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EXHIBIT 10.1
CONTRACT NO. FA522
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STANDARD CONTRACT
THIS CONTRACT is entered into between the
State of Florida, AGENCY FOR HEALTH
CARE ADMINISTRATION, hereinafter referred
to as the "AGENCY", whose address is
2727 Mahan Drive, Tallahassee, Florida
32308, and WELL CARE HMO, INC. d/b/a/
STAYWELL HEALTH PLAN OF FLORIDA,
hereinafter referred to as the "VENDOR", whose
address is 6800 N. Dale Mabry Highway,
Suite 168, Tampa, Florida 33614-3988, a
Florida Profit Corporation, to provide
health care services to Medicaid
beneficiaries.
I. THE
VENDOR HEREBY AGREES:
A.
GENERAL PROVISIONS
1. To
provide services according to the terms and
conditions set forth in this Contract, ATTACHMENT I,
Scope of Services, and all other attachments named
herein which are attached hereto and incorporated by
reference.
2. To
perform as an independent vendor and not as an
agent, representative, or employee of the Agency.
3. To
recognize that the State of Florida, by virtue of
its sovereignty, is not required to pay any taxes on
the services or goods purchased under the terms of
this Contract.
B.
FEDERAL LAWS AND REGULATIONS
1. If
this Contract contains federal funds, the Vendor
shall comply with the provisions of 45 CFR, Part 74,
and/or 45 CFR, Part 92, and other applicable
regulations as specified in ATTACHMENT I.
2.
If this
Contract contains federal funding in excess
of $100,000, the Vendor must, upon Contract
execution, complete the Certification Regarding
Lobbying form, ATTACHMENT IV. If a Disclosure of
Lobbying Activities form, Standard Form LLL, is
required, it may be obtained from the Agency's
Contract Manager. All disclosure forms as required by
the Certification Regarding Lobbying form must be
completed and returned to the Agency's Contract
Manager.
3.
Pursuant to 45 CFR, Part 76, if this Contract
contains federal funding in excess of $25,000, the
Vendor must, upon Contract execution, complete the
Certification Regarding Debarment, Suspension,
Ineligibility,
and Voluntary Exclusion
Contracts/Subcontracts, ATTACHMENT V.
C.
AUDITS AND RECORDS
1. To
maintain books, records, and documents (including
electronic storage media) pertinent to performance
under this Contract in accordance with generally
accepted accounting procedures and practices which
sufficiently and properly reflect all revenues and
expenditures of funds provided by the Agency under
this Contract.
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2. To
assure that these records shall be subject at all
reasonable times to inspection, review, or audit by
state personnel and other personnel duly authorized
by the Agency, as well as by federal personnel.
3. To
maintain and file with the Agency such progress,
fiscal and inventory reports as specified in
ATTACHMENT I, and other reports as the Agency may
require within the period of this Contract. In
addition, access to relevant computer data and
applications which generated such reports should be
made available upon request.
4. To
provide a financial and compliance audit to the
Agency as specified in ATTACHMENT II and to ensure
that all related party transactions are disclosed to
the auditor. Additional audit requirements are
specified in ATTACHMENT I.
5. To
include these aforementioned audit and record
keeping requirements in all approved subcontracts and
assignments.
D.
RETENTION OF RECORDS
1. To
retain all financial records, supporting
documents, statistical records, and any other
documents (including electronic storage media)
pertinent to performance under this Contract for a
period of five (5) years after termination of this
Contract, or if an audit has been initiated and audit
findings have not been resolved at the end of five
(5) years, the records shall be retained until
resolution of the audit findings.
2.
Persons duly authorized by the Agency and federal
auditors, pursuant to 45 CFR, Part 74 and/or 45 CFR,
Part 92, shall have full access to and the right to
examine any of said records and documents.
3. The
rights of access in this section must not be
limited to the required retention period but shall
last as long as the records are retained.
E.
MONITORING
1. To
provide reports as specified in ATTACHMENT I.
These reports will be used for monitoring progress or
performance of the contractual services as specified
in ATTACHMENT I.
2. To
permit persons duly authorized by the Agency to
inspect any records, papers, documents, facilities,
goods and services of the Vendor which are relevant
to this Contract.
F.
INDEMNIFICATION
The Contractor shall save and hold harmless and indemnify the
State of Florida and the Agency against any and all liability,
claims, suits, judgments, damages or costs of whatsoever kind
and nature resulting from the use, service, operation or
performance of work under the terms of this Contract,
resulting from any act, or failure to act, by the Vendor, his
subcontractor, or any of the employees, agents or
representatives of the Vendor or subcontractor.
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G.
INSURANCE
1. To
the extent required by law, the Vendor will be
self-insured against, or will secure and maintain
during the life of the
Contract, Worker's
Compensation Insurance for all his employees
connected with the work of this project and, in case
any work is subcontracted, the Vendor shall require
the subcontractor similarly to provide Worker's
Compensation Insurance for all of the latter's
employees unless such employees engaged in work under
this Contract are covered by the Vendor's self
insurance program. Such self insurance or insurance
coverage shall comply with the Florida Worker's
Compensation law. In the event hazardous work is
being performed by the Vendor under this Contract and
any class of employees performing the hazardous work
is not protected under Worker's Compensation
statutes, the Vendor shall provide, and cause each
subcontractor to provide, adequate insurance
satisfactory to the Agency, for the protection of his
employees not otherwise protected.
2. The
Vendor shall secure and maintain Commercial
General Liability insurance including bodily injury,
property damage, personal & advertising injury and
products and completed operations. This insurance
will provide coverage for all claims that may arise
from the services and/or operations completed under
this Contract, whether such services and/or
operations are by the Vendor or anyone directly, or
indirectly employed by him. Such insurance shall
include a Hold Harmless Agreement in favor of the
State of Florida and also include the State of
Florida as an Additional Named Insured for the entire
length of the Contract. The Vendor is responsible for
determining the minimum limits of liability necessary
to provide reasonable financial protections to the
Vendor and the State of Florida under this Contract.
3. All
insurance policies shall be with insurers
licensed or eligible to transact business in the
State of Florida. The Vendor's current certificate of
insurance shall contain a provision that the
insurance will not be canceled for any reason except
after thirty (30) days written notice to the Agency's
Contract Manager.
H.
ASSIGNMENTS AND SUBCONTRACTS
To neither assign the responsibility of this Contract to
another party nor subcontract for any of the work contemplated
under this Contract without prior written approval of the
Agency. No such approval by the Agency of any assignment or
subcontract shall be deemed in any event or in any manner to
provide for the incurrence of any obligation of the Agency in
addition to the total dollar amount agreed upon in this
Contract. All such assignments or subcontracts shall be
subject to the conditions of this Contract and to any
conditions of approval that the Agency shall deem necessary.
I.
FINANCIAL REPORTS
To provide financial reports to the Agency as specified in
ATTACHMENT I.
J.
RETURN OF FUNDS
To return to the Agency any overpayments due to unearned funds
or funds disallowed pursuant to the terms of this Contract
that were disbursed to the
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Vendor by the Agency. The Vendor shall return any overpayment
to the Agency within forty (40) calendar days after either
discovery by the Vendor, its independent auditor, or
notification by the Agency, of the overpayment.
K.
PURCHASING
1.
P.R.I.D.E.
It is expressly understood and agreed that any
articles which are the subject of, or required to
carry out this Contract shall be purchased from the
corporation identified under Chapter 946, Florida
Statutes, if available, in the same manner and under
the same procedures set forth in Section 946.515(2),
(4), Florida Statutes; and for purposes of this
Contract the person, firm or other business entity
carrying out the provisions of this Contract shall be
deemed to be substituted for this agency insofar as
dealings with such corporation are concerned.
The "Corporation identified" is PRISON REHABILITATIVE
INDUSTRIES AND DIVERSIFIED ENTERPRISES, INC.
(P.R.I.D.E.) which may be contacted at:
P.R.I.D.E.
2720-G Blair Stone Road
Tallahassee, Florida 32301
(850) 487-3774
Toll Free: 1-800-643-8459
Website: www.pridefl.com
2.
RESPECT OF FLORIDA
It is expressly understood and agreed that any
articles that are the subject of, or required to
carry out, this Contract shall be purchased from a
nonprofit agency for the blind or for the severely
handicapped that is qualified pursuant to Chapter
413, Florida Statutes, in the same manner and under
the same procedures set forth in Section 413.036(1)
and (2), Florida Statutes; and for purposes of this
Contract the person, firm, or other business entity
carrying out the provisions of this Contract shall be
deemed to be substituted for the state agency insofar
as dealings with such qualified nonprofit agency are
concerned.
The "nonprofit agency" identified is RESPECT of
Florida which may be contacted at:
RESPECT of Florida.
2475 Apalachee Parkway, Suite 205
Tallahassee, Florida 32301-4946
(850) 487-1471
Website: www.respectofflorida.org
3.
PROCUREMENT OF PRODUCTS OR MATERIALS WITH RECYCLED
CONTENT
It is expressly understood and agreed that any
products which are required to carry out this
Contract shall be procured in accordance with the
provisions of
Section 403.7065, Florida Statutes.
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L.
CIVIL RIGHTS REQUIREMENTS/VENDOR ASSURANCE
The Vendor assures that it will comply with:
1.
Title VI of the Civil Rights Act of 1964, as amended,
42 U.S.C. 2000d et seq., which prohibits
discrimination on the basis of race, color, or
national origin.
2.
Section 504 of the Rehabilitation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits
discrimination on the basis of handicap.
3.
Title IX of the Education Amendments of 1972, as
amended, 20 U.S.C. 1681 et seq., which prohibits
discrimination on the basis of sex.
4. The
Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination
on the basis of age.
5.
Section 654 of the Omnibus Budget Reconciliation Act
of 1981, as amended, 42 U.S.C. 9849, which prohibits
discrimination on the basis of race, creed, color,
national origin, sex, handicap, political affiliation
or beliefs.
6. The
Americans with Disabilities Act of 1990, P.L.
101-336, which prohibits discrimination on the basis
of disability and requires reasonable accommodation
for persons with disabilities.
7. All
regulations, guidelines, and standards as are now
or may be lawfully adopted under the above statutes.
The Vendor agrees that compliance with this assurance
constitutes a condition of continued receipt of or benefit
from funds provided through this Contract, and that it is
binding upon the Vendor, its successors, transferees, and
assignees for the period during which services are provided.
The Vendor further assures that all contractors,
subcontractors, subgrantees, or others with whom it arranges
to provide services or benefits to participants or employees
in connection with any of its programs and activities are not
discriminating against those participants or employees in
violation of the above statutes, regulations, guidelines, and
standards.
M.
DISCRIMINATION
An entity or affiliate who has been placed on the
discriminatory vendor list may not submit a bid, proposal, or
reply on a contract to provide any goods or services to a
public entity; may not submit a bid, proposal, or reply on a
contract with a public entity for the construction or repair
of a public building or public work; may not submit bids,
proposals, or replies on leases of real property to a public
entity; may not be awarded or perform work as a contractor,
supplier, subcontractor, or consultant under a contract with
any public entity; and may not transact business with any
public entity. The Florida Department of Management Services
is responsible for maintaining the discriminatory vendor list
and intends to post the list on its website. Questions
regarding the discriminatory vendor list may be directed to
the Florida Department of Management Services, Office of
Supplier Diversity at (850) 487-0915.
N.
REQUIREMENTS OF SECTION 287.058, FLORIDA STATUTES
1. To
submit bills for fees or other compensation for
services or expenses in sufficient detail for a
proper pre-audit and post-audit thereof.
2.
Where applicable, to submit bills for any travel
expenses in accordance with Section 112.061, Florida
Statutes. The Agency may, when specified
AHCA CONTRACT NO. FA522, PAGE 5 OF 10
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in N/A, establish rates lower than the maximum
provided in Section 112.061, Florida Statutes.
3. To
provide units of deliverables, including reports,
findings, and drafts, in writing and/or in an
electronic format agreeable to both parties, as
specified in ATTACHMENT I, to be received and
accepted by the Contract Manager prior to payment.
