AHCA CONTRACT NO. FA615 AMENDMENT NO. 9
Exhibit 10.15
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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AHCA
CONTRACT NO. FA615
AMENDMENT
NO. 9
THIS CONTRACT, entered into
between the STATE OF FLORIDA,
AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the
"Agency" and WELLCARE OF
FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred
to as the "Vendor" or “Health Plan” is hereby amended as follows:
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1.
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Attachment
II, Table of Contents, is hereby amended as
follows:
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Section
IV Enrollee Services and Marketing is hereby amended to now
read:
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Section
IV Enrollee Services, Community Outreach and Marketing
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--
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Section
IV, Item B. is hereby amended to now
read:
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B.
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Community
Outreach and Marketing
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2.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section I, Item A.,
Definitions, is hereby amended as
follows:
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--
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The
definition of Community Outreach Representative is hereby included as
follows:
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Community
Outreach Representative – A person who provides Community Outreach,
including health information, information that promotes healthy lifestyles,
information that provides guidance about social assistance programs, and
information that provides culturally and linguistically appropriate health or
nutritional education. Such representatives must be appropriately trained,
certified and/or licensed, including but not limited to, social workers,
nutritionists, physical therapists and other health care
professionals.
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--
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The
definition of Community Outreach is hereby included as
follows:
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Community
Outreach – The provision of health or nutritional
information, or information for the benefit and education of,
or assistance to, a community in regard to health-related matters or public
awareness that promotes healthy lifestyles. Community Outreach also
includes the provision of information about health care services, preventive
techniques and other health care projects and the provision of information
related to health, welfare, and social services or social assistance programs
offered by the State of Florida or local communities. or information for the
benefit and education of, or assistance to, a community in regard to
health-related matters or public awareness that promotes healthy
lifestyles.
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--
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The
definition of Community Outreach Materials is hereby included as
follows:
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Community
Outreach Materials – Materials regarding health or nutritional
information, or information for the benefit and education of, or assistance to,
a community in regard to health-related matters or public awareness that
promotes healthy lifestyles; such materials are specifically meant for the
community at-large and may also include information about health care services,
preventive techniques and other health care projects and the provision of
information related to health, welfare, and social services or social assistance
programs offered by the State of Florida or local
communities. Community Outreach Materials are limited to brochures,
fact sheets, posters, and ad copy for radio, television, print or the
Internet.
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The
definition of Market Area is hereby amended to now read as
follows:
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Market
Area – The
geographic area in which the Health Plan is authorized to conduct Community
Outreach.
AHCA
Contract No. FA615, Amendment No. 9, Page 1 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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The
definition of Marketing Representative is hereby deleted in its
entirety.
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The
definition of Pre-Enrollment is hereby amended to now read as
follows:
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Pre-Enrollment
– The provision of Marketing materials to a Medicaid Recipient.
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The
definition of Pre-Enrollment Application is hereby deleted in its
entirety.
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The
definition of Public Event is hereby amended to now read as
follows:
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Public
Event – An event that is organized or sponsored by an organization, for
the benefit and education of, or assistance to, a community in regard to
health-related matters or public awareness.
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The
definition of Remediation is hereby included as
follows:
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Remediation
- Remediation of encounter claims; where remediation is “the act or process of
correcting a fault or deficiency.”
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The
definition of Request for Benefit Information (RBI) is hereby deleted in
its entirety.
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3.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section I, Item B.,
Acronyms, is hereby amended as
follows:
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The
acronym ACCESS is hereby included as
follows:
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ACCESS – Automated Community
Connection to Economic Self-Sufficiency: The Department of Children
and Families’ (DCF’s) public assistance service delivery system.
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--
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The
acronym WEDI is hereby included as
follows:
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WEDI – Workgroup for
Electronic Data Interchange
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4.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section III, Eligibility
and Enrollment, Item C., Disenrollment, sub-item 2.a.(4), is hereby
amended as follows:
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(4)
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A
substantiated Marketing or Community Outreach violation has
occurred.
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5.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section IV, Enrollee
Services and Marketing, is hereby retitled “Enrollee Services, Community
Outreach and Marketing.”
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6.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section IV, Enrollee
Services, Community Outreach and Marketing, Item A., Enrollee Services, is
hereby amended to include sub-items 10. and 11. as
follows:
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10.
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Prescribed
Drug List (PDL)
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The
Health Plan’s website must include the Health Plan’s PDL. The Health Plan
may update the online PDL by providing thirty (30) days written notice of any
change to the Bureaus of Managed Health Care and Pharmacy Services.
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11.
