DEPARTMENT OF SOCIAL AND HEALTH SERVICES 2006 ? 2007 CONTRACT FOR HEALTHY OPTIONS AND STATE CHILDREN?S HEALTH INSURANCE PLAN APPROVED AS TO FORM BY THE ATTORNEY GENERAL?S OFFICE

 

1.             DEFINITIONS

 

The following definitions shall apply to this Contract:

 

1.1           Action means the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment of a service; or the failure to provide services or act in a timely manner as required herein (42 CFR 438.400(b)).

 

1.2           Advance Directive means a written instruction, such as a living will or durable power of attorney for health care, recognized under the laws of the State of Washington, relating to the provision of health care when an individual is incapacitated (WAC 388-501-0125, 42 CFR 438.6, 42 CFR 438.10, 42 CFR 422.128, and 42 CFR 489 Subpart I).

 

1.3           Ancillary Services means health services ordered by a provider including, but not limited to, laboratory services, radiology services, and physical therapy.

 

1.4           Appeal means a request for review of an action (42 CFR 438.400(b)).

 

1.5           Appeal Process means the Contractor’s procedures for reviewing an action.

 

1.6           Children with Special Health Care Needs means children identified by DSHS to the Contractor as children served under the provisions of Title V of the Social Security Act and children identified by the Contractor as having special health care needs.

 

1.7           Cold Call Marketing means any unsolicited personal contact by the Contractor or its designee, with a potential enrollee or an enrollee with another HO/SCHIP contracted managed care organization for the purposes of marketing (42 CFR 438.104(a)).

 

1.8           Comparable Coverage means an enrollee has other insurance that DSHS has determined provides a full scope of health care benefits.

 

1.9           Consumer Assessment of Health Plans Survey (CAHPS®) means a commercial and Medicaid standardized survey instrument used to measure client experience of health care.

 

1.10         Continuity of Care means the provision of continuous care for chronic or acute medical conditions through enrollee transitions in providers or service areas, between HO/SCHIP contractors and between Medicaid fee-for-service and HO/SCHIP in a manner that does not interrupt medically necessary care or jeopardize the enrollee’s health.

 

1.11         Coordination of Care means the Contractor’s mechanisms to assure that the enrollee and providers have access to and take into consideration, all required

 

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information on the enrollee’s conditions and treatments to ensure that the enrollee receives appropriate health care services (42 CFR 438.208).

 

1.12         Covered Services means medically necessary services, as set forth in Section 11, Benefits, covered under the terms of this Contract.

 

1.13         Duplicate coverage means an enrollee is privately enrolled on any basis with the Contractor and simultaneously enrolled with the Contractor under Healthy Options/SCHIP.

 

1.14         EPSDT (Early, Periodic Screening, Diagnosis and Treatment) means a package of services in a preventive (well child) exam covered by Medicaid as defined in the Social Security Act (SSA) Section 1905(r) and the DSHS EPSDT program policy and billing instructions (See Exhibit A for website link). Services covered by Medicaid include a complete health history and developmental assessment, an unclothed physical exam, immunizations, laboratory tests, health education and anticipatory guidance, and screenings for: vision, dental, substance abuse, mental health and hearing, as well as any medically necessary services found to be necessary during the EPSDT exam. EPSDT services covered by the Contractor are described in Section 11, Benefits.

 

1.15         Eligible Clients means Medicaid recipients certified eligible by DSHS, living in the service area, and eligible to enroll for health care services under the terms of this Contract, as described in Section 2.2.

 

1.16         Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part (42 CFR 438.114(a)).

 

1.17         Emergency Services means covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish the services and are needed to evaluate or stabilize an emergency medical condition (42 CFR 438.114(a)).

 

1.18         Enrollee means an Medicaid recipient eligible for any medical program who is enrolled in Healthy Options/SCHIP managed care through a health care plan having a Contract with DSHS (42 CFR 438.10(a)).

 

1.19         Enrollee with Special Health Care Needs means a Medicaid recipient who has chronic and disabling conditions as defined in WAC 388-538-050.

