Common use of INSERT NEW SECTION H Clause in Contracts

INSERT NEW SECTION H. 11.1.1 The Contractor shall ensure The Contractor and each through its contracts, provider (whether or not the subcontracts and in any other provider participates in the appropriate manner that Contractor's provider network) neither Enrollees nor the through which the Contractor District are held liable for furnishes or arranges for the Contractor's debts in the furnishing of items or event of Contractor's services covered under the insolvency. contract to an enrolled individual shall comply with the requirements of 1932(b)(6) of the Social Security Act, 42 U.S.C. 1396u-2(b)(6), that an enrolled individual or the individual's family or caregiver may not be held liable or be subject to collection efforts for: . debts or other obligations of the Contractor or any provider participating in the Contractor's provider network in the event of insolvency; . the cost of items and services covered under the contract in the event that the -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- POHC-2002-D-0003 PAGE 20 OF 23 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- CONTRACT MODIFICATION - M0001 DCHFP SUMMARY SHEET -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- CONTRACT SECTION CHANGED FROM CHANGED TO -------------------------------------------------------------------------------- Contractor fails to receive payment from DC; . the cost of items and services covered under the contract if a provider participating in the Contractor's provider network fails to receive payments from the Contractor; or . payments to a provider that furnishes items and services covered under the contract to an enrolled individual under a contractual, referral, or other arrangement with the Contractor in excess of the amount that would be owed by the enrolled individual if the Contractor had furnished such items or services directly. --------------------------------------------------------------------------------

INSERT NEW SECTION H. 11.1.1 The Contractor shall ensure provide language in all of their provider's contracts and subcontracts that preclude balance billing, except for any outstanding co-payments. Medicaid payment is "payment in full". The Contractor and each through its contracts, provider (whether or not the subcontracts and in any other provider participates in the appropriate manner that Contractorcontractor's provider network) neither Enrollees nor the through which the Contractor District are held liable for furnishes or arranges for the Contractorcontract shall preclude their providers from sending individual Medicaid recipient's debts in the furnishing of items or event of Contractor's services covered under the insolvencybills to collections agencies. contract to an enrolled individual shall comply with the requirements of 1932(b)(6) of the Social Security Act, 42 U.S.C. 1396u-2(b)(6), that an enrolled individual or the individual's family or caregiver may not be held liable or be subject to collection efforts for: . debts or other obligations of the Contractor or any provider participating in the Contractor's provider network in the event of insolvency; . the cost of items and services covered under the contract in the event that the -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- POHC-2002-D-0003 PAGE 20 21 OF 23 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- CONTRACT MODIFICATION - M0001 DCHFP SUMMARY SHEET -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- CONTRACT SECTION CHANGED FROM CHANGED TO -------------------------------------------------------------------------------- Contractor fails Protection of enrollees against balance billing through subcontractors (Amends SSA 1128B (d)(1) --BBA 4704(b) Section 1128b(d)(1) of the Act authorizes criminal penalties to receive payment from DC; . the cost of items and services covered under the contract if a provider participating providers in the Contractor's provider network fails to receive payments from the Contractor; or . payments to a provider that furnishes items and case of services covered under the contract provided to an individual enrolled individual with a managed care organization under contract under section 1903(m) of the Act which are charged at a contractual, referral, or other arrangement with the Contractor rate in excess of the amount rate permitted under the organization's contract. Section 1128B(d)(1) of the Act states that would be owed whoever knowingly and willfully charges, for any service provided to a patient under a State plan approved under Title XIX or under a managed care organization contract under 1903(m) of the Act, money or other consideration at a rate in excess of the rates established by the enrolled individual if the Contractor had furnished such items State or services directlycontract shall be guilty of a felony and upon conviction shall be fined no more than $25,000 or imprisoned for no more than five years, or both. --------------------------------------------------------------------------------