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Medicaid
Redetermination Notices
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Upon
implementation of a systems change relative to this section, the Agency will
provide Medicaid recipient redetermination date information to the Health
Plan.
AHCA
Contract No. FA615, Amendment No. 9, Page 2 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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a.
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This
information may be used by the Health Plan only as indicated in this
subsection.
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b.
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The
Agency will notify the Health Plan sixty (60) Calendar Days prior to
transmitting this information to the Health Plan and, at that time, will
provide the Health Plan with the file format for this information.
The Agency will decide whether or not to continue to provide this
information to Health Plan annually and will notify the Health Plans of
its decision by May 1 for the coming Contract Year. In addition, the
Agency reserves the right to provide thirty (30) Calendar Days notice
prior to discontinuing this subsection at any
time.
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c.
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Within
thirty (30) Calendar Days after the date of the Agency’s notice of
transmitting this redetermination date information, and annually by June 1
thereafter, the Health Plan must notify the Agency’s Bureau of Managed
Health Care (BMHC), in writing, if it will participate in the use of this
information for the Contract Year. The Health Plan’s participation
in using this information is
optional/voluntary.
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(1)
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If
the Health Plan does not respond in writing to the Agency within thirty
(30) Calendar Days after the date of the Agency’s notice, the Health Plan
forfeits its ability to receive and use this information until the next
Contract Year.
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(2)
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If
the Health Plan chooses to participate in the use of this information, it
must provide with its response indicating it will participate, to the
Agency for its approval, its policies and procedures regarding this
subsection.
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(a)
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A
Health Plan that chooses to participate in the use of this information may
decide to discontinue using this information at any time. In this
circumstance, the Health Plan must notify the Agency’s BMHC of such in
writing. The Agency will then delete the Health Plan from the list
of Health Plans receiving this information for the remainder of the
Contract Year.
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(b)
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A
Health Plan that chooses to participate in the use of this information
must train all affected staff, prior to implementation, on its policies
and procedures and the Agency’s requirements regarding this
subsection. The Health Plan must document such training has been
provided including a record of those trained for the Agency review within
five (5) Business days after the Agency’s
request.
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(3)
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If
the Health Plan has opted-out of participating in the use of this
information, it may not opt back in until the next Contract
Year.
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(4)
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Regardless
of whether or not the Health Plan has declined to participate in the use
of this information, it is subject to the sanctioning indicated in this
subsection if this information has been or is misused by the Health
Plan.
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d.
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If
the Health Plan chooses to participate in using this information, it may
use the redetermination date information only in the methods listed below,
and may choose to use both methods to communicate this information or just
one method.
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(1)
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The
Health Plan may use redetermination date information in written notices to
be sent to their Enrollees reminding them that their Medicaid eligibility
may end soon and to reapply for Medicaid if needed. If the Health
Plan chooses to use this method to provide this information to its
Enrollees, it must adhere to the following
requirements:
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(a)
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The
Health Plan must mail the redetermination date notice to each Enrollee for
whom the Health Plan received a redetermination date. The Health
Plan may send one notice to the Enrollee’s household when there are
multiple Enrollees within
a family that have the same Medicaid redetermination date provided that
these Enrollees share the same mailing
address.
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AHCA
Contract No. FA615, Amendment No. 9, Page 3 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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(b)
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The
Health Plan must use the Agency’s redetermination date notice template
provided to the Health Plan for its notices. The Health Plan may put
this template on its letterhead for mailing; however, the Health Plan may
make no other changes, additions or deletions to the letter
text.
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(c)
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The
Health Plan must mail the redetermination date notices to each Enrollee no
more than sixty (60) Calendar Days and no less than thirty (30) Calendar
Days prior to the redetermination date received from the
Agency.
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(2)
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The
Health Plan may use redetermination date information in automated voice
response (AVR) or integrated voice response (IVR) automated messages sent
to Enrollees reminding them that their Medicaid eligibility may end soon
and to reapply for Medicaid if needed. If the Health Plan chooses to
use this method to provide this information to its Enrollees, it must
adhere to the following
requirements:
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(a)
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The
Health Plan must send the redetermination date messages to each Enrollee
for whom the Health Plan has received a redetermination date and for whom
the Health Plan has a telephone number. The Health Plan may send an
automated message to the Enrollee’s household when there are multiple
Enrollees within a family that have the same Medicaid redetermination date
provided that these Enrollees share the same mailing address/phone
number.
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(b)
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For
the voice messages, the Health Plan must use only the language in the
Agency’s redetermination date notice template provided to the Health
Plan. The Health Plan may add its name to the message but may make
no other changes, additions or deletions to the message
text.
