MassHealth Senior Care Options Contract for Senior Care ... - CHCS

[Pages:127]MassHealth Senior Care Options Contract for Senior Care Organizations

TABLE OF CONTENTS Section 1. DEFINITIONS OF TERMS .....................................................................................1

Section 2. CONTRACTOR RESPONSIBILITIES..................................................................7

Section 2.1 Compliance ....................................................................................................7

Section 2.2 Contract Management ..................................................................................7

A. Director of the Contractor's Senior Care Options Program.............7 B. SCO Director Responsibilities ..............................................................7 Section 2.3 Enrollment Activities ....................................................................................9

A. Enrollment .................................................................................................9 B. PCPs ............................................................................................................9 C. Initial Assessment..................................................................................10 D. Enrollee Orientation ..............................................................................10 E. Disenrollment .........................................................................................12 F. Closing Enrollment................................................................................13 Section 2.4 Care Management and Integration...........................................................14

A. General .....................................................................................................14 B. Primary, Acute, and Preventive Care .................................................24 C. Long Term Care ......................................................................................26 D. Behavioral Health ..................................................................................27 E. Health Promotion and Wellness Activities.......................................29 Section 2.5 Provider Network .......................................................................................30

A. General .....................................................................................................30 B. Provider Qualifications and Performance.........................................30 C. Provider Training...................................................................................34 D. Provider Network Directory ................................................................35 E. Intellectual Property ..............................................................................36 Section 2.6 Enrollee Access to Services ........................................................................39

A. General .....................................................................................................39 B. Proximity Requirements.......................................................................39 C. Availability of Services.........................................................................39 D. Cultural Competence.............................................................................41 E. Access for Enrollees with Disabilities ...............................................42 F. Access to Home- and Community-Based Services ..........................42 Section 2.7 Enrollee Services..........................................................................................43

A. Enrollee Service Representatives (ESRs)...........................................43 B. ESR Support Functions .........................................................................43

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C. Enrollee Service Telephone Responsiveness ...................................43 Section 2.8 Enrollee Complaints ...................................................................................44

A. Complaint Filing ....................................................................................44 B. Complaint Administration...................................................................44 Section 2.9 Enrollee Appeals .........................................................................................45

A. Service Decisions ...................................................................................45 B. Internal Appeals.....................................................................................45 C. External Appeals ....................................................................................47 D. Hospital Discharge Appeals ................................................................50 Section 2.10 Quality Management ................................................................................51

A. Annual Performance Improvement Projects ....................................51 B. Continuous Quality Improvement .....................................................51 C. Quality Management Resources .........................................................52 D. Program Initiatives ................................................................................53 E. Assessment of New Medical Technology .........................................58 F. Enrollee Survey ......................................................................................58 G. Health Promotion and Wellness Activities Performance...............58 H. Ethics Committee ...................................................................................59 I. Serious Reportable Events ...................................................................59 Section 2.11 Outreach Standards ..................................................................................60

A. General Outreach Requirements ........................................................60 B. Requirements for Outreach and Enrollee Materials .......................60 C. Optional Outreach Activities...............................................................62 D. Prohibited Outreach Activities............................................................62 Section 2.12 Financial Requirements ............................................................................63

A. Financial Viability .................................................................................63 B. Financial Stability ..................................................................................64 C. Medical Loss Ratios ...............................................................................66 D. Other Financial Requirements ............................................................67 Section 2.13 Data Submissions, Reporting Requirements, and Surveys.................70

A. General Requirements for Data ..........................................................70 B. General Reporting Requirements.......................................................70 C. Participation in Surveys........................................................................72 D. Certification Requirements..................................................................73 Section 2.14 Required Program Reports ......................................................................74

A. Clinical Indicator Data..........................................................................74 B. Encounter Reporting .............................................................................76 C. Enrollee Orientation Performance......................................................76 D. Complaints and Appeals ......................................................................76 E. Disenrollment Rate................................................................................76

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F. Institutional Utilization Data ..............................................................77 G. Community Health Service Utilization .............................................78 H. Enrollees Medically Eligible for Nursing Facility Services ..........79 Section 2.15 Information Management and Information Systems...........................80