4. To
comply with the criteria and final date by which
such criteria must be met for completion of this
Contract as specified in Section III, Paragraph A. of
this Contract.
5. To
allow public access to all documents, papers,
letters, or other material made or received by the
Vendor in conjunction with this Contract, unless the
records are exempt from Section 24(a) of Article I of
the State Constitution and Section 119.07(1), Florida
Statutes. It is expressly understood that substantial
evidence of the Vendor's refusal to comply with this
provision shall constitute a breach of Contract.
6. In
accordance with Section 287.057 (14), this
Contract may be renewed for a period that may not
exceed three (3) years or the term of the original
Contract, whichever period is longer, unless
otherwise specified in ATTACHMENT I. Renewal of this
Contract shall be in writing and subject to the same
terms and conditions set forth in the initial
Contract prior to Contract termination. A renewal
contract may not include any compensation for costs
associated with the renewal. Renewals are contingent
upon satisfactory performance evaluations by the
Agency and subject to the availability of funds. A
renewal clause, including terms under which the cost
may change, must be specified in the invitation to
bid, request for proposal, or other bid instrument,
if applicable. This Contract may not be renewed if it
is the result of an emergency or single source method
of procurement.
O.
SPONSORSHIP
As required by Section 286.25, Florida Statutes, if the Vendor
is a nongovernmental organization which sponsors a program
financed wholly or in part by state funds, including any funds
obtained through this Contract, it shall, in publicizing,
advertising or describing the sponsorship of the program,
state:
"Sponsored by WELL
CARE HMO, INC. D/B/A STAYWELL HEALTH PLAN
OF FLORIDA and the State of Florida, AGENCY FOR HEALTH CARE
ADMINISTRATION".
If the sponsorship reference is in written material, the words
"State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION"
shall appear in the same size letters or type as the name of
the organization.
P.
FINAL INVOICE
The Vendor must submit the final invoice for payment to the
Agency no more than 90 days after the Contract ends or is
terminated. If the Vendor fails to do so, all right to payment
is forfeited and the Agency will not honor any requests
submitted after the aforesaid time period. Any payment due
under
AHCA CONTRACT NO. FA522, PAGE 6 OF 10
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the terms of this Contract may be withheld until all reports
due from the Vendor and necessary adjustments thereto have
been approved by the Agency.
Q. USE
OF FUNDS FOR LOBBYING PROHIBITED
To comply with the provisions of Section 216.347, Florida
Statutes, which prohibits the expenditure of Contract funds
for the purpose of lobbying the Legislature, the judicial
branch or a state agency.
R.
PUBLIC ENTITY CRIME
A person or affiliate who has been placed on the convicted
vendor list following a conviction for a public entity crime
may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public
entity, and may not transact business with any public entity
in excess of the threshold amount provided in Section 287.017,
Florida Statutes, for category two, for a period of 36 months
from the date of being placed on the convicted vendor list.
S.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
To comply with the Department of Health and Human Services
Privacy Regulations in the Code of Federal Regulations, Title
45, Sections 160 and 164, regarding disclosure of protected
health information as specified in ATTACHMENT III.
T.
CONFIDENTIALITY OF INFORMATION
Not to use or disclose any confidential information, including
social security numbers that may be supplied under this
Contract pursuant to law, and also including the identity or
identifying information concerning a Medicaid recipient or
services under this Contract for any purpose not in conformity
with state and federal laws, except upon written consent of
the recipient, or his/her guardian.
U.
EMPLOYMENT
To comply with Section 274A (e) of the Immigration and
Nationality Act. The Agency shall consider the employment by
any contractor of unauthorized aliens a violation of this Act.
If the Vendor knowingly employs unauthorized aliens, such
violation shall be cause for unilateral cancellation of this
Contract. The Vendor shall be responsible for including this
provision in all subcontracts with private organizations
issued as a result of this Contract.
V.
VENDOR PERFORMANCE
Penalties or sanctions for unsatisfactory performance under
this Contract are specified in ATTACHMENT I, if applicable.
II. THE AGENCY
HEREBY AGREES:
A.
CONTRACT AMOUNT
To pay for contracted services according to the conditions of
ATTACHMENT I in an amount not to exceed $634,852,345.00,
subject to the availability of funds.
AHCA CONTRACT NO. FA522, PAGE 7 OF 10
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The State of Florida's performance and obligation to pay under
this Contract is contingent upon an annual appropriation by
the Legislature.
B.
CONTRACT PAYMENT
Section 215.422, Florida Statutes, provides that agencies have
5 working days to inspect and approve goods and services,
unless bid specifications, Contract or purchase order
specifies otherwise. With the exception of payments to health
care providers for hospital, medical, or other health care
services, if payment is not available within forty (40) days,
measured from the latter of the date the invoice is received
or the goods or services are received, inspected and approved,
a separate interest penalty set by the Comptroller pursuant to
Section 55.03, F. S., will be due and payable in addition to
the invoice amount. To obtain the applicable interest rate,
please contact the Agency's Fiscal Section at (850) 488-5869,
or utilize the Department of Financial Services website at
www.dfs.state.fl.us/interest.html. Payments to health care
providers for hospitals, medical or other health care
services, shall be made not more than 35 days from the date of
eligibility for payment is determined, and the daily interest
rate is .0003333%. Invoices returned to a vendor due to
preparation errors will result in a payment delay. Invoice
payment requirements do not start until a properly completed
invoice is provided to the Agency. A Vendor Ombudsman, whose
duties include acting as an advocate for vendors who may be
experiencing problems in obtaining timely payment(s) from a
State agency, may be contacted at (850) 410-9724 or by calling
the State Comptroller's Hotline, 1-800-848-3792.
III. THE VENDOR AND
AGENCY HEREBY MUTUALLY AGREE:
A.
EFFECTIVE/END DATE
This Contract shall begin upon execution by both parties or
JULY 1, 2004, (whichever is later) and end JUNE 30, 2006,
inclusive.
B.
TERMINATION
1.
TERMINATION AT WILL
This Contract may be terminated by either party upon
no less than thirty (30) calendar days written
notice, without cause, unless a lesser time is
mutually agreed upon by both parties. Said notice
shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery.
2.
TERMINATION DUE TO LACK OF FUNDS
In the event funds to finance this Contract become
unavailable, the Agency may terminate the Contract
upon no less than twenty-four (24) hours written
notice to the Vendor. Said notice shall be delivered
by certified mail, return receipt requested, or in
person with proof of delivery. The Agency shall be
the final authority as to the availability of funds.
3.
TERMINATION FOR BREACH
Unless the Vendor's breach is waived by the Agency in
writing, the Agency may, by written notice to the
Vendor, terminate this Contract upon no less than
twenty-four (24) hours written notice. Said notice
shall be delivered by certified mail, return receipt
requested, or in person with
AHCA CONTRACT NO. FA522, PAGE 8 OF 10
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proof of delivery. If applicable, the Agency may
employ the default provisions in Chapter
60A-1.006(4), Florida Administrative Code.
Waiver of breach of any provisions of this Contract shall not
be deemed to be a waiver of any other breach and shall not be
construed to be a modification of the terms of this Contract.
The provisions herein do not limit the Agency's right to
remedies at law or to damages.
C.
CONTRACT MANAGERS
1. The
Agency's Contract Manager's name, address and
telephone number for this Contract is as follows:
CHRISTINA LOPEZ
AGENCY FOR HEALTH CARE ADMINISTRATION
2727 MAHAN DRIVE, MS 50
TALLAHASSEE, FL
32308
(850) 487-2355
2. The
Vendor's Contract Manager's name, address and
telephone number for this Contract is as follows:
TODD S. FARHA
WELL CARE HMO INC.,
D/B/A STAYWELL HEALTH PLAN OF FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
(813) 290-6377
3. All
matters shall be directed to the Contract
Managers for appropriate action or disposition. A
change in Contract Manager by either party shall be
reduced to writing through an amendment to this
Contract by the Agency.
D.
RENEGOTIATION OR MODIFICATION
1.
Modifications of provisions of this Contract shall
only be valid when they have been reduced to writing
and duly signed during the term of the Contract. The
parties agree to renegotiate this Contract if federal
and/or state revisions of any applicable laws, or
regulations make changes in this Contract necessary.
2. The
rate of payment and the total dollar amount may
be adjusted retroactively to reflect price level
increases and changes in the rate of payment when
these have been established through the
appropriations process and subsequently identified in
the Agency's operating budget.
E.
NAME, MAILING AND STREET ADDRESS OF PAYEE
1. The
name (Vendor name as shown on Page 1 of this
Contract) and mailing address of the official payee
to whom the payment shall be made:
WELL CARE HMO INC., D/B/A STAYWELL HEALTH PLAN OF
FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
AHCA CONTRACT NO. FA522, PAGE 9 OF 10
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2. The
name of the contact person and street address
where financial and administrative records are
maintained:
TODD S. FARHA
WELL CARE HMO INC., D/B/A STAYWELL HEALTH PLAN OF
FLORIDA
6800 N. DALE MABRY HIGHWAY, SUITE 168
TAMPA, FL 33614
F. ALL
TERMS AND CONDITIONS
This Contract and its attachments as referenced herein contain
all the terms and conditions agreed upon by the parties.
IN WITNESS THEREOF, the parties hereto have
caused this 186 page Contract, which
includes any referenced attachments, to be
executed by their undersigned
officials as duly authorized. This Contract
is not valid until signed and dated
by both parties.
VENDOR: WELL CARE HMO INC.,
STATE OF FLORIDA, AGENCY FOR
D/B/A STAYWELL HEALTH
HEALTH CARE ADMINISTRATION
PLAN OF FLORIDA
SIGNED
SIGNED
BY: _____________________________
BY:____________________________
NAME: TODD S. FARHA
NAME: ALAN LEVINE
TITLE: PRESIDENT AND CHIEF EXECUTIVE
TITLE:SECRETARY
OFFICER
DATE:
_____________________________
DATE:_____________________________
FEDERAL ID NUMBER (OR SS NUMBER FOR AN
INDIVIDUAL): 59-2583622
VENDOR FISCAL YEAR ENDING DATE: DECEMBER
31, 2004
List of attachments included as part of
this Contract:
Specify
Type
Number
Description (include number of pages)
----------------------------------------------------------------------
Attachment I
Scope of Services (166 Pages)
Attachment II
Financial and Compliance Audit (3 Pages)
Attachment III Health
Insurance Portability and
Accountability Act of 1996 Compliance
(2 Pages)
Attachment IV
Certification Regarding Lobbying (1 Page)
Attachment V
Certification Regarding Debarment (1 Page)
Attachment VI
2004-2005 HMO Rates (3 Pages)
AHCA CONTRACT NO. FA522, PAGE 10 OF 10
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July 2004
Medicaid HMO Contract
ATTACHMENT I
SCOPE OF SERVICES
10.0 COVERED SERVICES
AND ELIGIBLE BENEFICIARIES
10.1 GENERAL
The health maintenance organization vendor, hereinafter referred to
as
the plan, shall comply with all the provisions of this contract and
its
amendments, if any, and shall act in good faith in the performance
of
the contract provisions. The plan shall develop and maintain
written
policies and procedures to implement the provisions of this
contract.
The plan agrees that failure to comply with these provisions may
result
in the assessment of penalties and/or termination of the contract
in
whole or in part, as set forth in this contract.
The plan shall comply with all pertinent Agency rules in effect
throughout the duration of the contract.
The plan shall comply with all current Agency handbooks noticed in
or
incorporated by reference in rules relating to the provision of
services set forth in sections 10.4, Covered Services, and
10.5,
Optional Services, except where the provisions of the contract
alter
the requirements set forth in the handbooks. In addition, the
plan
shall comply with the limitations and exclusions in the Agency
handbooks unless otherwise specified by this contract. In no
instance
may the limitations or exclusions imposed by the plan be more
stringent
than those specified in the handbooks. Pursuant to 42 CFR
438.210(a)
the plan must furnish services up to the limits specified by
the
Medicaid program. The plan may exceed these limits. However,
service
limitations shall not be more restrictive than the Florida
fee-for-service program, pursuant to 42 CFR 438.210(a).
