STATE OF GEORGIA SEAL] AMENDED AND RESTATED CONTRACT BETWEEN THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH AND WELLCARE OF GEORGIA, INC. FOR PROVISION OF SERVICES TO GEORGIA FAMILIES CONTRACT NO. 0654 AMENDMENT #12

Back to Form 8-K

Exhibit 10.1

EXPLANATORY NOTE: "***" INIDICATES THE PORTION OF THIS EXHIBIT THAT HAS BEEN OMITTED AND SEPARATELY FILED WIH THE SECURITIES AND EXCHANGE COMMISSIION PURSUANT TO A REQUEST FOR CONFIDENTIAL TREATEMENT.

[STATE OF GEORGIA SEAL]

AMENDED AND RESTATED

CONTRACT BETWEEN

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

AND

WELLCARE OF GEORGIA, INC.

FOR

PROVISION OF SERVICES TO GEORGIA FAMILIES

CONTRACT NO. 0654

AMENDMENT #12

1

TABLE OF CONTENTS

1.0	SCOPE OF SERVICE	16
1.1	BACKGROUND	17
1.2	ELIGIBILITY FOR GEORGIA FAMILIES	17
1.2.1	MEDICAID	17
1.2.2	PEACHCARE FOR KIDS®	19
1.2.3	EXCLUSIONS	19
1.3	SERVICE REGIONS	20
1.4	DEFINITIONS	20
1.5	ACRONYMS	39
2.0	DCH RESPONSIBILITIES	42
2.1	GENERAL PROVISIONS	42
2.2	LEGAL COMPLIANCE	42
2.3	ELIGIBILITY AND ENROLLMENT	42
2.4	DISENROLLMENT	45
2.5	MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING	45
2.6	COVERED SERVICES & SPECIAL COVERAGE PROVISIONS	46
2.7	NETWORK	46
2.8	QUALITY MONITORING	46
2.9	COORDINATION WITH CONTRACTOR'S KEY STAFF	47
2.10	FORMAT STANDARDS	48
2.11	FINANCIAL MANAGEMENT	48
2.12	INFORMATION SYSTEMS	48
2.13	READINESS OR ANNUAL REVIEW	48
3.0	GENERAL CONTRACTOR RESPONSIBILITIES	49

2

4.0	SPECIFIC CONTRACTOR RESPONSIBILITIES	50
4.1	ENROLLMENT	50
4.1.1	ENROLLMENT PROCEDURES	50
4.1.2	SELECTION OF PRIMARY CARE PROVIDER (PCP)	51
4.1.3	NEWBORN ENROLLMENT	52
4.1.4	REPORTING REQUIREMENTS	52
4.2	DISERNROLLMENT	53
4.2.1	DISENROLLMENT INITIATED BY THE MEMBER OR P4HB PARTICIPANT	53
4.2.2	DISENROLLMENT INITIATED BY THE CONTRACTOR	54
4.2.3	ACCEPTABLE REASONS FOR DISENROLLMENT REQUESTED BY CONTRACTOR	55
4.2.4	UNACCEPTABLE REASONS FOR DISENROLLMENT REQUESTS BY CONTRACTOR	55
4.3	MEMBER AND P4HB PARTICIPANTS INFORMATION REQUIREMENTS	56
4.3.1	GENERAL PROVISIONS	56
4.3.2	REQUIREMENTS FOR WRITTEN MATERIALS	56
4.3.3	MEMBER HANDBOOK AND P4HB PARTICIPANTS INFORMATION REQUIREMENTS	57
4.3.4	MEMBER AND P4HB PARTICIPANT RIGHTS	62
4.3.5	PROVIDER DIRECTORY	63
4.3.6	MEMBER AND P4HB PARTICIPANT IDENTIFICATION (ID) CARD	64
4.3.7	TOLL-FREE MEMBER AND P4HB PARTICIPANT SERVICES LINE	65
4.3.8	INTERNET PRESENCE/WEB SITE	66
4.3.9	CULTURAL COMPETENCY	67
4.3.10	TRANSLATION SERVICES	67
4.3.11	REPORTING REQUIREMENTS	67
4.4	MARKETING	67

3

4.4.1	PROHIBITED ACTIVITIES	67
4.4.2	ALLOWABLE ACTIVITIES	68
4.4.3	STATE APPROVAL OF MATERIALS	68
4.4.4	PROVIDER MARKETING MATERIALS	69
4.5	COVERED BENEFITS AND SERVICES	69
4.5.1	INCLUDED SERVICES	69
4.5.2	INDIVIDUALS W/ DISABILITIES EDUCATION ACT (IDEA) SERVICES	69
4.5.3	ENHANCED SERVICES	70
4.5.4	MEDICAL NECESSITY	70
4.5.5	EXPERIMENTAL, INVESTIGATIONAL OR COSMETIC PROCEDURES, DRUGS, SERVICES OR DEVICES	71
4.5.6	MORAL OR RELIGIOUS OBJECTIONS	71
4.6	SPECIAL COVERAGE PROVISIONS	71
4.6.1	EMERGENCY SERVICES	71
4.6.2	POST-STABILIZATION SERVICES	74
4.6.3	URGENT CARE SERVICES	76
4.6.4	FAMILY PLANNING SERVICES	76
4.6.5	STERILIZATIONS, HYSTERECTOMIES AND ABORTIONS	77
4.6.6	PHARMACY	80
4.6.7	IMMUNIZATIONS	80
4.6.8	TRANSPORTAION	81
4.6.9	PERINATAL SERVICES	81
4.6.10	PARENTING EDUCATION	82
4.6.11	MENTAL HEALTH AND SUBSTANCE ABUSE	82
4.6.12	ADVANCE DIRECTIVES	83
4.6.13	XXXXXX CARE FORENSIC EXAM	83

4

4.6.14	LABORATORY SERVICES	83
4.6.15	MEMBER COST-SHARING	84
4.7	EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM:  HEALTH CHECK	84
4.7.1	GENERAL PROVISIONS	84
4.7.2	OUTREACH AND INFORMING	84
4.7.3	SCREENING	86
4.7.4	TRACKING	87
4.7.5	DIAGNOSTIC AND TREATMENT SERVICES	88
4.7.6	REPORTING REQUIREMENTS	88
4.8	PROVIDER NETWORK AND ACCESS	88
4.8.1	GENERAL PROVISIONS	88
4.8.2	PRIMARY CARE PROVIDERS (PCPS)	90
4.8.3	DIRECT ACCESS	92
4.8.4	PHARMACIES	93
4.8.5	HOSPITALS	93
4.8.6	LABORATORIES	93
4.8.7	MENTAL HEALTH/SUBSTANCE ABUSE	94
4.8.8	FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)	94
4.8.9	RURAL HEALTH CLINICS (RHCS)	94
4.8.10	FAMILY PLANNING CLINICS	95
4.8.11	NURSE PRACTIONERS CERTIFIED (NP-CS) AND CERTIFIED NURSE MIDWIVES (CNMS)	95
4.8.12	DENTAL PRACTITIONERS	95
4.8.13	GEOGRAPHIC ACCESS REQUIREMENTS	96
4.8.14	WAITING MAXIMUMS AND APPOINTMENT REQUIREMENTS	98

