The file's text, extracted by GovTribe without its formatting.
SCOPE OF WORK
DEFINITIONS AND ACRONYMS
Definitions
| Abuse |
| Unallowable practices that are inconsistent with sound fiscal and business practices or medical standards and that result in an unnecessary cost to NVHA, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes unallowable Beneficiary practices that result in unnecessary costs to NVHA. |
| Actuarially Sound or Actuarial Soundness |
| Actuarially sound capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the Contract and for the operation of the Specialty Managed Care Plan for the time period and the populations covered under the terms of the Contract. Such capitation rates are developed in accordance with the requirements of 42 CFR 438(b). |
| Actuary |
| An individual acting on NVHA’s behalf to develop and certify capitation rates, who meets the qualification standards established by the American Academy of Actuaries for an Actuary and follows the best practice standards established by the Actuarial Standards Board. |
| Advance Directive |
| A written statement completed in advance of a serious illness or condition that allows the Beneficiary to direct health care decisions when they are unable to do so. An advance directive allows the Beneficiary to make decisions regarding the use or refusal of life-sustaining treatments. An Advance Directive, further defined at NRS 449A.703, consists of Declarations (Living Wills) and Durable Powers of Attorney for Health Care Decisions recognized under Nevada law, which relate to the provision of care when an individual eighteen (18) years of age or older has an incurable or irreversible condition and is unable to communicate health care decisions verbally. |
| Adverse Benefit Determination |
| One of the following decisions by the Contractor: |
1. The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
2. The reduction, suspension, or termination of a previously authorized service;
3. The denial, in whole or in part, of payment for a service, unless the denial occurs solely because the claim does not meet the definition of a “clean claim”;
4. The failure to provide services in a timely manner as defined by NVHA;
5. The failure to process grievances, appeals, or expedited appeals within the required timeframes, including resolution and notification;
6. For a resident of rural area with only one (1) Contractor, the denial of an Enrollee’s request to exercise his or her right, to obtain services outside the network; and
7. The denial of an Enrollee’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other Enrollee financial liabilities.
| Alternative Payment Model |
| Per CMS subregulatory guidance and the Medicaid implementing regulations at 42 CFR 438, alternative payment models, such as those tested by the CMS Innovation Center, reward health care Providers for delivering high-quality and coordinated care. APMs can apply to a specific: |
· Health condition, like end-stage renal disease.
· Care episode, like joint replacement.
· Provider type, like primary care providers.
· Community, like rural areas.
· Innovation within Medicare Advantage, Medicare Part D, or Medicaid.
| Appeal |
| A review by an MCO of an adverse benefit determination. |
| Authorized Representative |
| An individual designated by an applicant or Enrollee as having authority to act on behalf of the applicant or Enrollee. |
| Behavioral Health Disability |
| Per the DOJ Settlement, a Serious Emotional Disturbance, Serious Mental Illness, and/or Substance Use Disorder. |
| Behavioral Health Services |
| Services that promote mental health, resilience, and wellbeing; treat mental health and substance use disorders; and support individuals who experience and/or are in recovery from these conditions. |
| Behavioral Health Targeted Case Management (BH-TCM) |
| Targeted case management services utilizing high-fidelity wraparound and intensive care coordination models, as outlined in the Medicaid Services Manual, delivered by Network Provider Care Management Entities (CMEs) to Enrollees in the Specialty Managed Care Plan. |
| Behavioral Support Services |
| Services designed to help Enrollees be successful in their home environment and their community, address behaviors that interfere with successful functioning in the home and community, and facilitate community integration by providing skills development for the family and Enrollee. |
| Beneficiary |
| An individual who has been determined eligible and is currently receiving Medicaid. Also may be referred to as a Member. |
| Beneficiary Advisory Council (BAC) |
| Pursuant to 42 CFR 431.12.(e), NVHA must form and support a BAC, which can be an existing beneficiary group, made up of current or former Medicaid Beneficiaries and people with direct experience supporting Medicaid Beneficiaries (family members and paid or unpaid caregivers of people enrolled in Medicaid), to advise NVHA regarding their experience with the Medicaid program, on matters of concern related to policy development and matters related to the effective administration of the Medicaid program. |
| Benefits |
| Pursuant to 42 CFR 110.3(d), payments and/or compensation for reasonable and necessary medical expenses. Referred throughout this SOW as Covered Services. |