Upon implementation of the Medicaid Prepaid Mental Health program
in
each Area the plan shall provide community mental health services
and
mental health targeted case management services in accordance
with
section 10.11, Behavioral Health Care, of this contract. Sections
2.2,
2.3 and 2.5 of the Area specific Prepaid Mental Health Plan
(PMHP)
requests for proposals (RFP) will apply to the respective Area
members.
All other general behavioral health service requirements shall
also
apply.
The plan may offer services to enrolled Medicaid beneficiaries
in
addition to those covered services specified in sections 10.4,
Covered
Services, 10.8, Manner of Service Provision, and 10.9, Quality
and
Benefit Enhancements. These services must be specifically defined
in
regards to amount, duration and scope, and must be approved in
writing
by the Agency prior to implementation.
The plan shall have a quality improvement program that ensures
enhancement of quality of care and emphasize quality patient
outcomes.
The Agency may restrict the plan's enrollment activities if
acceptable
quality improvement and performance indicators based on HEDIS and
other
outcome measures to be determined by the Agency are not met.
Such
restrictions may include the termination of mandatory
assignments.
10.2 ELIGIBLE
BENEFICIARIES
The categories of eligible beneficiaries authorized to be enrolled
in
the plan are: Low Income Families and Children; Foster Care;
Sixth
Omnibus Budget Reconciliation Act (SOBRA) Children;
Supplemental
Security Income (SSI) Medicaid Only; SSI Medicare Part B Only; and
SSI
Medicare Parts A & B. Beneficiaries who are residents of
Assisted
Living Facilities (ALFs) and not enrolled in an ALF waiver program
are
eligible for enrollment in the plan. Title XXI MediKids are
eligible
for enrollment in the plan in accordance with section 409.8132,
F.S.
Except as otherwise specified in this contract, Title XXI
MediKids
eligible participants are entitled to the same conditions and
services
as currently eligible Title XIX Medicaid beneficiaries. In
addition,
women enrolled in the plan who change eligibility categories to
the
SOBRA eligibility category due to their pregnancy will remain
eligible
for enrollment in the plan.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 1 OF 166
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\
July 2004
Medicaid HMO Contract
10.3 INELIGIBLE
BENEFICIARIES
The following categories describe beneficiaries who are not
eligible to
enroll in the plan:
a.
Medicaid eligible beneficiaries who, at the time of
application for enrollment and/or at the time of enrollment,
are domiciled or residing in an institution, including nursing
facilities (because the beneficiary was assessed by
Comprehensive Assessment and Review for Long Term Care (CARES)
and found to be at a custodial level of care), intermediate
care facilities for persons with developmental disabilities,
state hospitals or correctional institutions.
b.
Medicaid eligible beneficiaries who are receiving services
through a hospice program, the Medicaid AIDS waiver (Project
AIDS Care) program, a prescribed pediatric extended care
center, or enrolled in Children's Medical Services.
c.
Medicaid eligible beneficiaries who are also members of a
Medicare-funded health maintenance organization (HMO).
d.
Medicaid eligible beneficiaries whose Medicaid eligibility has
been determined through the medically needy program.
e.
Qualified Medicare beneficiaries (QMBs).
f.
Medicaid eligible beneficiaries who have other credible health
care coverage like TriCare or a private HMO.
g.
Medicaid eligible beneficiaries who reside in the following:
1.
Residential commitment programs/facilities operated
through the Department of Juvenile Justice (DJJ).
2.
Residential group care operated by the Family Safety
and Preservation Program in the Department of
Children and Families (DCF).
3.
Children's residential treatment facilities purchased
through the Alcohol, Drug Abuse, and Mental Health
Program Office (ADM)
in DCF (Purchased Residential
Treatment Services - PRTS).
4. ADM
residential treatment facilities licensed as
Level I and II facilities.
5.
Residential Level I and Level II substance abuse
treatment programs pursuant to section
65D-30.007(2)(a) and (b), F.A.C.
h.
Family Planning waiver beneficiaries.
i. Medicaid
eligible beneficiaries in the following programs may
not enroll in a frail/elderly component of a Medicaid HMO:
1. An
aged/disabled waiver program
2. The
Channeling program
3.
Developmental Services Waiver
4. TANF
beneficiaries
5. The
Assisted Living for the Elderly waiver, or
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 2 OF 166
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July 2004
Medicaid HMO Contract
j.
Medicaid eligible beneficiaries who are members of the Florida
Assertive Community Treatment Team (FACT team) in those areas
in which
the HMO is responsible for community mental health
and targeted case management services.
k.
Participants in the Sub-acute Inpatient Psychiatric Program
(SIPP).
l.
Pregnant women not enrolled in the plan prior to the effective
date of their SOBRA eligibility.
10.4 COVERED
SERVICES
The plan shall ensure the provision of the following covered
services
as defined and specified in sections 10.1, General and 10.8, Manner
of
Service Provision:
Child Health Check-Up
Inpatient Hospital
Services
Community Mental Health Services.
Mental Health
Targeted Case
Management
Family Planning Services
Outpatient Hospital
and Emergency
Services
Freestanding Dialysis Centers
Physician Services
Hearing Services
Prescribed Drug
Services
Home Health Services and Durable Medical Equipment Therapy Services
Independent Laboratory and X-Ray Services
Visual Services
THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 3 OF 166
<PAGE>
WellCare HMO d/b/a StayWell Health Plan of
Florida
Medicaid HMO Contract
July 1, 2004
10.5 OPTIONAL
SERVICES
These services are rendered within Medicaid guidelines at the
option of
the plan and the Agency.
Covered
Not Covered
Dental Services
_____________________
X
Transportation Services X (Dade Only)
_____________________
Frail/Elderly Program
X
_____________________
(in accordance with Exhibit 110.4 of this contract)
10.6 EXPANDED
SERVICES
These services are defined as those offered by the plan and
approved by
the Agency, which are as follows:
a.
Services in excess of the amount, duration and scope of those
listed in sections 10.4, Covered Services, and 10.5, Optional
Services.
b.
Services and benefits not listed in sections 10.4 and 10.5.
c. The
plan may offer an Agency approved over-the-counter
expanded drug benefit, not to exceed $10.00 per household, per
month. Such benefits shall be limited to non-prescription
drugs containing a National Drug Code (NDC) number, and first
aid and birth control supplies. Such benefits must be offered
through a plan's pharmacy or plan's subcontract with a
pharmacy. The plan shall make payments for the
over-the-counter drug benefit directly to the pharmacy.
The following is a list of expanded services:
1.
OVER
THE COUNTER DRUGS AND FIRST AID ITEMS not to exceed $10 per
month, per household through mail order program.
2.
ADULT
DENTAL SERVICES FOR BENEFICIARIES AGE 21 AND ABOVE office
visits, x-rays, exams as needed, two cleanings per year, no
limit
on one and two surface filings (amalgam and silver), one three
surface silver filling per year, four simple extractions at no
cost (non emergency), two surgical extractions per year (non
emergency) when medically necessary.
3.
ADULT EYE EXAMS AND GLASSES FOR BENEFICIARIES AGE 21 AND ABOVE
Unlimited routine eye exams and unlimited glasses as medically
necessary.
4.
ADULT HEARING SERVICES FOR BENEFICIARIES AGE 21 AND ABOVE One
hearing aid (limited selection) every three years, if medically
necessary.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 4 OF 166
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July 2004
Medicaid HMO Contract
10.7 EXCLUDED
SERVICES
The plan is not obligated to provide for the services that are
not
specified in sections 10.4, Covered Services, 10.5, Optional
Services,
10.6, Expanded Services and 10.9, Quality and Benefit
Enhancements.
Plan members who require services available through Medicaid but
not
covered by this contract shall receive these services through
the
existing Medicaid fee-for-service reimbursement system. The plan
shall
determine the need for these services and refer the member to
the
appropriate service
provider. The plan may request the assistance of
the local Medicaid Field Office for referral to the appropriate
service
setting.
For members requiring long term care institutional services,
institutional services for persons with developmental disabilities
or
state hospital services, the plan shall consult the DCF office
to
identify appropriate methods of assessment and referral. The plan
is
responsible for transition and referral to appropriate service
providers, including helping the member to obtain an attending
physician. Members requiring these services shall be disenrolled
from
the plan in accordance with section 30.11, Disenrollment, of
this
contract, except as required by Frail Elderly Program component
requirements, see Exhibit 110.4.
10.8 MANNER OF
SERVICE PROVISION
The Florida Medicaid Program provides multiple services/programs
for
Medicaid eligible beneficiaries. The service definitions that
follow
are those required by federal or state rule. The plan must
furnish
services up to the limits specified by the Medicaid program. The
plan
is responsible for contracting with providers who meet all provider
and
service and product standards specified in the Agency's
Medicaid
Services Coverage and Limitations handbooks and the plan's
provider
handbooks, which must be incorporated in all plan subcontracts
by
reference, for each service category covered by the plan.
Exceptions
exist where different standards are specified elsewhere in this
contract or if the standard is waived in writing by the Division
of
Medicaid on a case-by-case basis when the member's medical needs
would
be equally or better served in an alternative care setting or
using
alternative therapies or devices within the prevailing medical
community.
10.8.1 CHILD HEALTH CHECK-UP
Child Health Check-Up (CHCUP) services are comprehensive and
preventive
health examinations provided on a periodic basis that are aimed
at
identifying and correcting medical conditions in children and
young
people (birth through 20 years of age). Policies and procedures
are
described in the Child Health Check-Up Services Coverage and
Limitations Handbook. Policy requirements include:
a. The
health screening examination shall consist of:
comprehensive health and developmental history including
assessment of past medical history, developmental history and
behavioral health status; comprehensive unclothed physical
examination; developmental assessment; nutritional assessment;
appropriate immunizations according to the appropriate
Recommended Childhood Immunization Schedule for the United
States; laboratory testing (including blood lead test where
required; for children who the plan identifies through blood
lead screenings as having abnormal levels of lead, the plan
shall provide case management follow-up services as required
in chapter 2 of the Child Health Check-Up Services Coverage
and Limitations Handbook.); health education (including
anticipatory guidance); dental screening (including a direct
referral
to a dentist, or to a Prepaid Dental Health Plan
(PDHP) where applicable for members beginning at 3 years of
age or earlier as indicated); vision screening including
objective testing when required; and hearing screening
including objective testing, when required; diagnosis and
treatment; and referral and follow-up, as appropriate.
b.
Members shall be informed by the Agency through its fiscal
agent, of screenings due in accordance with the periodicity
schedule as specified in the Medicaid Child Health Check-Up
Services Coverage and Limitations Handbook. The plan is
required to contact members and follow-up on the state-issued
CHCUP letter to encourage the member to come in for a health
assessment and preventive care.
c.
Members must be referred to appropriate service providers for
further assessment and treatment of conditions found in the
examination within six months after the request for a CHCUP.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 5 OF 166
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Medicaid HMO Contract
d.
Members must be offered scheduling assistance to make medical
appointments and to obtain transportation.
e. This
service includes the maintenance of a coordinated system
to follow the member through the entire range of screening and
treatment, as well as supplying CHCUP training to providers.
f. In
accordance with section 409.912, F.S., the plan shall
achieve a CHCUP screening rate of at least 60 percent for
those members who are continuously enrolled for at least eight
(8) months. This screening compliance rate shall be based on
the CHCUP screening data reported by the plan pursuant to
section 60.0, Reporting Requirements of this contract, and the
data reported shall be monitored by the Agency for accuracy.
The plan must complete both the CHCUP Report template and the
- 60 percent Screening Ratio Template. If the plan does not
achieve the 60 percent screening ratio, a corrective action
plan is required to be filed with the Agency no later than
February 15th. Any data reported that is found to be
inaccurate shall be disallowed by the Agency and the Agency
may consider such findings as being in violation of the
contract (refer to section 70.17, Sanctions).
In addition to the above requirement, the plan shall adopt
annual screening and participation goals to achieve at least
an 80 percent CHCUP screening and participation rate in
accordance with section 5360, Annual Participation Goals, of
the State Medicaid Manual. If the plan does not meet the 80
percent screening and participation ratios, a corrective
action plan must be filed with the Agency no later than
February 15th.
