COMMUNITY HEALTHCHOICES AGREEMENT Table of Contents AGREEMENT AND RFP ACRONYMNS SECTION I: INCORPORATION OF DOCUMENTS ..................................................... 12 A. Operative Documents ................................................................... 12 B. Operational Updates and Department Communications ............... 12 SECTION II: DEFINITIONS ......................................................................................... 12 SECTION III: RELATIONSHIP OF PARTIES .............................................................. 31 A. Term of Agreement ....................................................................... 31 B. Nature of Agreement ..................................................................... 31 SECTION IV: APPLICABLE LAWS AND REGULATIONS ......................................... 31 A. Certification, Licensing and Accreditation ..................................... 31 1. National Accreditation ................................................................... 31 B. Specific to Medical Assistance Program........................................ 32 C. Specific to Medicare ...................................................................... 32 D. General Laws and Regulations ..................................................... 33 E. Limitation on the Department's Obligations ................................... 34 F. Health Care Legislation, Regulations, Policies and Procedures ....34 SECTION V: PROGRAM REQUIREMENTS ............................................................... 34 A. Covered Services .................................................................................... 34 1. Amount, Duration and Scope ........................................................ 34 2. Home and Community-Based Services ........................................ 34 3. Program Exceptions ...................................................................... 35 4. Expanded or Value-Added Services .............................................. 35 5. Referrals ....................................................................................... 36 6. Self-Referral/Direct Access ........................................................... 36 7. Behavioral Health Services ........................................................... 37 8. Pharmacy Services ....................................................................... 37 9. Emergency Services ..................................................................... 37 10. Post-Stabilization Services ............................................................ 39 11. Examinations to Determine Abuse or Neglect ............................... 40 12. Hospice Services .......................................................................... 41 1 13. Organ Transplants ........................................................................ 41 14. Transportation ............................................................................... 41 15. Healthy Beginnings Plus Program ................................................. 42 16. Nursing Facility Services ............................................................... 42 17. Participant Self-Directed Services ................................................. 43 18. Health and Wellness Education and Outreach for Participants and Caregivers ..................................................................................... 43 19. Settings for LTSS .......................................................................... 44 20. Service Delivery Innovation ........................................................... 44 21. Exceptional Durable Medical Equipment ....................................... 45 B. Prior Authorization of Services ...................................................... 45 1. General Prior Authorization Requirements .................................... 45 2. Time Frames for Notice of Decisions ............................................ 46 3. Prior Authorization of Outpatient Drug Services ............................ 48 C. Continuity of Care ......................................................................... 48 D. Choice of Provider ......................................................................... 50 E. Comprehensive Needs Assessments and Reassessments .......... 50 F. Person-Centered Planning Team Approach Required .................. 52 G. Person-Centered Service Plans .................................................... 52 H. Care Management and Care Plans ............................................... 54 I. Department Review of Changes in PCSPs ................................... 55 J. Service Coordination ..................................................................... 55 K. Service Coordinator and Service Coordinator Supervisor Requirements ................................................................................ 56 L. Nursing Home Transition Services ................................................ 57 M. Coordination of Services ............................................................... 57 1. CHC-MCO and BH-MCO Coordination ......................................... 57 2. Disability Advocacy Program ........................................................ 58 N. CHC-MCO Responsibility for Reportable Conditions .................... 58 O. Participant Enrollment, Disenrollment, Outreach, and Communication ............................................................................. 58 1. General ......................................................................................... 58 2. CHC-MCO Outreach Materials...................................................... 59 3. CHC-MCO Outreach Activities ...................................................... 60 4. Limited English Proficiency Requirements ................................... 62 5. Alternate Format Requirements .................................................... 62 6. CHC-MCO Enrollment Procedures ............................................... 63 7. Enrollment of Newborns ................................................................ 63 8. Transitioning Participants Between CHC-MCOs ........................... 63 9. Transitioning Participants Between CHC-MCOs and LIFE Programs ...................................................................................................... 63 10. Change in Status ........................................................................... 63 11. Participants Files ........................................................................... 