2002 - 2004 MEDICAID HMO CONTRACT
|
| AGENCY CORE CONTRACT | |
| ATTACHMENT 1 | |
| 10.0 | COVERED SERVICES AND ELIGIBLE RECIPIENTS (Section 10 is a PDF file with an interactive Table of Contents for each item listed here) |
| 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 Child Health Check-Up | |
| 10.8.2 Dental Services (optional) | |
| 10.8.3 Diabetes Supplies and Education | |
| 10.8.4 Family Planning Services | |
| 10.8.5 Freestanding Dialysis Facility Services | |
| 10.8.6 Hearing Services | |
| 10.8.7 Home Health Care Services and Durable Medical Equipment | |
| 10.8.8 Hospital Services | |
| 10.8.8.1 Inpatient | |
|
10.8.8.2 Outpatient |
|
|
10.8.8.3 Hospital Ancillary Services |
|
| 10.8.10 Independent Laboratory and Portable X-Ray Services | |
| 10.8.11 Physician Services | |
|
10.8.11.1 Pregnancy Related Requirements |
|
| 10.8.12 Prescribed Drug Services | |
| 10.8.13 Therapy Services | |
| 10.8.14 Transportation Services (optional) | |
| 10.8.15 Visual Services | |
| 10.9 Quality and Benefit Enhancements | |
| 10.10 Incentive Programs | |
| 10.11 Behavioral Health Care | |
| 10.11.1 Service Requirements (Behavioral Health) | |
| 10.11.2 Non Covered Services (Behavioral Health) | |
| 10.11.3 Care Coordination and Management (Behavioral Health) | |
| 10.11.4 Behavioral Clinical Record Requirement (Behavioral Health) | |
| 10.11.5 Functional Assessments (Behavioral Health) | |
| 10.11.6 Out-of-Plan Use (Behavioral Health) | |
| 10.11.7 Outreach Requirements (Behavioral Health) | |
| 10.11.8 Quality Improvement Requirements (Behavioral Health) | |
| 10.11.9 Administrative Staff Requirements (Behavioral Health) | |
| 10.11.10 Behavioral Health Subcontracts | |
| 10.11.11 Management Information System (Behavioral Health) | |
| 10.11.12 Monitoring (Behavioral Health) | |
| 10.12 Frail/Elderly Program (expanded service) | |
| 10.12.1 Mandatory Service Requirements (Frail/Elderly) | |
|
10.12.1.1 Nursing Home Placement (Frail/Elderly) |
|
| 10.12.2 Expanded Supportive Services Requirements (Frail/Elderly) | |
|
20.0
|
SCOPE OF WORK |
| 20.2 Minimum Standards | |
| 20.3 Administration and Management | |
| 20.4 Staff Requirements | |
| 20.4.1 Fraud Prevention Policies and Procedures | |
| 20.5 Licensure of Staff | |
| 20.5.1 Credentialing and Recredentialing Policies and Procedures | |
| 20.6 Physician Choice | |
| 20.7 Specialty Coverage | |
| 20.8 Case Management/Continuity of Care | |
|
20.8.3 Coordination with Community Mental Health Care Providers |
|
| 20.9 Out-of-Plan use of Non-Emergency Services | |
| 20.10 Emergency Care Requirements | |
| 20.11 Grievance System Requirements | |
| 20.12 Quality Improvement | |
| 20.13 Medical Records Requirements | |
| 20.14 Medical Record Review | |
| 20.15 Quality and Performance Measures Review | |
| 20.16 Annual Medical Record Audit | |
| 20.17 Independent Medical Review (External Quality Review) | |
|
30.0
|
MARKETING AND ENROLLMENT |
| 30.1 Marketing and Pre-enrollment Materials | |
| 30.2 Marketing Activities | |
| 30.3 Marketing Representatives | |
| 30.4 Marketing and Pre-enrollment Complaints | |
| 30.5 Pre-enrollment Activities | |
| 30.6 Enrollment | |
| 30.7 Member Notification | |
| 30.8 Enrollment Reinstatements | |
| 30.9 Newborn Enrollment | |
| 30.10 Enrollment Period | |
| 30.11 Enrollment Levels | |
| 30.12 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 Health Insurance Portability and Accountability Act Compliance | |
| 40.13 Systems Compliance | |
| 40.14 Certification Regarding Lobbying | |
| 40.15 Certification Regarding Debarment | |
| 40.16 Certification Regarding HIPAA Compliance | |
|
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 Interest | |
| 50.6 Savings | |
| 50.7 Fidelity Bonds | |
| 50.8 Financial and Compliance Audit Requirements | |
|
60.0
|
REPORTING
REQUIREMENTS (Section 60 is a PDF file with an interactive Table of Contents for each item listed below) |
| 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 (M***YYMM.dbf) |
|
|
60.2.3 Frail/Elderly Annual Disenrollment Summary Report (E***YY06.dbf) |
|
|
60.2.4 Newborn Payment Report (N***YYMM.dbf) |
|
|
60.2.5 Service Utilization Summary (S***YYQ.dbf) |
|
|
60.2.6 Grievance Report (G***YYQ.dbf) |
|
|
60.2.7 Inpatient Discharge Report (H***YYQ.dbf) |
|
|
60.2.8 Pharmacy Encounter Data (P***YYQ.dbf) |
|
|
60.2.9 Marketing Representative Report (R***YYMM.xls) |
|
|
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 (F***YYQ.dbf) |
|
|
60.2.14 Financial Reporting |
|
|
60.2.15 Minority Business Enterprise Contract Reporting |
|
|
60.2.16 Suspected Fraud Reporting |
|
|
60.2.17 Claims Inventory Summary Report |
|
| 60.3 Behavioral Health Reporting Requirements | |
|
60.3.1 Allocation of Recipients Report (Monthly Template_MH.xls |
|
|
60.3.2 Targeted Case Management Report (Monthly Template_MH.xls) |
|
|
60.3.3 Patient Satisfaction Reporting |
|
|
60.3.4 Grievance Reporting |
|
|
60.3.5 Quality Improvement Reporting |
|
|
60.3.6 Service Utilization Reporting (Quarterly Template_MH.xls) |
|
|
|
60.3.7 Critical Incident Reporting (Monthly Template_MH.xls) |
|
60.3.8 Behavioral Health Care Expenditure Report ( Annual Template_MH.xls) |
|
|
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 Legal Action Notification | |
| 70.13 Licensing | |
| 70.14 Misuse of Symbols, Emblems, or Names in Reference to Medicaid | |
| 70.15 Non-Renewal | |
| 70.16 Offer of Gratuities | |
| 70.17 Sanctions | |
| 70.18 Subcontracts | |
| 70.19 Termination Procedures | |
| 70.20 Third Party Resources | |
| 70.21 Waiver | |
| 70.22 Withdrawing Services from a County | |
|
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 | |
| 80.7 Overpayments | |
|
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 | |