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(c)
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The
Health Plan must make such automated calls to each Enrollee no more than
sixty (60) Calendar Days and no less than thirty (30) Calendar Days prior
to the redetermination date received from the
Agency.
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(3)
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The
Health Plan may not include the redetermination date information in any
file viewable by customer service or Community Outreach staff. This
information may only be used in the letter templates and automated scripts
provided by the Agency and cannot be verbally referenced or discussed by
the Health Plan with the Enrollees, unless in response to an Enrollee
inquiry regarding the letter received, nor may it be used a future time by
the Health Plan. If the Health Plan receives Enrollee inquiries
regarding the notices, such inquiries must be referred to the Department
of Children and Families.
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e.
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If
the Health Plan chooses to participate in using this information, the
Health Plan must keep the following information available regarding each
mailing made for the Agency’s review within five (5) Business Days after
the Agency’s request:
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(1)
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For
each month of mailings, a dated hard copy or pdf of the monthly template
used for that specific mailing.
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(a)
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A
list of each Enrollee for whom a monthly mailing was sent. This list
shall include each Enrollee’s name and Medicaid identification number to
whom the notice was mailed, the address to which the notice was
mailed, and the date of the Agency’s enrollment file used to create the
mailing list.
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AHCA
Contract No. FA615, Amendment No. 9, Page 4 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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(b) A log of returned, undeliverable
mail received for these notices, by month, for each Enrollee for whom a returned
notice was received.
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(2)
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For
each month of automated calls made, a list including of each Enrollee for
whom a call was made, the Enrollee’s Medicaid identification number,
telephone number to which the call was made, and the date each call was
made, and the date of the Agency’s enrollment file used to create the
automated call list.
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The
Health Plan must retain this documentation in accordance with the Agency’s
Standard Contract, I.D., Retention of Records.
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f.
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If
the Health Plan chooses to participate in using this information, the
Health Plan must keep up-to-date and approved policies and procedures
regarding the use, storage and securing of this information as well as
addressing all requirements of this
subsection.
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g.
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If
the Health Plan chooses to participate in using this information, the
Health Plan must submit to the Agency’s BMHC a completed quarterly summary
report in accordance with Section XII, X., of this
Attachment.
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h.
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Should
any complaint or investigation by the Agency result in a finding that the
Health Plan has violated this subsection, the Health Plan will be
sanctioned in accordance with Section XIV, B. The first such
violation will result in a 30-day suspension of use of Medicaid
redetermination dates; any subsequent violations will result in 30-day
incremental increases in the suspension of use of Medicaid redetermination
dates. In the event of any subsequent violations, additional
penalties may be imposed in accordance with Section XIV, B.
Additional or subsequent violations may result in the Agency’s rescinding
of the provision of redetermination date information to the Health
Plan.
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7.
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Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section IV, Item B.,
Marketing, is hereby deleted in its entirety and replaced as
follows:
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B.
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Community
Outreach and Marketing
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1.
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General
Provisions
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a.
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The
Health Plan’s Community Outreach Representative(s) may provide Community
Outreach at Health Fairs/Public events as noticed by the Health Plan to
the Agency in accordance with sub-item 4. of this Section. The
main purpose of a Health Fair/Public Event shall be to provide Community
Outreach and shall not be for the purpose of Medicaid Health Plan
Marketing.
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b.
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For
each new Contract Period, the Health Plan shall submit to the Agency
Bureau of Managed Health Care for written approval, all Community Outreach
material no later than sixty (60) Calendar Days prior to Contract renewal,
and for any changes in the Community Outreach Material, no later than
thirty (30) Calendar Days prior to implementation. All
materials developed shall be governed by the requirements set forth in
this Section.
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c.
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To
announce participation at a specific event (Health Fair/Public Event), the
Health Plan shall submit a notice to the Agency in accordance with
sub-item B.3., Permitted
Activities.
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d.
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The
Health Plan shall be responsible for developing and implementing a written
plan designed to control the actions of its Community Outreach
Representatives.
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e.
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All
of the Community Outreach policies set forth in this Contract apply to
staff, Subcontractors, Health Plan volunteers and all persons acting for
or on behalf of the Health
Plan.
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AHCA
Contract No. FA615, Amendment No. 9, Page 5 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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f.
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The
Health Plan is vicariously liable for any Outreach and Marketing
violations of its employees, agents or Subcontractors. Any
violations of this section shall subject the health plan to administrative
action by the Agency as determined by the Agency. The health
plan may dispute any such administrative action pursuant to Section XVI,
Item I., Disputes.
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g.