 

1.20         External Quality Review (EQR) means the analysis and evaluation by an EQRO of aggregated information on quality, timeliness and access to the health care services that the Contractor or its subcontractors furnish to Medicaid recipients (42 CFR 438.320).

 

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1.21         External Quality Review Organization (EQRO) means an organization that meets the competence and independence requirements set forth in 42 CFR 438.354, and performs external quality review, other EQR-related activities as set forth in 42 CFR 438.358, or both (42 CFR 438.320). DSHS must contract with one EQRO to conduct either EQR alone or EQR-related activities and may contract with additional EQROs to conduct EQR-related activities as set forth in 42 CFR 438.358.

 

1.22         External Quality Review Protocols means a series of nine (9) procedures or guidelines for validating performance. Two of the nine protocols must be used by state Medicaid agencies. These are:  1) Determining Contractor compliance with federal Medicaid managed care regulations; and 2) Validation of performance improvement projects undertaken by the Contractor. The current Centers for Medicare and Medicaid Services (CMS) Protocols (See Exhibit A for website link).

 

1.23         External Quality Review Report - (EQRR) means a technical report that describes the manner in which the data from all EQR activities are aggregated and analyzed, and conclusions drawn as to the quality, timeliness, and access to the care furnished by the Contractor. DSHS will provide a copy of the EQRR to the Contractor, through print or electronic media and to interested parties such as participating health care providers, enrollees and potential enrollees of the Contractor, recipient advocacy groups, and members of the general public. DSHS must make this information available in alternative formats for persons with sensory impairments, when requested.

 

1.24         Grievance means an expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights (42 CFR 438.400(b)).

 

1.25         Grievance Process means the procedure for addressing enrollees’ grievances.

 

1.26         Grievance System means the overall system that includes grievances and appeals handled by the Contractor and access to the fair hearing system (42 CFR 438.400).

 

1.27         Health Care Professional means a physician or any of the following acting within their scope of practice; a podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse midwife), licensed certified social worker, registered respiratory therapist, pharmacist and certified respiratory therapy technician (42 CFR 438.2).

 

1.28         Health Employer Data and Information Set - (HEDIS®) means a set of standardized performance measures designed to ensure that healthcare

 

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purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS® are related to many significant public health issues such as immunizations, smoking, asthma, and diabetes. HEDIS® also includes a standardized survey of consumers’ experiences that evaluates plan performance in areas such as customer service, access to care and claims processing. HEDIS® is sponsored, supported, and maintained by National Committee for Quality Assurance (NCQA).

 

1.29         Health Employer Data and Information Set (HEDIS®) Compliance Audit Program means a set of standards and audit methods used by an NCQA certified auditor to evaluate information systems capabilities assessment (IS standards) and a Contractor’s ability to comply with HEDIS® specifications (HD standards).

 

1.30         Managed Care means a prepaid, comprehensive system of medical and health care delivery, including preventive, primary, specialty and ancillary health services.

 

1.31         Managed Care Organization (MCO) means an organization having a certificate of authority or certificate of registration from the Office of Insurance Commissioner that contracts with DSHS under a comprehensive risk contract to provide prepaid health care services to eligible DSHS clients under the department’s managed care programs (WAC 388-538-050).

 

1.32         Marketing means any communication from the Contractor to a potential enrollee or enrollee with another DSHS contracted MCO that can be reasonably interpreted as intended to influence them to enroll with the Contractor or either to not enroll in, or to disenroll from, another DSHS contracted MCO (CFR 438.104(a)).

 

1.33         Marketing Materials means materials that are produced in any medium, by or on behalf of the Contractor that can be reasonably interpreted as intended as marketing. (42 CFR 438.104(a)).

 

1.34         Medically Necessary Services means services that meet the definition in WAC 388-500-0005. In addition, medically necessary services shall include services related to the enrollee’s ability to achieve age-appropriate growth and development.