A. General .....................................................................................................80 B. Design Requirements............................................................................80 C. System Access Management and Information Accessibility

Requirements ..........................................................................................81 D. System Security and Privacy Requirements .....................................82

Section 3. EOHHS RESPONSIBILITIES IN COORDINATION WITH CMS ..............83

Section 3.1 Contract Management ................................................................................83

A. Administration .......................................................................................83 B. Performance Evaluation........................................................................84 Section 3.2 Enrollment, Disenrollment, and Rating Category

Determinations ....................................................................................................85

Section 3.3 Outreach .......................................................................................................85

Section 4. PAYMENT AND FINANCIAL PROVISIONS..................................................86

Section 4.1 General Financial Provisions .....................................................................86

A. Capitation Payments .............................................................................86 B. Modifications to Capitation Rates ......................................................86 Section 4.2 MassHealth Rate Cells (RCs) .....................................................................87

A. Community Other ..................................................................................87 B. Community Alzheimer's Disease/Dementia or Chronic

Mental Illness (AD/CMI) .....................................................................88 C. Nursing Home Certifiable (NHC) ......................................................89 D. Institutional Tier 1 .................................................................................89 E. Institutional Tier 2 .................................................................................90 F. Institutional Tier 3 .................................................................................90 Section 4.3 Medicare Payment ......................................................................................90

Section 4.4 Payment Terms ............................................................................................91

A. Timing of Capitation Payments ..........................................................91 B. Patient Contribution to Care Amounts..............................................91 Section 4.5 MassHealth Transitions between Rate Cells ...........................................93

A. Institutional to Community RC ..........................................................93 B. Between Community RCs ....................................................................93

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C. Between Institutional RCs ...................................................................93 D. Community to Institutional RC ..........................................................93 Section 4.6 Reconciliation...............................................................................................94

A. MassHealth Capitation Reconciliation..............................................94 B. Audits .......................................................................................................94 Section 4.7 Federal Payment Approval........................................................................95

Section 4.8 Payment in Full............................................................................................95

Section 5. ADDITIONAL TERMS AND CONDITIONS ..................................................96

Section 5.1 Administration ............................................................................................96

A. Notification of Administrative Changes ...........................................96 B. Assignment..............................................................................................96 C. Independent Contractors ......................................................................96 D. Subrogation .............................................................................................96 E. Prohibited Affiliations..........................................................................97 F. Disclosure Requirements .....................................................................97 G. Physician Incentive Plans.....................................................................98 H. Physician Identifier ...............................................................................98 I. Timely Payments to Contracted Providers........................................99 J. Protection of Enrollee-Provider Communications ..........................99 K. Protecting Enrollee from Liability for Payment.............................100 Section 5.2 Program Integrity Requirements ............................................................102

A. Program Integrity Requirements ......................................................102 B. Fraud and Abuse Prevention, Detection and Reporting ..............102 C. Employee Education about False Claims Laws..............................103 Section 5.3 Continuity of Operations Plan ................................................................104

Section 5.4 Privacy and Security of Personal Data and HIPAA Compliance ......105

A. Statutory Requirements ......................................................................105 B. Personal Data ........................................................................................105 C. Data Security.........................................................................................105 D. Return of Personal Data......................................................................106 E. Research Data .......................................................................................106 Section 5.5 General Terms and Conditions ...............................................................107

A. Applicable Law.....................................................................................107 B. Massachusetts Law ..............................................................................107 C. Massachusetts Appropriations Law .................................................107 D. Sovereign Immunity............................................................................107 E. Advance Directives ..............................................................................107 F. Loss of Licensure..................................................................................108

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G. Indemnification....................................................................................108 H. Prohibition against Discrimination..................................................108 I. Anti-Boycott Covenant........................................................................109 J. Information Sharing ............................................................................109 K. Other Contracts.....................................................................................110 L. Counterparts..........................................................................................110 M. Entire Contract ......................................................................................110 N. No Third-Party Rights or Enforcement............................................110 O. Corrective Action Plan ........................................................................110 P. Intermediate Sanctions .......................................................................111 Q. Additional Administrative Procedures............................................112 R. Effect of Invalidity of Clauses ...........................................................112 S. Conflict of Interest ...............................................................................113 T. Insurance for Contractor's Employees .............................................113 U. Key Personnel .......................................................................................113 V. Waiver ....................................................................................................114 W. Section Headings .................................................................................114 Section 5.6 Record Retention, Inspection, and Audit ..............................................115

