2008-000065E
PHYSICAL HEALTH INSURANCE
CONTRACT
Puerto Rico
Health Insurance Administration (PRHIA) a public instrumentality of the Commonwealth of
Puerto Rico organized pursuant to Act 72, of September 7,
1993, as amended, hereinafter referred to as the “
ADMINISTRATION ”, and represented by its Executive
Director, Minerva Rivera González
TRIPLE S,
INC., a private
corporation duly organized and authorized to do business under the
laws of the Commonwealth of Puerto Rico, with Employer Social
Security Number 660-55-5677 , hereinafter referred to as
“ INSURER ”, and represented by its Chief
Executive Officer, Ms. Socorro Rivas ;
For the Provision of Health
Insurance coverage to eligible population under the Government
Health Insurance Plan
In
consideration of the mutual covenants and agreements hereinafter
set forth, the parties, their personal representative and
successors, agree as follows:
WHEREAS: The parties entered into contract number 08-065
to provide health insurance coverage for the North and Southwest
Area medically indigent population; enrolled in the Government
Health Insurance Plan (GHIP) for the period November 2006
to June 2008. While negotiating premium rates the parties
agree to extend that contract until August 30, 2008; contract
#08-065C.
WHEREAS: The Administration and TRIPLE S, INC,
conclude the negotiation process for the period of July 1,
2008 thru June 30, 2009 and the Board of Directors approved
the premiums rates finally agreed.
WHEREAS: The parties sign a contract that was not
approved by CMS, thus it was necessary to amend the contract with
the language suggested by CMS.
HENCEFORTH: The appearing Parties agree to amend and extend
the contract #08-065 as follows:
Article I: To amend in Article I
“Definitions”; the definitions of Action and
Grievance and incorporate the definitions of EQR, EQRO,
External Quality Review, External Quality Review Organizations and
Quality, to read as follows.
(5) The
failure of the MCO to act within the timeframes of 42CFR
438.408(b).
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EQR: Stands for external quality review.
EQRO: Stands for external quality review
organization.
EXTERNAL
QUALITY REVIEW: Means the
analysis and evaluation by an EQRO, of aggregated information on
quality, timeliness, and access to the health care services that an
MCO or their contractors furnish to Medicaid recipients.
EXTERNAL
QUALITY REVIEW ORGANIZATION: Means an organization that meets the competence
and independence requirements set forth in §438.354, and
performs external quality review, other EQR-related activities as
set forth in §438.358, or both.
GRIEVANCE: Formal complaint, either orally or in writing
made on the basis of something that somebody feels is unfair. Shall
mean the expression of dissatisfaction about any matter, other than
an action. Possible subject for grievances include, but are not
limited to, the quality of care or services provided, and aspects
of interpersonal relationship such as rudeness of a provider or
employee, or failure to respect enrollee’s rights.
QUALITY: As it pertains to external quality review, means
the degree to which an MCO and PHIP increases the likelihood of
desired health outcomes of its enrollees through its structural and
operational characteristics and through the provision of health
services that are consistent with current professional
knowledge.
Article II: To amend Article IX “Contracts
with HCO’s and All Participating Providers”; and
incorporate in provision six (6) new paragraphs identified by
the letters (n) and (o) and a new provision 18 to read as
follows :
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m.
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...
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n.
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The
financial responsibility for services included in the Basic
Coverage, as established in Appendix A of this contract
(Government Health Insurance Plan Coverage), will be the sole
obligation of the IPA/ HCO, except when the IPA/ HCO have
negotiated other risks with the INSURER and other financial
agreements are in place. In this case, the INSURER shall notify the
ADMINISTRATION
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of
this arrangement. These financial responsibilities include all
laboratories tests for the diagnostic of health conditions under
the Special Coverage. The INSURER is responsible to incorporate in
contract in contracts with HCO’s/IPA’s or any other
providers, all the provisions, as applicable, under Medicaid
Managed Care Rules or any other federal regulations, in order to
receive payments from federal funds.
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o.
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The
financial responsibility for services included in the Special
Coverage, established under Appendix A of this contract
(Government Health Insurance Plan Coverage), will be the sole
obligation of the INSURER, except in the cases that IPA/HCO have
negotiated other risks with the INSURER and other financial
agreements are in place. In this case, the INSURER shall notify the
ADMINISTRATION of this arrangement. These financial
responsibilities include all laboratories test for beneficiaries
included and registered in the Special Coverage. The INSURER is
responsible to incorporate in contracts with
HCO’s/IPA’s or any other providers, all the provisions,
as applicable, under Medicaid Manage Care Rules or any other
federal regulations, in order to receive payments from federal
funds.
