Contract Between United States Department of Health and ...

Contract Between United States Department of Health and Human Services Centers for Medicare & Medicaid Services In Partnership with The State of Michigan

and Effective: November 1, 2016

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Table of Contents

SECTION 1. DEFINITION OF TERMS

9

SECTION 2. ICO RESPONSIBILITIES

25

2.1. Compliance

25

2.1.1. ICO Requirements for State Operations

25

2.1.2. Compliance with Contract Provisions and Applicable Laws

26

2.2. Contract Management and Readiness Review Requirements

29

2.2.1. Contract Readiness Review Requirements

30

2.2.2. Contract Management

32

2.2.3. Organizational Structure

33

2.3. Eligibility and Enrollment Responsibilities

35

2.3.1. Eligibility Determinations

35

2.3.2. Eligible Populations

35

2.3.3. General Enrollment

36

2.3.4. Opt In Enrollment

37

2.3.5. Passive Enrollment

38

2.3.6. Enrollee Materials

42

2.3.7. Disenrollment

45

2.4. Covered Services

53

2.4.1. General

53

2.4.2. Excluded Services

57

2.5. Care Delivery Model

57

2.5.1. General

57

2.5.2. Integrated Care Team (ICT)

59

2.5.3. ICO Care Coordinators

62

2.5.4. LTSS Supports Coordinator

67

2.5.5. Coordination Tools

69

2.5.6. Health Promotion and Wellness Activities

71

2.6. Enrollee Stratification, Assessments, and Individual Integrated Care and Support Plan

(IICSP) 72

2.6.1. Enrollee Stratification

72

2.6.2. Initial Screening

72

2.6.3. Level I Assessments

73

2.6.4. Personal Care Assessment

79

2.6.5. Michigan Medicaid Nursing Facility Level of Care Determination

79

2.6.6. Level II Assessment

80

2.6.7. Reassessments

81

2.6.8. Individual Integrated Care and Supports Plan (IICSP)

82

2.6.9. Self-Determination

84

2.6.10. Continuity of Care

85

2.7. Provider Network

91

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2.7.1. Network Adequacy

91

2.7.2. Network Provider Requirements

95

2.7.3. Provider Contracting

98

2.7.4. Provider Payment and Reimbursement

105

2.7.5. Network Management

109

2.7.6. Provider Education and Training

110

2.7.7. Subcontracting Requirements

113

2.8. Enrollee Access to Services

114

2.8.1. General

114

2.8.2. Services Not Subject to Prior Approval

116

2.8.3. Authorization of Services

117

2.8.4. Behavioral Health Service Authorization Policies and Procedures

120

2.8.5. Authorization of LTSS

120

2.8.6. Utilization Management

120

2.8.7. Services for Specific Populations

121

2.8.8. Emergency and Post-stabilization Care Coverage

122

2.8.9. Emergency Medical Treatment and Labor Act (EMTALA)

124

2.8.10. Availability of Services

125

2.8.11. Linguistic Competency

125

2.8.12. Access for Enrollees with Disabilities

126

2.9. Enrollee Services

126

2.9.1. Enrollee Service Representatives (ESRs)

126

2.9.2. Enrollee Service Telephone Responsiveness

128

2.9.3. Coverage Determinations and Appeals Call Center Requirements

130

2.9.4. Enrollee Participation on the ICO Advisory Council

131

2.10. Enrollee Grievance

132

2.10.1. Grievance Filing

132

2.10.2. Grievance Administration

133

2.11. Enrollee Appeals

134

2.11.1. General Requirements

134

2.11.2. Appeals Process Overview

135

2.11.3. Internal (plan-level) Appeals

140

2.11.4. External Appeals

144

2.11.5. Hospital Discharge Appeals

146

2.11.6. Other Discharge Appeals

146

2.12. Provider Appeals

147

2.12.1. MDHHS Website

147

2.12.2. Payment Resolution Process

147

2.12.3. Arbitration/Rapid Dispute Resolution

147

2.12.4. Non-contracted provider appeals.

148

2.13. Quality Improvement Program

148

2.13.1. Quality Improvement:

148

2.13.2. QI Program Structure

149

2.13.3. QI Functions and responsibilities:

149

2.13.4. QI Activities

153

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2.13.5. QI Project Requirements

