COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE ...

COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

COMMONWEALTH COORDINATED CARE PLUS MCO CONTRACT FOR MANAGED LONG TERM SERVICES AND SUPPORTS July 1, 2021 - June 30, 2022

CCC Plus Contract Table of Contents

SECTION 1.0 SCOPE OF CONTRACT .............................................................................................................. 9 1.1 APPLICABLE LAWS, REGULATIONS, AND INTERPRETATIONS......................................................................9 1.2 COMMITMENT TO DEPARTMENT GOALS FOR DELIVERY SYSTEM REFORM AND PAYMENT TRANSFORMATION ................................................................................................................................................. 10 1.3 DEPARTMENTAL MEETINGS .....................................................................................................................10

SECTION 2.0 REQUIREMENTS PRIOR TO OPERATIONS.................................................................................11 2.1 ORGANIZATIONAL STRUCTURE.................................................................................................................11 2.2 READINESS REVIEW .................................................................................................................................. 13 2.3 LICENSURE ................................................................................................................................................ 14 2.4 CERTIFICATION OF QUALITY .....................................................................................................................14 2.5 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION .........................................15 2.6 DUAL ELIGIBLE SPECIAL NEEDS PLAN (D-SNP) ..........................................................................................15 2.7 BUSINESS ASSOCIATE AGREEMENT (BAA) ................................................................................................17 2.8 AUTHORIZATION TO CONDUCT BUSINESS IN THE COMMONWEALTH.....................................................17 2.9 CONFIDENTIALITY STATUTORY REQUIREMENTS ......................................................................................17 2.10 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST...........................................................................18 2.11 PROHIBITED AFFILIATIONS WITH ENTITIES DEBARRED BY FEDERAL AGENCIES .......................................20 2.12 EXCLUDED ENTITIES..................................................................................................................................21 2.13 CONTRACTOR COMPLIANCE PROGRAM ...................................................................................................21

SECTION 3.0 ENROLLMENT AND ASSIGNMENT PROCESS.............................................................................23 3.1 ELIGIBILITY AND ENROLLMENT RESPONSIBILITIES ...................................................................................23 3.2 CCC PLUS ENROLLMENT PROCESS ............................................................................................................26

SECTION 4.0 BENEFITS AND SERVICE REQUIREMENTS.................................................................................37 4.1 GENERAL BENEFITS PROVISIONS ..............................................................................................................37 4.2 BEHAVIORAL HEALTH SERVICES................................................................................................................37 4.3 DENTAL AND RELATED SERVICES..............................................................................................................52 4.4 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) ..........................................54 4.5 EARLY INTERVENTION (EI) ........................................................................................................................56 4.6 EMERGENCY AND POST-STABILIZATION SERVICES...................................................................................59 4.7 LONG TERM SERVICES AND SUPPORTS ....................................................................................................61 4.8 PHARMACY SERVICES ............................................................................................................................... 94 4.9 TELEMEDICINE AND TELEHEALTH SERVICES...........................................................................................102 4.10 NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES ....................................................................104 4.11 CARVED OUT SERVICES ........................................................................................................................... 121 4.12 STATE PLAN SUBSTITUTED (IN LIEU OF) SERVICES..................................................................................121