5

4.8.15	CREDENTIALING	99
4.8.16	MAINSTREAMING	100
4.8.17	COORDINATION REQUIREMENTS	100
4.8.18	NETWORK CHANGES	101
4.8.19	OUT-OF-NETWORK PROVIDERS	102
4.8.20	SHRINERS HOSPITALS FOR CHILDREN	102
4.8.21	REPORTING REQUIREMENTS	103
4.9	PROVIDER SERVICES	103
4.9.1	GENERAL PROVISIONS	103
4.9.2	PROVIDER HANDBOOKS	103
4.9.3	EDUCATION AND TRAINING	105
4.9.4	PROVIDER RELATIONS	105
4.9.5	TOLL-FREE PROVIDER SERVICES TELEPHONE LINE	106
4.9.6	INTERNET PRESENCE/WEB SITE	107
4.9.7	PROVIDER COMPLAINT SYSTEM	107
4.9.7.9	CLAIMS ADJUSTMENT REQUESTS	109
4.9.8	REPORTING REQUIREMENTS	110
4.10	PROVIDER CONTRACTS AND PAYMENTS	110
4.10.1	PROVIDER CONTRACTS	110
4.10.2	PROVIDER TERMINATION	114
4.10.3	PROVIDER INSURANCE	114
4.10.4	PROVIDER PAYMENT	115
4.10.5	REPORTING REQUIREMENTS	118
4.10.6	PROVIDER PAYMENT AGREEMENT	118
4.11	UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES	118

6

4.11.1	UTILIZATION MANAGEMENT	118
4.11.2	PRIOR AUTHORIZATION AND PRE-CERTIFICATION	119
4.11.3	REFERRAL REQUIREMENTS AND P4HB PARTICIANTS	120
4.11.4	TRANSITION OF MEMBERS	121
4.11.5	BACK TRANSFERS	125
4.11.6	COURT-ORDERED EVALUATONS AND SERVICES	125
4.11.7	SECOND OPINIONS	126
4.11.8	CARE COORDINATION RESPONSIBILITIES	126
4.11.9	CASE MANAGEMENT	127
4.11.10	DISEASE MANAGEMENT	128
4.11.11	DISCHARGE PLANNING	128
4.11.12	REPORTING REQUIREMENTS	129
4.12	QUALITY IMPROVEMENT	129
4.12.1	GENERAL PROVISIONS	129
4.12.2	QUALITY STRATEGIC PLAN REQUIREMENTS	129
4.12.3	PERFORMANCE MEASURES	130
4.12.4	REPORTING REQUIREMENTS	131
4.12.5	QUALITY ASSESSSMENT PERFORMANCE IMPROVEMENT (QAPI) PROGRAM	132
4.12.6	PERFORMANCE IMPROVEMENT PROJECTS	133
4.12.7	PRACTICE GUIDELINES	134
4.12.8	FOCUSED STUDIES	135
4.12.9	PATIENT SAFETY PLAN	135
4.12.10	RESERVED	136
4.12.11	EXTERNAL QUALITY REVIEW	136
4.12.12	REPORTING REQUIREMENTS	136

7

4.13	FRAUD AND ABUSE	136
4.13.1	PROGRAM INTEGRITY	136
4.13.2	COMPLIANCE PLAN	137
4.13.3	COORDINATION WITH DCH AND OTHER AGENCIES	138
4.13.4	REPORTING REQUIREMENTS	139
4.14	INTERNAL GRIEVANCE/APPEALS SYSTEM	139
4.14.1	GENERAL REQUIREMENTS	139
4.14.1.7	MEMBER MEDICAL REVIEW PROCESS FOR PEACHCARE FOR KIDS®	140
4.14.2	GRIEVANCE PROCESS	141
4.14.3	PROPOSED ACTION	141
4.14.4	ADMINISTRATIVE REVIEW PROCESS	143
4.14.5	NOTICE OF ADVERSE ACTION	145
4.14.6	ADMINISTRATIVE LAW HEARING	145
4.14.7	CONTINUATION OF BENEFITS WHILE THE CONTRACTOR APPEAL AND ADMINISTRATIVE LAW HEARING ARE PENDING	146
4.14.8	REPORTING REQUIREMENTS	147
4.15	ADMINISTRATION AND MANAGEMENT	148
4.15.1	GENERAL PROVISIONS	148
4.15.2	PLACE OF BUSINESS AND HOURS OF OPERATION	148
4.15.3	TRAINING	148
4.15.4	DATA AND REPORT CERTIFICATION	148
4.16	CLAIMS MANAGEMENT	149
4.16.1	GENERAL PROVISIONS	149
4.16.2	OTHER CONSIDERATIONS	151
4.16.3	ENCOUNTER DATA SUBMISSION REQUIREMENTS	151
4.16.4	REPORTING REQUIREMENTS	153

8

4.16.5	EMERGENCY HEALTH CARE SERVICES	153
4.17	INFORMATION MANAGEMENT AND SYSTEMS	154
4.17.1	GENERAL PROVISIONS	154
4.17.2	HEALTH INFORMATION TECHNOLOGY AND EXCHANGE	155
4.17.3	GLOBAL SYSTEM ARCHITECTURE AND DESIGN REQUIREMENTS	155
4.17.4	DATA AND DOCUMENT MANAGEMENT REQUIREMENTS BY MAJOR INFORMATION TYPE	157
4.17.5	SYSTEM AND DATA INTEGRATION REQUIREMENTS	157
4.17.6	SYSTEM ACCESS MANAGEMENT AND INFORMATION ACCESSIBILITY REQUIREMENTS	158
4.17.7	SYSTEMS AVAILABILITY AND PERFORMANCE REQUIREMENTS	159
4.17.8	SYSTEM USER AND TECHNICAL SUPPORT REQUIREMENTS	161
4.17.9	SYSTEM CHANGE MANAGEMENT REQUIREMENTS	162
4.17.10	SYSTEM SECURITY AND INFORMATION CONFIDENTIALITY AND PRIVACY REQUIREMENTS	163
4.17.11	INFORMATION MANAGEMENT PROCESS & INFORMATION SYSTEMS DOCUMENTATION REQUIREMENTS	164
4.17.12	REPORTING REQUIREMENTS	164
4.18	REPORTING REQUIREMENTS	164
4.18.1	GENERAL PROCEDURES	164
4.18.2	WEEKLY REPORTING	165
4.18.3	MONTHLY REPORTING	165
4.18.4	QUARTERLY REPORTING	169
4.18.5	ANNUAL REPORTS	177
4.18.6	AD HOC REPORTS	178
5.0	DELIVERABLES	180
5.1	CONFIDENTIALITY	180

9

5.2	NOTICE OF APPROVAL/DISAPPROVAL	180
5.3	RESUBMISSION WITH CORRECTIONS	180
5.4	NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION	180
5.5	DCH FAILS TO RESPOND	181
5.6	REPRESENTATIONS	181
5.7	CONTRACT DELIVERABLES	181
5.8	CONTRACT REPORTS	183
6.0	TERM OF CONTRACT	184
7.0	PAYMENT FOR SERVICES	185
7.1	GENERAL PROVISIONS	185
7.2	PERFORMANCE INCENTIVES	186
8.0	FINANCIAL MANAGEMENT	186
8.1	GENERAL PROVISIONS	186
8.2	SOLVENCY AND RESERVES STANDARDS	186
8.3	REINSURANCE	187
8.4	THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS	187
8.4.2	COST AVOIDANCE	188
8.4.3	COMPLIANCE	188
8.5	PHYSICIAN INCENTIVE PLAN	188
8.6	REPORTING REQUIREMENTS	189
9.0	PAYMENT OF TAXES	193
10.0	RELATIONSHIP OF PARTIES	193
11.0	INSPECTION OF WORK	194
12.0	STATE PROPERTY	194
13.0	OWNERSHIP AND USE OF DATA	195
13.1	SOFTWARE AND OTHER UPGRADES	195

