MEDICAID LONG-TERM SERVICES AGREEMENT

Consulting Services Agreement

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AMERIGROUP CORP | NEW MEXICO, INC

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Title: MEDICAID LONG-TERM SERVICES AGREEMENT
Governing Law: New Mexico Date: 10/28/2008
Industry: Insurance (Accident and Health) Sector: Financial

Exhibit 10.2

MEDICAID LONG-TERM SERVICES
AGREEMENT

BETWEEN

THE STATE OF NEW MEXICO

HUMAN SERVICES DEPARTMENT
AND
AGING & LONG-TERM SERVICES
DEPARTMENT

AND

AMERIGROUP COMMMUNITY
CARE OF NEW MEXICO, INC.

DATED: July 1, 2008

Table of Contents


*Article 1. Recitals*			7

*Article 2. Definitions*			9

*Article 3. Contractor Responsibilities*			17

3.1 Compliance			17

3.2 Contract Management			17

3.3 Member Enrollment			19
A. Maximum Medicaid Enrollment			19
B. Enrollment Requirements			19
C. Eligibility			20
D. State Exemptions			20
E. Special Situations			21
F. Enrollment Process for Members			21
G. Member Disenrollment, Request by CONTRACTOR			24
H. Member Initiated Disenrollment			25
I. State Initiated Disenrollment			25
J. Retroactive Reenrollment			25

3.4 Member Services			26
A. Policies and Procedures			26
B. Member Education			27
C. MCO Enrollment Information			28
D. Member Handbook			28
E. Benefit Information			29
F. Maintenance of Toll-Free Line			31
G. Member Identification Card			31
H. Member Bill of Rights and Responsibilities			31

3.5 Quality Assurance			32
A. Consumer Advisory Board Member			32
B. Quality Management and Quality Improvement (QM/QI) Program			32
C. Performance Measures and Tracking Measures			34
D. Member Satisfaction Survey			35
E. External Quality Review			36
F. Reports			37
G. Standards for ISP Development			38
H. Standards for Participant Safety			40
I. Standards for Consumer/Participant Direction			41
J. Standards for Access			41
K. Coordination			42
L. Disease Management Programs			45
M. Clinical Practice Guidelines for ISHCN			46
N. Utilization Management (UM)			46
O. Authorization and Notice of Services			47
P. Denials and Notice of Adverse Action			49


3.6 Providers			49
A. Required Policies and Procedures			50
B. General Information Submitted to the State			51
C. The Primary Care Provider (PCP)			51
D. Primary Care Responsibilities			51
E. CONTRACTOR Responsibility for PCP Services			52
F. Selection or Assignment to a PCP			52
G. Long-Term Services (LTS) Providers			53
H. CONTRACTOR Responsibility for LTS			54
I. Specialty Providers			54
J. Other Provider Types			54
K. Shared Responsibility between the CONTRACTOR and Public Health Offices			55
L. Indian Health Services (IHS) & Tribal Health Centers			55
M. Family Planning Services and Providers			56
N. State Operated Long-Term Care Facilities			57
O. Standards for Provider Credentialing and Re-Credentialing			57
P. Organizational Providers			58
Q. Primary Source Verification			58

3.7 Covered Services, Supports, and Goods; Excluded Benefits; and Value Added Services			58

3.8 Culturally Competent Services			59

3.9 Individuals with Special Heath Care Needs (ISHCN)			61
A. General Requirements			61

3.10 Grievance and Appeals			61
A. General Requirements for Grievance and Appeals			62
B. Grievance			63
C. Appeal			64
D. Expedited Resolution of Appeals			65
E. Special Rule for Certain Expedited Service Authorization Decisions			68
F. Information about Grievance System to Network Providers			68
G. Grievance and/or Appeal Files			68
H. Reporting			68
I. Provider Grievance and Appeals			68

3.11 Fiduciary Responsibilities			69
A. Financial Viability			69
B. Financial Stability			69
C. Other Financial Requirements			71
D. Other Fiduciary Requirements			73
E. Reinsurance			73

3.12 Program Integrity			74

3.13 System Requirements			75
A. General Requirements			75


B. System Hardware, Software and Information System Requirements			75
C. Provider Network Information Requirements			77
D. Claims Processing Requirements			77
E. Member Information Requirements			78
F. Encounter and Network Provider Reporting Requirements			79

*Article 4 – Limitation of Cost*			81

*Article 5 – HSD/MAD and ALTSD Responsibilities*			81

*Article 6 – Payments and Financial Provisions*			83

6.1 General Financial Provisions			83

6.2 Cohort Categories			85

6.3 Year-One Risk Adjustment to Capitation Rates for NF LOC Members			85
A. General Provisions			85
B. Timing of Risk Adjusted Capitation Rates in Year One			86
C. NF LOC Cohorts Year One Risk Adjusted Capitation Rates for April, 2009-June 30, 2009			86
D. Risk Adjustment Factors			86
E. Mix of Members			87

6.4 Payment Methodology			88
A. Capitation Rate Development			88
B. Capitation Payment Process and Terms of Service			88

6.5 Supplemental Payments for Services to Native Americans			90

6.6 Administrative Costs			90
A. Administrative Structure			90

6.7 Special Payment Requirements			92
A. Reimbursement of Federally Qualified Health Centers (FQHCS)			92
B. Reimbursement for Family Planning Services			93
C. Reimbursement for Women in the Third-Trimester of Pregnancy			93
D. Reimbursement for State Operated Long-Term Care Facilities			93
E. Other Special Payment Requirements.			94
F. Compensation for UM Activities			94
G. Special Circumstances for Pharmacy Reimbursement			94

6.8 Reimbursement for Emergency Services			95

6.9 Assignment of Responsibility for Member Care			96

6.10 Coordination of Benefits			97

*Article 7 – State Contract Administrator*			98


*Article 8 – Enforcement*			98

8.1			98

8.2 State Sanctions			98

8.3 Federal Sanctions			103

*Article 9 – Termination*			*104*

*Article 10 – Termination Agreement*			*106*

*Article 11 – Rights upon Termination or Expiration*			*108*

*Article 12 – Contract Modification*			*109*

*Article 13 – Intellectual Property and Copyright*			*109*

*Article 14 – Appropriations*			*110*

*Article 15 - Disputes*			*110*

*Article 16 – Applicable Law*			*111*

*Article 17 – Status of CONTRACTOR*			*112*

*Article 18 –Assignments*			*112*

*Article 19 - Subcontracts*			*112*

*Article 20 - Release*			*115*

*Article 21 – Records and Audit*			*116*

*Article 22 - Indemnification*			*118*

*Article 23 – Liability*			*120*

*Article 24 – Equal Opportunity Compliance*			*120*

*Article 25 – Rights to Property*			*120*

*Article 26 – Erroneous Issuance of Payment or Benefits*			*120*

*Article 27 – Excusable Delays*			*120*

*Article 28 - Marketing*			*121*

*Article 29 – Prohibition of Bribes, Gratuities & Kickbacks*			*123*


*Article 30 - Lobbying*			*123*

*Article 31 – Conflict of Interest*			*124*

*Article 32 - Confidentiality*			*124*

*Article 33 – Cooperation with the Medicaid Fraud Control Unit*			*125*

*Article 34 - Waivers*			*126*

*Article 35 – Provider Availability*			*126*

*Article 36 - Notice*			*127*

*Article 37 - Amendments*			*127*

*Article 38 – Suspension, Debarment, and other Responsibility Matters*			*127*

*Article 39 – New Mexico Employees Health Coverage*			*129*

*Article 40 – Entire Agreement*			*130*

*Article 41 – Authorization for Care*			*130*

*Article 42 – Duty To Cooperate*			*130*

*Article 43 – Merger*			*130*

*Article 44 – Penalties for Violation of Law*			*130*

*Article 45 – Workers Compensation*			*131*

*Article 46 – Invalid Term or Condition*			*131*

*Article 47 – Enforcement of Agreement*			*131*

*Article 48 – Authority*			*131*

Appendix A (BENEFITS/SERVICES EXCLUDED BENEFITS AND VALUE ADDED BENEFITS/SERVICES)

Appendix B (Reports)

Appendix C (Money Follows the Person)

Appendix D (Megs and Cohorts)

This Agreement (“Agreement”) between the New Mexico Human Services Department (“HSD”), the New Mexico Aging & Long-Term Services Department (“ALTSD”), jointly referred to as “the State” and AMERIGROUP Community Care of New Mexico, Inc. (“CONTRACTOR”) is entered into by and between the parties on this ___ day of , 200___.