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17.
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.....
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18.
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CONTRACTS WITH FQHC
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A.
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Standards for Contractor FQHC
Rates. The
Insurer shall not pay FQHCs less than the level and amount of
payment that the contractor would make for a similar set of
services if the services were furnished by a non-FQHC. The Insurer
may pay the FQHCs on a capitated basis. The Insurer shall make
payments for primary care equal to, or greater than, the average
amounts paid to other primary care providers. Services provided by
Specialist Physician may be included if mutually agreeable between
the contractor and FQHC.
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B.
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Department of Health Reimbursement
to FQHCs .
Under Title XIX, an FQHC shall be paid under a Prospective Payment
System (PPS) by Department of Health. At the end each calendar
quarter, the Insurer shall provide to the contracted FQHCs the
statistical data available and necessary for the FQHC to prepare
the cost reports that will enable Department of Health to determine
PPS reimbursement and compare that to what was actually paid by the
Insurer to the FQHC. Department of Health will reimburse FQHC
the
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difference between the PPS rate per
encounter and payments to the FQHC made by the Insurer if the
payments by the Insurer to the FQHC are less than the PPS rate. In
the event of an overpayment, the FQHC shall reimburse Department of
Health for payments received from the Insurer that are in excess of
the PPS rate. FQHC providers must meet the Insurer’s
credentialing and program requirements.
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C.
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Insurer Participation in
Reconciliation Process . The Insurer shall participate in
the reconciliation processes if there is a dispute between what the
insurer reported and what the FQHC reported as valid encounters or
payments.
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Article III: To amend in Article XII “Grievance
Procedure” provisions seven (7), eight (8) and
seventeen (17) to read as follows:
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6.
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...
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7.
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INSURER represents that it has
established an effective procedure that assures the compliance with
the basic minimum requirements established under the Medicaid
Regulations for the handling and resolution of all grievances made
by the beneficiaries and the participating providers. INSURER
grievance forms shall be approved by the ADMINISTRATION. The
approved grievance form shall be made available to all
beneficiaries, HCO’s, HCO’s network of participating
providers and the INSURER’s participating providers. The
parties shall make whatever adjustments are necessary to reconcile
their grievance procedure with provisions of Law No. 94 of
August 25, 2000 (known as the “Patient Bill of Rights
and Responsibilities”) and those contained in Law No. 11
of April 11, 2001 (known as the “Organic Law of the
Office of the Patient Advocate”), to the extent that such
provisions do not enter in direct conflict with, or may be deemed
an obstacle to, federal regulations.
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8.
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INSURER shall be responsible for
documenting in writing all aspects and details of said grievance
procedures.
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9.
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...
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17.
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The
Grievance Procedures shall comply with the minimum standards and
timeframes for prompt resolution of grievances and appeals set
forth in this Contract and any applicable laws and regulations of
the Commonwealth, such as Law No. 94 August 25, 2000(known as
the “Patient Bill Rights and Responsibilities”), and
Law No. 408, (the Mental Health Law) of August 25, 2000,
to the extent that provisions of said laws do not enter in direct
conflict with, or may be deemed an obstacle to, federal
regulations.
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Article IV: To amend in Article XV “Quality of
Healthcare and Performance” “Section C Statistical
Reports Program” , to read as follows:
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C.
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Statistical Reports Program
(SRP)
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1.
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The
INSURER agrees to provide to the ADMINISTRATION, on a regular basis
as needed, any and all data, information, reports, and
documentation that will permit Governmental Agencies, to compile
statistical data to substantiate the need for, and the appropriate
use of federal funds for federally and state financed health
programs.
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2.
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As
an additional measure to guarantee quality and adequacy of the
medical health services, the INSURER will conduct periodical
statistics analysis of the medical services rendered to the
beneficiaries and will compare them with the primary physician
practice profile of their regular health insurance plan. Quarterly
reports as to the analysis and comparison statistics will be
submitted to the ADMINISTRATION, upon request.
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3.
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The
INSURER upon the ADMINISTRATION request, must provide a utilization
control analysis based on:
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a.
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patient/family
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b.
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region, area/region town, (zip
code)
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c.
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provider (provider’s
identification number or social security account
numbers)
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d.
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diagnosis
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e.
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procedure or service
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4.
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The
ADMINISTRATION will require the INSURER the following quarterly
statistical reports that include, but are not limited:
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a.
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Claims Cost Distribution by Line of
Service (SRP-001)
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b.
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PMPM Claim Cost Summary Budgeted
& Actual (SRP-002)
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c.