64 12. Enrollment and Disenrollment Updates ......................................... 65 13. Services for New Participants ....................................................... 65 14. New Participant Orientation .......................................................... 65 2 15. CHC-MCO Identification Cards ..................................................... 66 16. Participant Handbook .................................................................... 66 17. Provider Directory ......................................................................... 67 18. Participant Advisory Committee .................................................... 68 19. Voluntary Disenrollment ................................................................ 69 20. Involuntary Disenrollment .............................................................. 69 P. Participant Services ...................................................................... 69 1. General ......................................................................................... 69 2. CHC-MCO Internal Participant Dedicated Hotline ......................... 70 3. Nurse Hotline ................................................................................ 71 4. Education and Outreach/Health Education Advisory Committee ... 71 5. Informational Materials…………………………………………… ….72 Q. Additional Addressee .................................................................... 72 R. Participant Complaint, Grievance and DHS Fair Hearing Process ……………………………………………………………… 72 S. OLTL and Other DHS Hotlines ...................................................... 74 T. Provider Dispute Resolution Process ............................................ 74 U. Certification of Authority and County Operational Authority .......... 74 V. Executive Management ................................................................. 75 W. Other Administrative Components ................................................ 76 X. Administration ............................................................................... 79 1. Participant Lock-in Program .......................................................... 79 2. Contracts and Subcontracts .......................................................... 80 3. Records Retention ........................................................................ 82 4. Fraud and Abuse ........................................................................... 82 5. Management Information Systems ................................................ 88 6. Department Access…………………………………………………..91 Y. Selection and Assignment of PCPs ............................................... 92 Z. Selection and Assignment of Service Coordinators ...................... 93 AA. Provider Services .......................................................................... 94 1. Provider Manual ............................................................................ 94 2. Provider Education ........................................................................ 95 BB. Provider Network ........................................................................... 97 1. Provider Qualifications .................................................................. 97 2. Provider Agreements .................................................................... 97 3. Cultural Competency, Linguistic Competency and Disability Competency .................................................................................. 98 4. Primary Care Practitioner Responsibilities .................................... 98 5. Specialists as PCPs ...................................................................... 99 6. Related Party .............................................................................. 100 7. Integration ................................................................................... 100 8. Network Changes/Provider Terminations .................................... 101 9. Other Provider Enrollment Standards ......................................... 102 10. Twenty-Four Hour Coverage ....................................................... 102 CC. QM and UM Program Requirements ........................................... 102 3 1. Overview ..................................................................................... 102 2. Quality Management/Performance Improvement ........................ 103 3. Utilization Management ............................................................... 104 4. Healthcare Effectiveness Data and Information Set (HEDIS) ...... 104 5. External Quality Review (EQR) ................................................... 104 6. Pay for Performance Programs ................................................... 104 7. QM/UM Program Reporting Requirements ................................. 104 8. Delegated Quality Management and Utilization Management Functions .................................................................................... 105 9. Participant Involvement in the Quality Management and Utilization Management Programs 105 10. Confidentiality.............................................................................. 105 11. Department Oversight ................................................................. 105 12. CHC-MCO Cooperation with Research and Evaluation 106 DD. Mergers, Acquisitions, Mark, Insignia, Logo and Product Name …………106 1. Mergers and Acquisitions ........................................................... 106 2. Mark, Insignia, Logo, and Product Name Changes ..................... 106 EE. Cooperation with the IEE ....................................................................... 106 FF. Employment Support 107 SECTION VI: PROGRAM OUTCOMES AND DELIVERABLES ............................... 107 SECTION VII: FINANCIAL REQUIREMENTS ........................................................... 107 A. Financial Standards .................................................................... 107 1. Equity Requirements and Solvency Protection ........................... 107 2. Risk Based Capital ..................................................................... 108 3. Prior Approval of Payments to Affiliates ...................................... 108 4. Change in Independent Actuary or Independent Auditor............. 109 5. Modified Current Ratio ................................................................ 109 6. Sanctions .................................................................................... 