Upon becoming effective, the term of this Agreement shall be from July 1, 2008 through June 30, 2012, or at an effective date determined by the United States Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”), or otherwise amended or terminated pursuant to its terms. Under no circumstances shall this Agreement exceed a total of four (4) years in duration. Further, this Agreement shall not become effective until approved in writing by the New Mexico Department of Finance and Administration and CMS.

The terms “contract” and “agreement” are used interchangeably throughout this Agreement.

ARTICLE 1 – RECITALS

1.1

All services provided pursuant to this Agreement are subject to the New Mexico Procurement Code and 1.4.1 NMAC, unless specifically provided otherwise herein.

1.2

All services purchased under this Agreement shall be subject to the following provisions for administration of the New Mexico Medicaid program, which are incorporated herein by reference and shall include:

(A)

the Human Services Department, Medical Assistance Division (“HSD/MAD”) program eligibility and provider policy manuals, including all updates, revision, substitutions and replacements;

(B)

Title XIX and Title XXI of the Social Security Act and Code of Federal Regulations, Title 42 Parts 430 to end, as revised or otherwise amended;

(C)

The Request for Proposal (“RFP”), all RFP Amendments, CONTRACTOR’s Questions and State’s Answers, and the State’s written Clarifications;

(D)

the CONTRACTOR’s Best and Final Offer;

(E)

the CONTRACTOR’s Proposal (including any and all written materials presented in the oral portions of the procurement process) where not inconsistent with this Agreement and subsequent amendments to this Agreement;

(F)

All applicable statutes, regulations and rules implemented by the Federal Government, the State of New Mexico, and HSD/MAD, concerning Medicaid services, managed care organizations (“MCOs”), health maintenance organizations, fiscal and fiduciary responsibilities applicable under the New Mexico Insurance Code of New Mexico, NMSA 1978, §§59A-1-1, et seq., and any other applicable statutes and regulations;

(G)

The HSD/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;

(H)

The HSD/MAD MCO/SCP Systems Manual, including all updates and revisions, submissions and replacements; and

(I)

The parties recognize that this Agreement reflects a shift and reorganization of the programs under the jurisdiction and management of HSD/MAD and ALTSD. It is specifically understood and agreed that references to specific laws, regulations, dates and other matters of a similar nature to currently existing and known laws, regulations, and dates. The parties understand and agree that such existing laws, rules, regulations and dates may change after execution of this Agreement, and that new enactments, adoptions, amendments, substitutions, replacements, successors, or the like will be given full force and effect and will govern this Agreement in the spirit in which this Agreement is made.

1.3		Due to increased budgetary constraints, a desire to increase efficiency and reduce fragmentation of long-term services, the State shall require that most Medicaid recipients of long-term care services, specifically full dual eligibles (those individuals that qualify for both Medicare and Medicaid services), nursing facility residents, Personal Care Option consumers, and individuals currently receiving Disabled & Elderly (D&E) Home and Community Based Waiver services enroll in the State’s Coordinated Long-Term Services (“CLTS”) program.

1.4		The State shall award a risk-based contract to the CONTRACTOR with statutory authority to enter into capitated agreements, assume risk and meet applicable requirements and/or standards delineated under State and Federal laws and regulations, including Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the Americans with Disabilities Act.

1.5		The CONTRACTOR possesses the required authorization and expertise to meet the terms of this Agreement.

1.6		The CLTS program is intended to coordinate program services for dual eligible recipients. In order to achieve this goal, the CONTRACTOR shall be in active pursuit, as of the effective date of this Agreement, of becoming a Medicare Special Needs Plan (SNP) or offer Medicare products in all counties agreed to by the parties. For purposes of this Section, “active pursuit” is defined as having applied to CMS to become a SNP or offer other Medicare products.

1.7		The parties acknowledge the need to work cooperatively to address and resolve problems that may arise in the administration and performance of this Agreement. The parties agree to document any amendments in writing prior to implementation of any new contract requirements.

1.8		The State may, in the administration of this Agreement, seek input on health and long-term service related issues from advisory groups, steering committees, or other consultants. The State may seek input from the CONTRACTOR on issues raised by such advisory groups, steering committees, or consultants that may affect the CONTRACTOR’s performance of its obligations under this Agreement.

1.9		The CONTRACTOR shall notify the State of the CONTRACTOR’s or its subcontractors’ potential public relations issues of which the CONTRACTOR becomes aware that could affect the State or this Agreement.

1.10		The parties recognize that the CLTS Program is contingent on approval by CMS of the State’s submission of a 1915(b) waiver for providing State Plan services utilizing a managed care approach and a 1915(c) home and-community based waiver for other services as presented by the State and permitted

by CMS, including all amendments thereto. The parties further recognize that 1915(c) home and-community based waiver services are dependent on funding requirements in order to provide such services. Therefore, the State shall determine access to CLTS 1915(c) home and-community based waiver services and shall notify the CONTRACTOR of Members deemed eligible for 1915(c) home and community-based waiver services.

1.11

This Agreement and its enforcement is contingent on the parties’ agreeing to the Capitation Rates for the first year of the CLTS Program.

NOW THEREFORE, in consideration of the mutual promises contained herein. HSD/MAD, ALTSD, and the CONTRACTOR agree as follows:

ARTICLE 2 — DEFINITIONS

2.1 Terms used throughout this Agreement have the following meaning, unless the context clearly indicates otherwise or as may be further defined herein:

“ Abuse ” means: (1) any intentional, knowing or reckless act or failure to act that produces or is likely to produce physical or great mental or emotional harm, unreasonable confinement, sexual abuse or sexual assault consistent with NMSA 1978, §30-47-1; or (2) provider practices that are inconsistent with sound fiscal, business, medical or service related practices and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse also includes Member practices that result in unnecessary cost to the Medicaid program pursuant to 42 C.F.R. §455.2.

“ Activities of Daily Living ” means eating, dressing, oral hygiene, bathing, mobility, toileting, grooming, taking medications, transferring from a bed or chair and walking, consistent with NMSA 1978, §28-17-3.

“ Advance Directive ” means written instructions such as an Advance Directive, Mental Health Advance Directive, living will, durable health care power of attorney, durable mental health care power of attorney, or Advance Health Directive, relating to the provision of health care when an adult is incapacitated. [See generally, NMSA, 1978, §§27-7A-1 — 27-7A-18, and §§24-7B-1 — 24-7B-16].

“ Adverse Determination ” means a determination by the CONTRACTOR or CONTRACTOR’s utilization review agent that the health care services furnished, or proposed to be furnished to a Member, are not medically necessary or not appropriate. [See, 42 C.F.R. §438.408].

“ Agency ” means a New Mexico government department, such as the New Mexico Human Services Department, the New Mexico Children Youth and Families Department, the New Mexico Department of Health, the New Mexico Aging & Long-Term Services Department, or any of the departments participating in Medicaid managed care.

“ ALTSD ” means the New Mexico Aging & Long-Term Services Department of the State of New Mexico.

“ Assignment Algorithm ” means a mathematically weighted pre-determined method for assigning to MCOs Members who have not proactively selected an MCO during the required Selection Period. [See, NMAC 8.305.1.1, and NMAC 8.305.5.9].

“ Assisted Living Services ” are residential services that include personal support services, companion services, assistance with medication administration as set forth in Department of Health Regulations, 7.8.2 RESIDENTIAL HEALTH FACILITIES.

“ At Risk ” means the period of time that a Member is enrolled with the CONTRACTOR during which time the CONTRACTOR is responsible for providing Covered Services under Capitation. [See, NMAC 8.305.11.9].

“ Begin Date ” means the first day of the first full month following selection or assignment except in the following circumstances:

(1)

Members who were in a NF prior to the LOC determination but not enrolled in Salud! for whom their Medicaid financial eligibility covers retroactive months. The Begin Date in this instance will be the first of the month in which both NF LOC and Medicaid eligibility coexist.