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Nothing
in this Section shall preclude a Health Plan from donating to or
sponsoring an event with a community organization where time, money or
expertise is provided for the benefit of the community. If such
events are not Health Fairs/Public Events, no Community Outreach Materials
or Marketing Materials may be distributed by the Health Plan, but the
Health Plan may engage in brand-awareness activities, including the
display of Health Plan or Product logos. Inquiries at such events
from prospective enrollees must be referred to the Health Plan’s member
services section or the Agency’s Choice Counselor/Enrollment
Broker.
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2.
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Prohibited
Activities
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The
Health Plan is prohibited from engaging in the following non-exclusive list of
activities:
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a.
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Marketing
for Enrollment to any potential members or conducting any Pre-Enrollment
activities not expressly allowed under this
Contract.
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b.
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Any
of the prohibited practices or activities listed in Section 409.912,
F.S.
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c.
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Engaging
in activities for the purpose of recruitment or
Enrollment.
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d.
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In
accordance with sections 409.912 and 409.91211, F.S., practices that are
discriminatory, including, but not limited to, attempts to discourage
Enrollment or reenrollment on the basis of actual or perceived health
status.
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e.
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Direct
or indirect Cold Call Marketing or other solicitation of Medicaid
Recipients, either by door-to-door, telephone or other means, in
accordance with section 4707 of the Balanced Budget Act of 1997, and
section 409.912, F.S.
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f.
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In
accordance with section 409.912, F.S., activities that could mislead or
confuse Medicaid Recipients, or misrepresent the Health Plan, it’s
Community Outreach Representatives, or the Agency. No
fraudulent, misleading, or misrepresentative information shall be used in
Community Outreach, including information regarding other governmental
programs. Statements that could mislead or confuse include, but
are not limited to, any assertion, statement or claim (whether written or
oral) that:
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(1)
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The
Medicaid Recipient must enroll in the Health Plan in order to obtain
Medicaid, or in order to avoid losing Medicaid
benefits;
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(2)
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The
Health Plan is endorsed by any federal, State or county government, the
Agency, or CMS, or any other organization which has not certified its
endorsement in writing to the Health
Plan;
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(3)
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Community
Outreach Representatives are employees or representatives of the federal,
State or county government, or of anyone other than the Health Plan or the
organization by whom they are
reimbursed;
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(4)
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The
State or county recommends that a Medicaid Recipient enroll with the
Health Plan; and/or
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AHCA
Contract No. FA615, Amendment No. 9, Page 6 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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(5)
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A
Medicaid Recipient will lose benefits under the Medicaid program, or any
other health or welfare benefits to which the Recipient is legally
entitled, if the Recipient does not enroll with the Health
Plan.
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g.
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Granting
or offering of any monetary or other valuable consideration for
Enrollment.
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h.
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Offers
of insurance, such as but not limited to, accidental death, dismemberment,
disability or life insurance.
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i.
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Enlisting
the assistance of any employee, officer, elected official or agent of the
State in recruitment of Medicaid Recipients except as authorized in
writing by the Agency.
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j.
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Offers
of material or financial gain to any persons soliciting, referring or
otherwise facilitating Medicaid Recipient Enrollment. The
Health Plan shall ensure that no plan staff market the Health Plan to
Medicaid Recipients at any location including State offices or DCF ACCESS
centers.
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k.
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Giving
away promotional items in excess of $5.00 retail value. Items
to be given away shall bear the Health Plan's name and shall only be given
away at Health Fairs/Public Events. In addition, such
promotional items must be offered to the general public and shall not be
limited to Medicaid Recipients.
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l.
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Providing
any gift, commission, or any form of compensation to the Choice
Counselor/Enrollment Broker, including the Choice Counselor/Enrollment
Broker's full-time, part-time or temporary employees and
Subcontractors.
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m.
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Provide
information, prior to the Enrollment, about the incentives that shall be
offered to the Enrollee as described in Section VIII.B.7., Incentive
Programs. The Health Plan may inform Enrollees on or after
their Enrollment effective date about the specific incentives or programs
available.
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n.
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Discussing,
explaining or speaking to a potential member about
Health-Plan-benefit-specific information other than to refer all Health
Plan inquiries to the Member Services section of the Health Plan or the
Agency’s Choice Counselor/Enrollment
Broker.
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o.
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Distributing
any Community Outreach Materials without prior written notice to the
Agency except as otherwise allowed under Permitted Activities and Provider
Compliance subsections.
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p.
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Distributing
any Marketing materials.
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q.
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Subcontract
with any brokerage firm or independent agent as defined in Chapters
624-651, F.S., for purposes of Marketing or Community
Outreach.