10.8.2 DENTAL SERVICES
(OPTIONAL)
Dental services are defined in the Medicaid Dental Services
Coverage
and Limitations Handbook. Children's Medicaid dental services
include
diagnostic services, preventive treatment, restorative
treatment,
endodontic treatment, periodontal treatment, restorative
treatment,
surgical procedures and/or extractions, orthodontic treatment
and
complete and partial dentures for beneficiaries under age 21.
Complete
and partial denture relines and repairs are also included, as well
as
adjunctive and emergency services. Adult services include
medically
necessary, emergency dental procedures to alleviate pain or
infection.
Emergency dental care shall be limited to emergency oral
examinations,
necessary radiographs, extractions, and incision and drainage
of
abscess.
10.8.3 DIABETES SUPPLIES AND
EDUCATION
In the same manner as specified in section 641.31, F.S., the plan
shall
provide coverage for medically appropriate and necessary
equipment,
supplies, and services used to treat diabetes, including
outpatient
self-management training and educational services, if the
member's
primary care physician, or the physician to whom the patient has
been
referred who specializes in treating diabetes, certifies that
the
equipment, supplies and services are necessary.
10.8.4 FAMILY PLANNING SERVICES
These services are rendered for the purposes of enabling
eligible
beneficiaries to make comprehensive, informed decisions about
family
size
and/or spacing of births as specified in the Medicaid Services
Coverage and Limitations handbooks. The provider provides the
following
minimum services: plan and referral; education and counseling;
initial
examination; diagnostic procedures and routine laboratory
studies;
contraceptive drugs and supplies; and follow-up care in accordance
with
the Medicaid Physicians Services Coverage and Limitations
Handbook.
Policy requirements include:
a.
The
plan shall furnish the services on a voluntary and
confidential basis.
b. The
plan shall allow members full freedom of choice of family
planning methods covered under the Medicaid program, including
Medicaid covered implants, when there are no medical
contraindications.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 6 OF 166
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July 2004
Medicaid HMO
Contract
c. In
accordance with section 381.0051, F.S., the plan shall
render these services to eligible members under the age of 18
provided the member is married, a parent, pregnant, has
written consent by a parent or legal guardian, or in the
opinion of a physician, the member may suffer health hazards
if the service is not provided.
d. The
provisions of this subsection shall not be interpreted so
as to prevent a provider or other person from refusing to
furnish any contraceptive or family planning service,
supplies, or information for medical or religious reasons; and
the provider or other person shall not be held liable for such
refusal.
e.
Pursuant to 42 CFR 431.51 (b), the plan shall allow each
member to obtain family planning services from any
participating Medicaid provider and require no prior
authorization for such services. If the member receives
services from a non-plan Medicaid provider, then the plan must
reimburse at the Medicaid reimbursement rate, unless another
payment rate is negotiated.
f. In
accordance with section, 409.912, F.S. the plan shall make
available and encourage all pregnant women and mothers with
infants to receive, scheduled postpartum visits for the
purpose of voluntary family planning, including discussion of
all methods of contraception, as appropriate, and counseling
and services for family planning to all women and their
partners. The plan shall direct providers to maintain
documentation in the medical records to reflect this.
10.8.5 FREESTANDING DIALYSIS
FACILITY SERVICES
Program requirements are specified in section 409.906, F.S., and
the
Freestanding Dialysis Center Services Coverage and Limitations
Handbook. Such services must be provided in accordance with the
policy
and service provisions specified by fee-for-service Medicaid.
10.8.6 HEARING SERVICES
These services include a hearing evaluation, diagnostic testing
and
selective amplification procedures necessary to certify an
individual
for a hearing aid device, and fitting and dispensing of hearing
aids
and repair services as specified in the Medicaid Hearing
Services
Coverage and Limitations Handbook. Medical and surgical treatment
for
hearing disorders is part of physician services.
10.8.7 HOME HEALTH CARE SERVICES
AND DURABLE MEDICAL EQUIPMENT
These services are intermittent nursing services by a registered
nurse
or licensed practical nurse and/or personal care services by a
home
health aide with accompanying necessary medical supplies,
appliances
and durable equipment appropriate for use in the beneficiary's
place of
residence. These services are provided for eligible
beneficiaries
primarily to maintain physical and emotional comfort and to assist
the
beneficiary toward independent living in a safe environment as
specified in the Medicaid Home Health Services Coverage and
Limitations
and the Durable Medical Equipment (DME)/Medical Supplies
Services
Coverage and Limitations Handbook. Policy requirements include, but
are
not limited to:
a. All
services and medical equipment furnished by the plan shall
be contained in an individualized written plan of care
developed by health care professionals, including the
attending physician. The plan of care is designed to meet the
medical, health, and rehabilitative needs of the recipient and
is approved by the attending physician as evidenced by his or
her original signature and re-approved at least:
-
Every 60 days or whenever the beneficiary's condition
for home health services changes.
-
For disposable medical supplies, the medical
necessity must be re-determined every 6 months and
the prescription cannot be dated more than 14 days
after initiation.
-
For oxygen services, the medical necessity renewal
time frame is 12 months.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 7 OF 166
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July 2004
Medicaid HMO Contract
b.
Services rendered by a home health aide shall be under the
continuous supervision of a registered nurse.
c. All
services provided to Medicaid beneficiaries in their place
of residence shall be prescribed by a physician. Provision of
medically necessary supplies/DME does not require a
beneficiary to be homebound.
d.
Medical equipment as specified in the DME/Medical Supplies
Services Coverage and Limitations Handbook.
10.8.8 HOSPITAL SERVICES
10.8.8.1 INPATIENT
These services are medically necessary services ordinarily
furnished by
a state licensed acute care hospital for the medical care and
treatment
of inpatients provided under the direction of a physician or
dentist in
a hospital maintained primarily for the care and treatment of
patients
with disorders other than mental diseases. Inpatient hospital
services
include but are not limited to medical supplies, diagnostic and
therapeutic services, use of facilities, drugs and biologicals,
room
and board, nursing care and all supplies and equipment necessary
to
provide adequate care as specified in the Medicaid Hospital
Services
Coverage and Limitations Handbook. This service includes inpatient
care
for any diagnosis including psychiatric and mental health (Baker
Act
and non-Baker Act), tuberculosis and renal failure when provided
by
general acute care hospitals in both emergent and non-emergent
conditions. Inpatient hospital services include rehab hospital
care.
Rehab inpatient care days are also counted as inpatient hospital
days.
The plan may provide services in a nursing home as downward
substitution for inpatient care. Such services shall not be counted
as
inpatient hospital days.
The service also includes the following:
a.
Medically necessary and appropriate transplants: bone marrow,
all ages; cornea, all ages; and kidney, all ages. For other
transplants not covered by Medicaid, the evaluations,
pre-transplant care and post-transplant follow-up care are
covered by Medicaid and, therefore, must be covered by the
plan even though the transplant procedure is not covered.
Transplant service components are also covered under
outpatient services, physician services and prescribed drug
services per the applicable Medicaid Services Coverage and
Limitations handbooks.
The plan is not responsible for the cost of transplant
evaluations, pre-transplant care and post transplant
follow-up, when an adult member (age 21 and over) is listed
with the United Network for Organ Sharing (UNOS) as a level
1A, 1B, or 2 candidate for heart transplant. The plan must
disenroll these members at the conclusion of the transplant
evaluation and cannot re-enroll the member until at least
one-year post transplant.
The plan is not responsible for the cost of a completed adult
heart transplant evaluation regardless of whether or not the
beneficiary was determined a candidate for a transplant. The
plan is responsible for the cost of adult heart transplant
evaluations that are not completed for any reason.
The plan is not responsible for the cost of pre-transplant
care and post transplant follow-up when a member has been
listed as a candidate for a pediatric heart, lung or
heart/lung transplant (ages 20 and under) or a liver
transplant (all ages). If, at the conclusion of the transplant
evaluation, the beneficiary is listed with UNOS as a level 1A,
1B or 2 for heart, lung or heart/lung or 1, Model End Stage
Renal Disease (meld) score of 11-25, for a liver transplant,
the plan will disenroll the beneficiary. The beneficiary will
have the option to re-enroll at one-year post transplant. The
plan is responsible for the cost of the above transplant
evaluations.
b.
Physical therapy services when necessary and provided during a
member's inpatient stay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 8 OF 166
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July 2004
Medicaid HMO Contract
c. The
plan shall be at risk for the provision of up to 45 days
of inpatient hospital care for each enrolled member, as
determined necessary by the physician responsible for
discharging an enrolled member from the hospital.
d. The
plan shall provide up to 45 days of inpatient coverage per
member from July 1 or the initial date of enrollment whichever
comes later, continuing through June 30.
d. The
plan shall provide up to 28 inpatient hospital days in an
inpatient hospital substance abuse treatment program for
pregnant substance abusers who meet ISD Criteria with Florida
Medicaid modifications as specified in InterQual Level of Care
2003-Acute Criteria-Pediatric and /or InterQual Level of Care
2003-Acute Criteria-Adult (McKesson Health Solutions, LLC,
"McKesson"), 2003 Edition or the most current edition, for use
in screening cases admitted to Rehabilitative Hospitals and
CON approved rehabilitative units in acute care hospitals with
admission dates of January 1, 2003 and after. In addition, the
plan shall provide inpatient hospital treatment for severe
withdrawal cases exhibiting medical complications which meet
the severity of illness criteria under the alcohol/substance
abuse system-specific set which generally requires treatment
on a medical unit where complex medical equipment is
available. Withdrawal cases (not meeting the severity of
illness criteria under the alcohol/substance abuse criteria)
and substance abuse rehabilitation (other than for pregnant
women), including court ordered services, are not covered in
the inpatient hospital setting. Such inpatient hospital care
shall be included in the 45 days of inpatient hospital care
for which the plan is at risk, as specified in c. and d.
above.
f. The
plan is responsible for the cost of transporting a member
from a non-participating facility or hospital to a
participating facility or hospital if the reason for transport
is solely for the plan's convenience, regardless of whether
the plan covers Medicaid transportation services.
g. The
plan shall adhere to the provisions of the Newborns' and
Mothers' Health Protection Act (NMHPA) of 1996 regarding
postpartum coverage for mothers and their newborns and comply
with the provisions of section 641.31, F.S.
1. The
plan shall provide for at least a 48-hour
hospital length of stay following a normal vaginal
delivery, and at least a 96-hour hospital length of
stay following a Cesarean section. In connection with
coverage for maternity care, the hospital length of
stay is required to be decided by the attending
provider in consultation with the mother.
2. The
plan shall prohibit the following practices:
Denying the mother or newborn child eligibility, or
continued eligibility, to enroll or renew coverage
under the terms of the plan, solely for the purpose
of avoiding the NMHPA requirements;
Providing monetary payments or rebates to mothers to
encourage them to accept less than the minimum
protections available
under NMHPA;
Penalizing or otherwise reducing or limiting the
reimbursement of an attending provider because the
provider provided care in a manner consistent with
NMHPA;
Providing incentives (monetary or otherwise) to an
attending provider to induce the provider to provide
care in a manner inconsistent with NMHPA;
Restricting benefits for any portion of the 48-hour
(or 96-hour) period prescribed by NMHPA in a manner
that is less favorable than the benefits provided for
any preceding portion of the hospital stay.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 9 OF 166
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Medicaid HMO Contract
10.8.8.2 OUTPATIENT
Outpatient hospital services are preventive, diagnostic,
therapeutic,
or palliative care under the direction of a physician at a
licensed
acute care hospital. Such outpatient hospital services include
emergency room, dressings, splints, oxygen and physician
ordered
services and supplies necessary for the clinical treatment of a
specific diagnosis or treatment as specified in the Medicaid
Hospital
Services Coverage and Limitations Handbook. Emergency medical
services
as defined in section 100.0, Glossary, of this contract, are
specified
in the Medicaid Hospital Services Coverage and Limitations Handbook
and
section 20.10, Emergency Care Requirements. Policy requirements
include:
a. The
plan shall provide outpatient hospital services and
emergency medical care services as medically necessary and
appropriate and without any specified dollar limitation.
b. The plan
shall cover the cost to all members of any medically
necessary duration of stay in a non-designated facility, which
resulted from a medical emergency until such time as they can
be safely transported to a plan facility.
c. The
plan shall have a procedure for the authorization of
dental care and associated ancillary services provided in an
outpatient hospital setting if that care meets the following
requirements;
-
Is provided under the direction of a dentist at a
licensed hospital;
-
Is medically necessary or, if not usually considered
medically necessary, is considered medically
necessary in a hospital setting due to the
beneficiary's disability, the beneficiary's mental
health condition, or the beneficiary's abnormal
behavior due to emotional instability or a
developmental disability, which necessitates the
services being provided in a hospital.