“ Behavioral Health ” means both mental health (MH), including emotional disorders, and substance abuse (SA), including chemical dependency disorders. Behavioral Health includes co-occurring MH and SA disorders.

“ Benefit Package ” means Medicaid Covered Services, including home and community-based services, which shall be furnished by the CONTRACTOR. [See, NMAC 8.305.7, 8.310.2, 8.311.1, et seq.].

“ Capitation ” means a method of payment to the CONTRACTOR by an Agency of a fixed amount of money each month for each enrolled Member, regardless of the amount of Covered Services used by the Member. [See, NMAC 8.305.1.7, 8.305.11.9].

“ Claim ” means a bill for services submitted to the CONTRACTOR manually or electronically; a line item of service on a bill; or all services for one Member within a bill.

“ Claim Dispute ” means a dispute, filed by a provider or CONTACTOR as applicable, involving payment of a claim, denial of a claim, or imposition of a sanction.

“ 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 the CONTRACTOR’s system. A Clean Claim may include errors originating in the State’s 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. A Clean Claim is not materially deficient or improper, such as one that lacks substantiating documentation currently required by the CONTRACTOR. A Clean Claim has no particular or unusual circumstances requiring special treatment that prevents payment from being made by the CONTRACTOR within 30 days of the date of receipt if submitted electronically or 45 days if submitted manually. [See, NMAC 8.305.1.7, 8.305.11.9].

“ CMS ” means the Centers for Medicare and Medicaid Services, which is the federal agency responsible for administering Medicare and overseeing state administration of Medicaid.

“ Complaint ” means an expression of dissatisfaction expressed by a Complainant, orally or in writing to the CONTRACTOR or to the State about any matter related to the CONTRACTOR other than an Action. The term “Action” is further defined in Section 3.10 of this Agreement. As provided for in 42 C.F.R. §438.400, possible subjects for Complaints, include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Member’s rights.

“ Concurrent Review ” means a process of updating clinical information from the provider to the CONTRACTOR regarding a Member who is already receiving a Covered Service to evaluate whether the service continues to be medically necessary.

“ Consumer/Participant Direction ” means the ability of the Member to be actively involved in and in control of, to the extent possible, in all aspects of the Member’s Individual Service Plan (ISP), to identify and include others in the ISP planning process, and to hire and direct personal assistance services as desired.

“ Continuous Quality Improvement ” means a process for improving quality that: (1) assumes opportunities of improvement are unlimited; (2) is Member-oriented; (3) is data driven; (4) results in implementation of improvements; (5) requires continual measurement of implemented improvements; and (6) requires modification of improvements as indicated. [See, NMAC 8.305.1.7].

“ Contractor ” means a person or entity that has a prepaid capitated contract with the State pursuant to NMAC 8.305 to provide health care to Members under this article either directly or through subcontracts with providers.

“ Copayment ” means a monetary amount specified by the State that the Member pays directly to the provider at the time Covered Services are rendered consistent with 42 C.F.R. §§447.53 through 447.56. [See also, NMAC 8.200.430].

“ Covered Services ” means those services listed in Appendix A of this Agreement delivered in accordance with this Agreement.

“ Critical Incident ” means a reportable incident that may include, but is not limited to, abuse, neglect, or exploitation; death; environmental hazards; law enforcement intervention; and emergency services, that encompasses the full range of physical health, other State Plan services, and home and community-based services.

“ Cultural Competence ” means a set of congruent behaviors, attitudes and polices that come together in a system, agency or among professionals, that enables them to work effectively in cross-cultural situations. Cultural competency involves the integration and transformation of knowledge, information and data about individuals and groups of people into specific clinical standards, service approaches, techniques and marketing programs that match an individual’s culture to increase the quality and appropriateness of health care and outcomes. [See, NMAC 8.305.1.7].

“ Day or Days ” means calendar day, unless specified otherwise. The first day is included and the last day is excluded. Timeliness 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.

“ Delegation ” means a formal process by which the CONTRACTOR gives another entity the authority to perform certain functions on its behalf. The CONTRACTOR retains full accountability for the delegated functions. [See, NMAC 8.305.1.7].

“ Denial, Administrative/Technical ” means a denial of authorization requests due to the requested procedure, service or item not being covered by Medicaid or due to provider noncompliance with administrative policies and procedures established by an Agency. [See, 42 C.F.R. §456, and NMAC 8.305.1.7].

“ Denial, Clinical ” means a decision not to authorize a service because the Member does not meet the clinical level of care criteria for a requested service. Utilization Management (UM) staff may recommend an alternative

service based on a Member’s medical, functional, or social need. If the requesting provider accepts this alternative service, it is considered a new request for the alternative service and a denial of the original request. [See, 42 C.F.R. §456, NMSA 1978, §59A-57-4, NMAC 8.305.7].

“ Disease Management ” means a strategy of delivering health services using interdisciplinary clinical teams, continuous analysis of relevant data, and cost-effective technology to improve the health outcomes of Members with specific diseases. MCOs must provide for a disease management program for Members through close coordination with and assistance from PCPs and seek to adopt uniform key health status indicators. Examples of chronic diseases that may be included are diabetes, cardiovascular disease, chronic obstructive pulmonary disease, asthma, and obesity. This list is not exclusive. [See, NMSA 1978, §27-2-12].

“ Disenrollment, Member Initiated ” means a request by a Member to be disenrolled for a substantial reason(s); or transfer of a Member as determined by State on a case-by-case basis from the MCO to a different MCO during a Member lock-in period. [See, NMAC 8.305.5].

“ Dual Eligible(s) ” means individuals, who, by reason of age, income and/or disability qualify for Medicare and full-Medicaid benefits under section 1902(a)(10)(A) or 1902(a)(10)(C), by reason of section 1902(f), or under any other category of eligibility for medical assistance for full benefits..

“ Durable Medical Equipment ” means equipment that can withstand repeated use, is primarily used to serve a medical purpose, is minimally or not useful to individuals in the absence of an illness or injury and is appropriate for use at home.

“ Emergency Medical Condition ” means a medical or behavioral health 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 care could result in:

(1) placing the Members’ health in serious jeopardy;

(2) serious impairment to bodily functions;

(3) serious dysfunction of any bodily organ or part; or

(4) serious disfigurement to the Member.

[See, NMAC 8.305.1].

“ Encounter ” means a Covered Service or group of Covered Services delivered by a provider to a Member during a visit between the Member and provider.

“ Encounter Data ” means data elements from Encounters, for fee-for-service claims or capitated services proxy claims. Encounter Data elements are a combination of those elements required by HIPAA-compliant transaction formats, which comprise a minimum core data set for states and MCOs and those required by CMS, or the State for use in managed care. [See, NMAC 8.305.1.7, 8.305.10].

“ Enrollee ” means a Medicaid recipient who is currently enrolled in an MCO managed care program.

“ Exemption ” means the removal of an eligible Medicaid Member from mandatory enrollment in CLTS and placement in the Medicaid fee-for-service program. Such action is only used in extraordinary circumstances, as determined by the State on a case-by-case basis.

“ Expedited Situation ” means a living situation or circumstances from which a Potential Enrollee or Member might reasonably result in placing the Potential Enrollee or Member’s health in serious jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part.

“ External Quality Review Organization (EQRO) ” means an organization contracted with CMS to serve as an external quality review entity, Quality Improvement Organization or Independent Review Entity in accordance with the Social Security Act, Section 1902(a)(30)(C).

“ FQHC ” mean a Federally Qualified Health Center, an entity which meets the requirements and receives a grant and funding pursuant to Section 330 of the Public Health Service Act. An FHQC includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (PL 93-638) or an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act. [See also, NMAC 8.305.11.9].

“ Fraud ” means an intentional deception or misrepresentation by a person or an entity with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law, consistent with NMAC 8.305.13.10. [See, NMAC 8.305.1.7].

“ Full Benefit Dual Eligible ” means individuals enrolled in Medicare and eligible for full Medicaid benefits, not limited to covering costs, such as Medicare premiums.

