2019 Contract Between Department of Health Services and ...

 CONTRACT between

WISCONSIN DEPARTMENT OF HEALTH SERVICES DIVISION OF MEDICAID SERVICES and > Issued January 1, 2018 Updated April 14, 2020

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Contract for Program between the Wisconsin Department of Health Services, Division of Medicaid Services

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Table of Contents

Preamble ....................................................................................................................................... 1

I. Definitions ......................................................................................................................... 3

II. MCO Governance and Consumer and Member Involvement .................................. 25 MCO Governing Board.............................................................................................. 25 Regional Long-Term Care Advisory Committees ..................................................... 25 MCO Member Advisory Committee ......................................................................... 25

III. Eligibility......................................................................................................................... 27 Eligibility Requirements ............................................................................................ 27 Program Specific Eligibility Criteria ......................................................................... 28 MCO Specific Eligibility Criteria .............................................................................. 30 Eligibility Determination Process .............................................................................. 30 Medicaid Deductibles or Cost Share.......................................................................... 32 Room and Board ........................................................................................................ 35 Long-Term Care Functional Screen........................................................................... 38

IV. Enrollment and Disenrollment ..................................................................................... 45 Enrollment.................................................................................................................. 45 Disenrollment............................................................................................................. 47 Monitoring, Coordination, Transition of Care, Discrimination and Dates ................ 53

V. Care Management.......................................................................................................... 56 Member Participation................................................................................................. 56 Interdisciplinary Team Composition ......................................................................... 57 Assessment and Member-Centered Planning Process ............................................... 58 Timeframes ................................................................................................................ 68 Providing, Arranging, Coordinating and Monitoring Services.................................. 70 Re-Enrollment Assessment and MCP Update ........................................................... 72 Reassessment and MCP Update................................................................................. 73 Interdisciplinary Team and Member Contacts........................................................... 74 Member Record ......................................................................................................... 75 Member Safety and Risk............................................................................................ 75 Service Authorization ................................................................................................ 79 Services During Periods of Temporary Absence....................................................... 88 MCO Responsibilities When a Member Changes County of Residence................... 89 Department Review ................................................................................................... 91 MCO Duty to Immediately Report Certain Member Incidents ................................. 91

VI. Self-Directed Supports................................................................................................... 93 Option to Self-Direct.................................................................................................. 93 MCO Requirements ................................................................................................... 93

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IDT Staff Responsibilities.......................................................................................... 94

VII. Services............................................................................................................................ 97 General Provisions ..................................................................................................... 97 Provision of Services in the Family Care Benefit Package ..................................... 100 Provision of Services in the Partnership and PACE Benefit Packages ................... 102 Prohibited Services .................................................................................................. 107 Primary Care and Coordination of Health Care Services ........................................ 108 Second Opinion ....................................................................................................... 108 Determining if Services, Procedures, Items and Treatments are Proven and Effective ................................................................................................................... 109 Changes in Mandated Services ................................................................................ 109 24-Hour Coverage ................................................................................................... 110 Billing Members ...................................................................................................... 111 Department Policy for Member Use of Personal Resources ................................... 112 Prevention and Wellness.......................................................................................... 116 Court-Ordered Services ........................................................................................... 118 Elder Adults/Adults at Risk Agencies and Adult Protective Services..................... 119 Facility Closures ...................................................................................................... 121 MOU on Institute for Mental Disease (IMD) Discharge Planning.......................... 121 Private Pay Care Management................................................................................. 121 Provider Moral or Religious Objection.................................................................... 123

VIII.

Provider Network......................................................................................................... 125 Member Choice........................................................................................................ 125 Member Communications........................................................................................ 126 Provider Agreements ............................................................................................... 127 Provider Agreement Language ................................................................................ 127 Prohibited Provider Agreement Language............................................................... 136 Network Providers ................................................................................................... 136 Provider Certification and Standards ....................................................................... 137 Cultural Competency ............................................................................................... 139 Access to Providers.................................................................................................. 139 Change in Providers ................................................................................................. 142 Health Information System ...................................................................................... 143 Payment.................................................................................................................... 143 Appeals to the MCO and Department for Payment/Denial of Providers Claims .... 149 Standards for MCO Staff ......................................................................................... 152 Network, Coverage and Payment Provisions Applicable to Indian Health Care Providers and Indian Members ................................................................................ 154 Non-risk Provisions for Members Receiving Care Management from an Indian Health Care Provider (IHCP)................................................................................... 155 Physician Incentive Plans for Partnership and PACE.............................................. 156