| Breach of Contract |
| A situation in which the Contractor does not perform according to the terms of the Contract and is subject to the penalties and other sanctions outlined in NRS 333.365 and the Contract Form attachment. |
| Business Day |
| Any Monday through Friday except for State-observed holidays. |
| Calendar Day |
| All seven (7) days of the week, including State holidays. |
| Capitation Payment or Capitation Rate |
| A payment NVHA makes periodically to a MCO on behalf of each Enrollee under the Contract for the provision of services under the State Plan. NVHA makes the payment regardless of whether the particular Enrollee receives services during the period covered by the payment. |
| Care Coordination |
| A set of activities that links persons with complex health needs or personal or social circumstances that place them at risk of not receiving appropriate services to their needed services, ensuring coordination across services. |
| Care Coordinator, Case Manager, or Care Manager |
| A professional whose background is most frequently anchored in the disciplines of social work and/or nursing who assesses, plans, implements, coordinates, monitors, and evaluates options to meet an individual’s health needs. |
| Care Management |
| A process by which an individual’s needs are identified and social and medical services to meet those needs are located, coordinated, and monitored. Care Management in this SOW is comprised of both Contractor-provided Care Coordination and CME-provided Targeted Case Management. |
| Care Management Entity (CME) |
| An entity that has entered into a Participating Provider Agreement with the Contractor to provide behavioral health assessments and targeted case management to Enrollees within defined regions or populations |
| Certified Community Behavioral Health Centers (CCBHCs) |
| Clinics responsible for directly providing or contracting with partner organizations to provide a continuum of behavioral health services, with an emphasis on the provision of 24-hour crisis care, utilization of evidence-based practices, care coordination and integration with physical health care. |
| Child or Children |
| Individuals under the age of 21. |
| Child and Family Team (CFT) |
| A group of individuals including family, service providers, educators, and natural supports led by a Wraparound Facilitator, who work together to develop and implement a Plan of Care. The child and family are active members, collaborating to ensure the child’s success at home, in school, and in the community, while building independence for adulthood. |
| Children and Youth with Special Health Care Needs (CYSHCN) |
| Children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition, and who also require health and related services of a type or amount beyond that required by children generally. |
| Children’s Health Insurance Program (CHIP) |
| A health insurance program provided by Title XXI of the Social Security Act to children whose families have incomes that exceed Medicaid eligibility limits but that are equal to or less than 205% of the federal poverty level. Nevada’s CHIP managed care program is referred to as the Nevada Check Up program. |
| Claim |
| A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. |
| Clean Claim |
| A claim that can be processed without obtaining additional information from the service Provider or a third party. It includes a claim with errors originating in NVHA’s claims system. It does not include a claim from a Provider who is under investigation for fraud, waste, or abuse or a claim under review for medical necessity. |
| Clinical Assessment Tool |
| A standardized, validated, and evidence-based mental health assessment tool of an Enrollee’s functioning and identified needs and strengths across crucial life domains and is used to inform decisions about level of care, and the type and intensity of services. |
| Cold Call Marketing |
| Any unsolicited personal contact by the Contractor with a Potential Enrollee for the purpose of marketing. |
| Compliance Review |
| Any investigation, audit, focused data analysis, or other assessment of whether improper payments have been made. |
| Comprehensive Assessment |
| Is an evaluation completed by a Qualified Mental Health Professional of an Enrollee’s presenting health concern(s) and the Enrollee’s history and functioning. |
| Confidentiality |
| All safeguards required to protect all information which concerns Medicaid Applicants, Beneficiaries, Potential Enrollees, Enrollees, and Providers, and any other information which may not be disclosed by any party pursuant to federal and state law and Medicaid regulations, including but not limited to NRS Chapter 422 and 42 CFR 431. |
| Contract |
| The document entitled Contract for Services of Independent Contractor and all Attachments or Incorporated Documents. |
| Contract Term |
| July 1, 2027, through December 31, 2030, unless otherwise adjusted by the mutual agreement of the State and the Contractor. |
| Contract Year |
| Within the Contract Term: (1) July 1, 2027 to December 31, 2027 for the first year of the Contract Term; and (2) January 1 to December 31 for each subsequent year after the first year of the Contract Term. |