10

14.0	CONTRACTOR: STAFFING ASSIGNMENTS & CREDENTIALS	195
14.1	STAFFING CHANGES	197
14.2	CONTRACTOR'S FAILURE TO COMPLY	198
15.0	CRIMINAL BACKGROUND CHECKS	198
16.0	SUBCONTRACTS	198
16.1	USE OF SUBCONTRACTORS	198
16.2	COST OR PRICING BY SUBCONTRACTORS	199
17.0	LICENSE, CERTIFICATE, PERMIT REQUIREMENT	199
18.0	RISK OF LOSS AND REPRESENTATIONS	200
19.0	PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES	201
20.0	RECORDS REQUIREMENTS	201
20.1	RECORDS RETENTION REQUIREMENTS	201
20.2	ACCESS TO RECORDS	201
20.3	MEDICAL RECORDS REQUESTS	202
21.0	CONFIDENTIALITY REQUIREMENTS	203
21.1	GENERAL CONFIDENTIALITY REQUIREMENTS	203
21.2	HIPAA COMPLIANCE	203
22.0	TERMINATION OF CONTRACT	203
22.1	GENERAL PROCEDURES	203
22.2	TERMINATION BY DEFAULT	204
22.3	TERMINATION FOR CONVENIENCE	204
22.4	TERMINATION FOR INSOLVENCY OR BANKRUPTCY	204
22.5	TERMINATION FOR INSUFFICIENT FUNDING	205
22.6	TERMINATION PROCEDURES	205
22.7	TERMINATION CLAIMS	206
23.0	LIQUIDATED DAMAGES	207

11

23.1	GENERAL PROVISIONS	207
23.2	CATEGORY 1	207
23.3	CATEGORY 2	208
23.4	CATEGORY 3	209
23.5	CATEGORY 4	210
23.6	OTHER REMEDIES	212
23.7	NOTICE OF REMEDIES	213
24.0	INDEMNIFICATION	213
25.0	INSURANCE	213
26.0	PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT	214
27.0	COMPLIANCE WITH ALL LAWS	215
27.1	NON-DISCRIMINATION	215
27.2	DELIVERY OF SERVICE AND OTHER FEDERAL LAWS	216
27.3	COST OF COMPLIANE WITH APPLICABLE LAWS	216
27.4	GENERAL COMPLIANCE	217
28.0	CONFLICT RESOLUTION	217
29.0	CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE	217
30.0	NOTICE	218
31.0	MISCELLANEOUS	219
31.1	CHOICE OF LAW OR VENUE	219
31.2	ATTORNEY'S FEES	219
31.3	SURVIVABILITY	219
31.4	DRUG-FREE WORKPLACE	219
31.5	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS	219
31.6	WAIVER	219

12

31.7	FORCE MAJEURE	220
31.8	BINDING	220
31.9	TIME IS OF THE ESSENCE	220
31.10	AUTHORITY	220
31.11	ETHICS IN PUBLIC CONTRACTING	220
31.12	CONTRACT LANGUAGE INTERPRETATION	220
31.13	ASSESSMENT OF FEES	220
31.14	COOPERATION WITH OTHER CONTRACTORS	220
31.15	SECTION TITLES NOT CONTROLLING	221
31.16	LIMITATION OF LIABILITY/EXCEPTIONS	221
31.17	COOPERATION WITH AUDITS	221
31.18	HOMELAND SECURITY CONSIDERATIONS	221
31.19	PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED	222
31.20	OWNERSHIP AND FINANCIAL DISCLOSURE	222
32.0	AMENDMENT IN WRITING	223
33.0	CONTRACT ASSIGNMENT	223
34.0	SEVERABILITY	223
35.0	COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)	223
36.0	ENTIRE AGREEMENT	223
SIGNATURE PAGE		224
ATTACHMENT A
	DRUG FREE WORKPLACE CERTIFICATE	225
ATTACHMENT B
	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS	227

13

ATTACHMENT C
	NONPROFIT ORGANIZATION DISCLOSURE FORM	229
ATTACHMENT D
	CONFIDENTIALITY STATEMENT	230
ATTACHMENT E
	BUSINESS ASSOCIATE AGREEMENT	231
ATTACHMENT F
	VENDOR LOBBYIST DISCLOSURE & REGISTRATION CERTIFICATION FORM	235
ATTACHMENT G
	RESERVED	237
ATTACHMENT H
	CAPITATION PAYMENT	238
ATTACHMENT I
	NOTICE OF YOUR RIGHT TO A HEARING	241
ATTACHMENT J
	MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS	242
ATTACHMENT K
	APPLICABLE CO-PAYMENTS	243
ATTACHMENT L
	INFORMATION MANAGEMENT AND SYSTEMS	245
ATTACHMENT M
	PERFORMANCE MEASURES	259
ATTACHMENT N
	DEMONSTRATION COVERED SERVICES	262

14

ATTACHMENT O
	DEMONSTRATION QUALITY STRATEGY	264
ATTACHMENT P
	RESOURCE MOTHER OUTREACH	272
ATTACHMENT Q
	CENTERS FOR MEDICARE & MEDICAID SERVICES SPECIAL TERMS AND CONDITIONS	275
ATTACHMENT R
	TABLE OF CONTRACTED RATES	293
ATTACHMENT S
	STATEMENT OF ETHICS	294
ATTACHMENT T
	DCH Ethics in Procurement Policy	299
ATTACHMENT U
	Code of Ethics and Conflict of Interest Policy	307

15

THIS AMENDED AND RESTATED CONTRACT is made and entered into by and between the Georgia Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and WellCare of Georgia, Inc. (hereinafter referred to as the “Contractor”) and is made effective on the date signed by the DCH Commissioner (hereinafter referred to as the “Effective Date”).

WHEREAS, DCH is responsible for health care policy, purchasing, planning and regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-2-1 et seq.;

WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et seq. (the “Medicaid Program”), and is charged with ensuring the appropriate delivery of health care services to Medicaid recipients and PeachCare for Kids® Members;

WHEREAS, DCH caused Request for Proposals Number 00000-000-0000000000 (hereinafter the “RFP”) to be issued through the Department of Administrative Services (DOAS), and it is expressly incorporated as if completely restated herein;

WHEREAS, DCH received from Contractor a proposal in response to RFP Number 00000-000-0000000000 on or about April 1, 2005 (hereinafter “Contractor’s Proposal”) which is expressly incorporated as if completely restated herein;

WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract with Contractor on July 18, 2005, for the provision of various services for the Department;

WHEREAS, DCH and Contractor now wish to amend and restate the Contract in its entirety; and

WHEREAS, the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services (CMS) must approve this Amended and Restated Contract as a condition precedent to its becoming effective for any purpose.

NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Department and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

1.0 SCOPE OF SERVICE

1.0.1 The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids® programs. These reforms will focus on system-wide improvements in performance and quality, will consolidate fragmented systems of care, and will prevent unsustainable trend rates in Medicaid and PeachCare for Kids® expenditures. The reforms will be implemented through a management of care approach to achieve the greatest value for the most efficient use of resources.

1.0.2 The Contractor shall assist the State of Georgia in this endeavor through the following tasks, obligations, and responsibilities.

16

1.1 BACKGROUND

1.1.1 In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid growth and projected that without a change to the system, Medicaid would require 50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving more than 35 percent of total growth each year. For that reason, DCH decided to employ a management of care approach to organize its fragmented system of care, enhance access, achieve budget predictability, explore possible cost containment opportunities and focus on system-wide performance improvements. Furthermore, DCH believed that managed care could continuously and incrementally improve the quality of healthcare and services provided to patients and improve efficiency by utilizing both human and material resources more effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care program called Georgia Families.

1.1.2 Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed care program through which health care services are delivered to members of Medicaid and PeachCare for Kids®. The intent of this program is to:

· Offer care coordination to members

· Enhance access to health care services

· Achieve budget predictability as well as cost containment

· Create system-wide performance improvements

· Continually and incrementally improve the quality of health care and services provided to members

· Improve efficiency at all levels

1.1.3                     The GF program is designed to:

· Improve the Health Care status of the Member and Planning for Healthy Babies (P4HB) 1115 Demonstration Participant population;

· Establish a Provider Home for the Member and P4HB Interpregnancy Care Participant through its use of assigned Primary Care Providers (PCPs);

· Establish a climate of contractual accountability among the state, the care management organizations and the health care Providers;

· Slow the rate of expenditure growth in the Medicaid program; and

· Expand and strengthen a sense of the Member’s and P4HB Participant’s responsibility that leads to more appropriate utilization of health care services

1.2 ELIGIBILITY FOR GEORGIA FAMILIES

1.2.1 Medicaid

1.2.1.1 The following Medicaid eligibility categories are required to enroll in GF:

17

· Low Income Families – Adults and children who meet the standards of the old AFDC (Aid to Families with Dependent Children) program.

· Transitional Medicaid – Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit.

· Pregnant Women (Right from the Start Medicaid - RSM) – Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive Medicaid through the RSM program.

· Children (Right from the Start Medicaid - RSM) – Children less than nineteen (19) years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family.

· Children (newborn) – A child born to a woman who is eligible for Medicaid on the day the child is born.

· Women Eligible Due to Breast and Cervical Cancer Women less than sixty-five (65) years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer.

· Refugees – Those individuals who have the required INS documentation showing they meet a status in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.

· Planning for Healthy Babies 1115 Demonstration Waiver Participants (otherwise known as P4HB Participants) – Women ages 18 through 44 who are otherwise uninsured with family income at or below two hundred percent (200%) of the Federal poverty level. This Demonstration includes two distinct groups: women eligible for Family Planning Services only and women eligible for Interpregnancy Care and Family Planning Services.

1.2.1.2 The following Medicaid eligibility categories are required to receive Resource Mothers Outreach through GF:

· Women ages 18 through 44 who qualify under the Low Income Medicaid Class of Assistance under the Georgia Medicaid State Plan who are already enrolled in GF and who deliver a Very Low Birth Weight (VLBW) baby on or after January 1, 2011.

· Women ages 18 through 44 who qualify under the Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State Plan and who deliver a VLBW baby on or after January 1, 2011.

18

1.2.2                  PeachCare for Kids®

1.2.2.1 PeachCare for Kids® – The State Children’s Health Insurance Program (SCHIP) in Georgia. Children less than nineteen (19) years of age who have family income that is less than two hundred thirty-five percent (235%) of the federal poverty level, who are not eligible for Medicaid, or any other health insurance program are eligible for services under PeachCare for Kids®. Effective January 1, 2012, employees of the State of Georgia may enroll their children in PeachCare for Kids® if the employee meets income and other eligibility requirements of the program.

1.2.3 Exclusions

             1.2.3.1 The following recipients are excluded from Enrollment in GF, even if the recipient is otherwise eligible for GF per section 1.2.1 and section 1.2.2.

· Recipients eligible for Medicare;

· Recipients that are Members of a Federally Recognized Indian Tribe;

· Recipients that are enrolled in fee-for-service Medicaid through Supplemental Security Income prior to enrollment in GF. Members that are already enrolled in a CMO through GF will remain in that CMO until the disenrollment is completed through the normal monthly process.

· Children less than twenty-one (21) years of age who are in xxxxxx care or other out-of-home placement;

· Children less than twenty-one (21) years of age who are receiving xxxxxx care or other adoption assistance under Title IV-E of the Social Security Act.

· Medicaid children enrolled in the Children’s Medical Services program administered by the Georgia Department of Public Health;

· Children less than twenty-one (21) years of age who are receiving xxxxxx care or other adoption assistance under Title IV-E of the Social Security Act (NOTE: Xxxxxx Children in “Relative” placement remain within the Georgia Families program);

· Children enrolled in the Georgia Pediatric Program (XXXX);

· Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act.

· Individuals enrolled in a Hospice category of aid.

· Individuals enrolled in a Nursing Home category of aid.

19

· Individuals enrolled in a Community Based Alternative for Youths (CBAY)

            1.2.3.2 The following recipients are excluded from the P4HB Demonstration (hereinafter referred to as “the Demonstration”):

· Women who become pregnant while enrolled in the Demonstration.

· Women determined to be infertile (sterile) or who are sterilized while enrolled in the Demonstration.

· Women who become eligible for any other Medicaid or commercial insurance program.

· Women who no longer meet the Demonstration’s eligibility requirements

· Women who are or become incarcerated.

1.3 SERVICE REGIONS

1.3.1 For the purposes of coordination and planning, DCH has divided the State, by county, into six (6) Service Regions. See Attachment J for a listing of the counties in each Service Region.

1.3.2 Members and P4HB Participants will choose or will be assigned to a Care Management Organization (CMO) plan that is operating in the Service Region in which they reside.

1.3.3 Contractor has the option of operating in all six (6) Service Regions within the State. Should Contractor choose this option, Contractor shall seek DCH approval pursuant to Section 1.3.4. Once approval is obtained, Contractor shall provide health care services in no less than all six (6) Service Regions and must meet all requirements set forth in the Contract, including, but not limited to, the following Sections: 4.8.5.2, 4.8.7.1, 4.8.8.1, 4.8.9.1, 4.8.13, 4.8.14, 4.8.17.1, 4.11.1.2, 4.11.1.3, 4.15.2.1, and 26.1.

1.3.4 Before DCH will approve the Contractor’s expansion into all six (6) Service Regions, the Contractor must demonstrate its ability to comply with all Contract requirements in these Service Regions by submitting the following to DCH no later than 5:00 pm EST on December 5, 2011: (a) an affidavit that the Contractor has met all applicable Contract requirements in these Service Regions; and (b) geographic access reports and supporting documentation regarding network access. If the Department approves the Contractor’s request, the effective date of the Service Region expansion will be January 1, 2012.

1.3.5 DCH reserves the right to require that the Contractor’s expansion in a particular Service Region reach all areas of the Service Region in question.

1.4 DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

Abandoned Call: A call in which the caller elects a valid option and is either not permitted access to that option or disconnects from the system.