IX. Marketing and Member Materials............................................................................. 159

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Marketing/Outreach Plans and Materials................................................................. 159 Member Materials ? General Requirements ............................................................ 161 Member Handbook .................................................................................................. 163 Provider Network Directory and Information.......................................................... 168 Accessible Formats and Languages and Cultural Sensitivity .................................. 170 Reproduction and Distribution of Materials ............................................................ 171 MCO Identification (ID) Cards................................................................................ 171

X. Member Rights and Responsibilities.......................................................................... 172 Protection of Member Rights................................................................................... 172 Member Rights......................................................................................................... 172 Member Responsibilities ......................................................................................... 173 Member Rights and Responsibilities Education ...................................................... 174 Member Rights Specialist and MCO Advocacy Services ....................................... 174 Legal Decision Makers ............................................................................................ 174 Informal Resolution ................................................................................................. 175 Advance Directives .................................................................................................. 175 Provision of Interpreters .......................................................................................... 176

XI. Grievances and Appeals .............................................................................................. 178 Purpose and Philosophy ........................................................................................... 178 Definitions................................................................................................................ 178 Overall Policies and Procedures for Grievances and Appeals................................. 180 Notice of Adverse Benefit Determination ............................................................... 183 Notification of Appeal Rights in Other Situations................................................... 188 MCO Grievance and Appeal Process ...................................................................... 191 The Department Review Process ............................................................................. 198 The State Fair Hearing Process................................................................................ 199 Documentation and Reporting ................................................................................. 201

XII. Quality Management (QM)......................................................................................... 205 Leadership and Organization of the QM Program................................................... 205 QM Annual Workplan and Evaluation .................................................................... 206 Activities of the QM Program.................................................................................. 206 Cooperation with the Department QM Program...................................................... 213

XIII.

MCO Administration................................................................................................... 214 Member Records ...................................................................................................... 214 Civil Rights Compliance/Affirmative Action Plan Requirements........................... 218 Subcontracting and Entering Provider Agreements................................................. 223 Management of Subcontractors and Providers ........................................................ 225 Memorandum of Understanding (MOU) ................................................................. 226 Claims Administration ............................................................................................. 226 Required Disclosures ............................................................................................... 229 Ineligible Organizations and Individuals ................................................................. 233

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Compliance with Applicable Law and Cooperation with Investigations ................ 236 Access to Premises and Information........................................................................ 236 Program Integrity Plan, Program and Coordination ................................................ 237 Business Continuity ................................................................................................. 241 Resource Center Conflict of Interest Policies and Procedures ................................ 243 Commercial Leases .................................................................................................. 243 MCO's Insurance Responsibility ............................................................................. 243 Business Associate Agreement ................................................................................ 244

XIV.

Reports and Data ......................................................................................................... 245 Management Information System Requirements..................................................... 245 Encounter Data......................................................................................................... 246 Reports: Regular Interval ......................................................................................... 248 Reports: As Needed ................................................................................................. 249 Disclosure of Financial Information ........................................................................ 249 Records Retention .................................................................................................... 249 MCO Data Integrity and Systems Assessments....................................................... 252 Required Use of the Secure ForwardHealth Portal.................................................. 253 Access to CARES Data............................................................................................ 254 Access to LTCare Data Warehouse ......................................................................... 257

XV. Functions and Duties of the Department ................................................................... 259 Bureau of Adult Long Term Care Services ............................................................. 259 Reports from the MCOs........................................................................................... 259 Enrollment and Disenrollment Reporting ................................................................ 259 ForwardHealth ID Cards.......................................................................................... 259 Capitation Payment Reporting ................................................................................. 260 Utilization Review and Control ............................................................................... 260 Right to Review ....................................................................................................... 260 Review of Study or Audit Results ........................................................................... 260 Provider Certification............................................................................................... 260 Technical Assistance................................................................................................ 261 Conflict of Interest ................................................................................................... 261

XVI.