| Contractor |
| The person or entity that performs services and/or provides goods for the State under the terms and conditions set forth in this Contract. |
| Coordination of Benefits (COB) |
| Activities involved in determining Medicaid benefits when an Enrollee has health care coverage through another individual, entity, insurer, or other program that is liable to pay for health care services. COB includes cost avoidance and recovery when other medical health insurance exists. |
| Corrective Action Plan |
| A detailed written plan describing the actions and/or procedures for the Contractor to remedy deviation from the stated standard(s) or contractual and/or legal mandates. |
| Covered Services |
| Services authorized by this Contract that the Contractor is required to provide Enrollees in the Specialty Managed Care Plan and in compliance with 42 CFR 438.210. |
| Credentialing Committee |
| The Nevada Medicaid Centralized Credentialing Committee is responsible for reviewing the Primary Source Verification (PSV) results of the credentialing application, results of state and federal database queries, and reports provided by the National Practitioner Data Bank (NPDB). The Committee reviews the credentialing information to issue a decision affirming or denying a Provider’s credentialing status. The Committee is supported and facilitated by the Credentialing Verification Organization (CVO). |
| Credentialing Verification Organization (CVO) |
| An entity contracted by NVHA to determine the qualifications and ascribed privileges of Providers to render specific health care services. The entity will facilitate credentialing decisions through a credentialing committee regarding whether a Provider meets requirements to enter into a Participating Provider Agreement with NVHA’s contracted managed care organizations. The entity must hold an applicable credentialing NCQA Accreditation that includes a review of decision-making. |
| Credible Allegation of Fraud (CAF) |
| An allegation of fraud from any source that has an indicia of reliability. |
| Crisis Plan |
| An individualized plan that identifies strategies, supports, and services that the Child and Family Team and any other Providers or supports will use to anticipate, prevent, and effectively respond to an Enrollee crisis. The Crisis Plan can also be referred to as a safety and soothing plan. |
| Cultural Competency |
| Understanding and respecting diverse customs, values, and beliefs, while integrating them into assessment treatment and interactions, to foster effective communication with Beneficiaries from all backgrounds and to increase the quality and appropriateness of health care services and outcomes. |
| Delivery Network |
| The Contractor’s network of appropriate Providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the Contract for all Enrollees. |
| Disenrollment |
| The process of Enrollees being terminated from enrollment with the Contractor, including both Enrollee-initiated and Contractor-requested termination in compliance with 42 CFR 438.56. |
| DOJ Settlement |
| The Settlement Agreement entered into on January 2, 2025, between the U.S. Department of Justice and the State of Nevada to address and resolve findings regarding the State’s behavioral health service system for children. The agreement sets forth obligations to enhance community-based services, ensure compliance with the ADA, and improve outcomes for children with behavioral health disabilities. |
| Durable Medical Equipment (DME) |
| Equipment, supplies, devices, and/or gases that can withstand repeated use, are primarily and customarily used to serve a medical purpose and generally are not useful to a person in the absence of illness or injury. |
| Early and Periodic Screening, Diagnosis and Treatment (EPSDT) |
| Pursuant to Section 1905(r) of the Act and 42 CFR 441 Subpart B, a preventive health care program aimed at providing Medicaid-eligible children under the age of 21 the most effective preventive health care through the use of periodic examinations, standard immunizations, diagnostic services, and treatment services, which are medically necessary and designed to correct or ameliorate defects in physical or mental illnesses or conditions. In Nevada, EPSDT is also referred to as Healthy Kids. |
| Electronic Verification System (EVS) |
| A means to verify an individual’s eligibility for Covered Services via the Internet. |
| Electronic Visit Verification (EVV) |
| A system under which visits conducted as part of personal care, home health care, or private duty nursing services are electronically verified with respect to: |
1. The type of service performed;
2. The individual receiving the service;
3. The date of the service;
4. The location of service delivery;
5. The individual providing the service; and
6. The times the service begins and ends.
| Eligibility |
| An individual’s status to receive Nevada Medicaid program benefits. |
| 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 the following: |
1. Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
2. Serious impairment to bodily functions.
3. (Serious dysfunction of any bodily organ or part.