10.8.8.3 HOSPITAL ANCILLARY SERVICES
Ancillary services that are provided by the hospital include, but
are
not limited to, radiology, pathology, neurology, neonatology
and
anesthesiology. When the plan or plan's authorized physician
authorizes
these services (either inpatient or outpatient), the plan must
reimburse the professional component of the service at the
Medicaid
line item rate, unless another reimbursement rate has been
negotiated.
This is also required for emergency services rendered by
non-plan
physicians for ancillary services provided in a hospital
setting.
10.8.9 IMMUNIZATIONS
In accordance with section 1905(r)(1) of the Social Security Act,
the
plan shall participate or direct its providers to participate in
the
Vaccines For Children Program (VFC), the program administered by
the
Department of Health (DOH), Bureau of Immunizations, which
provides
vaccines at no charge to physicians, and eliminates any need to
refer
children to county health departments (CHD) for immunizations.
For
immunizations covered by Medicaid but not provided through VFC the
plan
shall be responsible for coverage and reimbursement to the
provider.
The plan is required to:
a.
Provide immunizations in accordance with the childhood
immunization schedule as approved by the appropriate
Recommended Childhood Immunization Schedule for the United
States or when it is shown to be medically necessary for the
child's health in accordance with section 409.912, F.S.
b.
Document that the plan is enrolled in the VFC program or that
its
physicians have directly enrolled.
c.
Ensure its physicians have a sufficient supply of vaccines
from the plan if the plan is the VFC enrollee. If the plan's
physicians are directly enrolled in the VFC program, they
shall be directed to maintain adequate vaccine supplies.
d. Pay
no more than the Medicaid program vaccine administration
fee of $10.00 per administration unless another rate is
negotiated with the provider.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 10 OF 166
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July 2004
Medicaid HMO Contract
Title XXI MediKids participants do not qualify for the Vaccines
for
Children Program as specified in this section. For
immunizations
provided to Title XXI MediKids participants, the plan shall
advise
providers to bill Medicaid fee-for-service directly at a rate
determined by the Agency. The administration fee is included in
the
capitation rates for both Title XXI MediKids and Title XIX
Medicaid
programs.
10.8.10 INDEPENDENT LABORATORY AND
PORTABLE X-RAY SERVICES
These services are medically necessary and appropriate
diagnostic
laboratory procedures and portable x-rays ordered by a physician
or
other licensed practitioner of the healing arts. Policies,
procedures
and services covered by each program are described in the
Medicaid
Independent Laboratory Services Coverage and Limitations Handbook;
and
the Portable X-Ray Services Coverage and Limitations Handbook.
The programs encompass only those services approved by Medicaid for
a
licensed
independent laboratory or portable x-ray company under the
related service requirements and limitations described in the
services
coverage and limitations handbooks. Laboratory and x-ray
services
provided by a hospital, clinic or Medicaid provider enrolled as
physician services providers are not included in these programs.
Such
services provided by a hospital, physician or clinic is included in
the
definition of hospital, physician or clinic, as appropriate. In
addition, such services provided via a hospital setting are
also
discussed under section 10.8.8.3, Hospital Ancillary Services.
Policy
requirements include:
a. The
plan must furnish, at a minimum, those laboratory and
portable x-ray procedures currently covered by the independent
laboratory and portable x-ray programs as described in their
respective handbooks.
b. The
plan shall pay for laboratory tests provided by public
providers as specified in section 20.8.9, Public Provider
Claims, without prior authorization as specified in section
110.1, Laboratory Tests And Associated Office Visits To Be
Paid By Plan Without Prior Authorization When Initiated By
County Health Department.
10.8.11 PHYSICIAN SERVICES
Physician services are those services and procedures rendered by
a
licensed
physician at a physician's office, patient's home, hospital,
nursing facility or elsewhere when dictated by the need for
preventive,
diagnostic, therapeutic or palliative care, or for the treatment of
a
particular injury, illness or disease as specified in the
Medicaid
Physician Services Coverage and Limitations Handbook. For purposes
of
this contract advanced registered nurse practitioner (ARNP)
services,
physician assistant services (PA), podiatry services,
ambulatory
surgical centers service, CHD services, rural health clinic
services,
federally qualified health center (FQHC) services, birthing
center
services (including the services of certified nurse midwives
licensed
under chapter 464, F.S., and midwives licensed under chapter
467,
F.S.), and chiropractic services are included as physician
services
because they can be provided by a physician and, as such, are
included
in the capitation rate paid to the plan. These services must be
provided as specified in the appropriate Medicaid Services Coverage
and
Limitations handbook. Their listing does not mean that the
services
must be performed by the indicated professional category or at
the
indicated location. Policy requirements include:
a. The
plan shall furnish the full range of the preventive
medicine services program components as described in the
Medicaid
Coverage and Limitations handbooks.
b. The
plan shall furnish psychiatrist services as medically
necessary for Medicaid beneficiaries, which may be rendered in
the psychiatrist's office or in an outpatient or inpatient
setting.
c. The
plan shall exclude the provision of experimental and
clinically unproven procedures. (See section 409.905, F.S.)
d. The
plan shall provide for adult health screenings as
specified in the Agency's Medicaid Services Coverage and
Limitations Handbooks.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 11 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
e. The
provisions of sections 641.19, 641.31 and 641.51, F.S. are
incorporated by reference and as such the plan shall allow
members to use network chiropractic, dermatological services,
podiatric services, and OB/GYN services without authorization.
f.
Pursuant to section 4712 of the Balanced Budget Act of 1997,
plans contracting with FQHCs and rural health clinics (RHCs)
must reimburse those entities at rates comparable to those
rates paid for similar services in the FQHC's or RHC's
community. The plan shall report quarterly to the Agency the
payment rates
and the payment amounts made to FQHCs and RHCs
for contractual services provided by these entities.
g.
Notwithstanding subsection 20.8.9, Public Provider Claims,
without prior authorization, the plan shall pay, at the
contracted rate or the Medicaid fee-for-service rate, all
valid claims initiated in any CHD for office visits,
prescribed drugs, and laboratory services directly related to
DCF emergency shelter medical screening, and tuberculosis as
specified in section 110.1, Laboratory Tests And Associated
Office Visits To Be Paid By Plan Without Prior Authorization
When Initiated By County Health Department, once the CHD has
notified the plan and has provided the plan's primary care
provider with results of such testing and the associated
office visit. Reimbursement by the plan for such services is
required only if the CHD provides the plan with copies of the
appropriate medical record.
h. The
plan shall have a procedure for the authorization of
medically necessary dental care and associated ancillary
services provided in licensed ambulatory surgical center
settings if that care is provided under the direction of a
dentist as described in State Plan. Medical necessity shall be
determined in accordance with section 641.31, F.S.
10.8.11.1 PREGNANCY RELATED
REQUIREMENTS
a.
Florida's Healthy Start Prenatal Risk Screening.
The plan shall ensure that the provider offers, as required by
section 383.14, F.S., and Rule 64C-7.009, F.A.C., Florida's
Healthy Start prenatal risk screening to each member who is
pregnant as part of her first prenatal visit. The plan shall
ensure the provider uses the DOH prenatal risk DH Form 3134,
which can be obtained from the local county health department.
The plan shall ensure the provider retains a copy of the
completed screening instrument in the member's medical record
and shall provide a copy to the member. The plan shall ensure
the provider submits the completed DH Form 3134 to the county
health department in the county where the prenatal screen was
completed within ten business days of completion. The plan is
strongly encouraged to collaborate with the Healthy Start care
coordinator within the patient's county of residence to assure
risk-appropriate care is delivered.
b.
Florida's Healthy Start Infant (Postnatal) Screening
Instrument.
Risk factor information for the Florida's Healthy Start Infant
(Postnatal) Risk Screening Instrument (DH Form 3135) is taken
from the Certificate of Live Birth and is generally completed
by the staff who complete the Certificate of Live Birth. Plans
providing birthing services shall ensure the provider
completes Florida's Healthy Start Infant (Postnatal) Risk
Screening Instrument on each live birth and offer the family
referral to
further Healthy Start services as appropriate. The
plan must ensure the provider submits the Infant (Postnatal)
Risk Screening Instrument with the Certificate of Live Birth
to the CHD in the county where the infant was born. DH Form
3135 can be obtained from the local county health department.
The plan shall ensure the provider retains a copy of the
completed screening instrument in the member's medical record
and provide a copy to the member.
c.
Pregnant women or infants who do not score high enough to be
eligible for Healthy Start care coordination may be referred
for services regardless of their score on the Healthy Start
risk screen in the following ways:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 12 OF 166
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Medicaid HMO Contract
1. If
the referral is to be made at the same time the
risk screen is administered, the provider may
indicate on the risk screening form that the woman or
infant is invited to participate based on factors
other than score.
2. If
the determination is made subsequent to risk
screening, the provider may directly refer the woman
or infant to the Healthy Start care coordination
provider based on assessment of actual or potential
factors associated with high risk, such as HIV,
Hepatitis B, substance abuse, or domestic violence.
d. The
plan shall refer all pregnant, breastfeeding and
postpartum women, infants and children up to age five to the
local Women, Infants and Children (WIC) office. For the
initial referral for WIC certification, the plan must complete
the Florida WIC program Medical Referral Form with the current
height or length and weight (taken within 60 days of the WIC
appointment); hemoglobin or hematocrit (see chart below); and
any identified medical/nutritional problems. For subsequent
WIC certifications the plan shall encourage its providers to
coordinate with the local WIC office to provide the above
referral data from the most recent CHCUP. Each time a WIC
Referral Form is completed, the plan shall ensure the provider
gives a copy of the WIC Referral Form to the member and
retains a copy in the member's medical record.
<TABLE>
<CAPTION>
WIC CATEGORY
WIC BLOOD WORK SCREENING SCHEDULE
<S>
<C>
Pregnant Woman
Once during the current pregnancy
Breastfeeding Woman up to 1 year postpartum
Once after delivery
Postpartum Woman (not breastfeeding) up
to
6 months postpartum
Once after delivery/termination of pregnancy
Infant
Once between 6-12 months of age (preferably
between 9-12 months)
Child 1 - 2 years
Once, preferably between 15 - 18 months
Child 2 - 5 years
Once every year unless an abnormal value is
found, (<11.1gm/dl hemoglobin, <33%
hematocrit) then a follow-up blood
test is required at six month intervals
</TABLE>
e. The
plan shall ensure the provider provides, as required by
Chapter 381, F.S., all women of childbearing age HIV
counseling and offer them HIV testing. For prevention, early
identification of women with HIV infection, and reduction of
perinatal
transmission, the plan shall ensure that its
providers counsel and offer HIV testing to all women of
childbearing age. Florida law requires all pregnant women to
be counseled and offered HIV testing at the initial prenatal
care visit and again at 28-32 weeks. If a pregnant woman
declines HIV testing, a signed objection must be attempted, in
accordance with section 384.31, F.S. and Ch. 64D-3.019,
Florida Administrative Code. The plan shall ensure that all
pregnant women who are HIV infected are counseled about and
offered the latest anti-retroviral regimen recommended by the
U.S.