“ Grievance, Member ” means an oral or written statement by a Member expressing dissatisfaction with any aspect of the CONTRACTOR’s administration of CLTS or its operations that is not an Action. “Action” is defined in Section 3.10 of this Agreement. [See, NMAC 8.305.1.7, 8.305. 12.9].

“ Grievance, Provider ” means an oral or written statement by a provider expressing dissatisfaction with any aspect of the CONTRACTOR’s administration of CLTS or its operations that is not an Action. “Action” is defined in Section 3.10 of this Agreement. [See, NMAC 8.305.1.7].

“ HIPAA ” means the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §160, et seq., as amended or modified.

“ Human Services Department, Medical Assistance Division (HSD/MAD) ” means the administrative agency within the executive department of New Mexico state government established under Chapter 9, New Mexico Statutes Annotated 1978, or its designee, including but not limited to agencies of the Human Services Department.

“ Individualized Service Plan (ISP) ” means an individualized service plan developed with and for Members who have chronic or complex conditions. A Service Plan includes, but is not limited to, the following:

	(1)		A Member’s history;

	(2)		A summary of current medical and social needs and concerns;

	(3)		Short and long term care needs and goals; and

(4)

A list of services required and their frequency, and a description of who will provide the services.

In addition, and ISP means a plan developed by a team of professionals in consultation with the Member and others involved in the Member’s care to improve functional outcomes, including the standards in NMAC 8.314.3.15. The ISP must be in accordance with the approved CMS CLTS Home and Community Based Waiver program or New Mexico State Plan.

“ Individuals with Special Health Care Needs (ISHCN) ” means persons who have, or are at an increased risk for, a chronic physical, developmental, behavioral, neurobiological or emotional condition, or who have low to

severe functional limitation and who also require health and related services of a type or amount beyond that required by individuals generally.

“ Level of care ” means the level of nursing care needed by an individual.

“ Long-Term Services ” is a continuum of services and assistance, ranging from in-home and community based services for elderly and individuals with disabilities who need help in maintaining their independence to institutional services for those who require an institutional level of support. Throughout the continuum of long-term services and supports, the goal is to provide needed services and supports for the Member while striving to maintain the Member’s independence to the greatest extent possible. Long-term Services are listed in Appendix A.

“ Managed Care Organization (MCO) ” means an organization under contract to assist the Agency to meet the requirements established under NMSA 1978, §27-2-12.

“ Marketing ” means the act or process of promoting a business or commodity. Marketing materials include brochures, leaflets, billboard materials and information or ads placed on or with the internet, newspapers, magazines, radio, phone book, and any other presentation materials used by the MCO, MCO representative, or MCO subcontractor to attract or retain Medicaid enrollment. [See, NMAC 8.305.1.7, 8.305.5.13].

“ Medically Necessary Services ” means clinical and rehabilitative physical, mental or behavioral health services that:

	(1)		Are essential to prevent, diagnose or treat medical conditions or are essential to enable the Member to attain, maintain or regain the Member’s optimal functional capacity;

	(2)		Are delivered in the amount, duration, scope and setting that is both sufficient and effective to reasonably achieve their purposes and clinically appropriate to the specific physical, mental and behavioral health care needs of the Member;

	(3)		Are provided within professionally accepted standards of practice and national guidelines; and

	(4)		Are required to meet the physical, mental and behavioral health needs of the Member and are not primarily for the convenience of the Member, the provider or the CONTRACTOR.

“ Member ” means a person who is entitled to benefits under Title XIX of the Social Security Act and Medicaid, is in a Medicaid eligibility category included in the Program, and is enrolled in the Medicaid Program with the CONTRACTOR.

“ Mi Via ” is the State’s self-directed waiver program pursuant to a 1915(c) home and community-based waiver.

“ Network Provider ” means an individual provider, clinic, group, association or facility employed by or contracted with the CONTRACTOR to furnish medical or long-term care services to the CONTRACTOR’s Members under the provisions of this Agreement.

“ NF LOC ” means Nursing Facility Level of Care.

“ Non-Contracted Provider (Non-Network Provider) ” means an individual provider, clinic, group, association or facility who provides Covered Services as described in NMAC 8.305.7 and who does not have a contract with the CONTRACTOR.

“ Nursing Facility ” means a licensed Medicare/Medicaid facilitycertified in accordance with 42 C.F.R. 483 to provide inpatient room, board and nursing services to Members who require these services on a continuous basis but who do not require hospital care or direct daily care from a physician.

“ Potential Enrollee ” means a person who is determined eligible for the CLTS Program but has not yet enrolled.

“ Post-stabilization Care Services ” means Covered Services related to an Emergency Medical Condition that are provided after a Member is medically stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 C.F.R. §438.114(b) & (e) and 42 C.F.R. §422.113(c)(iii) to improve or resolve the Member’s condition.

“ Primary Care Physician or Primary Care Provider (PCP) ” means, for purposes of this Agreement, an individual who meets the requirements of NMAC 8.305.6.12, and is a Network Provider 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. A PCP may be a physician, certified nurse practitioner or physician assistant [see, NMAC 8.310.2.10, 8.310.2.13, and NMSA 1978, §§61-6-7, et seq.]; may include a specialist determined by the CONTRACTOR on an individualized basis for Members whose care is more appropriately managed by a specialist; faculty-led primary care teams consisting of residents and a supervising faculty physician; or other Network Providers who meet the CONTRACTOR’s credentialing requirements as a PCP. [See, NMAC 8.305.6.12].

“ Primary Care ” means all health services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, physician assistant, or certified nurse practitioner. [See, NMAC 8.305.1.7].

“ Provider Lock-In (PCP Lock-in) ” means a situation in which the CONTRACTOR requires that a Member see a specific identified Network Provider, while ensuring reasonable access to additional services, when the CONTRACTOR identifies utilization of unnecessary services or a Member’s behavior is detrimental or indicates a need to provide case continuity. [See, NMAC 8.305.6.12].

“ Quality Assurance ” means a process that is adopted by a health care entity that follows written standards and criteria. The process includes the activities of a health care entity or any of its committees that: investigate the quality of health care through the review of professional practices, training and experience; investigate patient cases or conduct of licensed health care providers, or encourage proper utilization of health care services and facilities, as required by NMAC 8.305.8. Quality Assurance follows a process of discovery, both prospective and retrospective to evaluate the program; identification of areas, for remediation; and implementation of quality improvement strategies to ensure that appropriate and timely action is taken, as indicated.

“ Related Party ” means a party that has, or may have, the ability to control or significantly influence the CONTRACTOR, or a party that is, or may be, controlled or significantly influenced by the CONTRACTOR. “Related Parties” include, but are not limited to, agents, managing employees, persons with an ownership or controlling interest in the disclosing entity, and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, or other entities controlled or managed by any such entities or persons.

“ Salud!” means the State’s managed care program for low-income eligible individuals not included in the State’s CLTS Program. The State operates Salud! pursuant to a 1915(b) waiver granted by CMS.

“ Service Coordination ” means a specialized service management that is performed by a Service Coordinator, in collaboration with the Member (and/or his/her family and representatives, as appropriate), and that includes but is not limited to:

	(1)		Identification of the Member’s needs, including physical health services, mental health services, social services, and long term support services; and development of the Member’s Individualized Service Plan (ISP) or treatment plan to address those needs;

	(2)		Assistance to ensure timely and a coordinated access to an array of providers and services;

	(3)		Attention to addressing unique needs of Members; and

	(4)		Coordination with other services delivered outside the ISP, as necessary and appropriate.

Service Coordination operates independently within the MCO using recognized professional standards adopted by the CONTRACTOR and approved by the State, based on the Service Coordinator’s independent judgment to support the needs of the Member and is structurally linked to the other MCO systems, such as quality assurance, member services and grievances. Clinical and other decisions shall be based on the Medical Necessity of Covered Services and not fiscal consideration. [See, NMAC 8.305.1.7(7)].

“ Service Coordinator ” means an employee or subcontractor of CONTRACTOR with primary responsibility for providing service coordination/management to Members who have complex care needs including long term service and supports or needs, or who otherwise want assistance with service planning. The Service Coordinator need not be a medical professional. This person is authorized by the CONTRACTOR to approve the provision and delivery of Covered Services.