| Emergency Medical Transportation |
| The use of a ground or air ambulance, as medically necessary, to transport a Beneficiary with an emergency medical condition. |
| Emergency Room Care |
| Services needed to treat or evaluate an emergency medical condition in an emergency room. |
| Emergency Services |
| Covered inpatient and outpatient services that are furnished by a Provider that is qualified to furnish these services and needed to evaluate or stabilize an emergency medical condition. |
| Encounter |
| A covered service or group of services delivered by a Provider to an Enrollee during a visit or as a result of a visit (e.g., pharmacy) between the Enrollee and Provider. |
| Enrollee |
| A Medicaid Beneficiary who is currently enrolled in an MCO, PIHP, PAHP, PCCM, or PCCM entity in a given managed care program. In this SOW, the term Enrollee means an Enrollee of the Specialty Managed Care Plan. |
| Enrollee Encounter Data |
| Detailed data collected and maintained by the Contractor sufficient to identify the Provider who delivers any item(s) or service(s) to Enrollees; and submitted by the Contractor to NVHA in the format, at a frequency, and with the level of detail that permits NVHA to comply with reporting requirements to CMS pursuant to 42 CFR 438.818. |
| Essential Community Provider (ECP) |
| A healthcare Provider that (1) Has historically provided services to underserved populations and demonstrates a commitment to serve low-income, underserved populations who make up a significant portion of its patient population or, in the case of a sole community Provider, serves underserved patients within its clinical capability; and (2) Waives charges or charges for services on a modified sliding fee scale based on income and does not restrict access or services because of a client’s financial limitations. Also includes any Provider identified by NVHA as critical to ensuring access to covered services in the Contractor’s Provider network and is designated as an essential community provider in this Contract. |
| Excluded Services |
| Benefits that are not covered under NVHA’s Specialty Managed Care Plan. |
| External Quality Review (EQR) |
| Federally required external independent review of each State Medicaid Agency contract with a Medicaid MCO on an annual basis conducted by a qualified independent entity of the quality, outcomes, and timeliness of, and access to, the items and services for which the MCO is responsible under the contract. |
| External Quality Review Organization (EQRO) |
| An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and that performs external quality reviews and other related activities as set forth in 42 CFR 438.358. |
| Family |
| Biological parents, adoptive parents, kinship caregivers (including both relatives and fictive kin), or other guardians or custodians of an Enrollee. |
| Family Peer Support |
| Family Peer Support Services provide structured support to parents and caregivers of children and youth with behavioral health disorders, as defined in MSM Chapter 4300. |
| Family Planning Services |
| Services and supplies that are related to fertility and the voluntary planning of conception and childbearing, including but not limited to screening, testing, diagnosis, treatment, drugs, contraception, and counseling. |
| Family Therapy |
| A mental health treatment service provided to an Enrollee and the Enrollee’s family by a qualified mental health professional for the purpose of effectively addressing the Enrollee’s behavioral health needs, improving the family’s ability to provide effective support for the Enrollee, and facilitating positive interactions among family members. |
| Federal Financial Participation (FFP) |
| Federal reimbursement to states for a share of their total Medicaid program costs. States receive FFP based on their reports of allowable Medicaid expenditures to the federal government. |
| Federally Qualified Health Center (FQHC) |
| Health centers that receive federal grant funding under Section 330 of the Public Health Service Act. FQHCs focus on providing comprehensive and affordable primary and preventable health care to individuals with low incomes who are uninsured and underinsured, as well as other vulnerable populations. |
| Fee-For-Service (FFS) |
| A Medicaid delivery system where NVHA pays Providers directly for each covered service received by a Beneficiary. FFS covers both Beneficiaries not enrolled in a managed care program, as well as for excluded services for managed care program Enrollees. |
| Fiscal Agent |
| An entity contracted by NVHA that is responsible for the prompt and proper processing of all claims for payment of covered services in accordance with Nevada Medicaid policies and procedures. Additionally, the fiscal agent may: |