Department of Health and Human Services, Public Health
Service Task Force entitled Recommendations for the Use of
Antiretroviral Drugs in Pregnant HIV-1 Infected Women for
Maternal Health and Interventions to Reduce Perinatal HIV-1
Transmission in the United States. To receive a copy of the
guidelines, contact the Florida Department of Health, Bureau
of HIV/AIDS at (850) 245-4334, or you may reach the DHHS
website at http://aidsinfo.nih.gov/guidelines/.
f. The
plan shall ensure that providers routinely screen all
Medicaid eligible women receiving prenatal care for the
Hepatitis B surface antigen (HBsAg) early in each pregnancy,
preferably during the first prenatal visit. All pregnant women
shall be routinely tested for the hepatitis B surface antigen
(HBsAg) at the time of the first examination relating to the
current pregnancy. Pregnant women who tested negative at the
first visit and are considered high-risk for hepatitis B
infection shall have a second HBsAG test performed at 28 to 32
weeks of pregnancy. This test shall be performed at the same
time that other routine prenatal screening is ordered. All
HBsAg-positive women shall be reported to the local county
health department. Women who are HBsAg-positive shall be
referred to Healthy Start regardless of their Healthy Start
screening score.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 13 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
g.
Infants born to HBsAg-positive members shall receive Hepatitis
B Immune Globulin (HBIG) and the Hepatitis B vaccine once they
are physiologically stable, preferably within 12 hours of
birth and shall complete the hepatitis B vaccine series
according to the recommended vaccine schedule per the
guidelines established by the appropriate Recommended
Childhood Immunization Schedule for the United States. These
infants shall be tested for HBsAg and Hepatitis B surface
antibodies (anti-HBs) six months after the completion of the
vaccine series to monitor the success or failure of the
therapy. A positive HBsAg result in any child aged 24 months
or less shall be report to the local county health department
within 24 hours. Infants born to women who are HBsAg-positive
shall be referred to Healthy Start regardless of their Healthy
Start screening score.
h. All
HBsAg-positive prenatal or postpartum women, their
infants, and contacts shall be reported to the Perinatal
Hepatitis B Prevention Coordinator at the local County Health
Department. Information collected for each individual shall
include: name, date of
birth, race, ethnicity, address, ex
(infants and contacts), laboratory test performed and date
sample collected, due date or EDC, whether or not prenatal
care was received (prenatal woman), and immunization dates
(infants and contacts). Use of the current Perinatal Hepatitis
B Case and Contact Report (DH Form 1876) is strongly
encouraged but not required. This form may be obtained from
the Department of Health. For further information please see
Rule 64D-3.013 of the Florida Administrative Code at website:
http://fac.dos.state.fl.us/faconline/chapter64.pdf and/ or
contact your county or state Perinatal Hepatitis B Prevention
Coordinator.
i. The
plan shall allow pregnant women to choose the plan's
contracted or staff OB/GYNs as their primary care physicians
to the extent that the OB/GYN is willing to participate as a
primary care provider. The plan shall not require more
restrictive authorization criteria for OB/GYN primary care
physicians than it has for non-OB/GYN primary care physicians.
If the plan requires prior authorization for ancillary
services, it may require that an OB/GYN obtain prior
authorization for certain pregnancy-related ancillary services
(such as non-stress-tests, ultrasounds), and amniocentesis.
j. The
plan is required to provide the most appropriate and
highest level of quality care for pregnant members. Required
care also includes the following:
1.
PRENATAL CARE: Requirements include a pregnancy test
and a nursing assessment with referrals to a
physician, physician's assistant or nurse
practitioner for comprehensive evaluation; case
management through the gestational period according
to the needs of the client; referrals and follow-up.
The high medical risk diagnoses are listed in
Appendix B of the Medicaid Physician Services
Coverage and Limitations Handbook and REQUIRE DIRECT
CARE BY THE PHYSICIAN.
The plan must schedule return or more frequent visits
as the member's condition warrants, at least every
four weeks until the 32nd week, every two weeks until
the 36th week, and every week thereafter until
delivery, unless the member's condition requires more
frequent visits.
For members who fail to keep appointments, the plan
must contact the members as soon as possible and
arrange for their necessary and continued prenatal
care. Members must be assisted if necessary in making
delivery arrangements.
All pregnant women must be screened for tobacco use
with provision of smoking cessation counseling and
appropriate treatment as needed.
2.
NUTRITION ASSESSMENT/COUNSELING: The plan shall
ensure the provider provides nutrition assessment and
counseling to all pregnant members. Nutrition
assessment/counseling should include the provision of
safe and adequate nutrition for infants by the
protection and promotion of breastfeeding and by the
proper use of breast milk substitutes. The plan
should make a mid-level nutrition assessment.
Individualized diet counseling and a nutrition care
plan are to be provided by public health
nutritionists, nurses or physicians following
nutrition assessments. The nutrition care plan must
be documented in the member's medical record by the
person providing counseling.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 14 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
3.
OBSTETRICAL DELIVERY: The plan must develop and use
generally accepted and approved protocols for both
low risk and high risk deliveries which shall reflect
the highest standards of the medical profession,
including Healthy Start, prenatal screen specified in
section B.4.h Florida's Healthy Start Prenatal Risk
Screening, of this attachment, and ensure that its
providers use such protocols. A preterm delivery risk
assessment must be determined and documented in the
member's medical record by the 28th week.
If the delivery is determined to be high risk,
obstetrical care during labor and delivery must
include preparation by all attendants of
extraordinary symptomatic evaluation, progress
through the final stages of labor and immediate
postpartum care. The high medical risk diagnoses are
listed in Appendix B of the Medicaid Physician
Services Coverage and Limitations Handbook and
require direct care by the physician.
4.
NEWBORN CARE: The plan must ensure the provider
provides for the highest level of care for the
newborn beginning immediately after birth, which must
include but is not limited to:
a)
Instilling of a prophylaxis into each eye of
the newborn in accordance with section
383.04 F.S.
b)
Securing of a cord blood sample for
laboratory testing for type Rh determination
and direct Coombs test when the mother is Rh
negative.
c)
Weighing and measuring of the newborn.
d)
Inspecting for abnormalities and/or
complications.
e)
Administering of one half milligram of
vitamin K.
f)
APGAR scoring.
g) Any
other necessary and immediate need for
referral and consultation from a specialty
physician, such as the Healthy Start
(postnatal) infant screen, as specified in
section B.4.i., Florida's Healthy Start
Infant (Postnatal), of this attachment.
h)
NEWBORN HEARING SCREENINGS: All newborn and
infant hearing screenings must be conducted
by an audiologist licensed under Chapter
468, F.S.; a physician licensed under
Chapter 458 or 459, F.S.; or an individual
who has completed documented training
specifically for newborn hearing screenings
and who is directly or indirectly supervised
by a licensed physician or licensed
audiologist.
5. POSTPARTUM
CARE: Plans must provide a postpartum examination
for the mother within
six weeks after delivery. This visit
shall include voluntary family planning, including a
discussion of all methods of contraception, as appropriate.
The plan shall ensure that eligible newborns be appropriately
enrolled and that continuing care of the newborn be provided
through the Child Health Check-Up program component.
10.8.11.2 HYSTERECTOMIES, STERILIZATIONS,
AND ABORTIONS
The plan must maintain a log of all hysterectomy, sterilization,
and
abortion procedures performed for plan members. The log must
include,
at a minimum, member name and identifying information and date
and
type of procedure.
10.8.12 PRESCRIBED DRUG SERVICES
These services are defined as those products and services
associated
with the dispensing of medicinal drugs pursuant to a valid
prescription as defined in chapter 465, F.S. (the "Florida
Pharmacy
Act"). This benefit
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 15 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
generally includes all legend drugs dispensed to members in
outpatient
settings and includes patent or proprietary preparations as
well.
Covered drugs, injectables, food supplements and other prescribed
drug
services are described in the Prescribed Drugs Services
Coverage,
Limitations and Reimbursement Handbook. These services also
include
payment for Medicaid reimbursable psychotropic drugs. Policy
requirements include:
a. The
plan shall make available those drugs and dosage forms
currently covered by the Medicaid Program.
b. The
plan shall not arbitrarily deny or reduce the amount,
duration, or scope of prescriptions solely because of the
diagnosis, type of illness, or condition. The plan may place
appropriate limits on prescriptions based on criteria such as
medical necessity or for the purpose of utilization control,
provided the services can reasonably be expected to achieve
the purpose set forth in the State Plan. The plan may not
place limits on prescription drugs listed in section 409.912,
F.S., such as anti-psychotics, anti-depressants and
HIV-specific anti-retrovirals.
c. The
plan's pharmacy benefit shall comply with all applicable
federal and state laws. The plan shall submit for Agency
review a description of its pharmacy benefit, including but
not limited to its formulary and prior authorization process.
This information must be submitted to the Agency within 30
days following the effective date of this contract and prior
to any changes.
d. The
plan shall provide one course of twelve weeks duration or
the manufacturer's recommendation per year of nicotine
replacement therapy, either nicotine transdermal patches or
nicotine gum, to members who are currently smoking and desire
to quit smoking in accordance with the Medicaid Prescribed
Drug Services Coverage, Limitations and Reimbursement
Handbook.
e.
The
plan shall comply with the settlement agreement for
Hernandez, et. al. v. Medows, case number 02-20964
Civ-Gold/Simonton. The plan shall ensure that its enrollees
are receiving the functional equivalent of those goods and
services received by Medicaid fee-for-service recipients in
accordance with the Hernandez settlement. Additionally, the
plan shall maintain a log of all correspondence and
communications from enrollees relating to the Ombudsman
process. Plan enrollees are third party beneficiaries for this
section of this contract.
f. The
plan shall conduct surveys of participating plan
pharmacies for compliance with the Hernandez settlement and
this contract. The plan shall document these surveys and
maintain the survey documents and site visit results for at
least five years.
g. The
plan shall provide name brand drugs in compliance with
Florida law. The plan shall reimburse a pharmacy for the cost
of a multi-source brand drug if the prescriber writes in his
or her own handwriting on the valid prescription that the drug
is medically necessary (and otherwise complies with F.S.
465.025) and the prescriber submits a form to the plan. The
form shall be the functional equivalent of the F.D.A. MedWatch
form. The form will require the prescriber to confirm in
writing that an individual patient has had an adverse reaction
to a generic drug or has had, in his or her medical opinion,
better medical results when taking the brand name drug.
10.8.13 THERAPY SERVICES
Medicaid therapy services provide physical, speech-language
(including
augmentative and alternative communication systems), occupational
and
respiratory therapies. Medicaid pays only for therapy services that
are
medically necessary for the provision of therapy evaluations
and
individual therapy treatment. Medicaid therapy services are limited
to
children and young people who are under the age of 21 as specified
in
the Therapy Services Coverage and Limitations Handbook. In
addition,
adults are covered for physical and respiratory therapy services
under
the outpatient hospital services program as specified in the
Medicaid
Hospital Services Coverage and Limitations Handbook. Policy
requirements include:
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 16 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
a.
Members must be referred to appropriate service providers for
further assessment and treatment of conditions.
b.
Members must be offered scheduling assistance in making
treatment appointments and obtaining transportation.
c. This
service includes the maintenance of a coordinated system
to follow the member through the entire range of screening and
treatment.
d. The
Agency shall reimburse schools participating in the
certified school match program pursuant to sections 236.0812
and 409.908, F.S., for school-based therapy services rendered
to members in accordance with section 20.8.10, Certified
School Match Program.
e. The
provision of school-based therapy services to a plan
member is not a
replacement, substitution, or fulfillment of a
service prescription or doctors' orders for therapy services
external to this plan.
10.8.14 TRANSPORTATION SERVICES
(OPTIONAL)
These services are the arrangement and provision of an appropriate
mode
of transportation for members to receive necessary medical care
services. Types of transportation services include: ambulance,
non-emergency medical vehicles, public and private
transportation
vehicles and air ambulances as specified in the Medicaid
Transportation
Services Coverage and Limitations Handbook. Policy requirements
include:
a. The
plan must assure that providers of transportation are
appropriately licensed and insured in accordance with the
provisions of the Medicaid Transportation Services Coverage
and Limitations Handbook.
b. The
plan must provide transportation for its members seeking
necessary Medicaid services whether or not those services are
covered under terms of this contract.
c. The
plan is not required to follow the requirements of the
Commission for the Transportation Disadvantaged or the
Transportation Coordinating Boards as set forth in chapter
427, Florida Statutes.
d. The
plan will be responsible for the cost of transporting a
member from a non-participating facility or hospital to a
participating facility or hospital if the reason for transport
is solely for the plan's convenience, regardless of whether
the plan
covers Medicaid transportation services.