156

2.13.6. External Quality Review (EQR) Activities

157

2.13.7. QI for Utilization Management Activities

159

2.13.8. Clinical Practice Guidelines

160

2.13.9. QI Workgroups

161

2.13.10. Evaluation Activities

163

2.14. Marketing, Outreach, and Enrollee Communications Standards

164

2.14.1. Requirements, General

164

2.14.2. Requirements for Materials

165

2.14.3. Requirements for the Submission, Review, and Approval of Materials

166

2.14.4. Requirements for Dissemination of Materials

167

2.14.5. Requirements for the Provider and Pharmacy Network Directory

172

2.15. Financial Requirements

175

2.15.1. Financial Viability

175

2.15.2. Solvency Requirements

175

2.15.3. Other Financial Requirements

175

2.16. Data Submissions, Reporting Requirements, and Survey

176

2.16.1. General Requirements for Data

176

2.16.2. General Reporting Requirements

176

2.16.3. Information Management and Information Systems

177

2.16.4. Accepting and Processing Assessment Data

179

2.17. Encounter Reporting

180

2.17.1. Requirements

180

SECTION 3. CMS AND MDHHS RESPONSIBILITIES

183

3.1. Contract Management

183

3.1.1. Administration

183

3.1.2. Performance Evaluation

184

3.2. Enrollment and Disenrollment Systems

185

3.2.1. CMS and MDHHS

185

3.2.2. MDHHS Enrollment Broker

185

SECTION 4. PAYMENT AND FINANCIAL PROVISIONS

187

4.1. General Financial Provisions

187

4.1.1. Capitation Payments

187

4.1.2. Demonstration Year Dates

187

4.2. Capitated Rate Structure

188

4.2.1. Medicaid Component of the Capitation Payment

188

4.2.2. Medicare Component of the Capitation Payment

190

4.2.3. Aggregate Savings Percentages

192

4.2.4. Risk Adjustment Methodology

193

4.3. Risk Mitigation Approaches

194

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4.3.1. Risk Corridor

194

4.3.2. Medical loss ratio (MLR)

195

4.4. Payment Terms

197

4.4.1. Timing of Capitation Payments

197

4.4.2. Enrollee Contribution to Care Amounts

198

4.4.3. Modifications to Capitation Payments

198

4.4.4. Quality Withhold Policy

200

4.4.5. American Recovery and Reinvestment Act of 2009

207

4.4.6. Suspension of Payments

207

4.5. Transitions between Rating Categories and Risk Score Changes

207

4.5.1. Rating Category Changes

207

4.5.2. Medicare Risk Score Changes

207

4.6. Reconciliation

207

4.6.1. General

208

4.6.2. Medicaid Capitation Reconciliation

208

4.6.3. Medicare Capitation Reconciliation

208

4.6.4. Audits/Monitoring

208

4.7. Payment in Full

208

4.7.1. General

208

SECTION 5. ADDITIONAL TERMS AND CONDITIONS

210

5.1. Administration

210

5.1.1. Notification of Administrative Changes

210

5.1.2. Assignment

210

5.1.3. Independent ICOs

210

5.1.4. Subrogation

210

5.1.5. Prohibited Affiliations

211

5.1.6. Disclosure Requirements

211

5.1.7. Physician Incentive Plans

212

5.1.8. Physician Identifier

212

5.1.9. Timely Provider Payments

212

5.1.10. Protection of Enrollee-Provider Communications

213

5.1.11. Protecting Enrollee from Liability for Payment

214

5.1.12. Moral or Religious Objections

215

5.1.13. Third Party Liability Comprehensive Health Coverage

215

5.1.14. Medicaid Drug Rebate

216

5.2. Confidentiality

216

5.2.1. Statutory Requirements

216

5.2.2. Non-Disclosure of Confidential Information.

217

5.2.3. Data Security

219

5.2.4. Return of Personal Data and Confidential Information

220

5.2.5. Destruction of Personal Data

220

5.2.6. Research Data

221

5.2.7. State Data.

221

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