“ State Fiscal Year (SFY) ” means July 1 ^st through June 30 ^th .

“ Single Statewide Entity (SE) ” means the managed behavioral health organization that is contracted to deliver behavioral heath services to eligible Medicaid recipients.

“ Special Needs Individual ” means a Medicare Advantage (MA) eligible individual who is institutionalized, is entitled to medical assistance under a State plan under Title XIX, or has a severe or disabling chronic condition(s) and would benefit from enrollment in a specialized MA plan. [See, 42 C.F.R. §422.2].

“ Special Needs Plan (SNP) ” means a specialized Medicare Advantage coordinated care plan for special needs individuals, that exclusively or disproportionately serves special needs individuals under 42 C.F.R. §§422.2 and 422.52].

“ State ” means HSD/MAD and/or ALTSD, as applicable throughout this Agreement.

“ State Plan ” means a state-wide plan for Medicaid services submitted for approval to CMS under Title XIX of the federal Social Security Act.

“ Subcontract (Third-Party Contract) ” means a written agreement between the CONTRACTOR and a third-party, or between a subcontractor and another subcontractor, to provide services to the CONTRACTOR or subcontractor.

“ Suspension or Suspended Provider ” means that items or services furnished by a specified provider who has been convicted of a program-related offense in a Federal, State, or local court will not be reimbursed under Medicaid. [42 C.F.R. §455.2].

“ Third Party Assessor ” is a contracted entity with HSD/MAD that shall perform level of care assessments and re-assessments and/or utilization review(s) to determine eligibility into CLTS.

“ Third Party Liability ” means an individual, entity or program, which is or may be liable to pay all or part of the expenditures for Medicaid Members for services furnished under the New Mexico State Plan. [See, NMAC 8.305.1.7, and 8.305.11.9].

“ Tribal Facility 638 ” means a facility operated by a Native American/Indian tribe authorized to provide services pursuant to the Indian Self-Determination and Education Assistance Act. [See, 25 C.F.R. §900, as amended].

“ Tribal Provider or IHS Provider ” means a facility that is operated by a Native American/Alaskan Indian tribe authorized to provide services as defined in the Indian Health Care Improvement Act, 25 U.S.C. §§1601, et seq.

“ Utilization Management (UM) ” means a system for reviewing the appropriate and efficient allocation of health care services given or proposed to be given to a Member. [See, NMSA 1978, §59A-57-3].

“ Value Added Service ” means any service or benefit offered by the CONTRACTOR that is beyond the required Medicaid and home and community-based services.

“ Waiver Program ” means one or more of the State of New Mexico Medicaid home and community-based waiver programs authorized by CMS.

ARTICLE 3 — CONTRACTOR RESPONSIBILITIES

The CONTRACTOR shall perform professional services, including but not limited to, the following:

3.1 COMPLIANCE

The CONTRACTOR must, to the satisfaction of the State, comply with:

(A)

All provisions set forth in this Agreement;

(B)

All applicable provisions of federal and state laws, regulations, waivers, and variances, as may be amended, including the implementation of a compliance plan; and

(C)

All provisions relating to criminal history screening pursuant to 7.1.9 NMAC and NMSA 1978, §§29-17-2, et seq. of the Caregivers Criminal History Screening Act.

3.2 CONTRACT MANAGEMENT

(A)

The CONTRACTOR must employ a qualified individual to serve as the Contract Manager for New Mexico operations. The Contract Manager must be primarily dedicated to the CONTRACTOR’s programs, hold a senior management position in the CONTRACTOR’s organization, and be authorized and empowered to represent the CONTRACTOR on all matters pertaining to the CONTRACTOR’s program and specifically this Agreement. The Contract Manager must act as a liaison between the CONTRACTOR, the State, and other state agencies and has responsibilities that include but are not limited to the following:

(1)

ensuring the CONTRACTOR’s compliance with the terms of this Agreement, including securing and coordinating resources necessary for such compliance;

(2)

implementing all action plans, strategies, and timeliness, including but not limited to the State’s work plan(s) in implementing its Money Follows the Person initiatives, see Appendix C;

(3)

overseeing all activities by the CONTRACTOR and its subcontractors;

(4)

receiving and responding to all inquiries and requests by the State, or any State or Federal agency, in time frames and formats reasonably acceptable to the parties;

(5)

meeting with representatives of HSD/MAD, ALTSD, and other Agencies, on a periodic or as-needed basis and resolving issues that arise;

(6)

attending and participating in regular meetings with HSD/MAD, ALTSD and other Agencies and attending and participating in stakeholder meetings;

(7)

making best efforts to promptly resolve any issues related to this Agreement identified by the State, or the CONTRACTOR; and

(8)

working cooperatively with other State of New Mexico contracting partners, including but not limited to: (1) SALUD! Managed Care Organizations; (2) SE; (3) Mi Via contractors; (4) MMIS contractor, which is currently ACS; (5) the TPA, and (6) other identified contractors as, from time-to-time may be identified by the State.

(B)

The State reserves the right to require the CONTRACTOR to make changes in its staff assignments, subject to applicable laws, regulations and reasonable CONTRACTOR employment policies as uniformly applied to CONTRACTOR’s staff with thirty (30) days notice.

(C)

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 CONTRACTOR’s obligations under this Agreement.

(D)

Compliance . The CONTRACTOR shall:

(1)

designate a compliance officer and a compliance committee that are accountable to senior management;

(2)

provide effective training and education for the compliance officer and the CONTRACTOR’s employees;

(3)

implement effective lines of communication between the compliance officer and the CONTRACTOR’s employees;

(4)

require enforcement of standards through well-publicized disciplinary guidelines; and

(5)

have a provision for prompt response to detected offenses and for development of corrective action initiatives relating to compliance with the this Agreement.

(E)

Delegation . The CONTRACTOR shall:

(1)

not assign, transfer or delegate key management functions such as utilization review, utilization management or care coordination without the explicit written approval of the State;

(2)

oversee and be held accountable for any function and responsibility, including claims submission requirements, that it delegates to any subcontractor;

(3)

evaluate the prospective subcontractor’s ability to perform the activities to be delegated;

(4)

have a written agreement between the CONTRACTOR and the subcontractor that specifies the activities and report responsibilities delegated to the subcontractor and provides for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate;

(5)

monitor the subcontractor on an ongoing basis and subject it to review on a periodic basis as agreed upon by CONTRACTOR and State; and

(6)

ensure that if deficiencies or areas for improvement are identified, corrective action must be taken by CONTRACTOR and the subcontractor.

3.3

MEMBER ENROLLMENT

	(A)		Maximum Medicaid Enrollment

			The State and the CONTRACTOR may mutually agree in writing to establish a maximum Medicaid enrollment level for Members, which may vary throughout the term of this Agreement. The maximum Medicaid enrollment also may be established by the State 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 the capacity to provide statewide Covered Services to its Members. Subsequent to the establishment of this limit, if the CONTRACTOR wishes to change its maximum enrollment level, the CONTRACTOR shall notify the State in writing ninety (90) calendar days prior to the desired effective date of the proposed change. The State shall approve all requests for changing maximum enrollment levels before implementation. Should a maximum enrollment level be reduced to below the actual enrollment level, the State may disenroll Members to establish compliance with the new limit. The State may reduce the maximum enrollment levels for reasons such as imposing a sanction for not having sufficient Network Providers to guarantee access, violating marketing regulations, or for a material breach of this Agreement.

	(B)		Enrollment Requirements

			As required by 42 C.F.R. §434.25, the CONTRACTOR shall accept eligible individuals, in the order in which they apply and:

	(1)		without restriction, and pursuant to waiver authority, unless authorized by CMS Regional Administrator;

	(2)		up to the limits established pursuant to this Agreement;

(3)

the CONTRACTOR shall not discriminate against eligible individuals on the basis of health status, need for health services, disability, race, color, national origin, sexual orientation, religion, and gender, and will not use any policy or practice that has the effect of discriminating on the basis of race, color, or national origin; and

(4)

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.