20

Abuse:  Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for Health Care. It also includes Member and P4HB Participant practices that result in unnecessary cost to the Medicaid program.

Administrative Law Hearing:  The appeal process administered by the State in accordance with O.C.G.A. §49-4-153 and as required by federal law, available to Members, P4HB Participants and Providers after they exhaust the Contractor’s Appeals Process.

Administrative Review:  The formal reconsideration, as a result of the proper and timely submission of a Provider’s, Member’s or P4HB Participant’s request, by an Office or Unit of the Division, which has proposed an adverse action.

Administrative Service(s):  The contractual obligations of the Contractor that include but may not be limited to utilization management, credentialing providers, network management, quality improvement, marketing, enrollment, Member and P4HB Participant services, claims payment, management information systems, financial management, and reporting.

Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Advance Directives: A written instruction, such as a living will or durable power of attorney for Health Care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of Health Care when the individual is incapacitated.

After-Hours:  Provider office/visitation hours extending beyond the normal business hours of a Provider, which are Monday-Friday 9-5:30 and may extend to Saturday hours.

Agent:  An entity that contracts with the State of Georgia to perform administrative functions, including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment activities; Systems and technical support; etc.

Appeal: A request for review of an action, as “action” is defined in 42 C.F.R. §438.400.

Appeals Process:  The overall process that includes Appeals at the Contractor level and access to the State Fair Hearing process (the State’s Administrative Law Hearing).

Assess:  Means the process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

At Risk:  Any service for which the Provider agrees to accept responsibility to provide, or arrange for, in exchange for the Capitation payment and Obstetrical: Delivery Payments.

Authoritative Host:  A system that contains the master or “authoritative” data for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master data files to other systems in real time or in batch mode. Data in an Authoritative Host is expected to be up-to-date and reliable.

21

Authorized Representative:  A person authorized by the Member or P4HB Participant in writing to make health-related decisions on behalf of a Member or P4HB Participant, including, but not limited to Enrollment and Disenrollment decisions, filing Appeals and Grievances with the Contractor, and choice of a Primary Care Physician (PCP). The authorized representative is either the Parent or Legal Guardian for a child. For an adult this person is either the legal guardian (guardianship action), health care or other person that has power of attorney, or another signed HIPAA compliant document indicating who can make decisions on behalf of the member. 

Automatic Assignment (or Auto-Assignment):  The Enrollment of an eligible person, for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new Member or P4HB IPC Participant to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.

Benefits:  The Health Care services set forth in this Contract, for which the Contractor has agreed to provide, arrange, and be held fiscally responsible.

Blocked Call:  A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up beyond a defined threshold.

Business Days: Monday through Friday from 9 A.M. to 5 P.M., excluding State holidays.

Calendar Days:  All seven days of the week.

Capitation:  A Contractual agreement through which a Contractor agrees to provide specified Health Care services to Members and P4HB Participants for a fixed amount per month. Payments are contingent upon the availability of appropriated funds.

Capitation Payment:  A payment, fixed in advance, that DCH makes to a Contractor for each Member and P4HB Participant covered under a Contract for the provision of medical services and assigned to the Contractor. This payment is made regardless of whether the Member or P4HB Participant receives Covered Services or Benefits during the period covered by the payment. Payments are contingent upon the availability of appropriated funds.

Capitation Rate:  The fixed monthly amount that the Contractor is paid by DCH for each Member and P4HB Participant assigned to the Contractor to ensure that Covered Services and Benefits under this Contract are provided. Payments are contingent upon the availability of appropriated funds.

Capitated Service:  Any Covered Service for which the Contractor receives an actuarially sound Capitation Payment.

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Coordination is also referred to as Care Management.

Care Management Organization (CMO): An entity organized for the purpose of providing Health Care, has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers, and furnishes Health Care services on a capitated basis to Members and P4HB Participants in a designated Service Region.

22

Case Management: Any intensive intervention undertaken with the purpose of helping Members and P4HB IPC Participants receive appropriate care. In the case of a P4HB IPC Participant, case management follows the delivery of a Very Low Birth Weight infant where that P4HB Participant has any disease(s) or condition(s) which may have contributed to the Very Low Birth Weight birth. Case Management is distinguished from utilization management in that it is voluntary and it is distinguished from disease management by its intensity and focus on any disease(s) or conditions the Member and P4HB IPC Participant has.

Centers for Medicare & Medicaid Services (CMS):  The Agency within the U.S. Department of Health and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health Insurance Program.

Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under State law to practice as a nurse-midwife, and has completed a program of study and clinical experience for nurse-midwives or equivalent.

Children’s Health Insurance Program (CHIP formerly State Children’s Health Insurance Program (SCHIP)): A joint federal-state Health Care program for targeted, low-income children, established pursuant to Title XXI of the Social Security Act. Georgia’s CHIP is called PeachCare for Kids®.

Chronic Condition:  Any ongoing physical, behavioral, or cognitive disorder, including chronic illnesses, impairments and disabilities. There is an expected duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive device, etc) and service use or need beyond that which is considered Routine Care.

Claim:  A xxxx for services, a line item of services, or all services for one recipient within a xxxx.

Claims Administrator:  The entity engaged by DCH to provide Administrative Service(s) to the CMO Plans in connection with processing and adjudicating risk-based payment, and recording health benefit encounter Claims for Members and P4HB Participants.

Claim Adjustment:  A claim that has been incorrectly paid, incorrectly submitted or, as the result of an updated payment policy, the payment amount can be changed.

Clean Claim:  A claim received by the CMO for adjudication, in a nationally accepted format in compliance with standard coding guidelines, which requires no further information, adjustment, or alteration by the Provider of the services in order to be processed and paid by the CMO. The following exceptions apply to this definition: i. A Claim for payment of expenses incurred during a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and iii. A Claim for which a Third Party Resource should be responsible.

Cold-Call Marketing:  Any unsolicited personal contact by the CMO Plan, with a potential Member or P4HB Participant, for the purposes of marketing.

Community Mental Health Rehabilitation Services (CMHRS): Services that are intended for the maximum reduction of mental disability and restoration of an individual to his or her best possible functional level.

23

Completion/Implementation Timeframe: The date or time period projected for a project goal or objective to be met, for progress to be demonstrated or for a proven intervention to be established as the standard of care for the Contractor.

Condition:  A disease, illness, injury, disorder, of biological, cognitive, or psychological basis for which evaluation, monitoring and/or treatment are indicated.

Consecutive Enrollment Period:  The consecutive twelve (12) month period beginning on the first day of Enrollment or the date the notice is sent, whichever is later. For Members and P4HB Participants that use their option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment, the twelve-month consecutive Enrollment period will commence when the Member or P4HB Participant enrolls in the new CMO plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment period.

Contested Claim:  A Claim that is denied because the Claim is an ineligible Claim, the Claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the Claim requires special treatment.

Contract:  The written agreement between the State and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.

Contract Execution:  The date upon which all parties have signed the Contract.

Contractor:  The Care Management Organization with a valid Certificate of Authority in Georgia that contracts hereunder with the State for the provision of comprehensive Health Care services to Members on a capitated basis.

Contractor’s Representative:  The individual legally empowered to bind the Contractor, using his/her signature block, including his/her title. This individual will be considered the Contractor’s Representative during the life of any Contract entered into with the State unless amended in writing.