110 7. DSH/GME Payment for Disproportionate Share Hospitals and Graduate Medical Education 8. Participant Liability ...................................................................... 111 B. Commonwealth Capitation Payments ......................................... 111 1. Payments For Covered Services ................................................. 111 2. Program Changes ....................................................................... 112 C. Acceptance of Actuarially Sound Rates ...................................... 113 D. Claims Processing Standards, Monthly Report and Penalties .... 113 1. Timeliness Standards .................................................................. 113 2. Sanctions .................................................................................... 114 E. Other Financial Requirements..................................................... 116 1. Physician Incentive Arrangements .............................................. 116 2. Retroactive Eligibility Period ........................................................ 117 3. In-Network Services .................................................................... 117 4. Payments for Out-of-Network Providers ...................................... 118 4 5. Payments to FQHCs and Rural Health Centers ......................... 118 6. Liability During an Active Grievance or Appeal ........................... 119 7. Financial Responsibility for Dual Eligible Participants ................. 119 8. Confidentiality.............................................................................. 119 9. Audits .......................................................................................... 120 10. Restitution for Overpayments ...................................................... 120 11. Penalty Periods……………………………………………………….120 F. Third Party Liability ....................................................................................... 120 1. Cost Avoidance Activities ............................................................ 120 2. Post-Payment Recoveries ........................................................... 121 3. Requests for Additional Data ...................................................... 123 4. Accessibility to TPL Data ............................................................ 123 5. Third Party Resource Identification ............................................. 124 6. Estate Recovery .......................................................................... 124 SECTION VIII: REPORTING REQUIREMENTS ........................................................ 124 A. General ....................................................................................... 124 B. Systems Reporting ...................................................................... 125 1. Encounter Data Reporting ........................................................... 125 2. Third Party Liability Reporting ..................................................... 127 3. PCP Assignment ......................................................................... 128 4. Provider Network ......................................................................... 128 5. Alerts ........................................................................................... 128 C. Operations Reporting .................................................................. 128 1. Fraud and Abuse ......................................................................... 129 D. Financial Reports ........................................................................ 129 E. Equity .......................................................................................... 129 F. Claims Processing Reports ......................................................... 130 G. Presentation of Findings ............................................................. 130 H. Sanctions .................................................................................... 130 I. Non-Duplication of Financial Penalties ........................................ 131 SECTION IX: REPRESENTATIONS AND WARRANTIES OF THE CHC-MCO ....... 132 A. Accuracy of Proposal .................................................................. 132 B. Disclosure of Interests ................................................................. 132 C. Disclosure of Change in Circumstances ..................................... 132 SECTION X: TERMINATION AND DEFAULT........................................................... 133 A. Termination by the Department ................................................... 133 1. Termination for Convenience Upon Notice ................................. 133 2. Termination for Cause ................................................................. 133 3. Termination Due to Unavailability of Funds/Approvals ................ 133 B. Termination by the CHC-MCO .................................................... 134 C. Responsibilities of the CHC-MCO Upon Termination .................. 134 5 1. Continuing Obligations ................................................................ 134 2. Notice to Participants and Network Providers ............................. 135 3. Submission of Invoices ............................................................... 135 4. Termination Requirements .......................................................... 135 D. Transition at Expiration or Termination of Agreement ................. 136 SECTION XI: RECORDS ........................................................................................... 136 A. Financial Records Retention ....................................................... 136 B. Operational Data Reports ........................................................... 136 C. Medical Records Retention ......................................................... 136 D. Review of Records ...................................................................... 137 SECTION XII: SUBCONTRACTUAL RELATIONSHIPS ........................................... 137 A. Compliance with Program Standards .......................................... 137 B. Consistency with Regulations ..................................................... 138 SECTION XIII: CONFIDENTIALITY ........................................................................... 138 SECTION XIV: INDEMNIFICATION AND INSURANCE ........................................... 139 A. Indemnification ............................................................................ 139 B. Insurance .................................................................................... 