(C)

Eligibility

The State, or its designee, including but not limited to a TPA shall determine eligibility for enrollment into the CLTS program. Continued eligibility for the CLTS program shall be done annually and shall include a re-assessment by the State, or its designee, including but not limited to a TPA. Mandatory populations include:

(1)

Full benefit Dual Eligible Members;

	(2)		Members, 21 years of age or older who are receiving or who qualify for current Medicaid State Plan Personal Care Option services;

	(3)		Members residing in a Nursing Facility;

(4)

Members currently receiving, or who qualify for, D&E Home and Community-Based waiver services; and

(5)

Members in the Mi Via 1915(c) waiver who meet current D&E or Brain Injury categories of eligibility. The CONTRACTOR will only be at-risk and financially responsible for 1915(b) waiver services for these Members. Members will self-direct any 1915(c) waiver services.

			Individuals of any age who meet eligibility criteria set forth in New Mexico’s 1915(c) Developmental Disabilities and/or New Mexico’s 1915(c) Medically Fragile and/or New Mexico’s 1915(c) HIV/AIDS Home and Community-Based Waivers are not eligible.

			The State, or its designee, shall further determine eligibility for CLTS 1915(c) home and community-based waiver services through an allocation process and notification of eligibility to the CONTRACTOR. Such allocation and notification from the State to the CONTRACTOR shall be outlined in a Letter of Direction (LOD) issued by the State prior to implementation of the CLTS Program and after consultation with the CONTRACTOR.

			For re-assessments, the State shall send reassessment reminder lists to the CONTRACTOR who shall assist the Member and facilitate in gathering the necessary documentation required to the State, or its designee, including but not limited to a TPA for the level of care determination and continued eligibility for the CLTS program.

(D)

State Exemptions

The State shall grant exemptions to mandatory enrollment based upon criteria established by it. A Member or his/her representative, parent, or legal guardian shall submit a request for such an exemption in writing to the State, including a description of the special circumstances justifying

an exemption. Requests are evaluated by the State and forwarded to the HSD/MAD Medical Director or his/her designee for final determination.

(E)

Special Situations

	(1)		Hospitalized Members . For a Member who is hospitalized at the time of disenrollment from the CONTRACTOR, whether disenrollment is due to disenrollment from CLTS or an approved switch to another CLTS MCO, the CONTRACTOR shall be responsible until the date of discharge for payment for all covered facility and professional services provided within a licensed acute care facility or non-psychiatric specialty unit as designated by the New Mexico Department of Health. The payer at the date of hospital admission (MCO or FFS) remains responsible for services until the date of discharge.

	(2)		Members Receiving Hospice Services . Members who have elected and are receiving hospice services prior to enrollment in CLTS shall be exempt from enrolling in an MCO unless they revoke their hospice election.

(F)

Enrollment Process for Members

	(1)		Enrollment Choice Period. A new Member shall have no less than sixteen (16) calendar days to select an MCO. This shall constitute the “Minimum Selection Period” for new Members. If the new Member does not make a selection during this selection period, the State shall assign the new Member to an MCO.

	(2)		Begin Date of Enrollment . Enrollment shall begin the first day of the first full month following selection, unless the Member entered the Nursing Facility while not in Salud! and both the Member’s NF LOC and Medicaid eligibility precede the first full month following selection. The CONTRACTOR’s coverage for Members with a NF LOC with retroactive eligibility is limited to a maximum period of six (6) months. Members with a NF LOC with retroactive eligibility with a mid-month effective date will be covered under the fee-for-service program until the first day of the first full month of CLTS eligibility. The CONTRACTOR will be paid a capitation rate at the appropriate cohort rate for any period of retroactive coverage. Additionally, for any period of retroactive coverage where the CONTRACTOR is responsible for services for which prior authorization and/or utilization management policies were unable to be enforced, payment to providers for medically necessary Covered Services will be made at the lesser of a negotiated rate or the Medicaid fee-for-services rate.

	(3)		Member Switch and Loss of Medicaid Eligibility .

(a)

A current CONTRACTOR Member has the opportunity to change MCOs without cause during the first ninety (90) calendar days of a twelve-month period. The State shall notify the CONTRACTOR’s Member of this opportunity to select a new MCO by sending notice of eligibility and enrollment materials to the Member. A Member is limited to one ninety-day switch period per MCO. After exercising the switching rights, and returning to a previously selected MCO, the Member shall remain with the MCO until his/her twelve-month lock-in period expires before being permitted to switch MCOs.

(b)

If a Member loses Medicaid eligibility for a period of six (6) months or less, he/she will be automatically reenrolled with the former MCO, as long as a NF level of care is in place; assuming the Member requires NF level of care in order to meet enrollment criteria. If the Member misses the annual enrollment choice opportunity during this six-month time-period, he/she may request to be assigned to another MCO.

(4)

Mass Transfer Process . The mass transfer process is initiated by the State when the State determines that the transfer of CONTRACTOR’s Members from one CONTRACTOR to another is appropriate. Such mass transfers shall be conducted in accordance with HSD/MAD regulations.

(5)

Transition of Care . The implementation of CLTS will involve a phasing in of enrollment during the first fiscal year. The CONTRACTOR shall have the resources and policies and procedures related to transition of care in place, and shall ensure transition of care, including continuity of care, without disruption in service to Members. At a reasonable time prior to each transition period, the CONTRACTOR will provide the State with adequate assurances of the CONTRACTOR’s readiness to implement the transition. These assurances may include copies of its agreements with providers, providers’ policies and procedures, as well as the CONTRACTOR’s readiness plans, as specified below. The CONTRACTOR shall:

(a)

develop a detailed plan that addresses the clinical transition issues and transfer of potentially large numbers of Members into or out of its organization. This transition may be to or from either an MCO, a Salud! MCO, or a fee-for-service provider. This plan shall include how the CONTRACTOR proposes to identify services currently received by the Member;

(b)

develop a detailed plan for the transition of an individual Member, which includes Member and provider education about the CONTRACTOR and the CONTRACTOR’s process to ensure any existing courses of treatment are revised as necessary;

(c)

be able to identify Members and provide necessary data and information to a future CONTRACTOR for Members switching MCOs, either individually or in large numbers, to avoid unnecessary delays in treatment that could be detrimental to the Members;

(d)

honor all prior approvals granted by the State for the first sixty (60) calendar 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. The CONTRACTOR is expected to work with the Member, the TPA, and other State representatives on the re-assessment of transitioning Members within the time periods allowed under this Agreement;

(e)

reimburse providers and facilities approved by the State, if a donor organ becomes available during the first thirty (30) days of enrollment and transplant services previously approved by HSD/MAD;

(f)

fill prescriptions for drug refills for the first ninety (90) days or until the CONTRACTOR has made other arrangements, for newly enrolled Members who are eligible for the Medicaid prescription drug benefit;

(g)

pay for Durable Medical Equipment (DME) costing two thousand dollars ($2,000) or more, approved by the CONTRACTOR but delivered after disenrollment;

(h)

be responsible for Covered Services provided to the Member for any month the CONTRACTOR received a capitated payment, even if the Member has lost Medicaid eligibility, provided that if the State recovers premium payments for any month from the CONTRACTOR as a result of a Member’s loss of eligibility, the CONTRACTOR may recover payments made to providers for such Covered Services furnished during such month;

(i)

be responsible for payment of all inpatient services provided by a general acute-care or rehabilitation hospital until discharge from the hospital if the Member is hospitalized in such a facility at the time the Member becomes exempt or switches MCO;

(j)

cooperate with the SE in the transition of services and the provision of records necessary for behavioral health services;

(k)

accept prior authorization for long-term nursing facility placement and D&E and PCO services as per the State’s enrollment roster request; and

(l)

reimburse Non-Network Providers during the Transition of Care at the Medicaid Fee-for-Service rates as determined by the State.

(6)

Newly Eligible Enrollment and Expedited Service Requests . For potential enrollees eligible for the first time and not transitioning from an existing home and-community based waiver, PCO, nursing facility, or Salud!, the CONTRACTOR shall perform assessment of the Member’s acute care, long-term care, behavioral health, and social supports within the first thirty (30) calendar days of enrollment. Authorized Covered Services shall be initiated within fourteen (14) calendars day following the assessment.