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Premium Trend (SRP-003)
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d.
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Aggregate Stop Loss/Reinsurance
(SRP-004)
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e.
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Early Periodic Screening Diagnostics
Tests (EPSDT) (SRP-005)
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f.
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Providers Network Credentialing
(SRP-006)
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g.
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Medical Record Review
(SRP-007)
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h.
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Hospital Concurrent Review
(SRP-008)
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i.
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Retrospective Medical Record Review
(SRP-009)
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j.
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Fraud and Abuse (SRP-010)
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Pre-authorizations
(SRP-011)
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Coordination of Benefits
(SRP-012)
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Capitation Settlement Quarterly
Report (SRP-013)
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Grievances and Appeals
(SRP-014)
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o.
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Financial Operation Quarterly
Summary (SRP-015)
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p.
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Education Report
(SRP-016)
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q.
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Preventive Services Report
(SRP-16a-h)
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Insured Population by IPA and
Primary Care Physician (SRP-017)
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Eligible and Insured Population by
Group of Age and Gender (SRP-017a)
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t.
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Providers in and out of network
(SRP-018)
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5.
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The
INSURER will be responsible to provide to the ADMINISTRATION all
quarterly reports detailing the services furnished under the
Preventive Program.
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6.
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The
INSURER will deliver all the quarterly reports by the twenty-fifth
day (25) of the next month following the reporting quarter.
The reports will be delivered on an electronic media (i.e., CD Rom
disc) accompanied with a letter of submission to the ADMINISTRATION
Planning and Clinical Affairs Office Director. Concurrently, such
letter must be copy to the ADMNISTRATION Compliance Office
Director.
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7.
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The
INSURER must provide and deliver the last quarterly reports for the
corresponding fiscal period by the 25 th day of July and the 25
th
day of January,
following the next fiscal period. All quarterly reports will be
based on utilization and completion lag of twelve (12) months
of incurred services and eighteen (18) months of paid
services.
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8.
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The
ADMINISTRATION and the INSURER will agree on the required format in
order to comply with the reporting requirements in this Section,
and, for which will be accomplish through electronic or magnetic
media.
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Article V : To amend Article XVIII
“Information Systems and Reporting Requirements" , to
read as follows:
ARTICLE XVIII
INFORMATION SYSTEMS REQUIREMENTS
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The
INSURER shall be responsible for the data collection of all
services provided including, but not limited, to encounter and real
cost of each one, claims services and any other pertinent data from
all HCO’s, participating providers or any other entity which
provides services to beneficiaries under the program, said data to
be classified by provider, by beneficiary, by diagnosis, by
procedure and by the date the service is rendered. INSURER shall
also provide information on utilization grievances and appeals, and
disenrollment for other than loss of Medicaid eligibility. The data
collected
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must then be forwarded to the
ADMINISTRATION on a monthly basis in an electronic or on machine
readable media format. The data fields and specific data elements
required to be transmitted are contained in the document titled,
“Carrier to ASES Data Submissions, New File Layouts”.
The ADMINISTRATION reserves the right to modify, expand or delete
the requirements contained therein or issue new requirements,
subject to consultation with the INSURER and cost negotiation, if
necessary.
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Accordingly the INSURER must submit
to the ADMINISTRATION a detailed Systems Requirements Inventory
Report which details the following:
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a)
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Plan’s compliance with each
information system requirement;
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b)
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Action plan of INSURER’s
response to the requirements;
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c)
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Actual date that each system
requirement will be completely operational, not to exceed the
effective date of coverage under this contract.
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2.
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The
INSURER agrees to submit to the ADMINISTRATION the System Inventory
Report for final approval not later than the date of the signing of
this contract.
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3.
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All
Management Information Systems Requirements shall be fully
operational as of the first day of coverage under this Contract and
shall remain as such for the duration of the Contract. If INSURER
is not in compliance with this requirement will be subject to the
cancellation of this contract.
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4.
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The
INSURER agrees that all required data and information needs to be
collected and reported through electronic or machine readable media
commencing with the effective date of coverage of this contract to
the ADMINISTRATION, and upon request to CMS. The MCO ensures that
data received from providers is screened for completeness, logic,
and consistency.
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4.1
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Data that must be certified by
INSURER. The data that must be certified include and is not limited
to, documents specified by the ADMINISTRATION, enrollment
information, encounter data and other information required in this
contract and RFP. Any payment by the ADMINISTRATION that is based
on data submitted by the INSURER, must comply with the
certification as provided on 42 CFR 438.606. The certification must
attest, based on the best knowledge, information and
belief
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