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r.
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Pay
commission compensation to Community Outreach Representatives for new
Enrollees. The payment of a bonus to a Community Outreach
Representative shall not be considered a commission if such bonus is not
related to enrollment or membership
growth.
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s.
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All
activities included in Section 641.3903,
F.S.
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3.
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Permitted
Activities
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The
Health Plan may engage in the following activities upon prior written notice to
the Agency Bureau of Managed Health Care:
AHCA
Contract No. FA615, Amendment No. 9, Page 7 of 13
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WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
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| a. | The Health Plan may attend Health Fairs/Public Events upon request by the sponsor and after written notification to the Agency as described in sub-item 4. | |
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b.
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The
Health Plan may leave Community Outreach Materials at Health Fairs/Public
Events at which the Health Plan
participates.
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c.
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The
Health Plan may provide Agency-approved Community Outreach
Materials. Such Materials may include Medicaid enrollment and
eligibility information and information related to other health care
projects and health, welfare and social services provided by the State of
Florida or local communities. The Health Plan staff, including
Community Outreach Representatives, must refer all Health Plan inquiries
to the member services section of the Health Plan or the Agency’s Choice
Counselor/Enrollment Broker. The Agency must approve the script
used by the Health Plan’s member services section before
usage.
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d.
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Health
Plans may distribute Community Outreach Materials to community
agencies.
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4.
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Community Outreach Notification
Process
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a.
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The
Health Plan shall submit in writing to the Agency Bureau of Managed Health
Care, a notice of its intent to attend and provide Community Outreach
Materials at Health Fairs/Public Events at least two (2) weeks prior to
the event (see 4.b. and c. below for further notice
information). Such submission shall include the items listed
below:
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(1)
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The
following Health Fair/Public Event disclosure information and other
information as may be required by the
Agency:
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(a)
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The
announcement of the event that will be given out to the
public;
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(b)
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The
date, time and location of the
event;
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(c)
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The
name and type of organization sponsoring the
event;
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(d)
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The
event contact person and contact
information;
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(e)
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The
Health Plan contact person and contact information;
and
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(f)
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Names
of participating Community Outreach Representative(s), their contact
information and services they will provide at the
event.
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(2)
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In
addition to the disclosure information listed in (1) above, if the Health
Plan is the primary organizer of the Health Fair, the Health Plan shall
submit complete disclosure of information from each organization
participating in a Health Fair prior to the event. Such
information shall include the name of the organization, contact person
information, and confirmation of
participation.
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(3)
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In
addition to the disclosure information listed in (1) above, if the Health
Plan has been invited by a community organization to be a sponsor or
attendee of an event, the Health Plan shall provide to the Agency Bureau
of Managed Health Care a copy of the letter of invitation from the Health
Fair/Public Event sponsor(s) to the Health Plan requesting sponsorship of,
or attendance at, the event.
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b.
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The
Health Plan shall submit notice to the Agency of Health Fairs/Public
Events no later than ten (10) Business Days after the Health Plan’s
receipt of the invitation to attend or, if the Health Plan is the primary
organizer of the Health Fair, no later than ten (10) days after a decision
has been made to organize the
event.
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c.
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Notwithstanding
the other notice requirements in this subsection, the two week and the
10-day advance notice requirements are waived in cases of force majeure
provided the Health Plan notices the Bureau of Managed Health Care by the
time of the event. Force majeure events includes destruction
due to hurricanes, fires, war, riots, and other similar acts. When
providing the Agency with notice of attendance at such events, the Health
Plan shall include a description of the force majeure event requiring
waiver of notice.
|
AHCA
Contract No. FA615, Amendment No. 9, Page 8 of 13
|
WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
|
|
|
d.
|
The
Agency will establish a statewide log to track the Community Outreach
notifications received and may monitor such
events.
|
|
|
5.
|
Provider
Compliance
|
The
Health Plan shall ensure, through provider education and outreach, that its
health care Providers are aware and comply with the following
requirements:
|
|
a.
|
Health
care Providers may display Health-Plan-specific materials in their own
offices.
|
|
|
b.
|
Health
Care Providers cannot orally or in writing compare Benefits or provider
networks among Health Plans, other than to confirm Health Plan network
participation.
|
|
|
c.
|
Health
care Providers may announce a new affiliation with a Health Plan or give a
list of Health Plans with which they contract to their
patients.
|
|
|
d.
|
Health
care Providers may co-sponsor events, such as Health Fairs, and advertise
with the Health Plan in indirect ways; such as television, radio, posters,
fliers, and print advertisement.
|
|
|
e.
