Common use of CAHPS Clause in Contracts

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: • Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. • Any marketing activities at the enrollment events where participation is mandatory. • Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except where the term “working days” is expressly used, all references in this Contract will be construed as calendar days. Default Enrollment (Assignment) – a process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees.

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: • Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. • Any marketing activities at the enrollment events where participation is mandatory. • Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except where the term “working days” is expressly used, all references in this Contract will be construed as calendar days. Default Enrollment (Assignment) – a process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in 1Section 1905(r)(5) of the Social Security Act accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- EQR-related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees. Family Planning Services – those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. These services include: health education and counseling necessary to make informed choices and understand contraceptive methods; limited history and physical examination; laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods; diagnosis and treatment of sexually transmitted diseases (STDs) if medically indicated; screening, testing, and counseling of at-risk individuals for human immunodeficiency virus (HIV) and referral for treatment; follow-up care for complications associated with contraceptive methods issued by the family planning provider; provision of contraceptive pills /devices/supplies; tubal ligation; vasectomies; and pregnancy testing and counseling. Fiscal Agent - an entity performing administrative service functions, including member eligibility and capitation payment functions, for the managed care program under a separate Contract with the Department.

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: •  Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. •  Any marketing activities at the enrollment events where participation is mandatory. •  Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except where the term “working days” is expressly used, all references in this Contract will be construed as calendar days. Default Enrollment (Assignment) – a process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in 1Section 1905(r)(5) of the Social Security Act accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- EQR-related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees. Family Planning Services – those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. These services include: health education and counseling necessary to make informed choices and understand contraceptive methods; limited history and physical examination; laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods; diagnosis and treatment of sexually transmitted diseases (STDs) if medically indicated; screening, testing, and counseling of at-risk individuals for human immunodeficiency virus (HIV) and referral for treatment; follow-up care for complications associated with contraceptive methods issued by the family planning provider; provision of contraceptive pills /devices/supplies; tubal ligation; vasectomies; and pregnancy testing and counseling. Fiscal Agent - an entity performing administrative service functions, including member eligibility and capitation payment functions, for the managed care program under a separate Contract with the Department.

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a A comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - counseling- the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Clinical Edit – a process for verifying that a member’s medical condition matches the clinical criteria for dispensing a requested drug. Clinical Edits must be based on evidence-based clinical criteria. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: •  Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. •  Any marketing activities at the enrollment events where participation is mandatory. •  Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractorsubcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays Copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except Except where the term “working days” is expressly used, all references in this Contract contract will be construed as calendar days. Default Enrollment (Assignment) – a - process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) 65 years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a -a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, medical or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a A dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contractcontract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contractcontract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- quality review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees. Family Planning Services – those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. These services include: health education and counseling necessary to make informed choices and understand contraceptive methods; limited history and physical examination; laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods; diagnosis and treatment of sexually transmitted diseases (STDs) if medically indicated; screening, testing, and counseling of at-risk individuals for human immunodeficiency virus (HIV) and referral for treatment; follow-up care for complications associated with contraceptive methods issued by the family planning provider; provision of contraceptive pills /devices/supplies; tubal ligation; vasectomies; and pregnancy testing and counseling. Fiscal Agent - an entity performing administrative service functions, including member eligibility and capitation payment functions, for the managed care program under a separate contract with the Department.

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a A comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - counseling- the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Clinical Edit – a process for verifying that a member’s medical condition matches the clinical criteria for dispensing a requested drug. Clinical Edits must be based on evidence-based clinical criteria. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: • Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. • Any marketing activities at the enrollment events where participation is mandatory. • Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractorsubcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays Copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except Except where the term “working days” is expressly used, all references in this Contract contract will be construed as calendar days. Default Enrollment (Assignment) – a - process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) 65 years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a -a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, medical or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a A dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contractcontract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contractcontract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- quality review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees. Family Planning Services – those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. These services include: health education and counseling necessary to make informed choices and understand contraceptive methods; limited history and physical examination; laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods; diagnosis and treatment of sexually transmitted diseases (STDs) if medically indicated; screening, testing, and counseling of at-risk individuals for human immunodeficiency virus (HIV) and referral for treatment; follow-up care for complications associated with contraceptive methods issued by the family planning provider; provision of contraceptive pills /devices/supplies; tubal ligation; vasectomies; and pregnancy testing and counseling. Fiscal Agent - an entity performing administrative service functions, including member eligibility and capitation payment functions, for the managed care program under a separate contract with the Department.