Contractual Relationship ............................................................................................ 262 Contract.................................................................................................................... 262 Precedence When Conflict Occurs .......................................................................... 262 Cooperation of Parties and Dispute Resolution ....................................................... 262 MCO Certification ................................................................................................... 263 Sanctions for Violation, Breach, or Non-Performance ............................................ 263 Modification and Termination of the Contract ........................................................ 274 Delegations of Authority.......................................................................................... 278 Indemnification ........................................................................................................ 278 Independent Capacity of the MCO .......................................................................... 279 Omissions................................................................................................................. 279

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Choice of Law.......................................................................................................... 279 Waiver...................................................................................................................... 280 Severability .............................................................................................................. 280 Force Majeure .......................................................................................................... 280 Headings .................................................................................................................. 280 Assignability ............................................................................................................ 280 Right to Publish........................................................................................................ 280 Survival .................................................................................................................... 280

XVII. Fiscal Components/Provisions .................................................................................... 282 Financial Management............................................................................................. 282 Financial Reporting.................................................................................................. 288 Financial Certification Process ................................................................................ 289 Financial Examinations............................................................................................ 289 Financial Audit......................................................................................................... 289 Other Regulatory Reviews and Identified Irregularities .......................................... 291 Reporting on Savings Initiatives .............................................................................. 292 Medical Loss Ratio (MLR) ...................................................................................... 292

XVIII. Payment to the Managed Care Organization............................................................ 295 Purpose..................................................................................................................... 295 Medicaid Capitation Rates ....................................................................................... 295 Actuarial Basis ......................................................................................................... 295 Annual Determination of Capitation Rates.............................................................. 295 Pay for Performance ................................................................................................ 296 Retention of Risk ..................................................................................................... 301 Payment Schedule .................................................................................................... 301 Payment Method ...................................................................................................... 301 Health Insurance Fee Reimbursement ? Partnership Only ...................................... 302 Coordination of Benefits (COB) .............................................................................. 304 Suspension of Payment Based on Credible Allegation of Fraud ............................. 307 Recoupments............................................................................................................ 309 IMD Stays Within a Capitation Month For Members Age 21-64 ........................... 310

XIX.

MCO Specific Contract Terms ................................................................................... 311 Program.................................................................................................................... 311 Geographic Coverage Where Enrollment Is Accepted ............................................ 311 Contracting Contingencies:...................................................................................... 313 Maximum Enrollment Level.................................................................................... 314 Age Group................................................................................................................ 314 Target Group ............................................................................................................ 314 Capitation Rate......................................................................................................... 314 Signatures................................................................................................................. 315

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ADDENDA

I. Actuarial Basis ............................................................................................................. 316 Actuarial Soundness of Capitation Rates................................................................. 316 Retrospective Adjustments ...................................................................................... 316

II. State Reporting Requirements for 2018 .................................................................... 324 Materials with specific due dates ? all programs..................................................... 324 Materials with specific due dates ? Partnership and PACE..................................... 327 Materials without specific due dates ? all programs................................................ 327 Materials without specific due dates ? Partnership and PACE................................ 328

III. Requirements for Memoranda of Understanding .................................................... 330

IV. MCO Quality Indicators ............................................................................................. 332 Quality Indicators ? Family Care, PACE and Partnership ...................................... 332 Other Quality Indicators ? PACE and Partnership Programs .................................. 332

V. Performance Improvement Projects .......................................................................... 333 Overview.................................................................................................................. 333 Performance Improvement Projects: Schedule ........................................................ 333 Performance Improvement Projects: Guidance ....................................................... 333

VI. Data Certification......................................................................................................... 335 Encounter Data Certification ................................................................................... 335 Financial Certification ............................................................................................. 335

VII. Personal Experience Outcomes in Long-Term Care ................................................ 338

VIII.

Benefit Package Service Definitions ........................................................................... 339 Home and Community-Based Waiver Services ...................................................... 339 Medicaid State Plan Services ? Family Care Benefit Package................................ 365 Medicaid State Plan Services ? Partnership and PACE Benefit Packages .............. 367

IX. Direct Care Workforce Funding Dates...................................................................... 371 Materials with specific due dates ? all programs........................................................... 371

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