 

1.35         National CAHPS® Benchmarking Database - (NCBD) means a national repository for data from the Consumer Assessment of Health Plans Survey (CAHPS).  The database facilitates comparisons of CAHPS® survey results by survey sponsors.  Data is compiled into a single national database, which enables NCBD participants to compare their own results to relevant benchmarks (i.e., reference points such as national and regional averages). The NCBD also offers an important source of primary data for specialized research related to consumer assessments of quality as measured by CAHPS®.

 

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1.36         National Committee for Quality Assurance - (NCQA) means an organization responsible for developing and managing health care measures that assess the quality of care and services that commercial and Medicaid managed care clients receive.

 

1.37         Participating Provider means a person, health care provider, practitioner, or entity, acting within their scope of practice, with a written agreement with the Contractor to provide services to enrollees under the terms of this Contract.

 

1.38         Peer-Reviewed Medical Literature means medical literature published in professional journals that submit articles for review by experts who are not part of the editorial staff. It does not include publications or supplements to publications primarily intended as marketing material for pharmaceutical, medical supplies, medical devices, health service providers, or insurance carriers.

 

1.39         Physician Group means a partnership, association, corporation, individual practice association, or other group that distributes income from the practice among its members. An individual practice association is a physician group only if it is composed of individual physicians and has no subcontracts with physician groups.

 

1.40         Physician Incentive Plan means any compensation arrangement between the Contractor and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services to enrollees under the terms of this Contract.

 

1.41         Post-stabilization Services means covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition (42 CFR 438.114 and 42 CFR 422.113).

 

1.42         Potential Enrollee means any Medicaid recipient eligible for enrollment in Healthy Options/SCHIP who is not enrolled with a health care plan having a contract with DSHS (42 CFR 438.10(a)).

 

1.43         Primary Care Provider (PCP) means a participating provider who has the responsibility for supervising, coordinating, and providing primary health care to enrollees, initiating referrals for specialist care, and maintaining the continuity of enrollee care. PCPs include, but are not limited to Pediatricians, Family Practitioners, General Practitioners, Internists, Physician Assistants (under the supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as designated by the Contractor. The definition of primary care provider is inclusive of the definition of primary care physician in 42 CFR 400.203 and all Federal requirements for primary care physicians will be applicable to primary care providers as the term is used in this Contract.

 

1.44         Quality as it pertains to external quality review means the degree to which a Contractor increases the likelihood of desired health outcomes of its enrollees through its structural and operational characteristics and through the provision of

 

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health services that are consistent with current professional knowledge (42 CFR 438.320).

 

1.45         Risk means the possibility that a loss may be incurred because the cost of providing services may exceed the payments made for services. When applied to subcontractors, loss includes the loss of potential payments made as part of a physician incentive plan, as defined herein.

 

1.46         Service Areas means the geographic areas covered by this Contract as described in Section 2.1.

 

1.47         State Children’s Health Insurance Program (SCHIP) means a state-funded program to provide access to medical care for children whose family income exceeds the limit for Medicaid eligibility, but is not greater than two hundred fifty percent of the federal poverty level (FPL). SCHIP is authorized by Title XXI of the Social Security Act and by RCW 74.09.450 (WAC 388-542).

 

1.48         Subcontract means a written agreement between the Contractor and a subcontractor, or between a subcontractor and another subcontractor, to perform all or a portion of the duties and obligations the Contractor is obligated to perform pursuant to this Contract.

 

1.49         Validation means the review of information, data, and procedures to determine the extent to which they are accurate, reliable, and free from bias and in accord with standards for data collection and analysis (42 CFR 438.320).

 

2.             ENROLLMENT

 

2.1           Service Areas:

 

2.1.1                The Contractor’s service areas are described in Exhibit B, Premiums, Service Areas, and Capacity. DSHS shall update Exhibit B, Premiums, Service Areas, and Capacity for service area changes as describe herein.

 

2.1.2                Clients in the eligibility groups described in Section 2.2 are eligible to enroll with the Contractor if they reside in the Contractor’s service areas.