Co-payment:  The part of the cost-sharing requirement for Members in which a fixed monetary amount is paid for certain services/items received from the Contractor’s Providers.

Core Services: Covered services for both the Rural Health Centers (RHC) and Federally Qualified Health Centers (FQHC) programs defined as follows: Physician services, including required physician supervision of Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs); services and supplies furnished as incident to physician professional services; services of PAs, NPs and CNMs; services of clinical psychologists and clinical social workers (when providing diagnosis and treatment of mental illness); services and supplies furnished as incident to professional services provided by PAs, NPs, CNMs, clinical psychologists, and clinical social workers; Visiting nurse services on a part time or intermittent basis to homebound patients (limited to areas in which there is a designated shortage of home health agencies).

Corrective Action Plan:  The detailed written plan required by DCH to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.

24

Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic investigation of discrepancies (failures and/or deviations) in an attempt to prevent their reoccurrence. To ensure that corrective and preventive actions are effective, the systematic investigation of the failure incidence is pivotal in identifying the corrective and preventive actions undertaken.

Cost Avoidance:  A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance has been exhausted.

Covered Services:  Those Medically Necessary Health Care services provided to Members, the payment or indemnification of which is covered under this Contract or those Demonstration services provided to P4HB Participants, the payment or indemnification of which is covered under this Contract.

Credentialing:  The Contractor’s determination as to the qualifications and ascribed privileges of a specific Provider to render specific Health Care services.

Critical Access Hospital (CAH): Critical access hospital means a hospital that meets the requirements of the federal Centers for Medicare and Medicaid Services to be designated as a critical access hospital and that is recognized by the Department of Community Health as a critical access hospital for purposes of Medicaid.

Cultural Competency:  A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among and between groups and the sensitivity to know how these differences influence relationships with Members and P4HB Participants. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Member and P4HB Participant needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.

Deliverable:  A document, manual or report submitted to DCH by the Contractor to fulfill requirements of this Contract.

Demonstration: The 1115 Demonstration waiver program in Georgia supported by CMS that expands the delivery of family planning services to uninsured women, ages 18 through 44, who have family income at or below 200 percent of the Federal poverty level (FPL) and who are not otherwise eligible for Medicaid or the Children’s Health Insurance Program (CHIP). Also referred to as the Family Planning Waiver or the P4HB Program.

Demonstration Enrollee: An individual meeting P4HB Program eligibility requirements who selects or is otherwise assigned to a Georgia Families Care Management Organization in order to receive Demonstration services.

Demonstration Enrollment: The process by which an individual eligible for the P4HB program applies to utilize a Georgia Families Care Management Organization to receive Demonstration services and such application is approved by DCH or its Agent.

Demonstration Disenrollment:  The removal of a P4HB Participant from participation in the Demonstration.

Demonstration Period: The period from January 1, 2011 through December 31, 2013 in which the Demonstration will be effective.

25

Demonstration Provider: A physician, advanced practice nurse or other health care provider who meets the State’s Medicaid provider enrollment requirements for the Demonstration, hospital, facility, or pharmacy licensed or otherwise authorized to provide Demonstration related Services to P4HB Participants within the State or jurisdiction in which they are furnished. Also known as P4HB Provider.

Demonstration Related Emergency Medical Condition: A medical condition resulting from a Demonstration related Service and manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the woman in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. A Demonstration related Emergency Medical condition shall not be defined on the basis of lists of diagnoses or symptoms.

Demonstration Related Post Stabilization Services: Covered Services related to Demonstration related Emergency Medical Condition that are provided after a P4HB Participant is stabilized in order to maintain the stabilized condition or to improve or resolve the P4HB Participant’s condition.

Demonstration Related Services: Those Demonstration Services identified in the CMS Special Terms and Conditions and approved by CMS that are available to P4HB Participants.

Demonstration Related Urgent Care Services: Medically Necessary treatment of a Demonstration related injury, illness or another type of Condition (usually not life threatening) which should be treated within twenty-four (24) hours.

Dental Subspecialty Providers:  Endodontists; Oral Pathologist; Orthodontist; Oral Surgeon; Periodontist; Pedodontist; Public Health Dentist; and Prosthodontist.

Department of Community Health (DCH):  The Agency in the State of Georgia responsible for oversight and administration of the Medicaid program, the PeachCare for Kids® program, the Planning for Healthy Babies Program and the State Health Benefits Plan (SHBP).

Department of Insurance (DOI):  The Agency in the State of Georgia responsible for licensing, overseeing, regulating, and certifying insuring entities.

Diagnostic Related Group (DRG):  Any of the payment categories that are used to classify patients and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred and that are based especially on the principal diagnosis, surgical procedure used, age of patient, and expected length of stay in the hospital.

Diagnostic Services:  Any medical procedures or supplies recommended by a physician or other licensed medical practitioner, within the scope of his or her practice under State law, to enable him or her to identify the existence, nature or extent of illness, injury, or other health deviation in a Member or P4HB Participant.

Discharge: Point at which Member or P4HB Participant is formally released from a hospital, by the treating physician, an authorized member of the physician’s staff or by the Member or P4HB Participant after they have indicated, in writing, their decision to leave the hospital contrary to the advice of their treating physician.

26

Disenrollment:  The removal of a Member from participation in the Contractor’s plan, but not necessarily from the Medicaid or PeachCare for Kids® program.

Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts may include written correspondence that outlines contracted negotiations between the parties, including rate and contract terms disclosure, as well as documented verbal conversations, to include date and time and parties involved.

Durable Medical Equipment (DME):  Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program:  A Title XIX mandated program that covers screening and Diagnostic Services to determine physical and mental deficiencies in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered. P4HB Participants are not eligible to participate in the EPSDT Program.

Emergency Medical Condition:  A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition shall not be defined on the basis of lists of diagnoses or symptoms.

Emergency Services:  Covered inpatient and outpatient services furnished by a qualified Provider needed to evaluate or stabilize an Emergency Medical Condition that is found to exist using the prudent layperson standard.

Encounter:  A distinct set of health care services provided to a P4HB Participant, Medicaid or PeachCare for Kids® Member enrolled with a Contractor on the dates that the services were delivered.

Encounter Data:  Health Care Encounter Data include: (i) All data captured during the course of a single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment associated with the Member or P4HB Participant receiving services during the Encounter; (ii) The identification of the Member or P4HB Participant receiving and the Provider(s) delivering the Health Care services during the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

Enrollee:  See Member.

Enrollment:  The process by which an individual eligible for Medicaid or PeachCare for Kids® applies (whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and such application is approved by DCH or its Agent.

Enrollment Broker:  The entity engaged by DCH to assist in outreach, education and Enrollment activities associated with the GF program.

27

Enrollment Period:  The twelve (12) month period commencing on the effective date of Enrollment.

Evaluate:  The process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

External Quality Review (EQR):  The analysis and evaluation by an external quality review organization of aggregated information on quality, timeliness, and access to the Health Care services that a CMO or its Subcontractors furnish to Members and to DCH.

External Quality Review Organization (EQRO):  An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality review, and other related activities.

Family Planning Provider: A physician, advanced practice nurse, or other health care provider who meets the State’s Medicaid provider enrollment requirements for the Demonstration and delivers or prescribes Family Planning Services.