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4.13 ENHANCED BENEFITS..............................................................................................................................122 4.14 SERVICES RELATED TO FEDERAL MORAL/RELIGIOUS OBJECTIONS.........................................................123 4.15 TRANSLATION & INTERPRETER SERVICES ...............................................................................................123 4.16 MEDICAID WORKS .................................................................................................................................. 124 4.17 ACA MINIMUM ESSENTIAL BENEFITS FOR MEDICAID EXPANSION POPULATION ...............................124 4.18 FOSTER CARE AND ADOPTION ASSISTANCE CHILDREN ........................................................................125 4.19 MATERNITY SERVICES ............................................................................................................................ 126 SECTION 5.0 CCC PLUS MODEL OF CARE ................................................................................................... 127 5.1 GENERAL REQUIREMENTS AND COVERED POPULATIONS .....................................................................127 5.2 MEDICALLY COMPLEX DETERMINATION ................................................................................................129 5.3 HEALTH RISK ASSESSMENTS (HRA).................................................................................................................133 5.4 PERSON-CENTERED INDIVIDUALIZED CARE PLAN (ICP) ..........................................................................142 5.5 INTERDISCIPLINARY CARE TEAM (ICT) ....................................................................................................146 5.6 REASSESSMENTS.....................................................................................................................................148 5.7 CARE COORDINATION STAFFING ............................................................................................................149 5.8 CARE COORDINATION PARTNERSHIPS....................................................................................................151 5.9 CARE COORDINATOR STAFFING RATIOS.................................................................................................151 5.10 CARE COORDINATION REQUIREMENTS..................................................................................................154 5.11 CARE COORDINATION WITH TRANSITIONS OF CARE..............................................................................156 5.12 VIRGINIA EMERGENCY DEPARTMENT CARE COORDINATION PROGRAM ..............................................158 5.13 COORDINATION WITH THE MEMBER'S MEDICARE OR OTHER MCO PLAN ............................................159 5.14 CLINICAL WORKGROUP MEETINGS.........................................................................................................162 5.15 CONTINUITY OF CARE ............................................................................................................................. 162 5.16 CARE DELIVERY MODEL POLICY AND PROCEDURES ...............................................................................166 SECTION 6.0 UTILIZATION MANAGEMENT REQUIREMENTS ...................................................................... 172 6.1 GENERAL UTILIZATION MANAGEMENT REQUIREMENTS .......................................................................172 6.2 SERVICE AUTHORIZATION.......................................................................................................................172 6.3 PATIENT UTILIZATION MANAGEMENT & SAFETY (PUMS) PROGRAM....................................................180 6.4 ELECTRONIC VISIT VERIFICATION (EVV) SYSTEM ....................................................................................183 6.5 NOTIFICATION TO THE DEPARTMENT OF SENTINEL EVENTS .................................................................184 SECTION 7.0 SUBCONTRACTOR DELEGATION AND MONITORING REQUIREMENTS ....................................185 7.1 GENERAL REQUIREMENTS FOR SUBCONTRACTORS...............................................................................185 7.2 DELEGATION REQUIREMENTS ................................................................................................................186 7.3 MONITORING REQUIREMENTS...............................................................................................................187 7.4 DATA SHARING CAPABILITIES .................................................................................................................187 7.5 BEHAVIORAL HEALTH SERVICES ADMINISTRATOR .................................................................................187

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SECTION 8.0 PROVIDER NETWORK MANAGEMENT ................................................................................... 189 8.1 GENERAL NETWORK PROVISIONS ..........................................................................................................189 8.2 SPECIALIZED NETWORK PROVISIONS .....................................................................................................190 8.3 CERTIFICATION OF NETWORK ADEQUACY .............................................................................................194 8.4 PROVIDER CREDENTIALING STANDARDS................................................................................................195 8.5 PROVIDER AGREEMENTS ........................................................................................................................ 198

SECTION 9.0 ACCESS TO CARE STANDARDS...............................................................................................205 9.1 GENERAL STANDARDS ............................................................................................................................ 205 9.2 CHOICE OF PROVIDER STANDARDS ........................................................................................................205 9.3 MEMBER TRAVEL TIME AND DISTANCE STANDARDS.............................................................................206 9.4 EXCEPTIONS TO ACCESS STANDARDS .....................................................................................................207 9.5 TWENTY-FOUR HOUR COVERAGE ..........................................................................................................207 9.6 URGENT CARE ACCESS ............................................................................................................................ 207 9.7 EMERGENCY SERVICES COVERAGE .........................................................................................................208 9.8 INPATIENT HOSPITAL ACCESS .................................................................................................................208 9.9 MEMBER PRIMARY CARE ACCESS (ADULT AND PEDIATRIC)...................................................................208 9.10 TIMELINESS ACCESS STANDARDS ...........................................................................................................210 9.11 SECOND OPINIONS ................................................................................................................................. 211 9.12 OUT-OF-NETWORK SERVICES .................................................................................................................211 9.13 OUT-OF-STATE SERVICES ........................................................................................................................ 211 9.14 PROVIDER TRAVEL CONSIDERATIONS.....................................................................................................212 9.15 POLICY OF NONDISCRIMINATION...........................................................................................................212 9.16 ACCOMMODATING PERSONS WITH DISABILITIES ..................................................................................212 9.17 ASSURANCES THAT ACCESS STANDARDS ARE BEING MET .....................................................................213 9.18 NATIVE AMERICAN HEALTH CARE PROVIDERS .......................................................................................213