1. Provide the auditing function for Providers under cost reimbursement;
2. Perform a cursory pre-payment review on all claims;
3. Trace identify and apply any and all prior resources, including third-party liability and subrogation;
4. Supply Provider education and Provider services; and
5. Offer other administrative services.
| Focus Population |
| The Focus Population includes Medicaid and CHIP-eligible children with a behavioral health disability who are in a hospital or residential treatment facility, or who meet at least one of the following criteria: |
1. Hospital or Residential Treatment Facility Interaction: The Beneficiary is referred to, seeks authorization for, or is discharged from a hospital or residential treatment facility.
2. Clinical Assessment Tool Score: The Beneficiary receives a score indicating eligibility for, or risk of, hospitalization or placement in a residential treatment facility.
3. Frequent Mobile Crisis Services: The Beneficiary accesses mobile crisis response and stabilization services three or more times within a 12-month period.
4. Release from Juvenile Detention or Youth Parole Center: Upon release, the Beneficiary’s clinical assessment score indicates a risk of hospitalization or need for residential treatment facility services.
5. Extended Stay in Emergency Shelter: The Beneficiary remains in a child welfare emergency shelter for over seven days and receives a clinical assessment tool score indicating risk of hospitalization or need for residential treatment facility services.
| Foster Care |
| For the purpose of this SOW, Foster Care means: |
1. Enrollees up to age 21 in the custody of DCFS making them Medicaid eligible;
2. Enrollees up to age 21 formerly in the custody of DCFS who receive an adoption subsidy making them Medicaid eligible; and
3. Enrollees up to age 26 formerly in the custody of and who aged out of any state’s child welfare system, making them Medicaid eligible.
Foster Care may also be referred to as Child- Welfare Involved in this SOW.
| Fraud |
| An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themselves or another person or entity. It includes any act that constitutes fraud under applicable Medicaid federal or state law, including as defined under 42 CFR 455.2. |
| Gag Clause |
| A contractual provision that directly or indirectly restricts a plan or issuer from sharing specific cost and quality information with another party. |
| Geographic Service Area or Service Area |
| The geographic area served is described in Section 7.2 for the Nevada Specialty Managed Care Plan. |
| Grievance |
| An expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a Provider or Contractor employee, or failure to respect the Enrollee's rights regardless of whether remedial action is requested. Grievance includes an Enrollee's right to dispute an extension of time proposed by the Contractor to make an authorization decision. |
| Grievance and Appeal System |
| The processes the Contractor implements to handle appeals of an adverse benefit determination and grievances, as well as the processes to collect and track information about them. |
| Habilitation Services and Devices |
| Services and devices designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in a home and community-based setting. Habilitation services and devices are further defined in MSM Chapter 1800. |
| Healthcare Effectiveness Data and Information Set (HEDIS®) |
| The Contractor will report quality results to NVHA in part using HEDIS®. HEDIS® includes more than 90 measures across 6 domains of care: |
· Effectiveness of Care.
· Access/Availability of Care.
· Experience of Care.
· Utilization and Risk Adjusted Utilization.
· Health Plan Descriptive Information.
· Measures Reported Using Electronic Clinical Data Systems
| Home and Community Based Services (HCBS) |
| Covered Services under this Contract that are provided to Enrollees in a home or community setting and referred to as HCBS in the DOJ Settlement. Note this is distinct from HCBS Waiver Services, which are excluded from coverage in this Contract. |
| Home Health Services or Home Health Care |
| A mandatory benefit for individuals entitled to nursing facility services under the Nevada Medicaid State Plan that includes: nursing services, as defined in the State's Nurse Practice Act, that are provided on a part-time or intermittent basis by a home health agency (HHA); home health aide services provided by a HHA; and medical supplies, equipment, and appliances suitable for use in any setting in which normal life activities take place. |
| Hospice Services |
| A comprehensive set of services identified and coordinated by an interdisciplinary Provider group to address the physical, psychosocial, spiritual, and emotional needs of terminally ill individuals and/or their family members, as outlined in an individualized plan of care. Per the State Plan, a Covered Service in Nevada Medicaid. |
| Hospital |
| An inpatient medical facility licensed to provide services at an acute level of care for the diagnosis, care, and treatment of human illness primarily for patients with disorders other than mental diseases. Institutions for Mental Diseases (IMDs), nursing facilities (NFs), and intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs) are not hospitals regardless of name or licensure. |
| Hospital Outpatient Care |
| Preventive, diagnostic, therapeutic, rehabilitative, or palliative services that: |
1. Are furnished to outpatients;
2. Are furnished by or under the direction of a physician or dentist;
3. Are furnished by an institution that is licensed or formally approved as a hospital by an officially designated authority for State standard-setting and meets the requirements for participation in Medicare as a hospital;
4. May be limited by a Medicaid agency if those types of items and services are not generally furnished by most hospitals in the State.