Family Planning Services: Family planning services and supplies include at a minimum:

· Education and counseling necessary to make informed choices and understand contraceptive methods;

· Initial and annual complete physical examinations;

· Follow-up, brief and comprehensive visits;

· Pregnancy testing;

· Contraceptive supplies and follow-up care;

· Diagnosis and treatment of sexually transmitted diseases; and

· Infertility assessment

Family Planning Waiver: See Demonstration.

Federal Financial Participation (FFP):  The funding contribution that the federal government makes to the Georgia Medicaid and PeachCare for Kids® programs.

Federally Qualified Health Center (FQHC):  An entity that provides outpatient health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.

Fee-for-Service (FFS):  A method of reimbursement based on payment for specific services rendered to a Member.

Financial Relationship:  A direct or indirect ownership or investment interest (including an option or non vested interest) in any entity. This direct or indirect interest may be in the form of equity, debt, or other means and includes any indirect ownership or investment interest no matter how many levels removed from a direct interest, or a compensation arrangement with an entity.

Fraud:  An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable federal or State law.

28

Georgia Families (GF): The risk-based managed care delivery program for Medicaid and PeachCare for Kids® in which the Department contracts with Care Management Organizations to manage the care of eligible Members and P4HB Participants.

Georgia Technology Authority (GTA): The state agency that manages the state’s information technology (IT) infrastructure i.e. data center, network and telecommunications services and security, establishes policies, standards and guidelines for state IT, promotes an enterprise approach to state IT, and develops and manages the state portal.

Grievance:  An expression of dissatisfaction about any matter other than an Action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided or aspects of interpersonal relationships such as rudeness of a Provider or employee, or failure to respect the Enrollee’s or P4HB Participant’s rights.

Grievance System:  The overall system that address the manner in which the CMO handles Grievances at the Contractor level.

Health Care:  Health Care means care, services, or supplies related to the health of an individual. Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental Condition, or functional status, of an individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

Health Care Professional:  A physician or other Health Care Professional, including but not limited to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians licensed in the State of Georgia.

Health Check:  The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment program pursuant to Title XIX of the Social Security Act.

Health Information Technology: Hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for our support the use of health care entities or patients for the electronic creation, maintenance, access, or exchange of health information. Source is ARRA - H.R.1 -115 Sec. 3000 (5)

Health Information Technology for Economic and Clinical Health Act (HITECH Act) Title IV: The legislation establishes a transparent and open process for the development of standards that will allow for the nationwide electronic exchange of information between doctors, hospitals, patients, health plans, the government and others by the end of 2009. It establishes a voluntary certification process for health information technology products. The National Institute of Standards and Technology will provide for the testing of such products to determine if they meet the national standards that allow for the secure electronic exchange and use of health information.

Health Insurance Portability and Accountability Act (HIPAA):  A federal law that includes requirements to protect the privacy of individually identified health information in any format, including written or printed, oral and electronic, to protect the security of individually identified health information in electronic format, to prescribe methods and formats for exchange of electronic medical

29

information, and to uniformly identify providers. When referenced in this Contract it includes all related rules, regulations and procedures.

Health Maintenance Organization:  As used in Section 8.6 a Health Maintenance Organization is an entity that is organized for the purpose of providing Health Care and has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers and furnishes Health Care services on a capitated basis to Members in a designated Service Region.

Health Professional Shortage Area (HPSA): An area designated by the United States Department of Health and Human Services’ Health Resources and Services Administration (HRSA) as being underserved in primary medical care, dental or mental health providers. These areas can be geographic, demographic or institutional in nature. A care area can be found using the following website: xxxx://xxxxxxxx.xxxx.xxx/.

Healthcare Effectiveness Data and Information Set (HEDIS): A widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA).

Historical Provider Relationship: A Provider who has been the main source of Demonstration, Medicaid or PeachCare for Kids® services for the Member or P4HB Participant during the previous year (decided on by the most recent Provider on the Member’s or P4HB Participant’s claim history).

Immediately: Within twenty-four (24) hours.

In-Network Provider:  A Provider that has entered into a Provider Contract with the Contractor to provide services.

Incentive Arrangement:  Any mechanism under which a Contractor may receive additional funds over and above the Capitation rates, for exceeding targets specified in the Contract.

Incurred-But-Not-Reported (IBNR):  Estimate of unpaid Claims liability, includes received but unpaid Claims.

Individuals with Disabilities Education Act (IDEA): A United States federal law that ensures services to children with disabilities throughout the United States. IDEA governs how states and public agencies provide early intervention, special education and related services to children with disabilities.

Information:  i. Structured Data: Data that adhere to specific properties and Validation criteria that is stored as fields in database records. Structured queries can be created and run against structured data, where specific data can be used as criteria for querying a larger data set; ii. Document: Information that does not meet the definition of structured data includes text, files, spreadsheets, electronic messages and images of forms and pictures.

Information System/Systems:  A combination of computing hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e. structured data (which may include digitized audio and video) and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction.

Inpatient Facility: Hospital or clinic for treatment that requires at least one overnight stay.

30

Insolvent: Unable to meet or discharge financial liabilities.

Interpregnancy Care (IPC): An additional benefit available to some P4HB Participants who meet the Demonstration’s eligibility requirements and who delivered a Very Low Birth Weight baby on or after initiation of the Demonstration.

Interpregnancy Care Services: Services available under the Demonstration for P4HB Participants who meet the eligibility criteria for the IPC program. These services are in addition to Family Planning Services and include: limited primary care services; management and treatment of chronic diseases; substance abuse treatment (detoxification and intensive outpatient rehabilitation); case management, including Resource Mothers Outreach; limited dental; prescription drugs (non-family planning) for the treatment of chronic conditions that may increase the risk of a subsequent VLBW delivery and non-emergency transportation.

Interpregnancy Care Service Providers: Those Demonstration Providers serving the IPC P4HB Participants including nurse case managers and Resource Mothers.

Limited-English-Proficient Population:  Individuals with a primary language other than English who must communicate in that language if the individual is to have an equal opportunity to participate effectively in, and benefit from, any aid, service or benefit provided by the health Provider.

Low Birth Weight: Birth weight below 2,500 grams (5.5 pounds).

Mandatory Enrollment:  The process whereby an individual eligible for the Demonstration, Medicaid or PeachCare for Kids® is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to receive covered Demonstration, Medicaid or PeachCare for Kids® services.

Marketing:  Any communication from a CMO plan to any Demonstration, Medicaid or PeachCare for Kids® eligible individual that can reasonably be interpreted as intended to influence the individual to enroll in that particular CMO plan, or not enroll in or disenroll from another CMO plan.

Marketing Materials:  Materials that are produced in any medium, by or on behalf of a CMO, and can reasonably be interpreted as intended to market to any Demonstration, Medicaid or PeachCare for Kids® eligible individual.

Material Subcontractor:  A Subcontractor, excluding Providers, receiving Subcontractor payments from the Contractor in amounts equal to or greater than $10 million annually during the state fiscal year.

Measurable: Applies to a Contractor objective and means the ability to determine definitively whether or not the objective has been met, or whether progress has been made toward a positive outcome.

Medicaid:  The joint federal/state program of medical assistance established by Title XIX of the Social Security Act, which in Georgia is administered by DCH.