SECTION 10.0 QUALITY MANAGEMENT AND IMPROVEMENT.....................................................................214 10.1 QUALITY DEFINITION AND DOMAINS .....................................................................................................214 10.2 CONTINUOUS QUALITY IMPROVEMENT PRINCIPLES AND EXPECTATIONS ............................................214 10.3 QUALITY INFRASTRUCTURE ....................................................................................................................214 10.4 ANNUAL EVALUATION OF THE QAPI/QI PROGRAM ...............................................................................216 10.5 QI STAFFING............................................................................................................................................216 10.6 PERFORMANCE MEASUREMENT ............................................................................................................217 10.7 PERFORMANCE IMPROVEMENT PROJECTS (PIPs) ..................................................................................220 10.8 EXTERNAL QUALITY REVIEW (EQR) ACTIVITIES.......................................................................................221 10.9 WAIVER ASSURANCES.............................................................................................................................223 10.10 QI FOR UTILIZATION MANAGEMENT ACTIVITIES....................................................................................223

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10.11 CLINICAL PRACTICE GUIDELINES.............................................................................................................223 10.12 QUALITY COLLABORATIVE AND OTHER WORKGROUPS .........................................................................224 10.13 MEMBER INCENTIVES ............................................................................................................................. 225 10.14 SOCIAL DETERMINANTS OF HEALTH.......................................................................................................225 10.15 BEHAVIORAL HEALTH SERVICES OUTCOMES..........................................................................................227 10.16 ARTS SPECIFIC MEASUREMENT AND REPORTING ..................................................................................227 10.17 MEDICAID EXPANSION POPULATION SPECIFIC MEASUREMENT AND REPORTING ....................................227 10.18 QUALITY SYSTEM .................................................................................................................................... 228 10.19 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION .......................................228 SECTION 11.0 MEMBER SERVICES AND COMMUNICATIONS ...................................................................... 230 11.1 MEMBER CALL CENTERS .........................................................................................................................230 11.2 MEMBER INQUIRIES ............................................................................................................................... 233 11.3 MEMBER RIGHTS AND PROTECTIONS ....................................................................................................233 11.4 ADVANCED DIRECTIVES .......................................................................................................................... 234 11.5 CULTURAL COMPETENCY........................................................................................................................234 11.6 COST-SHARING........................................................................................................................................ 234 11.7 PROTECTING MEMBER FROM LIABILITY FOR PAYMENT ........................................................................235 11.8 MEMBER ADVISORY COMMITTEE ..........................................................................................................235 11.9 PROTECTION OF CHILDREN AND AGED OR INCAPACITATED ADULTS ....................................................236 11.10 PROTECTION OF MEMBER-PROVIDER COMMUNICATIONS ...................................................................236 11.11 MEMBER COMMUNICATIONS AND ENROLLMENT MATERIALS .............................................................237 11.12 MARKETING REQUIREMENTS .................................................................................................................242 11.13 PROHIBITED MARKETING AND OUTREACH ACTIVITIES ..........................................................................246 SECTION 12.0 PROVIDER SERVICES AND CLAIMS PAYMENT.......................................................................248 12.1 PROVIDER CALL CENTER .........................................................................................................................248 12.2 PROVIDER TECHNICAL ASSISTANCE ........................................................................................................250 12.3 PROVIDER EDUCATION ........................................................................................................................... 250 12.4 PROVIDER PAYMENT SYSTEM.................................................................................................................252 12.5 INCREASED PAYMENTS TO ENSURE ACCESS...........................................................................................262 SECTION 13.0 VALUE BASED PAYMENTS ................................................................................................... 264 13.1 BACKGROUND......................................................................................................................................... 264 13.2 CONTRACTOR VBP PLAN.........................................................................................................................264 13.3 VBP STATUS REPORT............................................................................................................................... 265 13.4 CONTRACTOR HCP-LAN APM DATA COLLECTION SUBMISSION .............................................................265 13.5 DMAS APPROVAL OF VBP FOR CERTAIN SERVICES.................................................................................266 SECTION 14.0 PROGRAM INTEGRITY (PI) AND OVERSIGHT ......................................................................... 267