 

2.1.3                Service Area Changes:

 

2.1.3.1             With the written approval of DSHS, the Contractor may expand into additional service areas at any time by giving written notice to DSHS, along with evidence, as DSHS may require, demonstrating the Contractor’s ability to support the expansion. DSHS may withhold approval of a requested expansion, if, in DSHS’ sole judgment, the requested expansion is not in the best interest of DSHS.

 

2.1.3.2             The Contractor may decrease service areas by giving DSHS ninety (90) calendar days written notice. The decrease shall not be effective until

 

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the first day of the month that falls after the ninety (90) calendar days has elapsed.

 

2.1.3.3             The Contractor shall notify enrollees affected by any service area decrease sixty (60) calendar days prior to the effective date. Notices shall have prior approval of DSHS. If the Contractor fails to notify affected enrollees of a service area decrease sixty (60) calendar days prior to the effective date, the decrease shall not be effective until the first day of the month which falls sixty (60) calendar days from the date the Contractor notifies enrollees.

 

2.1.4                If the U.S. Postal Service alters the zip code numbers or zip code boundaries within the Contractor’s service areas, DSHS shall alter the service area zip code numbers or the boundaries of the service areas with input from the affected contractors.

 

2.1.5                DSHS shall determine, in its sole judgment, which zip codes fall within each service area. No zip code will be split between service areas.

 

2.1.6                DSHS will determine whether an enrollee resides within a service area.

 

2.2           Eligible Client Groups: DSHS shall determine eligibility for enrollment under this Contract. Clients in the following eligibility groups at the time of enrollment are eligible for enrollment under this Contract, and must enroll in Healthy Options/SCHIP unless the enrollee has duplicate coverage as defined herein, has comparable coverage as defined herein, or is exempted pursuant to Section 2.4.

 

2.2.1                Clients receiving Medicaid under Social Security Act (SSA) provisions for coverage of families receiving Temporary Assistance for Needy Families and clients who are not eligible for cash assistance who remain eligible for Medicaid.

 

2.2.2                Children, from birth through eighteen years of age, eligible for Medicaid under expanded pediatric coverage provisions of the Social Security Act (“H” Children).

 

2.2.3                Pregnant Women, eligible for Medicaid under expanded maternity coverage provisions of the Social Security Act (“S” women).

 

2.2.4                Children eligible for SCHIP (See Exhibit A for website link).

 

2.3           Client Notification: DSHS shall notify eligible clients of their rights and responsibilities as Healthy Options/SCHIP enrollees at the time of initial eligibility determination and at least annually. The Contractor shall provide enrollees with additional information as described in this Contract.

 

2.4           Exemption from Enrollment: A client may request exemption from enrollment. Each request for exemption will be reviewed by DSHS pursuant to WAC 388-

 

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538 or WAC 388-542. When the client is already enrolled with the Contractor and wishes to be exempted, the exemption request will be treated as a disenrollment request consistent with the provisions of Section 2.9.

 

2.5           Enrollment Period: Subject to the provisions of Section 2.7, enrollment is continuously open. Enrollees shall have the right to change enrollment prospectively, from one Healthy Options/SCHIP plan to another without cause, each month.

 

2.6           Enrollment Process: To enroll with the Contractor, the client, their representative or their responsible parent or guardian must complete and submit a DSHS enrollment form to DSHS, or call the DSHS, Division of Client Support toll-free enrollment number. If the client does not exercise their right to choose a Healthy Options/SCHIP plan, DSHS will assign the client, and all eligible family members, to a Healthy Options/SCHIP plan in accord with Section 5.12 of this Contract.

 

DSHS will make every effort to enroll all family members with the same Healthy Options/SCHIP plan. If a family member is covered by the Basic Health, DSHS will make every effort to enroll the remainder of the family with the same managed care plan if the plan contracts with DSHS to provide Healthy Options/SCHIP. If the plan does not contract with DSHS, the remaining family members will be enrolled with a single, but different Healthy Options/SCHIP plan of the client’s choice, or the client will be assigned as described above if they do not choose.