10.8.15 VISUAL SERVICES
These services include a visual examination; the fitting,
dispensing,
and adjustment of eyeglasses; follow-up examinations, and
contact
lenses as specified in the Medicaid Visual and Optometric
Services
Coverage and Limitations Handbooks. Examinations for eye diseases
and
treatment are part of the physician and optometric services
programs.
Lenses must meet American National Standards Institute (ANSI)
standards. Eyeglasses are available through Prison
Rehabilitative
Industries and Diversified Enterprise (PRIDE) if available at
lower
prices for comparable quality than those charged by the Division
of
Corrections optical laboratory. An abbreviated list of
products/services available from PRIDE may be obtained by
contacting
PRIDE's Tallahassee branch office at (850) 487-3774 or Suncom
277-3774.
10.9 QUALITY AND
BENEFIT ENHANCEMENTS
In addition to those covered services specified in this section,
the
plan shall offer those quality and benefit enhancements to
enrolled
Medicaid beneficiaries as specified below. Quality and benefit
enhancements shall be offered in community settings that are
accessible
to members. The plan shall inform members and providers of the
quality
and benefit enhancement programs, and how to access those
services,
through the member and provider handbooks. The plan shall develop
and
maintain written policies and procedures to implement these
enhancements. Annual training of providers that is sponsored by
multiple plans shall meet
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 17 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
the provider training requirements for the programs listed
below
provided that the plan is a co-sponsor of the training. The plan
is
encouraged to actively collaborate with community agencies and
organizations, including county health departments, local Early
Intervention Programs, Healthy Start Coalitions, and local
school
districts in offering these services. If the plan involves the
member
in existing community programs for purposes of meeting the quality
and
benefit enhancements requirements, the plan is encouraged to
document
referrals and follow-up on the member's receipt of services from
the
community provider.
CHILDREN'S PROGRAMS: The plan shall provide regular general
wellness
programs targeted specifically towards plan members from birth to
the
age of five or the plan shall make a good faith effort to
involve
members in existing community children's programs. Programs
shall
promote increased utilization of prevention and early
intervention
services for at risk families with children in the target
population.
The plan shall pay for services recommended by the Early
Intervention
Program when they are covered services and medically necessary.
The
plan shall offer annual training for providers that promotes
proper
nutrition, breastfeeding, immunizations, CHCUP, wellness,
prevention
and early intervention services.
DOMESTIC VIOLENCE: The plan shall have primary care physicians
screen
members for signs of domestic violence, and shall offer
referral
services to applicable domestic violence prevention community
agencies.
PREGNANCY PREVENTION: Regularly scheduled pregnancy prevention
programs shall be conducted by the plan or the plan shall make a
good
faith effort to involve members in existing community pregnancy
prevention programs, such as the Abstinence Education Program.
The
programs shall be targeted towards teen members, but shall be open
to
all members, regardless of age, gender, pregnancy status or
parental
consent.
PRENATAL/POSTPARTUM PREGNANCY PROGRAMS: The plan shall provide
regular
home visits, conducted by a home health nurse or aide, and
counseling
and educational materials to pregnant members and postpartum
members
who are not in compliance with the plan's prenatal and
postpartum
programs. The plan shall coordinate with the Healthy Start care
coordinator to prevent duplication of services.
SMOKING CESSATION: Regularly scheduled smoking cessation
programs
shall be conducted by the plan as an option for all plan members
or
the plan shall make a good faith effort to involve members in
existing
community smoking cessation programs. Members shall also have
access
to smoking cessation counseling. The plan shall provide primary
care
physicians with the Quick Reference Guide, a distilled version of
the
Public Health Service-sponsored Clinical Practice Guideline,
Treating
Tobacco Use and Dependence, to assist in identifying tobacco users
and
supporting and delivering effective smoking cessation
interventions.
Copies of this guide may be obtained by contacting the DHHS,
Agency
for Health Care Research and Quality (AHR) Publications
Clearinghouse,
at 1-800-358-9295 or write to P.O. Box 8547, Silver Spring, MD
20907.
SUBSTANCE ABUSE: The plan shall have primary care physicians
screen
members for signs of substance abuse as part of prevention
evaluation
at the following times and in the following circumstances:
initial
contact with a new enrollee; routine physical examination;
initial
prenatal contact; when the enrollee evidences serious
overutilization
of medical, surgical, trauma, or emergency services; and when
documentation of emergency room visit suggests need. Targeted
members
shall be asked to attend community or plan sponsored substance
abuse
programs. The plan shall offer substance abuse screening training
to
its providers on an annual basis. The plan is encouraged to use
the
Florida Supplement to the American Society of Addictions
Medicine
Patient Placement Criteria for coordination and treatment of
substance-related disorders with substance abuse providers.
10.10 INCENTIVE
PROGRAMS
The plan may offer incentives for members to receive preventive
care
services. The plan shall receive written approval from the
Agency
prior to the use of any special incentive items for members.
Any
incentive program offered must be provided to all eligible
individuals
and will not be used to direct individuals to select providers.
Additionally, any limitations and requirements below apply to
all
incentive programs.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 18 OF 166 AHCA Form
<PAGE>
July 2004
Medicaid HMO Contract
a. Services
which are eligible for incentive programs include CHCUP,
immunizations, adult health screenings, family planning,
prenatal
care, smoking/tobacco cessation, preventive health classes,
health education for management of chronic conditions,
education
in appropriate use of plan services and adolescent/teen good
citizen sessions. All incentive programs must be approved, in
writing, by the Agency prior to use.
b. Incentives
must have some health or child development related
function (e.g., clothing, food, books, safety devices, infant
care items, magazine subscriptions to publications which devote
at least 10 percent of their copy and ads to health related
subjects, membership in clubs advocating educational
advancement
and healthy lifestyles, etc.). Incentive dollar values must be
in
proportion to the importance of the health service to be
utilized
(e.g., a tee-shirt for attending one prenatal class but a car
seat for
completion of a series of classes).
c. Incentives
shall be limited to a dollar value of $10, except in
the case of incentives for the completion of a series of
services, health education, classes, or other educational
activities, in which case the incentive shall be limited to a
dollar value of $50. A special exception to the dollar value
shall be made for infant car seats, strollers, and cloth baby
carriers or slings. Funds spent on transportation of members to
services or childcare provided during the provision of services
shall not be included in the dollar limits on incentives to use
services.
d. The plan may
offer an Agency-approved program for pregnant women
in order to encourage the commencement of prenatal care visits
in
the first trimester of pregnancy and successful completion of
prenatal and post-partum care to promote early intervention and
prenatal care to decrease infant mortality and low birth weight
and to enhance healthy birth outcomes. The program may include
the provision of maternity and health related items and
education
as an incentive. The request for approval must contain a
detailed
description of the program and its mission.
10.11 BEHAVIORAL HEALTH CARE
The plan shall provide medically necessary behavioral health
care
services pursuant to this section and section 10.1, General, for
all
members once it has demonstrated its ability to provide such
services.
The plan shall demonstrate its ability by the following: submittal
of
a behavioral health services implementation plan that shall be
submitted to the Agency, and through an Agency conducted
on-site
survey. See section 60.3 for behavioral health reporting
requirements.
All provisions
in the Medicaid HMO contract that are not in conflict
with this section are still in effect and are to be performed at
the
levels specified in the contract. Where there is a conflict,
the
requirements in section 10.11, Behavioral Health Care, prevail.
10.11.1 SERVICE REQUIREMENTS
(BEHAVIORAL HEALTH)
The plan shall provide a full range of behavioral health care
service
categories authorized under the State Medicaid Plan; sections 2.2,
2.3
and 2.5 of the Area specific Prepaid Mental Health Plan (PMHP)
requests for proposals (RFP) will apply to the respective Area
members.
The plan shall comply with the Mental Health Targeted Case
Management
Coverage and
Limitations Handbook, the Community Mental Health
Services Coverage and Limitations Handbook, and specific
service
requirements as described in the general service requirements of
the
PMHP RFP specific to the Medicaid Area except as provided
below:
The plan shall continue to provide Prescribed Drug Services in
accordance with section 10.8.12 of this contract.
The plan shall continue to provide outpatient medical services
in
accordance with
section 10.8.8.2 of this contract.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 19 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
During the contract period the plan will work in conjunction with
the
Managed Mental Health Care Advisory Group, Prepaid Providers,
and
Behavioral Health Providers to establish clubhouse services in
each
AHCA area.
In addition to the above requirements, the plan shall also adhere
to
the requirements specified below.
a. Community
Treatment of Patients Discharged from State Mental
Hospitals
The plan shall provide medically necessary behavioral health
services to members who have been discharged from any state
mental hospital. The plan of care shall be aimed at encouraging
the members to achieve a high quality of life while living in
the
community in the least restrictive environment which is
medically
appropriate; and reducing the likelihood that these members
shall
be readmitted to a state mental hospital.
b. Evaluation
and Treatment Services for Enrolled Children
The plan shall provide the medically necessary evaluation and
treatment services for children referred by DCF, DJJ, and by
the
elementary, middle and secondary schools.
The plan shall establish medically necessary children's
services
in such a way as to minimize disruption of services available
to
high-risk populations currently served by DCF (e.g., children
in
delinquent programs, and other in-reach initiatives in schools
and housing projects). The plan shall promptly evaluate,
provide
psychological testing to, and serve children (including
delinquent and dependent children) referred by the department
in
accordance with medical necessity, and within the time limits
specified in e. below.
The plan shall provide court-ordered evaluation and treatment
required for children who are members pursuant to the
specifications in the Medicaid Community Mental Health Services
Coverage and Limitations Handbook.
For any child receiving services through the plan, the plan
must
participate in all DCF or school staffing that may result in
the
provision of services for which the plan is responsible. The
plan
shall refer children to DCF when residential treatment is
medically necessary. The plan shall not be responsible for
providing any residential treatment for children enrolled in
the
plan. Placement shall be coordinated with the appropriate DCF
ADM
or DJJ district program office.
The plan's case management of children in the plan is to
include
involvement of persons, schools, programs, networks and
agencies
that figure importantly in the child's life. The plan shall
make
determinations about care based on a comprehensive evaluation,
consultation from the above parties, as indicated, and
appropriate protocols for admission and retention. The Agency
shall monitor services for adequacy and conformity with
agreements.
c. Psychiatric
Evaluations for Members Applying for Nursing Home
Admission
The plan shall, upon request from the Alcohol, Drug Abuse and
Mental Health District (ADM) Offices, promptly arrange for and
authorize psychiatric evaluations for members applying for
admission to a nursing facility pursuant to OBRA 1987, and who,
on the basis of a screening conducted by CARES workers, are
thought to need mental health treatment. The examination shall
be
adequate to determine the need for "specialized treatment"
under
the Act. State regulations have been interpreted by the state
to
permit any
"mental health professional" defined under section
394.455, F.S., to make the observations preparatory to the
evaluation, although a psychiatrist must sign such evaluations.
The plan shall not be responsible for annual resident reviews
or
for providing services as a result of a Pre-admission Screening
Assessment Annual Resident Review (PASSAR) evaluation.
d. The plan
shall operate, as part of its crisis support/emergency
services, a 24 hours a day, seven days a week, crisis emergency
hot-line to be available to all members.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 20 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
e. The plan
shall adhere to the minimum staffing, availability, and
access standards described in the minimum access and staffing
standards, of the Medicaid PMHPs RFPs except for the following
provisions: For a rural county, the Agency may waive the
requirement, in writing, that at least one board certified
adult
psychiatrist and at least one board certified child
psychiatrist,
or one who meets all education and training criteria for board
certification, are available within thirty minutes typical
travel
time of all enrolled beneficiaries if a provider with this
experience is not available.
f. For all
members meeting the criteria for mental health targeted
case management as specified in the Medicaid Targeted Case
Management Services Coverage and Limitations Handbook, the plan
shall adhere to the staffing ratio of at least 1 FTE behavioral
health care case manager per 20 children, and at least 1 FTE
behavioral care case manager per 40 adults. Direct service
behavioral health care providers shall not be counted as
behavioral health care case managers.