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14.1 GENERAL PRINCIPLES..............................................................................................................................267 14.2 PROGRAM INTEGRITY PLAN, POLICIES, & PROCEDURES ........................................................................267 14.3 COMPLIANCE OFFICER ............................................................................................................................ 272 14.4 PROGRAM INTEGRITY LEAD....................................................................................................................272 14.5 TRAINING AND EDUCATION ...................................................................................................................272 14.6 EFFECTIVE LINES OF COMMUNICATION BETWEEN CONTRACTOR STAFF ..............................................272 14.7 ENFORCEMENT OF STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES...................273 14.8 DEVELOPMENT OF CORRECTIVE ACTION INITIATIVES............................................................................273 14.9 REPORTING AND INVESTIGATING SUSPECTED FRAUD AND ABUSE TO THE DEPARTMENT ...................273 14.10 QUARTERLY FRAUD/WASTE/ABUSE REPORT .........................................................................................274 14.11 COOPERATION WITH STATE AND FEDERAL INVESTIGATIONS ................................................................275 14.12 MEDICAID FRAUD CONTROL UNIT (MFCU).............................................................................................275 14.13 MINIMUM AUDIT REQUIREMENTS.........................................................................................................275 14.14 PROVIDER AUDITS, OVERPAYMENTS, AND RECOVERIES........................................................................275 SECTION 15.0 MEMBER AND PROVIDER GRIEVANCES AND APPEALS..........................................................278 15.1 GENERAL REQUIREMENTS ......................................................................................................................278 15.2 GRIEVANCES ........................................................................................................................................... 279 15.3 GENERAL APPEALS REQUIREMENTS .......................................................................................................280 15.4 MEMBER APPEALS .................................................................................................................................. 280 15.5 PROVIDER APPEALS ................................................................................................................................ 286 15.6 EVALUATION OF GRIEVANCES AND APPEALS.........................................................................................291 15.7 GRIEVANCE AND APPEAL REPORTING ....................................................................................................291 15.8 RECORDKEEPING AND DOCUMENT PRESERVATION ..............................................................................292 SECTION 16.0 INFORMATION MANAGEMENT SYSTEMS ............................................................................. 293 16.1 GENERAL REQUIREMENTS ......................................................................................................................293 16.2 DESIGN REQUIREMENTS.........................................................................................................................293 16.3 SYSTEM ACCESS MANAGEMENT AND INFORMATION ACCESSIBILITY REQUIREMENTS .........................293 16.4 SYSTEM AVAILABILITY AND PERFORMANCE REQUIREMENTS................................................................293 16.5 ELECTRONIC CARE COORDINATION SYSTEM ..........................................................................................294 16.6 CENTRAL DATA REPOSITORY ..................................................................................................................295 16.7 DATA INTERFACES SENT TO AND RECEIVED FROM DMAS .....................................................................296 16.8 INTERFACE AND CONNECTIVITY TO THE VIRGINIA MEDICAID MANAGEMENT INFORMATION SYSTEM (VAMMIS) AND MEDICAID ENTERPRISE SYSTEM (MES)........................................................................................297 16.9 DATA QUALITY REQUIREMENTS .............................................................................................................297 16.10 DATA SECURITY AND CONFIDENTIALITY OF RECORDS ...........................................................................305 SECTION 17.0 REPORTING REQUIREMENTS...............................................................................................311

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17.1 GENERAL REQUIREMENTS ......................................................................................................................311 17.2 ALL PAYERS CLAIM DATABASE................................................................................................................312 17.3 CRITICAL INCIDENT REPORTING AND MANAGEMENT............................................................................313 17.4 CONTRACTOR REQUIREMENTS TO RESPOND.........................................................................................314 SECTION 18.0 ENFORCEMENT, REMEDIES, AND COMPLIANCE .................................................................... 315 18.1 CCC PLUS PROGRAM EVALUATION ACTIVITIES.......................................................................................315 18.2 COMPLIANCE MONITORING PROCESS (CMP) .........................................................................................315 18.3 OTHER ? SPECIFIC PRE-DETERMINED SANCTIONS..................................................................................318 18.4 REMEDIAL ACTIONS ................................................................................................................................ 318 18.5 COMPLIANCE ACTIONS ........................................................................................................................... 325 18.6 INTERMEDIATE SANCTIONS AND CIVIL MONETARY PENALTIES .............................................................326 18.7 NOTICE OF SANCTION AND PRETERMINATION HEARING ......................................................................327 SECTION 19.0 CONTRACTOR PAYMENT AND FINANCIAL PROVISIONS ........................................................ 328 19.1 FINANCIAL STATEMENTS ........................................................................................................................ 328 19.2 REPORTING OF REBATES.........................................................................................................................329 19.3 FINANCIAL RECORDS...............................................................................................................................329 19.4 INTERNAL CONTROLS REPORT................................................................................................................329 19.5 FINANCIAL SOLVENCY ............................................................................................................................. 329 19.6 CHANGES IN RISK BASED CAPITAL REQUIREMENTS ...............................................................................330 19.7 MINIMUM MEDICAL LOSS RATIO (MLR) AND LIMIT ON UNDERWRITING GAIN ....................................330 19.8 RISK MANAGEMENT PROVISIONS ..........................................................................................................332 19.9 CAPITATION RATES ................................................................................................................................. 334 19.10 CERTIFICATION (NON-ENCOUNTERS) .....................................................................................................340 19.11 CCC PLUS DISCRETE INCENTIVE TRANSITION PROGRAM........................................................................341 19.12 EMERGENCY ROOM UTILIZATION PROGRAM.............................................................................................342 19.13 MEDICAID HOSPITAL READMISSIONS POLICY .............................................................................................343 19.14 HAZARD PAYMENT FOR PERSONAL CARE ATTENDANTS/ AIDES ................................................................343 SECTION 20.0 APPEAL RIGHTS OF THE CONTRACTOR ................................................................................. 349 20.1 CONTRACTOR RIGHT TO APPEAL ............................................................................................................349 20.2 DISPUTES ARISING OUT OF THE CONTRACT ...........................................................................................349 20.3 RESOLUTION OF CONTRACT DISPUTES...................................................................................................349 20.4 PRESENTATION OF DOCUMENTED EVIDENCE ........................................................................................351 SECTION 21.0 RENEWAL/TERMINATION OF CONTRACT ............................................................................. 352 21.1 CONTRACT RENEWAL ............................................................................................................................. 352 21.2 SUSPENSION OF CONTRACTOR OPERATIONS.........................................................................................352 21.3 TERMS OF CONTRACT TERMINATION.....................................................................................................352