A. Record Retention..................................................................................115 B. Inspection and Audit...........................................................................115 Section 5.7 Termination of Contract ...........................................................................116

A. Termination without Prior Notice ....................................................116 B. Termination with Prior Notice ..........................................................116 C. Continued Obligations of the Parties ..............................................116 Section 5.8 Order of Precedence..................................................................................118

Section 5.9 Contract Term ............................................................................................118

Section 5.10 Amendments............................................................................................118

Section 5.11 Written Notices........................................................................................119

APPENDICES

Appendix A: Covered Services Appendix B: Model Outline for Evidence of Coverage Appendix C: Requirements for Provider Agreements & Subcontracts Appendix D: Reporting Requirements Appendix E: Capitation Rates Appendix F: Cities and Zip Codes in Greater Boston Region

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This Contract is between the Commonwealth of Massachusetts, acting by and through the MassHealth Office of Long Term Care of the Executive Office of Health and Human Services (EOHHS),. The Contractor's principal place of business is.

WHEREAS, EOHHS is an agency of the Commonwealth of Massachusetts responsible for operating a program of medical assistance (MassHealth) under 42 U.S.C. ?1396 et seq., and M.G.L. c. 118E, ?1 et seq., designed to pay for medical services for eligible individuals;

WHEREAS, the Contractor is in the business of providing medical services and EOHHS desired to purchase such services from the Contractor;

WHEREAS, the Contractor agrees to furnish these services in accordance with the terms and conditions of this Contract and in compliance with all federal and State laws and regulations;

NOW, THEREFORE, in consideration of the mutual promises set forth in this Contract, the parties agree as follows:

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SECTION 1. DEFINITIONS OF TERMS

The following terms or their abbreviations, when capitalized in this Contract and its Appendices, are defined as follows, unless the context clearly indicates otherwise.

Aging Services Access Point (ASAP) - an entity organized under Massachusetts General Law (M.G.L.) c.19 ?4B that contracts with the Executive Office of Elder Affairs to manage the Home Care Program in Massachusetts and that performs case management, screening, and authorization activities for certain long term care services.

Appeal ? An Enrollee's request for formal review of an action of the Contractor in accordance with Section 2.9 of the Contract.

Capitation Rate - a fixed monthly fee paid prospectively by EOHHS to the Contractor for each Enrollee for all Covered Services actually and properly delivered to the Enrollees in accordance with and subject to the provisions of this Contract and all applicable federal and state laws, regulations, rules, billing instructions, and bulletins, as amended.

Centers for Medicare & Medicaid Services (CMS) - the federal agency under the Department of Health and Human Services responsible for administering the Medicare and Medicaid programs under Titles XVIII and XIX of the Social Security Act.

Centralized Enrollee Record - centralized and comprehensive documentation, containing information relevant to maintaining and promoting each Enrollee's general health and well being, as well as clinical information concerning illnesses and chronic medical conditions. See Subsection 2.4(A)(8-10) of the Contract for more information about the contents of the Centralized Enrollee Record.

Complaint - an Enrollee's informal oral or written expression of grievance or dissatisfaction with any aspect of his or her care, in accordance with Subsection 2.8 of the Contract.

Complex Care Need - any condition or situation that demonstrates the Enrollee's need for expert coordination of multiple services (see Subsection 2.4(A)(4) of the Contract), including, but not limited to: clinical eligibility for institutional long term care; and medical illness, psychiatric illness, or cognitive impairment that requires skilled nursing to manage essential unskilled services and care.

Consumer ? a MassHealth Member, aged 65 or older, or the spouse, sibling, child, or unpaid Primary Caregiver of a MassHealth Member who is aged 65 or older.

Attachment A: SCO Contract

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Section 1: Definitions of Terms

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