If the TPA, or other State designee, determines that the Member has an emergent need for Covered Services, the TPA, or other State designee shall coordinate with the CONTRACTOR to have an assessment performed within seven (7) business days and services initiated within seven (7) calendar days following the assessment.

(7)

Geographic Roll-Out . The State intends to geographically roll-out the CLTS Program as follows:

(a)

Phase one shall include: Bernalillo County, Sandoval County, Torrance County, Valencia County, Santa Fe County, and Los Alamos County;

(b)

Phase two shall include: Sierra County, Dona Ana County, Catron County, Luna County, Grant County, Hidalgo County, and Otero County;

(c)

Phase three shall include: Cibola County, San Juan County, McKinley County, and Socorro County; and

(d)

Phase four shall include: Curry County, DeBaca County, Lincoln County, Chaves County, Eddy County, Lea County, Quay County, Roosevelt County, San Miguel County, Guadalupe County, Taos County, Rio Arriba County, Mora County, Colfax County, Union County, and Harding County.

(8)

Re-Assessment of Members Enrolled in CLTS for Long-Term Services . An annual re-assessment of Members is required for all Members enrolled in CLTS with a Nursing Facility Level of Care and will be completed by the TPA. If the TPA is unable to complete the re-assessment prior to the end date provided to the TPA and the CONTRACTOR on the LTC Re-Assessment Reminder file due to lack of information or cooperation provided by the CONTRACTOR, the CONTRACTOR will not receive capitation for that Member until such time as the CONTRACTOR receives information needed to perform the re-assessment is provided to the TPA. The Member will continue to be enrolled with the CONTRACTOR and remain the CONTRACTOR’s responsibility until such time as the State receives either a termination of Level of Care or a renewal of the Level of Care. The CONTRACTOR will continue to receive capitation payments for any Members whose re-assessment is delayed to reasons unrelated to the CONTRACTOR’s cooperation with the TPA.

	(G)		Member Disenrollment, Requests by CONTRACTOR

			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 the State, with all supporting documentation meeting the State’s requirements. 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 MCO. If a request for disenrollment is granted, the Member shall not be re-enrolled with the CONTRACTOR for a period of time to be determined by the State. Conditions that may permit lock-out or disenrollment are:

(1)

the CONTRACTOR demonstrates that it has made a good faith effort to accommodate the Member’s health care or other medically necessary covered needs, but such efforts have been unsuccessful;

(2)

the conduct of the Member is such that it is not feasible, safe, or prudent to provide Covered Services;

(3)

the CONTRACTOR has offered to the Member in writing and other means, reasonably calculated to apprise the Member of the opportunity to utilize the grievance process; or

(4)

the CONTRACTOR has received threats or attempts of intimidation from the Member to the CONTRACTOR, its Network Providers, or its own employees.

The CONTRACTOR shall not request disenrollment because of an adverse change in the Member’s health status, or because of the Member’s utilization of Covered Services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his/her continued enrollment with the CONTRACTOR seriously impairs the CONTRACTOR’s ability to furnish services to either this particular Member or other Members).

			The CONTRACTOR shall provide adequate documentation that the CONTRACTOR’s request for termination is proper.

	(H)		Member Initiated Disenrollment

			A Member who is required to participate in CLTS may request to be disenrolled from the CONTRACTOR “for cause” at any time, even during a lock-in period. The Member or his or her representative, must submit an oral or written request to the State. The following are causes for disenrollment:

(1)

the Member moves out of the CONTRACTOR’s service area, if applicable;

(2)

the CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks;

(3)

the Member needs related Covered Services (for example, a caesarian section and a tubal ligation) to be performed at the same time, there is no Network Provider able to do this and another provider determines that receiving the services separately would subject the Member to unnecessary risk; and

(4)

other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Network Providers experienced in dealing with the Member’s needs.

The effective date of an approved enrollment must be no later than the first day of the second month following the month in which the Member or the CONTRACTOR files for the request. If the State fails to made a disenrollment determination within this timeframce, the disenrollment is considered approved. If a Member is dissatisfied with the State’s determination denying a request to transfer/disenroll, access to a Fair Hearing will be provided.

	(I)		State Initiated Disenrollment

			The State may initiate disenrollment in three (3) circumstances:

(1)

if a Member loses Medicaid eligibility and/or loses level of care eligibility;

(2)

if the Member is re-categorized into a Medicaid coverage category not included in the CLTS initiative; or

(3)

the CONTRACTOR’s enrollment maximum is reduced to below levels established in this Agreement.

After the State becomes aware of, or is alerted to, the existence of one of the reasons listed herein, the State shall immediately notify the Member or family and the CONTRACTOR and shall update the enrollment roster.

(J)

Retroactive Reenrollment

A Member who is no longer enrolled with the CONTRACTOR for a period of six (6) months or less, whether in error or otherwise, shall be retroactively reenrolled by the CONTRACTOR only when the following criteria are met:

(1)

Member continues to meet nursing facility level of care; and

(2)

Member has been in a NF LOC setting during the period of disenrollment; and

(3)

Medicaid eligibility has been re-determined retroactively.

			Members in CLTS through their status of dual eligibility or the Mi Via Home and-Community Based Waiver will not be eligible for retroactive reenrollment, unless they meet the criteria found in (1) — (3) above..

			The State will notify the CONTRACTOR on a daily enrollment file which will list retroactive enrollments. Reenrollment will be confirmed and any retro-capitation payments will be generated during the monthly cycle.

3.4		MEMBER SERVICES

		The CONTRACTOR shall adhere to procedures developed by the State governing the following activities: (1) development of information and educational materials; (2) provisions of materials explaining the enrollment options and process to potential Members; and (3) provisions of informational presentations to eligible enrollees, Members, Member advocates and other interested parties.

		The CONTRACTOR shall employ sufficient staff to coordinate communication with Members and perform other Member Services functions as designated. 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; adults who are in the custody of the State; 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 regulations. The CONTRACTOR shall maintain and comply with written policies and procedures:

(1)

that describe a process to detect, measure, and eliminate operational bias or discrimination against enrolled Members by the CONTRACTOR or its subcontractors;

(2)

regarding Member’s and/or legal guardians’ right to select a PCP and to make decisions regarding needed social services and supports;

(3)

governing the development and distribution of marketing materials for Members. Such written polices and procedures must be submitted to the State for approval;

(4)

that are specifically mandated in the CLTS Medicaid regulations that shall be available upon request to Members and their representatives for review during normal business hours;

(5)

with respect to advance directives, the CONTRACTOR shall provide adult Members with written information on advance directive policies that includes a description of applicable state law and regulation. The information must reflect changes in state law and regulation as soon as possible, but no later than ninety (90) calendar days after the effective date of such change; and

(6)

to ensure through its Network Providers that:

(a)

written information is provided to adult Members concerning their rights to accept or refuse medical or surgical treatment and to formulate advance directives, and includes the CONTRACTOR’s policies and procedures with respect to the implementation of such rights;

(b)

documentation exists in the Member’s record whether or not the Member has executed an advance directive;

(c)

discrimination is prohibited against a Member in the provision of care or in any other manner discriminating against a Member based on whether the Member has executed an advance directive;

(d)

compliance with federal and state law and regulation is met;

(e)

education is provided for staff and the community on issues concerning advance directives; and

(f)

Members are informed that complaints concerning noncompliance with the advance directive requirements may be filed with the State survey and certification agency, currently DOH; and

(7)

to ensure provider notification to the Member regarding abnormal results of diagnostic laboratory, diagnostic imaging, and other testing and, if clinically indicated, informing the Member of a scheduled follow-up visit. Confirmation of this shall be documented in the Member’s record at the provider’s office.

