HEALTHY INDIANA PLAN SCOPE OF WORK Sample Clauses

HEALTHY INDIANA PLAN SCOPE OF WORK. The Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR). For the HIP line of business, POWER Account expenditures may be included in both the numerator and denominator of the MLR calculation. The calculation must fully comply with 42 CFR 438.8. In addition, the State provides the following clarifications:  The MLR calculation shall be performed separately for each MLR reporting year.  The MLR calculation shall be performed separately for each program. The MLR for the HIP program shall be calculated separately from other managed care programs.  For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out.  Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting).  Under Sub-Capitated or Sub-Contracted arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The MCE should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. The Contractor shall maintain, at minimum, a MLR of eighty-seven percent (87%) for its HIP line of business. The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for HIP. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR is less than eighty-seven percent (87%) for the HIP line of business.
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HEALTHY INDIANA PLAN SCOPE OF WORK. The Contractor shall actively encourage members to make their POWER Account contributions utilizing member education, outreach and reminders. Member education and outreach should be included in new member materials and coordinated with any contact the Contractor makes with new members for health screenings, risk assessments and PMP selections. The Contractor shall notify members when the member fails to make a POWER Account contribution and tobacco surcharge payment by the due date. The Contractor shall provide at least two (2) written notices of the delinquent payment as a payment reminder, the first of which shall be sent on or before the seventh (7th) calendar day of non- payment. The reminders shall include the following information, at a minimum:  The date by which the contribution shall be paid to prevent the non-payment penalties described in Section 4.7.
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HEALTHY INDIANA PLAN SCOPE OF WORK to the GTW eligibility and operational requirements outlined in the MCE Policy and Procedure manual. The Contractor shall participate in GTW readiness reviews, conducted by OMPP, which may include documentation provided by the Contractor and on-site walkthroughs. The State will assign a GTW Referral Status for all fully eligible HIP members and provide the Referral Status to the Contractor. For all members who are referred to participate in the GTW program, the Contractor shall monitor each member’s compliance with the required GTW community engagement hours using the data provided by the member in the GTW member portal. The Contractor shall complete all outbound GTW member communications requirements as applicable to each member participating in GTW according to the MCE Policy and Procedure manual. The Contractor shall assist members who contact the Contractor regarding help with GTW requirements and shall conduct assessments and develop Assistance Plans according to the requirements set forth in the MCE Policy and Procedures manual. If during the assessment process, the Contractor identifies an exemption to the member’s participation in GTW or a member reports an exemption, the Contractor shall appropriately record or refer the exemption depending upon the type of exemption identified. The Contractor shall attempt to develop an Assistance Plan for a member if the member meets the criteria set forth in the MCE Policy and Procedure manual, including for failure to comply with GTW reporting requirements, or if the member requests an Assistance Plan. The Contractor shall conduct outreach to GTW members with an Assistance Plan per the requirements set forth in the MCE Policy and Procedure manual. If the member is non-compliant with GTW requirements when the Assistance Plan expires, the Contractor shall assess if a new Assistance Plan is appropriate. In accordance with the MCE Policy and Procedure manual, each calendar year the Contractor shall review Gateway to Work compliance for each member required to participate in the program based upon the referral status provided by the State. Non- compliant members will have the opportunity to complete pre-suspension activities, and the Contractor shall conduct all pre-suspension activity communication requirements. The State shall make all final eligibility decisions related to a member’s compliance with GTW requirements. The Contractor shall complete their assigned number of GTW verifications of member qualifying ac...