|
Health
care Providers shall not furnish lists of their Medicaid Recipients to
Health Plans with which they contract, or any other entity, nor can
Providers furnish other Health Plans' membership lists to any Health Plan,
nor can Providers assist with Health Plan
Enrollment.
|
|
|
f.
|
For
the Health Plan, health care Providers may distribute information about
non-Health-Plan-specific health care services and the provision of health,
welfare, and social services provided by the State of Florida or local
communities as long as any inquiries from prospective enrollees are
referred to the member services section of the health plan and the
Agency’s Choice Counselor/Enrollment
Broker.
|
|
|
6.
|
Community
Outreach Representatives
|
|
|
a.
|
The
Health Plan shall report to the Agency Bureau of Managed Health Care any
Health Plan staff or Community Outreach Representative who violates any
requirements of this Contract, within fifteen (15) Calendar Days of
knowledge of such violation.
|
|
|
b.
|
While
attending Health Fairs/Public Events, Community Outreach Representatives
shall wear picture identification that identifies the Health Plan
represented.
|
|
|
c.
|
If
asked, the Community Outreach Representative shall inform the Medicaid
Recipient that the Representative is not an employee of the State and is
not a Choice Counseling Specialist, but is a Representative of the Health
Plan.
|
|
|
d.
|
The
Health Plan shall instruct and provide initial and periodic training to
its Community Outreach Representatives regarding the Community Outreach
and Marketing provisions of this
Contract.
|
|
|
e.
|
The
Health Plan shall implement procedures for background and reference checks
for use in its Community Outreach Representative hiring
practices.
|
|
|
f.
|
The
Health Plan shall register each Community Outreach Representative with the
Agency’s Bureau of Managed Health Care in accordance with Section XII of
this Contract.
|
AHCA
Contract No. FA615, Amendment No. 9, Page 9 of 13
|
WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
|
|
8.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration
and Management, Item B., Staffing, sub-item 1.g., is hereby deleted in its
entirety and replaced as follows:
|
|
|
g.
|
Community Outreach
Oversight Coordinator: If the Health Plan engages in
Community Outreach, the Health Plan shall have a designated person,
qualified by training and experience, to assure the Health Plan adheres to
the community outreach and marketing requirements of this
Contract.
|
|
9.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration
and Management, Item C., Provider Contract Requirements, sub-item 2.s., is
hereby deleted in its entirety and replaced as
follows:
|
|
|
s.
|
Require
that any Community Outreach Materials related to this Contract that are
displayed by the Provider be submitted to the Agency for written approval
before use;
|
|
10.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration
and Management, Item E., Provider Services, sub-item 5.d., is hereby
deleted in its entirety and replaced as
follows:
|
|
|
d.
|
The
Health Plan’s call center systems shall have the capability to track call
management metrics identified in Section IV, Community Outreach and
Marketing, Item A., Enrollee Services, sub-item 7., Toll-Free Help
Line.
|
|
11.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section X, Administration
and Management, Item H., Encounter Data, is hereby deleted in its entirety
and replaced as follows:
|
|
|
H.
|
Encounter
Data
|
|
|
1.
|
The
Health Plan shall submit Encounter Data that meets established Agency data
quality standards as defined herein. These standards are
defined by the Agency to ensure receipt of complete and accurate data for
program administration and will be closely monitored and
enforced. The Agency will revise and amend these standards with
ninety (90) Calendar Days advance notice to the Health Plan to ensure
continuous quality improvement. The Health Plan shall make
changes or corrections to any systems, processes or data transmission
formats as needed to comply with Agency data quality standards as
originally defined or subsequently
amended.
|
|
|
2.
|
The
Encounter Data submission standards required to support encounter
reporting and submission are defined by the Agency in the Medicaid
Encounter Data System (MEDS) Companion Guide and this
Section. In addition, the Agency will post encounter reporting
requirements on its MEDS website for the Health Plans to follow: ▇▇▇▇://▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇/▇▇▇▇/.
|
|
|
3.
|
The
Health Plan shall adhere to the following requirements for the Encounter
Data submission process:
|
|
|
a.
|
The
Agency shall notify the Health Plan, in writing, of the start date for
resuming the submission of encounters through the current Fiscal
Agent.
|
|
|
b.
|
Once
the Health Plan is notified by the Agency of the date for recommencing
encounter submissions (submission start date), the Health Plan shall
submit its schedule for transmitting Encounter Data for all typical
and atypical services collected for historical claims
beginning July 1, 2008, and up to the submission start
date.