(8)

to ensure that its Network Providers and facilities are in compliance with the applicable provisions of the Americans with Disabilities Act, 42 U.S.C. §§12101, et seq., (“ADA”), and its regulations;

	(B)		Member Education

			Members and/or their legal guardian shall be educated about their rights, responsibilities, service availability and administrative rules, the meaning of Consumer/Participant Direction and how to exercise their right to make choices. Member education is initiated when Members become eligible for Medicaid and is augmented by information from the State and the CONTRACTOR. The State will be responsible for developing materials and disseminating information about Medicaid programs generally and CLTS specifically. The CONTRACTOR will be responsible for any materials about the requirements and benefits of its available plans and services. The State must grant prior approval of all informational materials used by the CONTRACTOR, including the Handbook and benefits information described in subparagraph (D) and (E) below.

	(C)		MCO Enrollment Information

			Once a Member is determined to be a CLTS Member, the State provides specific information about Covered Services, MCOs from which the Member can choose, and enrollment of the Member(s), including information about the Member’s disenrollment rights at the time of enrollment and annually thereafter. The CONTRACTOR shall have written policies and procedures regarding the utilization of information on race, ethnicity, and primary language spoken, as provided by the State to the CONTRACTOR at the time of enrollment in the MCO of each Member.

(D)

Member Handbook

(1)

The CONTRACTOR is responsible for providing Members with a Member handbook and Provider Directory within thirty (30) calendar days of the CONTRACTOR being notified by the State of the Member’s enrollment or upon request by the Member or the State. The CONTRACTOR must notify all Members at least once per year, in a newsletter or other written form of correspondence, of their right to request and obtain this information.

(2)

The CONTRACTOR shall include language in the Member Handbook to clearly explain that a Native American Member may self-refer to an Indian Health Service (IHS) or Tribal health care facility for services. The Provider Directory shall include a separate section with a listing of all IHS and Tribal facilities, including hospitals, outpatient clinics, pharmacies, and dental clinics.

(3)

The CONTRACTOR may direct a person requesting a Member handbook or Provider Directory to an Internet site, unless the person makes a specific request for a printed document.

(4)

The Member handbook and Provider Directory must meet all requirements:

(a)

set forth in 42 C.F.R. §438.10(f)(2) and §438.10(g), regarding the grievance process, advance health directives, and any physician incentive plans;

(b)

set forth in 42 C.F.R. §438.10(f)(6) and NMAC 8.305.2.9, regarding language accessibility; and

(c)

regarding Grievance and Appeals and how Members and/or their representatives can file a Grievance and/or an Appeal, and the resolution process. The Member Handbook shall also advise Members of their right to file a request for an administrative hearing with the HSD/MAD Hearings Bureau, upon notification of a CONTRACTOR action, or concurrent with or following an Appeal of the CONTRACTOR action. The information shall meet the standards for communication set forth in the HSD/MAD Program Manual.

(5)

The CONTRACTOR shall provide potential Members, upon request, and enrolled Members with a Member Handbook that includes the CONTRACTOR’s addresses and telephone numbers. The CONTRACTOR shall also provide, upon request, a listing of PCP and Specialty Providers with the identity, location, phone number, and qualifications

that include area of specialty, board certification, and any other useful information that would be helpful to individuals deciding to enroll with the CONTRACTOR. This material must be available in an easily understood manner and format.

(6)

Other requirements. All educational material shall:

(a)

be prepared in a manner and format that is clear and understandable to an individual who has completed no more than the sixth grade;

(b)

be available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency and have a process in place for notifying potential enrollees and Members of the availability of these alternative formats;

(c)

have an oral interpretation available free of charge to potential members or Members. Oral interpretations shall be available in all non-English languages, not just those languages the CONTRACTOR or the State determine to be prevalent. The CONTRACTOR shall notify potential members that oral interpretation is available in any language, that written information is available in prevalent languages and about how to access this information; and

(d)

ensure that all Members are notified at least once per year of their right to request and obtain this information.

(E)

Benefit Information

(1)

The CONTRACTOR shall provide each Member or potential enrollees and/or legal guardian with written information in English or prevalent language, i.e., prevalent language are all languages in any service area spoken by approximately five percent (5%) or more of the population, about benefits including:

(a)

all benefits, services, and goods, as well as preventive and long-term services, included in, and excluded from coverage; such information shall be made available in a one-page, two-sided summary format, distinguishing between services available pursuant to the State’s approved 1915(b) and 1915(c) home and community-based waivers;

(b)

services for which prior authorization or a referral is required, and the method of obtaining both;

(c)

any restrictions on the Member’s freedom of choice among Network Providers;

(d)

the CONTRACTOR’s policy on referrals for specialty care, long-term services, and other benefits;

(e)

information regarding the Member’s right of access to and coverage of emergency services which include:

(i)

the fact that the Member has a right to use any hospital or other setting for emergency care; and

(ii)

what constitutes emergency medical condition, emergency services, and post-stabilization services; and

(f)

information that provides potential Members, upon request, and enrolled Members with a list of all items and services that are available to Members covered directly or through a method of referral and/or prior authorization. This material must be available in an easily understood manner and format.

(2)

The CONTRACTOR shall send out a questionnaire within thirty (30) calendar days of enrollment to all new Members which must include a question regarding the new Member’s primary language spoken and/or written. The CONTRACTOR shall make a good faith effort to obtain this information.

(3)

The CONTRACTOR shall provide affected Members and/or legal guardians with written updated information within thirty (30) calendar days of the intended effective date of any material change. In addition, the CONTRACTOR must make a good faith effort to give written notice of termination of a Network Provider, within fifteen (15) calendar days after receipt or issuance of termination notice to each Member who received his or her primary care from, or was treated at least four (4) times within the last twelve (12) calendar months prior to the termination by the terminated provider.

(4)

The CONTRACTOR shall not prohibit or otherwise restrict a Network Provider or Non-Network Provider from advising a Member who is a patient of the provider about the health status of the Member or medical care or treatment for the Member’s condition of disease, regardless of whether Covered Benefits for such care or treatment are provided for under the contract, if the provider is acting within the lawful scope of practice. This subsection, however, shall not be construed as requiring the CONTRACTOR to provide, reimburse, or provide coverage of any service if the CONTRACTOR:

	(a)		objects to the provision of a counseling or referral service on moral or religious grounds, provided that the CONTRACTOR notifies Members of these objections at the earliest possible time, optimally during the enrollment process whether the service in question is covered or not;

	(b)		notifies the State within ten (10) business days after the effective date of this Agreement of its current policies and procedures regarding it’s objection to providing such counseling or referral services based on moral or religious grounds, or within fifteen (15) calendar days after it adopts a change in policy regarding such counseling or referral services; or

	(c)		makes available information on its policies regarding such service to prospective Members within thirty (30) calendar days after the date the CONTRACTOR adopts a change in policy regarding such a counseling or referral service; or

(d)

can demonstrate that the service in question is not included as a Covered Service required by this Agreement; or

(e)

determines that the recommended service is not Medically Necessary as defined by the State Plan in effect with CMS as of the time the service is delivered, under

the CONTRACTOR’s policies and procedures, and in accordance with the definition set forth above.

(5)

For Member access to second opinions, the CONTRACTOR:

(a)

shall provide Members with the option of receiving a second opinion from another Network Provider when Members need additional information regarding recommended treatment or when requested care, service, or good has been denied by a Network Provider;

(b)

may select the Network Provider giving the second opinion in accordance with a method established by the CONTRACTOR to equitably distribute these duties, provided that the Network Provider selected practices in an area that provides expertise appropriate to the Member’s specific treatment or condition; and

(c)

shall provide for a second opinion from a qualified Network Provider, or arrange for the Member to receive a second opinion from a non-Network Provider if there is not another qualified Network Provider, at no cost to the Member.

	(F)		Maintenance of Toll-Free Line

			The CONTRACTOR shall maintain one (1) or more toll-free telephone line(s) accessible twenty-four (24) hours a day, seven (7) days a week, to facilitate Member access to qualified clinical staff. 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. The CONTRACTOR will maintain adequate staff trained and dedicated to the specific purpose of receiving and answering and/or resolving issues raised by Members. The CONTRACTOR will identify such staff as “consumer specialists.”

	(G)		Member Identification Card

			The CONTRACTOR shall issue to each Member a Member Identification Card within thirty (30) calendar days of Enrollment. The card shall be substantially the same as the card issued to commercial enrollees and shall not include the Member’s social security number.

	(H)		Member Bill of Rights and Responsibilities