CAHPS. the Consumer Assessment of-Health Plans Survey. This survey is conducted annually by the EQRO. Capitation Payment – a payment the State makes periodically to the MCO on behalf of each beneficiary enrolled under this Contract and based on the actuarially sound capitation rate for the provision of services under the State plan. The State makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment. Cardiac Rehabilitation - a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. Choice Counseling - the provision of information and services designed to assist beneficiaries in making enrollment decisions; it includes answering questions and identifying factors to consider when choosing among managed care plans. Choice counseling does not include making recommendations for or against enrollment into a specific MCO. Cold-Call Marketing – any unsolicited personal contact by the MCO with a potential member for the purpose of influencing the potential member to enroll in that particular MCO. Cold Call Marketing includes, without limitation: • Unsolicited personal contact with a potential member outside of an enrollment event, such as door-to-door or telephone marketing. • Any marketing activities at the enrollment events where participation is mandatory. • Any other personal contact with a potential member if the potential member has not initiated the contact with the MCO. Common Area (Marketing) – any area in a provider’s facilities that is accessible to the general public. Common areas include, without limitation: reception areas, waiting rooms, hallways, etc. Complaint – an expression of dissatisfaction made about an MCO decision or services received from the MCO when an informal grievance is filed; some complaints may be subject to appeal. Consultant/Consultant Affiliates – any corporation, company, organization, or person or their affiliates retained by the Department to provide assistance in this project or any other project; not the MCO or Subcontractor. Corrective Action – an improvement in a business process that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Covered Services (Contract Services) - health care services the MCO must arrange to provide to Medicaid members, including all services required by this Contract and state and federal law, and all Value-Added Services negotiated by the MCO and the Department. CMS – the Centers for Medicare and Medicaid Services, a division within the federal Department of Health and Human Services. Corrective Action Plan – a detailed written plan that may be required by the Department to correct or resolve a deficiency in the MCO’s processes or actions. Cost-Sharing - copays that the MCO enrollee is billed at the time of service. Copays are determined by the Department based on the member’s family income. There are no premiums or deductibles under the West Virginia Medicaid program. Day – except where the term “working days” is expressly used, all references in this Contract will be construed as calendar days. Default Enrollment (Assignment) – a process established by the Department through the CMS waiver authority to assign an enrollee who has not selected an MCO to an MCO. Department or Bureau for Medical Services (BMS) – the West Virginia Department of Health and Human Resources. DHHS – the United States Department of Health and Human Services. Direct Mail Marketing – any materials sent to potential members by the MCOs or their agents through U.S. mail or any other direct or indirect delivery method. Disabled Person or Person with Disability - a person under sixty-five (65) years of age, including a child, who qualifies for Medicaid services because of a disability. Disability - a physical or mental impairment that substantially limits one (1) or more of an individual’s major life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and/or working. Eligible Recipient or Recipient - a person who receives Medicaid in accordance with the State Plan. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – Medically Necessary services, including interperiodic and periodic screenings, listed in Section 1905(a) of the Social Security Act. EPSDT entitles Medicaid-eligible infants, children, and adolescents to any treatment or procedure that fits within any of the categories of Medicaid-covered services listed in Section 1905(a) of the Social Security Act if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.1 Emergency Care – includes inpatient and outpatient services needed immediately and provided by a qualified Medicaid provider for emergency medical, behavioral health, or dental conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing their health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part; and that are needed to evaluate or stabilize an emergency medical condition. These include accidental injury and poison related problems and complaints that may be indicative of serious, life threatening medical problems, such as chest or abdominal pain, difficulty breathing or swallowing, or loss of consciousness. If the patient presents at the hospital emergency department and requests an examination, a nurse triage screening is always allowed. In the 1Section 1905(r)(5) of the Social Security Act case of behavioral health services, emergency care means those clinical, rehabilitative, or supportive behavioral health services provided for behavioral health conditions or disorders for which a prudent layperson with an average knowledge of health and medicine, could reasonably expect to result in risk of danger to a person’s self or others if not immediately treated. These include, but are not limited to, crisis stabilization treatment services. Emergency Dental Condition - a dental or oral condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine requires immediate services for relief of symptoms and stabilization of the condition; such conditions may include severe pain, hemorrhage, acute infection, traumatic injury to the teeth and surrounding tissue, or unusual swelling of the face or gums. Emergency Medical Condition – conditions where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part. Encounter Data – procedure-level data on each contact between an enrolled individual and the health care system for a health care service or set of services included in the covered services under the Contract. Enrollee – a Medicaid recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the MCO enrollment information which the Department will transmit to the MCO every month in accordance with an established notification schedule. An enrollee is also referred to as a member. External Quality Review- the analysis and evaluation by an EQRO, of aggregated information on quality, timeliness, and access to the health care services that the MCO or its Subcontractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO) – the entity contracted by the Department to conduct periodic independent studies regarding the quality of care delivered to West Virginia Medicaid managed care enrollees. EQRO must meet the competence and independence requirements set forth in 42 CFR 438.354, and perform external quality review, other EQR- related activities as set forth in 42 CFR 438.358, or both. Enrollment Broker – the entity contracted by the Department to conduct outreach and enrollment of eligible West Virginia Medicaid managed care enrollees. Family Planning Services – those services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy. These services include: health education and counseling necessary to make informed choices and understand contraceptive methods; limited history and physical examination; laboratory tests if medically indicated as part of decision making process for choice of contraceptive methods; diagnosis and treatment of sexually transmitted diseases (STDs) if medically indicated; screening, testing, and counseling of at-risk individuals for human immunodeficiency virus (HIV) and referral for treatment; follow-up care for complications associated with contraceptive methods issued by the family planning provider; provision of contraceptive pills /devices/supplies; tubal ligation; vasectomies; and pregnancy testing and counseling. Fiscal Agent - an entity performing administrative service functions, including member eligibility and capitation payment functions, for the managed care program under a separate Contract with the Department.