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HEALTHY INDIANA PLAN SCOPE OF WORK. Effective April 1, 2020, if the Contractor chooses to use a list of diagnosis codes to initially determine whether a service may be an emergency, the MCE must, at a minimum, use the State’s Emergency Department Autopay List, accessible from the Code Sets page at xx.xxx/xxxxxxxx/xxxxxxxxx. The Contractor must check at a minimum the diagnosis codes in fields 67 and 67A-E on the UB04 and 21A-F on the CMS 1500 against the emergency department autopay list. By April 1, 2020 the Contractor’s provider remittance advices for claims reduced to a screening fee shall include a notice alerting providers:  Where to submit medical records for prudent layperson review.  That the provider has 120 days to submit medical records for prudent layperson review.  The location where the provider can find any additional requirements for the submission of medical records for prudent layperson review. If a prudent layperson review determines the service was not an emergency, the Contractor shall reimburse for physician services billed on a CMS-1500 claim, in accordance with the IHCP Provider Bulletin. The Contractor shall reimburse for facility charges billed on a UB-04 in accordance with the IHCP Provider Bulletin, if a prudent layperson review determines the service was not an emergency. The Contractor shall have the following mechanisms in place to facilitate payment for emergency services and manage emergency room utilization:  A mechanism in place for a plan provider or Contractor representative to respond within one hour to all emergency room providers twenty four (24)-hours-a-day, seven (7)-days- a-week. The Contractor will be financially responsible for the post-stabilization services if the Contractor fails to respond to a call from an emergency room provider within one hour.  A mechanism to track the emergency services notification to the Contractor (by the emergency room provider, hospital, fiscal agent or member’s PMP) of a member’s presentation for emergency services.  A mechanism to document a member’s PMP’s referral to the emergency room and pay claims accordingly.
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HEALTHY INDIANA PLAN SCOPE OF WORK. ▪ Identify Medically Frail members and provide effective disease management, case management and care management programs for those that would benefit from such services; ▪ Coordinate health and social services; ▪ Integrate physical and behavioral health services; ▪ Develop innovative member and provider incentives; ▪ Use technology to ease administrative burden and help accomplish program goals; ▪ Develop innovative utilization management techniques that incorporate member and provider education to facilitate the right care, at the right time, in the right location; ▪ Emphasize communication, training and collaboration with network providers; and ▪ Engage in provider and member outreach regarding preventive care, wellness and a holistic approach. The Healthy Indiana Plan (HIP) is a program created to provide health care coverage to low- income adults. Indiana offers HIP members a comprehensive benefit package through a high deductible health plan paired with a personal health care account called a POWER (Personal Wellness and Responsibility) Account. The health plan is subject to a $2,500 deductible and includes “first dollar” coverage for ACA required preventive services. Services considered preventive but not required by the ACA may be provided at $500 first dollar coverage per year. For purposes of clarification, MCEs may cap first dollar preventive services at $500 per year, but shall provide all required ACA preventive services first dollar as required by the ACA. The preventive services benefit is designed to help eliminate barriers to obtaining preventive care. Indiana offers HIP members comprehensive benefits in several benefit packages (HIP Plus, HIP Basic, HIP State Plan, HIP Maternity, and Hospital Presumptive Eligibility) as described in Section 3. A description of the HIP covered services is set forth in Exhibit 6 of the Contract. The POWER Account is modeled in the spirit of a traditional Health Savings Account (HSA) and is funded with state and individual contributions. Employers and other third parties may also contribute. Members use POWER Account funds to meet the $2,500 deductible. POWER Accounts are funded with post-tax dollars and are not considered HSAs or other health spending accounts (e.g., Flexible Spending Accounts, Health Reimbursement Accounts, etc.) under federal law. Therefore, they are not subject to regulation under the U.S. Tax Code as such. Members who consistently make required contributions to their POWER account will ...
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HEALTHY INDIANA PLAN SCOPE OF WORK. ▪ Provide assurances satisfactory to the State showing that its provision against the risk of insolvency is adequate to ensure that its members will not be liable for the Contractor's debts if the entity becomes insolvent ▪ Meet the solvency standards established by the State for private health maintenance organizations, or be licensed or certified by the State as a risk-bearing entity Also, see Section 2.6.3 below.
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  • Work Plan Coordinate a work plan including a list of the proposed meetings and coordination activities, and related tasks to be performed, a schedule and an estimate. The work plan must satisfy the requirements of the project and must be approved by the State prior to commencing work.