31

Medicaid Care Management Organizations Act: O.C.G.A. §33-21A-1, et seq. MEDICAID CARE MANAGEMENT ORGANIZATIONS ACT. A xxxx passed by the Georgia General Assembly, signed into law by the Governor, and effective July 1, 2008 which outlines several administrative requirements with which the administrators of the Medicaid Managed Care plan, Georgia Families, must comply. Some of the requirements include dental provider networks, emergency room claims payment requirements, eligibility verification, and others.

Medicaid Eligible:  An individual eligible to receive services under the Medicaid Program but not necessarily enrolled in the Medicaid Program.

Medicaid Management Information System (MMIS):  Computerized system used for the processing, collecting, analysis, and reporting of Information needed to support Medicaid and SCHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

Medical Director:  The licensed physician designated by the Contractor to exercise general supervision over the provision of health service Benefits by the Contractor.

Medical Records:  The complete, comprehensive records of a Member or P4HB Participant including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s or P4HB Participant’s participating Primary Care or Demonstration physician or Provider, that document all medical services received by the Member or P4HB Participant, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable DCH rules and regulations, and signed by the medical professional rendering the services.

Medical Screening:  An examination: i. provided on hospital property, and provided for that patient for whom it is requested or required, ii. performed within the capabilities of the hospital’s emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State statutes and regulations and hospital bylaws.

Medically Necessary Services:  Those services that meet the definition found in Section 4.5.

Member: A Medicaid or PeachCare for Kids® recipient who is currently enrolled in a CMO plan.

Methodology: The planned process, steps, activities or actions taken by a Contractor to achieve a goal or objective, or to progress toward a positive outcome.

Monitoring:  The process of observing, evaluating, analyzing and conducting follow-up activities.

National Committee for Quality Assurance (NCQA):  An organization that sets standards, and evaluates and accredits health plans and other managed care organizations.

Net Capitation Payment:  The Capitation Payment made by DCH to Contractor less any quality assessment fee made by Contractor to DCH. This payment amount also excludes a payment to a Contractor for obstetrical or other medical services that are on a per occurrence basis rather than a per member basis.

Non-Emergency Transportation (NET):  A ride, or reimbursement for a ride, provided so that a Member or P4HB Participant with no other transportation resources can receive services from a medical

32

provider. NET does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.

Non-Institutional Claims:  Claims submitted by a medical Provider other than a hospital, nursing facility, or intermediate care facility/mentally retarded (ICF/MR).

Normal Birth Weight: Birth weight greater than or equal to 2,500 grams (5.5 pounds).

Nurse Practitioner Certified (NP-C):  A registered professional nurse who is licensed by the State of Georgia and meets the advanced educational and clinical practice requirements beyond the two or four years of basic nursing education required of all registered nurses.

Objective: Means a measurable step, generally in a series of progressive steps, to achieve a goal.

Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a Contractor for each birth of a child to a Member. The Contractor is responsible for all medical services related to the delivery of the Member’s child.

Out-of-Network Provider:  A Provider of services that does not have a Provider contract with the Contractor.

Participating Provider:  A Provider that has signed a contract with CMOs to provide services to Georgia Families members and P4HB Participants.

Patient Protection and Affordable Care Act (PPACA): The Patient Protection and Affordable Care Act is a federal statute, signed into law on March 23, 2010. The law includes numerous health-related provisions that will take effect over a four year period, including expanding Medicaid eligibility, subsidizing insurance premiums, establishing health insurance exchanges and support of medical research.

P4HB Participant: An individual meeting the eligibility requirements for the Demonstration who is enrolled in and/or receiving Demonstration Services through the Contractor. Also referred to as Participant.

P4HB Provider: See Demonstration Provider.

PeachCare for Kids®:  The State of Georgia’s Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

Performance Concern:  The informal documentation of an issue. The CMO is required to respond to the Performance Concern by defining a process to detect, analyze and eliminate non-compliance and potential causes of non-compliance. This is a “warning” and failure to complete the Corrective Action Preventive Action/Performance Concern (CAPA/PC) form may result in formal action against the contractor (CAPA). If the concern is a Performance Concern, the following information must be completed by the offending CMO:

· Direct Cause:  The cause that directly resulted in the event (the first cause in the chain).

33

· Corrective Action: actions taken to correct the root cause generally a reactive process used to address problems after they have occurred

Performance Improvement Project (PIP): A planned process of data gathering, evaluation and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery.

Pharmacy Benefit Manager (PBM):  An entity responsible for the provision and administration of pharmacy benefit management services including but not limited to claims processing and maintenance of associated systems and related processes.

Physician Assistant (PA):  A trained, licensed individual who performs tasks that might otherwise be performed by physicians or under the direction of a supervising physician.

Physician Incentive Plan:  Any compensation arrangement between a Contractor and a physician or physician group that may directly have the effect of reducing or limiting services furnished to Members.

Planning for Healthy Babies Program: The name of the 1115 Demonstration Waiver Program in Georgia.

Post-Stabilization Services:  Covered Services, related to an Emergency Medical Condition that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member’s condition.

Potential P4HB Participant: An individual meeting the eligibility requirements for the Demonstration who is subject to mandatory Enrollment in a care management program but is not yet enrolled in a specific CMO plan.

Potential Enrollee:  See Potential Member.

Potential Member: A Medicaid or CHIP recipient who is subject to mandatory Enrollment in a care management program but is not yet the Member of a specific CMO plan.

Pre-Certification:  Review conducted prior to a Member’s or P4HB Participant’s admission, stay or other service or course of treatment in a hospital or other facility.

Preconception Health Care: The primary prevention of maternal and perinatal morbidity and mortality, comprised of interventions that identify and modify biomedical, behavioral and social risks to pregnancy outcomes for women and their offspring. To have maximal impact on pregnancy outcomes, strategies to address risks must occur before conception or before prenatal care is typically initiated.

Preferred Health Organization (PHO): A coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licensed or organized under State law as an HMO.

Pregnancy Rate:  The number of pregnancies occurring to females in a specified age group per 1,000 females in the specified age group. The rate is calculated by using the following formula: Pregnancy

34

rate = [Number of pregnancies in age group / Female population in age group] * 1000. Rates that use Census Population Estimates in the denominator are unable to be calculated when the selected population is unknown.

Prevalent Non-English Language:  A language other than English, spoken by a significant number or percentage of potential Members or P4HB Participants.

Preventive Services:  Services provided by a physician or other licensed health practitioner within the scope of his or her practice under State law to: prevent disease, disability, and other health Conditions or their progression; treat potential secondary Conditions before they happen or at an early remediable stage; prolong life; and promote physical and mental health and efficiency.

Primary Care:  All Health Care services and laboratory services, including periodic examinations, preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of Referrals to specialty Providers described in this Contract, and for maintaining continuity of patient care. These services are customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse practitioner to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

Primary Care Provider (PCP):  A licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required Primary Care services to Members or IPC P4HB Participants. A PCP shall include general/family practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these Contract provisions and licensure requirements.

Prior Authorization:  Authorization granted in advance of the rendering of a service after appropriate medical review. (Also known as “pre-authorization” or “prior approval”).

Proposed Action:  The proposal of an action for the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Provider:  Any person (including physicians or other Health Care Professionals), partnership, professional association, corporation, facility, hospital, or institution certified, licensed, or registered by the State of Georgia to provide Health Care Services that has contracted with a Care Management Organization to provide health care services to Members and P4HB Participants.

35