 

2.7           Effective Date of Enrollment:

 

2.7.1                Except for newborns whose mother is enrolled in a Healthy Options/SCHIP plan, enrollment with the Contractor shall be effective on the later of the following dates:

 

2.7.1.1             If the enrollment is processed on or before the DSHS cut-off date for enrollment, enrollment shall be effective the first day of the month following the month in which the enrollment is processed; or

 

2.7.1.2             If the enrollment is processed after the DSHS cut-off date for enrollment, enrollment shall be effective the first day of the second month following the month in which the enrollment is processed.

 

2.7.2                Newborns whose mothers are enrollees shall be deemed enrollees and enrolled beginning from the newborn’s date of birth or the mother’s date of enrollment, whichever is later. If the mother is disenrolled before the newborn receives a separate client identifier from DSHS, the newborn’s coverage shall end when the mother’s coverage ends, except as provided in Section 11.12, Enrollee Hospitalized at Disenrollment. If the newborn does not receive a separate client identifier by the sixtieth (60th) day of life, supplemental premiums and coverage shall only be available through the end of the month in which the sixtieth (60th) day of life falls in accord with

 

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Healthy Options Licensed Health Carrier Billing Instructions, published by DSHS (See Exhibit A for website link).

 

2.7.3                Adopted children shall be covered consistent with the provisions of Title 48 RCW.

 

2.7.4                No retroactive coverage is provided under this Contract, except as described in this Section.

 

2.8           Enrollment Listing and Requirements for Contractor’s Response:

 

2.8.1                Before the end of each month DSHS will provide the Contractor with an electronic file listing the Contractor’s enrollees whose enrollment is terminated by the end of that month, and the Contractor’s enrollees for the following month. The electronic file will be provided via a Health Insurance Portability and Accountability Act (HIPAA) compliant secure web-based transfer system in the 834 benefit enrollment and maintenance format.

 

2.8.2                The Contractor shall have ten (10) calendar days from the receipt of the enrollment listing to notify DSHS in writing of the refusal of an application for enrollment or any discrepancy regarding DSHS’ proposed enrollment effective date. Written notice shall include the reason for refusal and must be agreed to by DSHS. The effective date of enrollment specified by DSHS shall be considered accepted by the Contractor and shall be binding if the notice is not timely or DSHS does not agree with the reasons stated in the notice. Subject to DSHS approval, the Contractor may refuse to accept an enrollee for the following reasons:

 

2.8.2.1             DSHS has enrolled the enrollee with the Contractor in a service area the Contractor is not contracted for.

 

2.8.2.2             The enrollee is not eligible for enrollment under the terms of this Contract.

 

2.9           Termination of Enrollment:

 

2.9.1                Voluntary Termination: Enrollees may request termination of enrollment by submitting a written request to terminate enrollment to DSHS or by calling the Medical Assistance Customer Service Center (MACSC) toll-free enrollment number. Requests for termination of enrollment may be made to enroll with another Healthy Options plan, or to disenroll from Healthy Options as provided in WAC 388-538 or WAC 388-542. Except as provided in WAC 388-538 or WAC 388-542, enrollees whose enrollment is terminated will be prospectively disenrolled. DSHS shall notify the Contractor of enrollee terminations pursuant to Section 2.8. The Contractor may not request voluntary disenrollment on behalf of an enrollee.

 

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2.9.2                Involuntary Termination Initiated by DSHS for Ineligibility: The enrollment of any enrollee under this Contract shall be terminated if the enrollee becomes ineligible for enrollment due to a change in eligibility status.

 

2.9.2.1             When an enrollee’s enrollment is terminated for ineligibility, the termination shall be effective:

 

2.9.2.1.1                  The first day of the month following the month in which the termination is processed by DSHS if the termination is processed on or before the DSHS cut-off date for enrollment or the Contractor is informed by DSHS of the termination prior to the first day of the month following the month in which the termination is processed by DSHS.