|
| (1) | The Health Plan shall submit this schedule for approval to the Agency’s Medicaid Encounter Data System team (at ▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇) within ten (10) Business days after the date of the Agency’s notice to begin submitting encounters. |
AHCA
Contract No. FA615, Amendment No. 9, Page 10 of 13
|
WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
|
Medicaid HMO
Contract
|
|
|
(2)
|
At
a minimum, such submission schedule must include that historical encounter
transmissions will begin no later than sixty (60) Calendar Days after the
submission start date.
|
|
|
c.
|
In
accordance with the submission schedule approved by the Agency, the Health
Plan shall submit the historical encounters for all typical and atypical
services with Health Plan paid dates of July 1, 2008, up to the submission
start date.
|
|
|
d.
|
The
Health Plan shall submit encounters for all typical and atypical services
with Health Plan paid dates on or after the submission start date on an
ongoing basis within sixty (60) Calendar Days following the end of the
month in which the Health Plan paid the claims for
services.
|
|
|
e.
|
For
all encounters submitted after the recommencing of encounter submissions
(submission start date), including historical and ongoing claims, if the
Agency or its Fiscal Agent notifies the Health Plan of encounters failing
X12 Electronic Data Interface (EDI) compliance edits or FMMIS threshold
and repairable compliance edits, the Health Plan shall Remediate all such
encounters within sixty (60) Calendar Days after such
notice.
|
|
|
f.
|
There
will be no requirement to submit encounters for Health Plan paid dates
prior to July 1, 2008.
|
|
|
4.
|
The
Health Plan shall have a comprehensive automated and integrated Encounter
Data system that is capable of meeting the requirements
below. The Health Plan shall comply as
follows:
|
|
|
a.
|
All
Health Plan encounters shall be submitted to the Agency in the standard
HIPAA transaction formats, namely the ANSI X12N 837 Transaction formats (P
- Professional, I - Institutional, and D – Dental), and, for Pharmacy
services, in the National Council for Prescription Drug Programs (NCPDP)
format. Health Plan paid amounts must be provided for
non-capitated network providers.
|
|
|
b.
|
The
Health Plan shall collect and submit to the Agency’s Fiscal Agent,
Enrollee service level Encounter Data for all Covered
Services. Health Plans will be held responsible for errors or
noncompliance resulting from their own actions or the actions of an agent
authorized to act on their behalf.
|
|
|
c.
|
The
Health Plan shall convert all information that enters their claims systems
via hard copy paper claims or other proprietary formats to Encounter Data
to be submitted in the appropriate HIPAA compliant
formats.
|
|
|
d.
|
The
Health Plan shall provide complete and accurate encounters to the
Agency. Health Plans will implement review procedures to
validate Encounter Data submitted by
providers.
|
|
|
(1)
|
Complete: A
Health Plan submitting encounters that represent at least 95% of the
Covered Services provided by the Health Plan’s Providers and
non-participating providers. It is expected that the Health
Plan will strive to make every effort to achieve a 100% complete
submission rate.
|
|
|
(2)
|
Accurate: 95%
of the records in a Health Plan’s encounter batch submission pass X12 EDI
compliance edits and the FMMIS threshold and repairable compliance
edits. The X12 EDI compliance edits are established through
SNIP levels 1 through 4. FMMIS threshold
and repairable edits that report exceptions are defined in the MEDS
Companion Guide.
|
AHCA
Contract No. FA615, Amendment No. 9, Page 11 of 13
|
WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
|
Medicaid HMO
Contract
|
|
|
e.
|
The
Health Plan shall designate sufficient IT and staffing resources to
perform these encounter functions as determined by generally accepted best
industry practices.
|
|
|
f.
|
The
Health Plan shall retain submitted historical Encounter Data for a period
not less than five years as specified in I.D., Retention of Records, in
the Agency’s Standard Contract.
|
|
|
5.
|
Where
a Health Plan has entered into capitation reimbursement arrangements with
Providers, the Health Plan must comply with sub-item 4. of this
Section. The Health Plan shall require timely submissions from
its Providers as a condition of the capitation
payment.
|
|
|
6.
|
The
Health Plan shall participate in Agency sponsored workgroups directed at
continuous improvements in Encounter Data quality and
operations.
|
|
|
7.
|
If
the Agency determines that the Health Plan’s MEDS performance is not
acceptable, the Agency shall require the Health Plan to submit a
corrective action plan (CAP). If the Health Plan fails to
provide a CAP or to implement an approved CAP within the time specified by
the Agency, the Agency shall sanction the Health Plan in accordance with
the provisions of Section XIV, Sanctions, and may immediately terminate
all Enrollment activities and Mandatory Assignments. When
considering whether to impose a Sanction, the Agency will take into
account the Health Plan’s cumulative performance on all MEDS activities,
including progress made toward completeness and accuracy of Encounter Data
as defined in sub-item H.4.d. of this
Section.
