.5 Licensure of Staff
       20.5.1 Credentialing and Recredentialing Policies and Procedures
  20.6 Physician Choice
  20.7 Specialty Coverage
  20.8 CaseManagement and Continuity of Care
       20.8.1 Chronic and Disabling Conditions
       20.8.2 Members with Developmental  Disabilities
       20.8.3 Coordination with Community Mental Health Care Providers
       20.8.4 New Member Procedures
       20.8.5 Pediatrician Assignment to Pregnant Women
       20.8.6 Protective Custody
       20.8.7 Immunization from Non-Plan Provider
       20.8.8 Immunization Data Sharing
 

     20.8.9 Public Provider Claims
       20.8.10 Certified School Match Program
       20.8.11 Continued Care from Terminated Providers
       20.8.12  Out-of-Plan Specially Qualified Providers
  20.9 Out-of-Plan use of Non-Emergency Services
  20.10 Emergency Care Requirements
  20.11 Grievance System Requirements
  20.12 Quality Assurance
       20.12.1 Utilization Management
       20.12.2 Independent Member Satisfaction Survey
  20.13 Medical Records Requirements
  20.14 Medical Record Review
  20.15 Annual Medical Record Audit
  20.16 Independent Medical Review
30.0
 MARKETING AND ENROLLMENT 
  30.1 Marketing and Pre-enrollment Materials
       30.1.1 Frail/Elderly Marketing and Pre-enrollment Materials
  30.2 Marketing Activities
       30.2.1 Prohibited Activities 
       30.2.2 Permitted Activities
            30.2.2.1 Approval Process
       30.2.3 Subcontractor's Compliance
  30.3 Marketing Representatives 
  30.4 Marketing and Pre-enrollment Complaints
  30.5 Pre-enrollment Activities
  30.6 Enrollment
       30.6.1 Behavioral Health Enrollment
       30.6.2 Frail/Elderly Enrollment
  30.7 Member Notification
       30.7.1 Member Services Handbook
       30.7.2 Provider Directory
       30.7.3 Member Information
       30.7.4 New Member Materials
            30.7.4.1 Undeliverable Materials
  30.8 Enrollment Reinstatements
  30.9 Newborn Enrollment
  30.10 Enrollment Period
  30.11 Enrollment Levels
  30.12 Disenrollment
       30.12.1 Voluntary Disenrollments
       30.12.2 Involuntary Disenrollments
            30.12.2.1 Frail/Elderly Disenrollment
  30.13 Enrollment/Disenrollment Verification
40.0 
 ASSURANCES AND CERTIFICATIONS 
  40.1 Monitoring Provisions
  40.2 Certification of Laboratories and Portable X-Ray Companies
  40.3 Good Faith Effort with School Districts 
  40.4 Good Faith Effort with County Health Departments 
  40.5 Accreditation
  40.6 Minority Recruitment and Retention
  40.7 Ownership and Management Disclosure
  40.8 Independent Provider
  40.9 General Insurance Requirement
  40.10 Workers Compensation Insurance
  40.11 State Ownership
  40.12 Certification Regarding Lobbying
  40.13 Certification Regarding Debarment
50.0
 FINANCIAL REQUIREMENTS 
  50.1 Insolvency Protection
  50.2 Insolvency Protection Account Waiver
  50.3 Surplus Start Up Account 
  50.4 Surplus Requirement
  50.5 Waiver of Surplus Requirement 
  50.6 Interest
  50.7 Savings
  50.8 Fidelity Bonds
60.0
 REPORTING REQUIREMENTS 
  60.1 Fiscal Agent Reports
  60.2 HMO Reporting Requirements
       60.2.1 Enrollment, Disenrollment, and Cancellation Report for Payment
       60.2.2 Medicaid HMO Disenrollment Summary
       60.2.3 Frail/Elderly Disenrollment Summary
       60.2.4 Newborn Payment Report
       60.2.5 Service Utilization Summary
       60.2.6 Grievance Report
       60.2.7 Inpatient Discharge Report
       60.2.8 Pharmacy Encounter Data 
       60.2.9 Marketing Representative Tracking Report
       60.2.10 Provider Network Report
       60.2.11 Child Health Check-Up Reporting
       60.2.12 AHCA Quality Indicators
       60.2.13 Frail/Elderly Care Service Utilization Report
       60.2.14 Financial Reporting
       60.2.15 Minority Business Enterprise Contract Reporting
  60.3 Behavioral Health Reporting Requirements
       60.3.1 Allocation of Recipients Report
       60.3.2 Patient Satisfaction Reporting
       60.3.3 Grievance Reporting
       60.3.4 Quality Assurance Reporting
       60.3.5 Service Utilization Reporting
       60.3.6 Staff Reporting
       60.3.7 Critical Incident Reporting
70.0 
 TERMS AND CONDITIONS 
  70.1 Agency Contract Management
  70.2 Applicable Laws and Regulations
  70.3 Assignment
  70.4 Attorney's Fees
  70.5 Conflict of Interest
  70.6 Contract Variation
  70.7 Court of Jurisdiction or Venue
  70.8 Crossover Claims for Medicaid/Medicare Eligible Members
  70.9 Damages for Failure to Meet Contract Requirements
  70.10 Disputes
  70.11 Force Majeure
  70.12 Hospital Subcontracts
  70.13 Legal Action Notification
  70.14 Licensing
  70.15 Misuse of Symbols, Emblems, or Names in Reference to Medicaid
  70.16 Non-Renewal
  70.17 Offer of Gratuities
  70.18 Sanctions
  70.19 Subcontracts
  70.20 Termination Procedures
  70.21 Third Party Resources
  70.22 Waiver
  70.23 Withdrawing Services from a County
  70.24 Year 2000 Systems Compliance
80.0
 METHOD OF PAYMENT 
  80.1 Payment to Plan by Agency
  80.2 Newborn Payment and Procedures
  80.3 Rate Adjustments
  80.4 Errors
  80.5 Member Payment Liability Protection
  80.6 Copayments
90.0
 PAYMENT AND MAXIMUM AUTHORIZED ENROLLMENT LEVELS
100.0 
 GLOSSARY 
110.0 
 EXHIBITS
  110.1 Policies and Procedures: Hysterectomies, Sterilizations, and Abortions
  110.2 Preventive Medicine 
  110.3 Laboratory Tests and Associated Office Visits
  110.4 CHD Model Memorandum of Agreement
  110.5 Sample Multiple Signature Verification Agreement
  110.6 Sample HMO Adult Health Screening
  110.7 Florida Patient's Bill of Rights and Responsibilities
  110.8 Memorandum of Understanding between School District and HMO
 

110.9 Frail/Elderly Program Statement of Understanding