10.11.2 NON COVERED SERVICES
(BEHAVIORAL HEALTH)
If the plan determines the need for behavioral health services
not
covered under the contract, the plan shall refer the member to
the
appropriate service provider. The plan may request the assistance
of
the Medicaid Field Office or the DCF Districts' ADM offices for
referral to the appropriate service setting.
Long term care institutional services of a nursing home, an
institution for persons with developmental disabilities,
specialized
therapeutic foster care, children's residential treatment services,
or
state hospital services are not covered. For members requiring
those
services, the plan shall consult the Medicaid Field Office and/or
the
Districts' DCF ADM offices to identify appropriate methods of
assessment and referral. The plan is responsible for transition
and
referral to appropriate service providers. Members receiving
those
services shall be disenrolled from the plan.
10.11.3 CARE COORDINATION AND
MANAGEMENT (BEHAVIORAL HEALTH)
The plan shall be responsible for the coordination and management
of
behavioral health care and continuity of care for all enrolled
Medicaid beneficiaries through the following minimum functions:
a. Contacting
each new member to authorize the release of their
clinical records within 30 days of enrollment and for current
members within 5 days after their first behavioral health
service
provision. The plan shall then request the clinical records
from
the previous behavioral health care providers.
b. Minimizing
disruption to the member as a result of any change in
service provider or behavioral health care case manager
occurring
as a result of this contract. For current members, upon
implementation of this attachment, and for new members,
thereafter, who have been receiving behavioral health care
services, the plan shall continue to authorize and pay valid
claims for services until the plan has reviewed the member's
treatment plan and developed and implemented an appropriate
written transition plan. However, if the previous treating
provider is unable to allow the plan access to the member's
clinical record because the member refuses to release the
medical
record, then the plan shall be responsible for up to four
sessions of individual or group therapy, or one psychiatric
medical session, or two one-hour Intensive Therapeutic On Site
or
Home and Community Based Rehabilitative Sessions, or six days
of
Day Treatment Services.
c. Documenting
in behavioral clinical records all member emergency
behavioral encounters and appropriate follow-up and, where
medical in nature, in the primary care physician's medical
record.
d. Documenting
all referral services in the members' behavioral
clinical records.
e. Monitoring
members admitted to state mental health institutions
as follows: the plan shall participate in discharge planning
and
community placement of members who are being discharged within
sixty days of losing their plan enrollment due to state
institutionalization. The Agency may sanction the plan for any
inappropriate over-utilization of state mental hospital
services
for its members.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 21 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
f. Coordinating
hospital and/or institutional discharge planning for
psychiatric admissions and substance abuse detoxification that
includes appropriate post-discharge care.
g. Providing
appropriate referral of the member for non-covered
services to the appropriate service setting, and requesting
referral assistance, as needed, from the Medicaid Field Office.
The plan is encouraged to use the Florida Supplement to the
American Society of Addictions Medicine Patient Placement
Criteria for coordination and treatment of substance-related
disorders with substance abuse providers. Coordination of care
with community-based substance abuse agencies shall be included
in protocols developed for continuity of care practices for
enrollees with dual diagnoses of mental illnesses and substance
abuse or dependency.
h. Entering,
prior to commencement of services, into agreements with
agencies funded pursuant to chapter 394, Part IV, F.S., that
shall not be a part of the plan's provider network, regarding
coordination of care and treatment of members jointly or
sequentially served. A listing of these agencies is available
at
the Medicaid Office. These agreements shall be approved by the
Agency. The plan shall be released from this requirement by the
Agency if
good faith efforts are made by the plan and no
agreement is consummated.
i. Providing
court ordered mental health evaluations for its
members. The plan shall also provide expert mental health
testimony for its enrolled beneficiaries.
j. Providing
appropriate screening, assessment, crisis intervention
and support for members who are in the care and custody of the
state pursuant to the specifications indicated in the Medicaid
Community Mental Health Services Coverage and Limitations
Handbook.
k. Requesting
current behavioral health provider information from
all new members upon enrollment. The plan shall solicit these
current providers to enroll in the plan's provider network. The
plan may request in writing that the Agency grant an exemption
for the plan from soliciting a specific provider on a
case-by-case basis.
l. Providing,
upon an Assisted Living Facility's (ALF) request, the
plan's procedures for the ALF to follow should an emergent
condition arise with one of its members that reside in an ALF,
as
specified in section 409.912, F.S.
m. The plan
shall participate, as requested by the DCF district
administrators, in each DCF district's ADM planning process
pursuant to chapter 394.75, F.S.
10.11.4 BEHAVIORAL CLINICAL RECORD
REQUIREMENT (BEHAVIORAL HEALTH)
The plan shall maintain a behavioral clinical record for each
member
under this contract. The record shall include documentation
sufficient
to disclose the quality, quantity, appropriateness and timeliness
of
services performed under this contract. Each member's record must
be
legible and maintained in detail consistent with good clinical
and
professional practice which facilitates effective internal and
external peer review, medical audit, and adequate follow-up
treatment.
Identification of the physician or other service provider, date
of
service, the units of service and type of service must be
clearly
evident for each service provided.
10.11.5 FUNCTIONAL ASSESSMENTS
(BEHAVIORAL HEALTH)
The plan shall ensure its providers administer functional
assessments
using the Functional Assessment Rating Scales (FARS) (for persons
over
age 18) and Child Functional Rating Scale (CFARS) (for persons age
18
and under). The plan shall ensure the provider administers and
maintains the FARS and CFARS for beneficiaries of behavioral
health
care
services and upon termination of providing such services.
Additionally, the plan must evaluate these data and report
outcome
measures to the Agency on an annual basis by August 15.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 22 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
10.11.6 OUT-OF-PLAN USE (BEHAVIORAL
HEALTH)
The provisions of the Medicaid service requirements of the
current
Medicaid Areas PMHP RFPs govern the payment of emergency
behavioral
health services within the contract service area. However, the
out-of-area, non-contract provider must notify the plan within
24
hours of the member presenting for emergency behavioral health
services that the member has come to the non-contract provider
for
treatment. In cases in which the member has no identification, or
is
unable to verbally identify himself when presenting for services,
the
provider must notify the plan within 24 hours of learning the
member's
identity. The provider must also provide clinical records to the
plan
that document that the identity of the member could not be
ascertained
due to the member's condition.
If the non-contract provider fails to provide the plan with an
accounting of the member's presence and status within 24 hours
after
the member presents for treatment and provides identification,
the
plan shall be obligated to pay only for the time period required
for
emergency services, as documented by the patient's clinical
record.
The plan must review and approve or disapprove out-of-plan
emergency
mental health service claims based on the definition of
emergency
(behavioral health) services specified in section 100.0,
Glossary,
within the time frames specified for emergency claims payment
in
section 20.10, Emergency Care Requirements, of this contract.
The plan must submit to the Agency for review and final
determination
denied appeals from providers for denied emergency behavioral
health
service claims. Such denied appeals must be submitted within ten
days
after the plan has made final appeal determination. The plan must
pay
within 35 days previously denied emergency mental health
service
claims if the decision by the Agency is to honor the claim. The
35-day
period begins when notification of the final decision from the
Agency
is received by the plan.
The plan must evaluate and authorize or deny payment for care
for
members presenting at non-plan receiving facilities (that are
not
crisis stabilization units) within the contract service area
for
involuntary examination within three hours of being notified by
phone
by the receiving facility. The receiving facility at which the
member
presents must notify the plan within four hours of the member
presenting that the member has come to the receiving facility
for
treatment. If the receiving facility fails to provide the plan with
an
accounting of the member's presence and status within four hours,
the
plan shall be obligated to pay only for the first four hours of
the
enrollee's treatment, subject to medical necessity.
If the receiving facility is a non-plan receiving facility and
documents in the clinical record that it is unable (after good
faith
effort) to identify the patient as a plan member and, therefore,
fails
to notify the plan of the member's presence, the plan shall be
obligated to pay for medical stabilization lasting no more than
three
days from the date the member presented at the receiving facility,
as
documented by the patient's medical record and subject to
medical
necessity, unless there is irrefutable evidence in the clinical
record
that a longer period was required.
Refer to the provisions of section 20.9, Out-of-plan Use of Non
Emergency Services.
10.11.7 OUTREACH REQUIREMENTS
(BEHAVIORAL HEALTH)
At a minimum, the plan shall have an outreach plan that is designed
to
encourage members to seek behavioral health care assistance with
the
plan when assistance is perceived to be needed. In addition,
the
outreach plan shall provide for the following:
a. Outreach
communications that are written at the fourth grade
reading level.
b. Outreach
communications that are written in a language spoken by
the member.
c. The plan
shall develop and implement a program designed to assist
primary care providers in the identification and management of
clinical depression.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 23 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
10.11.8 QUALITY IMPROVEMENT
REQUIREMENTS (BEHAVIORAL HEALTH)
The plan's quality improvement program shall include a
behavioral
health component in order to monitor and assure that behavioral
health
services provided are sufficient in quantity, of acceptable
quality,
and meet the needs of the enrolled population. Specifically,
treatment
plans must identify reasonable and appropriate objectives,
planned
services that are appropriate to meet the identified objective,
and
retrospective reviews that must confirm that the care provided and
its
outcomes were consistent with approved treatment plans and
appropriate
for the members' needs.
In determining if behavioral health care is acceptable under
current
standards, the plan shall perform the following:
a. A quarterly
review of a random selection of 10 percent or 50
member records, whichever is fewer, of members who have
received
behavioral health care services during the previous quarter.
b. Review
elements for these reviews shall include management of
specific diagnoses, appropriateness and timeliness of care,
comprehensiveness of and compliance with the plan of care, and
evidence of special screening for high-risk individuals or
conditions.
The plan shall send representation to the local advisory groups
that
convene quarterly and report to the Agency on behavioral health
advocacy and programmatic concerns. These groups shall provide
technical and policy advice to the Agency regarding prepaid
behavioral
health care.
10.11.9 ADMINISTRATIVE STAFF
REQUIREMENTS (BEHAVIORAL HEALTH)
The plan must identify a plan staff person with oversight
responsibility for the behavioral health services required in
this
section and to act as liaison to the Agency.
The plan's medical director shall appoint a board certified or
board
eligible psychiatrist to oversee the proper provision of
covered
behavioral health services to members. This appointment may be to
a
subcontractor of the plan.
The Agency shall review and approve the plan's staff and
subcontracted
behavioral health care providers in order to determine the
plan's
compliance with the requirements of section 20.5, Licensure of
Staff,
of this contract, prior to the plan's expansion.
10.11.10 BEHAVIORAL HEALTH SUBCONTRACTS
If the plan subcontracts with a Managed Behavioral Health
Organization
(MBHO) for the provision of services stipulated in this section,
the
MBHO shall be accredited by one of the recognized national
accreditation organizations.
The plan must submit model subcontracts for each behavioral
health
specialist type
or facility for Agency approval.
All subcontracts must adhere to the requirements set forth in
this
contract, section 70.18, Subcontracts.
10.11.11 MANAGEMENT INFORMATION SYSTEM
(BEHAVIORAL HEALTH)
The plan shall perform the following management information
system
functions:
a. Maintain
member behavioral health service, utilization, and
expenditure profiles, and current and historical data with
beginning and ending dates.
AHCA CONTRACT NO. FA522, ATTACHMENT I, PAGE 24 OF 166
<PAGE>
July 2004
Medicaid HMO Contract
b. Maintain data
documenting behavioral health service utilization
by service, (including procedure code), encounter or claim
information, date of service per encounter/claim, beneficiary
Medicaid ID number, diagnosis, designated groups of
beneficiaries, and providers.
c. Maintain data
documenting behavioral health management,
administrative, and service costs.
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