|
|
|
8.
|
The
Encounter Data submission time frames specified in this Section do not
affect time frames specified in Section XII for either pharmacy data
encounter reporting for risk adjustment or behavioral health encounter
(including pharmacy) reporting.
|
|
12.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting
Requirements, Item A., Health Plan Reporting Requirements, sub-item 7.,
Digit 1 Report Identifiers table, is hereby deleted in its entirety and
replaced as follows:
|
|
Digit
1 Report Identifiers
|
|
|
R
|
Community Outreach Representative
|
|
I
|
Information Systems Availability
|
|
G
|
Grievance System Reporting
|
|
H
|
Inpatient Discharge Reporting
|
|
F
|
Financial Reporting
|
|
M
|
Minority Reporting
|
|
C
|
Claims Inventory
|
|
T
|
Transportation
|
|
S
|
Critical Incident Summary
|
|
E
|
Behavioral Health Encounter Data
|
|
B
|
Behavioral Health Pharmacy Encounter Data
|
|
P
|
Behavioral Health Required Staff/Providers
|
|
O
|
FARS/CFARS
|
|
13.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting
Requirements, Table 1, Summary of Reporting Requirements, “Marketing
Representative Report” is hereby retitled “Community Outreach
Representative Report.”
|
|
14.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section XII, Reporting
Requirements, Item E., Marketing Representative Report, is hereby deleted
in its entirety and replaced as
follows:
|
AHCA
Contract No. FA615, Amendment No. 9, Page 12 of 13
|
WellCare of Florida, Inc.
d/b/a
Staywell Health Plan of Florida
|
Medicaid HMO
Contract
|
|
|
E.
|
Community
Outreach Representative Report
|
|
|
1.
|
The
Health Plan shall register each Community Outreach Representative with the
Agency as specified below. The registration file must be
submitted to the Agency at the following e-mail address prior to any
initial Community Outreach
activity: ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇. The
Agency-supplied template must be used – Community Outreach Representative
Registration Template.xls. This template is provided at
▇▇▇▇://▇▇▇.▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/▇▇▇▇/▇▇▇▇▇▇▇_▇▇▇▇▇▇_▇▇▇▇/▇▇▇▇/▇▇▇_▇▇▇▇.▇▇▇▇▇.
|
|
|
2.
|
Changes
to the Community Outreach Representative’s initial registration must be
submitted to the Agency immediately upon occurrence at e-mail
address: ▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇. The
Agency-supplied template must be used. The Health Plan shall
not change or alter the template. This template contains the following
required data elements:
|
|
15.
|
Attachment
II, Medicaid Prepaid Health Plan Model Contract, Section XVI, Terms and
Conditions, Item Q., Termination Procedures, sub-item 2.c., is hereby
deleted in its entirety and replaced as
follows:
|
|
|
c.
|
Terminate
all Community Outreach activities and subcontracts relating to Community
Outreach.
|
This Amendment shall have an effective
date of March 1, 2009, or the date on which both parties execute the Amendment,
whichever is later.
All
provisions in the Contract and any attachments thereto in conflict with this
Amendment shall be and are hereby changed to conform with this
Amendment.
All
provisions not in conflict with this Amendment are still in effect and are to be
performed at the level specified in the Contract.
This
Amendment, and all its attachments, are hereby made part of the
Contract.
This
Amendment cannot be executed unless all previous Amendments to this Contract
have been fully executed.
IN
WITNESS WHEREOF, the parties hereto have caused this thirteen (13) page
Amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
|
WELLCARE
OF FLORIDA, INC.
D/B/A
STAYWELL HEALTH PLAN
OF
FLORIDA
|
STATE
OF FLORIDA, AGENCY FOR
HEALTH
CARE ADMINISTRATION
|
|
SIGNED
BY:
|
/s/
▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇
|
SIGNED
BY:
|
/s/
▇▇▇▇▇ ▇▇▇▇▇▇
|
|
|
NAME:
|
▇▇▇▇▇
▇▇▇▇▇▇▇▇▇
|
NAME:
|
▇▇▇▇▇
▇▇▇▇▇▇
|
|
|
TITLE:
|
President
and CEO
|
TITLE:
|
Secretary
|
|
|
DATE:
|
25
March 2009
|
DATE:
|
3/25/09
|
REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK
AHCA
Contract No. FA615, Amendment No. 9, Page 13 of 13