 

2.9.2.1.2                  Effective the first day of the second month following the month in which the termination is processed if the termination is processed after the DSHS cut-off date for enrollment and the Contractor is not informed by DSHS of the termination prior to the first day of the month following the month in which the termination is processed by DSHS.

 

2.9.2.2             Enrollees Eligible for Social Security Income (SSI):

 

2.9.2.2.1                  Newborn enrollees with a date-of-birth after calendar year 2003 who are determined by the Social Security Administration (SSA) to have an SSI eligibility effective date within the first sixty-days of life, not counting the birth date, shall be ineligible for services under the terms of this Contract when DSHS receives the SSI eligibility information from the SSA through the State Data Exchange (SDX). Such newborn enrollees will be disenrolled retroactively effective the date-of-birth. DSHS shall recoup premiums paid in accord with Section 4.5.5.

 

2.9.2.2.2                  Except as provided in Section 2.9.2.2.1, enrollees determined by the SSA to be eligible for SSI shall be ineligible for services under the terms of this Contract when DSHS receives the SSI eligibility information from the SSA through the electronic SDX. Such enrollees will be disenrolled prospectively as described in Section 2.9.2.1. DSHS shall not recoup any premiums for enrollees determined SSI eligible and the Contractor shall be responsible for providing services under the terms of this Contract until the effective date of disenrollment.

 

2.9.2.2.3                  If the Contractor believes an enrollee has been determined by SSA to be eligible for SSI, the Contractor shall present documentation of such eligibility to DSHS, DSHS will attempt to verify the eligibility and, if the enrollee is SSI eligible, DSHS will act upon SSI eligibility in accord with this Section.

 

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2.9.3                Involuntary Termination Initiated by DSHS for Comparable Coverage or Duplicate Coverage:

 

2.9.3.1             The Contractor shall notify DSHS as set forth below when an enrollee has health care insurance coverage with the Contractor or any other carrier:

 

2.9.3.1.1                  Within fifteen (15) working days when an enrollee is verified as having duplicate coverage, as defined herein.

 

2.9.3.1.2                  Within sixty (60) calendar days of the date when the Contractor becomes aware that an enrollee has any health care insurance coverage with any other insurance carrier. The Contractor is not responsible for the determination of comparable coverage, as defined herein.

 

2.9.3.2             DSHS will involuntarily terminate the enrollment of any enrollee with duplicate coverage or comparable coverage as follows:

 

2.9.3.2.1                  When the enrollee has duplicate coverage that has been verified by DSHS, DSHS shall terminate enrollment retroactively to the beginning of the month of duplicate coverage and recoup premiums as describe in Section 4.5, Recoupments.

 

2.9.3.2.2                  When the enrollee has comparable coverage which has been verified by DSHS, DSHS shall terminate enrollment effective the first day of the second month following the month in which the termination is processed if the termination is processed on or before the DSHS cut-off date for enrollment or, effective the first day of the third month following the month in which the termination is processed if the termination is processed after the DSHS cut-off date for enrollment.

 

2.9.4                Involuntary Termination Initiated by the Contractor: To request involuntary termination of an enrollee, the Contractor shall send written notice to DSHS as described in Section 12.26, Notices. Involuntary termination will occur only with written DSHS approval. DSHS shall review each request on a case by case basis, and approve or disapprove the request for termination within thirty (30) working days of receipt of such notice and the documentation required to substantiate the request. For the termination to be effective, DSHS must approve the termination request, notify the Contractor, and disenroll the enrollee. The Contractor shall continue to provide services to the enrollee until they are disenrolled. DSHS will not disenroll an enrollee solely due to a request based on an adverse change in the enrollee’s health status, the cost of meeting the enrollee’s health care needs, because of the enrollee’s utilization of medical services, uncooperative or disruptive behavior resulting from his or her special needs or diminished mental capacity (WAC 388-538-130). DSHS shall

 

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involuntarily terminate the enrollee when the Contractor has substantiated in writing all of the following:

 

2.9.4.1             The enrollee’s behavior is inconsistent with the Contractor’s rules and regulations, such as intentional misconduct;