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21.4 TERMINATION PROCEDURES ..................................................................................................................355 SECTION 22.0 GENERAL TERMS AND CONDITIONS ..................................................................................... 358

22.1 NOTIFICATION OF ADMINISTRATIVE CHANGES......................................................................................358 22.2 ASSIGNMENT .......................................................................................................................................... 358 22.3 INDEPENDENT CONTRACTORS ...............................................................................................................358 22.4 BUSINESS TRANSACTION REPORTING ....................................................................................................358 22.5 LOSS OF LICENSURE ................................................................................................................................ 359 22.6 INDEMNIFICATION..................................................................................................................................359 22.7 CONFLICT OF INTEREST...........................................................................................................................359 22.8 INSURANCE FOR CONTRACTOR'S EMPLOYEES .......................................................................................359 22.9 IMMIGRATION AND CONTROL ACT OF 1986 ..........................................................................................360 22.10 SEVERABILITY .......................................................................................................................................... 360 22.11 ANTI-BOYCOTT COVENANT.....................................................................................................................360 22.12 RECORD RETENTION, INSPECTION, AND AUDITS....................................................................................360 22.13 OPERATION OF OTHER CONTRACTS .......................................................................................................361 22.14 PREVAILING CONTRACT .......................................................................................................................... 361 22.15 NO THIRD-PARTY RIGHTS OR ENFORCEMENT ........................................................................................361 22.16 EFFECT OF INVALIDITY OF CLAUSES........................................................................................................361 22.17 APPLICABLE LAW .................................................................................................................................... 361 22.18 SOVEREIGN IMMUNITY........................................................................................................................... 361 22.19 WAIVER OF RIGHTS.................................................................................................................................361 22.20 INSPECTION ............................................................................................................................................ 362 22.21 DEBARMENT STATUS .............................................................................................................................. 362 22.22 ANTITRUST..............................................................................................................................................362 22.23 DRUG-FREE WORKPLACE ........................................................................................................................ 362 22.24 COVID-19 ................................................................................................................................................ 362 22.25 CHANGES TO LEGAL AUTHORIZATION FOR STATE PROGRAMS..............................................................363 SECTION 23.0 DEFINITIONS AND ACRONYMS.............................................................................................365 23.1 DEFINITIONS ........................................................................................................................................... 365 23.2 ACRONYMS ............................................................................................................................................. 403 ATTACHMENTS 408 ATTACHMENT 1 - CCC PLUS CONTRACTOR SPECIFIC CONTRACT TERMS..............................................................409 ATTACHMENT 2 - BUSINESS ASSOCIATE AGREEMENT..........................................................................................411 ATTACHMENT 3 - BHSA/CCC PLUS MCO COORDINATION AGREEMENT...............................................................417 ATTACHMENT 4 - SAMPLE CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION ...................................................................................................................................................... 420

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