140 SECTION XV: DISPUTES ......................................................................................... 140 SECTION XVI: GENERAL ......................................................................................... 140 A. Suspension From Other Programs .............................................. 140 B. Rights of the Department and the CHC-MCO ............................. 140 C. Invalid Provisions ........................................................................ 141 D. Notice .......................................................................................... 141 E. Counterparts ............................................................................... 141 F. Headings ..................................................................................... 142 G. No Third Party Beneficiaries........................................................ 142 6 APPENDICES 1 Community HealthChoices RFP 2 Proposal 3a ACA Health Insurance Providers Fee 3b Explanation of Capitation Payments 3c Risk Corridor 3d Capitation Rates 3e Overview of Methodologies for Rate Setting and Determination of Risk Sharing Withhold Amounts 3f Five Percent Capitation Withhold 3g Individual Stop Loss Re-Insurance 4 Nursing Facility Access to Care Payments AGREEMENT EXHIBITS A Managed Long Term Services and Supports Regulatory Compliance Guidelines B CHC-MCO Pay for Performance Program C CHC-MCO Requirements for Provider Terminations D Standard Terms and Conditions for Services E Specific Federal Regulatory Cites for Managed Care Agreements E(1) DHS Addendum to Standard Contract Terms and Conditions F Family Planning Services Procedures G Prior Authorization Guidelines for Participating Managed Care Organizations in the CHC Program J Medical Assistance Transportation Program K(1) Quality Management and Utilization Management Program Requirements K(2) External Quality Review K(3) Critical Incident Reporting and Management and Provider Preventable Conditions/Preventable Serious Adverse Events Reporting K(4) Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) L Notice of Denial M Coordination with BH-MCOs N Written Coordination Agreements Between CHC-MCO and Network Providers O Guidelines for CHC-MCO Advertising, Sponsorships, and Outreach P CHC-MCO Participant Coverage Document Q Data Support for CHC-MCOs R CHC-MCO Participant Handbook S Provider Directories T Complaint, Grievance, and DHS Fair Hearing Processes U Reporting Suspected Fraud and Abuse to the Department V Required Contract Terms for Administrative Subcontractors W Provider Manuals X Guidelines for Sanctions Regarding Fraud and Abuse 7 Y CHC Audit Clause Z Encounter Data Submission Requirements and Sanction Applications AA Auto-Assignment BB Provider Network Composition/Services Access CC Outpatient Drug (Pharmacy) Services DD CHC-MCO Provider Agreements EE Covered Services FF Participants’ Rights GG MIPPA Requirements 8 AGREEMENT and RFP ACRONYMS For the purpose of this agreement and RFP, the acronyms set forth shall apply. ACA — Affordable Care Act. ADA — Americans with Disabilities Act. ADL – Activities of Daily Living APS – Adult Protective Services BH — Behavioral Health. BHA — Bureau of Hearings and Appeals. BH-MCO — Behavioral Health Managed Care Organization. BLE – Benefit Limit Exception BPI – Bureau of Program Integrity CAHPS — Consumer Assessment of Healthcare Providers and Systems. CAO — County Assistance Office. CDC — Centers for Disease Control and Prevention. CHC – Community HealthChoices. CHC-MCO – Community HealthChoices MCO. CHS — Contract Health Services. CIS — Client Information System. CLIA — Clinical Laboratory Improvement Amendment. CMN — Certificate of Medical Necessity. CMS — Centers for Medicare & Medicaid Services. COB — Coordination of Benefits. CRNP — Certified Registered Nurse Practitioner. DEA — Drug Enforcement Agency. DESI —Drug Efficacy Study Implementation. DME — Durable Medical Equipment. DOH — Department of Health (of the Commonwealth of Pennsylvania). D-SNP – Dual Eligible Special Needs Plan DHS — Department of Human Services. DRG — Diagnosis Related Group. DUR — Drug Utilization Review. ED – Emergency Department EOB — Explanation of Benefits. EQR — External Quality Review. EQRO — External Quality Review Organization. EVS — Eligibility Verification System. ERISA — Employees Retirement Income Security Act of 1974. FDA — Food and Drug Administration. FFS — Fee-for-Service. FMS – Financial Management Services FQHC — Federally Qualified Health Center. FTP — File Transfer Protocol. HBP — Healthy Beginnings Plus. HCAC — Healthcare-Acquired Condition. 9 HCBS – Home and Community Based Services HCRP — High Cost Risk Pool. HEDIS — Healthcare Effectiveness Data and Information Set. HIPAA — Health Insurance Portability and Accountability Act. HIPP — Health Insurance Premium Payment. HMO — Health Maintenance Organization. IADL --- Instrumental Activities of Daily Living ID --- Intellectual Disability IEE – Independent Enrollment Entity. IHS — Indian Health Service. IRM — Information Resource Management. LEP – Limited English Proficiency I/T/U — Indian Tribe, Tribal Organization, or Urban Indian Organization. LTC – Long Term Care LTSS – Long-Term Services and Supports. JCAHO — Joint Commission for the Accreditation of Healthcare Organizations. LIFE—Living Independence for the Elderly. MA --- Medical Assistance MAAC — Medical Assistance Advisory Committee. MATP — Medical Assistance Transportation Program. MCO — Managed Care Organization. MIPPA - Medicare Improvements for Patients and Providers Act of 2008. MIS — Management Information System. MPI — Master Provider Index. NCPDP — National Council for Prescription Drug Programs. NCQA — National Committee for Quality Assurance. NF – Nursing Facility. NFCE --- Nursing Facility Clinically Eligible NFI --- Nursing Facility Ineligible NHT – Nursing Home Transition. NPDB — National Practitioner Data Bank. NPI — National Provider Identifier. OAPS – Older Adult Protective Services. OBRA — Omnibus Budget Reconciliation Act. OIP — Other Insurance Paid. OLTL – Office of Long-Term Living. OMAP — Office of Medical Assistance Programs. ORC — Other Related Conditions. OTC — Over-the-Counter. OVR- Department of Labor & Industry Office of Vocational Rehabilitation P&T — Pharmacy & Therapeutics. PAC – Participant Advisory Committee PARP — Prior Authorization Review Panel. PBM — Pharmacy Benefit Manager. PCP — Primary Care Practitioner. PCSP – Person-Centered Service Plan. 10