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  • Project Plan Development of Project Plan Upon the Authorized User’s request, the Contractor must develop a Project Plan. This Project Plan may include Implementation personnel, installation timeframes, escalation procedures and an acceptance plan as appropriate for the Services requested. Specific requirements of the plan will be defined in the RFQ. In response to the RFQ, the Contractor must agree to furnish all labor and supervision necessary to successfully perform Services procured from this Lot. Project Plan Document The Contractor will provide to the Authorized User, a Project Plan that may contain the following items: • Name of the Project Manager, Contact Phone Numbers and E-Mail Address; • Names of the Project Team Members, Contact Phone Numbers and E-Mail Address; • A list of Implementation milestones based on the Authorized User’s desired installation date; • A list of responsibilities of the Authorized User during system Implementation; • A list of designated Contractor Authorized Personnel; • Escalation procedures including management personnel contact numbers; • Full and complete documentation of all Implementation work; • Samples of knowledge transfer documentation; and • When applicable, a list of all materials and supplies required to complete the Implementation described in the RFQ. Materials and Supplies Required to Complete Implementation In the event that there are items required to complete an Implementation, the Contractor may request the items be added to its Contract if the items meet the scope of the Contract. Negotiation of Final Project Plan If the Authorized User chooses to require a full Project Plan, the State further reserves the right for Authorized Users to negotiate the final Project Plan with the apparent RFQ awardee. Such negotiation must not substantively change the scope of the RFQ plan, but can alter timeframes or other incidental factors of the final Project Plan. The Authorized User will provide the Contractor a minimum of five (5) business days’ notice of the final negotiation date. The Authorized User reserves the right to move to the next responsible and responsive bidder if Contractor negotiations are unsuccessful.

  • Contractor Key Personnel ‌ The Contractor shall assign a Corporate OASIS Program Manager (COPM) and Corporate OASIS Contract Manager (COCM) as Contractor Key Personnel to represent the Contractor as primary points-of-contact to resolve issues, perform administrative duties, and other functions that may arise relating to OASIS and task orders solicited and awarded under XXXXX. Additional Key Personnel requirements may be designated by the OCO at the task order level. There is no minimum qualification requirements established for Contractor Key Personnel. Additionally, Contractor Key Personnel do not have to be full-time positions; however, the Contractor Key Personnel are expected to be fully proficient in the performance of their duties. The Contractor shall ensure that the OASIS CO has current point-of-contact information for both the COPM and COCM. In the event of a change to Contractor Key Personnel, the Contractor shall notify the OASIS CO and provide all Point of Contact information for the new Key Personnel within 5 calendar days of the change. All costs associated with Contractor Key Personnel duties shall be handled in accordance with the Contractor’s standard accounting practices; however, no costs for Contractor Key Personnel may be billed to the OASIS Program Office. Failure of Contractor Key Personnel to effectively and efficiently perform their duties will be construed as conduct detrimental to contract performance and may result in activation of Dormant Status and/or Off-Ramping (See Sections H.16. and H.17.).

  • Change in Scope of Work Any change in the scope of the Work, method of performance, nature of materials or price thereof, or any other matter materially affecting the performance or nature of the Work shall not be paid for or accepted unless such change, addition, or deletion is approved in advance and in writing by a valid change order executed by the District. Contractor specifically understands, acknowledges, and agrees that the District shall have the right to request any alterations, deviations, reductions, or additions to the Project or Work, and the cost thereof shall be added to or deducted from the amount of the Contract Price by fair and reasonable valuations. Contractor also agrees to provide the District with all information requested to substantiate the cost of the change order and to inform the District whether the Work will be done by the Contractor or a subcontractor. In addition to any other information requested, Contractor shall submit, prior to approval of the change order, its request for a time extension (if any), as well as all information necessary to substantiate its belief that such change will delay the completion of the Work. If Contractor fails to submit its request for a time extension or the necessary supporting information, it shall be deemed to have waived its right to request such extension.

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