| Hospitalization |
| Admission to, or period of stay in, a health care institution that is licensed as a hospital. |
| In Lieu of Service (ILOS) |
| A service or setting that is provided to an Enrollee as a substitute for a covered service or setting under the Nevada Medicaid State Plan in accordance with 42 CFR 438.3(e)(2). An ILOS can be used as an immediate or longer-term substitute for a covered service or setting under the State Plan, or when the ILOS can be expected to reduce or prevent the future need to utilize the covered service or setting under the State Plan. |
| Improper Payment |
| As referenced under MSM 3302.4, a payment made for any Medicaid service that was not authorized, performed, documented, billed, and paid in accordance with Nevada Medicaid policy and all applicable federal and state laws. The term encompasses fraud, waste, and abuse, as well as errors made by the Provider or the Contractor. |
Indian Health Service
The federal agency established by the Indian Health Care Improvement Act ((IHCIA, P.L. 94-437) and amended by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) responsible for providing federal health services for American Indians and Alaska Natives (AI/AN).
| Individual Therapy |
| A direct one-on-one, structured, and strengths-based mental health service provided to an Enrollee for the purpose of addressing a presenting behavioral health need by an individual therapist. |
| Institutions for Mental Diseases (IMD) |
| A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an IMD is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual Disabilities is not an IMD. |
| Intensive Care Coordination |
| Is a service that coordinates all formal and informal supports and services delivered to an Enrollee. Intensive care coordination includes development of the plan of care and referral and linkage to and coordination with appropriate services, based on the comprehensive assessment and the plan of care. |
| Intensive Care Coordinator |
| Is an individual who is trained to work in a strengths-based manner to develop a plan of care for an Enrollee, in coordination with the Enrollee and family, and who supports referral, linkage and coordination between identified services. |
| Intensive In-Home Services |
| A coordinated set of highly engaging and supportive services provided in any setting in which the Enrollee is naturally located, such as the home, school, or other community setting. These services include wraparound facilitation, respite care, individual therapy, family therapy, behavioral support services, family peer support, and youth peer support. These services are implemented to address the recommendations of, and in furtherance of the goals described in, the plan of care. |
| Key Personnel |
| Contractor staff with management responsibility or principal technical responsibility for the functional areas described in Contract. |
| Managed Care Organization (MCO) |
| An entity that has, or is seeking to qualify for, a comprehensive risk contract under 42 CFR 438. The Contractor for the Specialty Managed Care Plan must be classified as an MCO. |
| Marketing |
| Any communication, from an MCO, PIHP, PAHP, PCCM or PCCM entity to a Beneficiary who is not enrolled in that entity, that can reasonably be interpreted as intended to influence the Beneficiary to enroll in that particular MCO's, PIHP's, PAHP's, PCCM's or PCCM entity's Medicaid product, or either to not enroll in or to disenroll from another MCO's, PIHP's, PAHP's, PCCM's or PCCM entity's Medicaid product. |
| Marketing Materials |
| Materials that -- |
1. Are produced in any medium, by or on behalf of an MCO, PIHP, PAHP, PCCM, or PCCM entity; and
2. Can reasonably be interpreted as intended to market the MCO, PIHP, PAHP, PCCM, or PCCM entity to Potential Enrollees.
| Medicaid |
| A joint federal-state program authorized by Title XIX of the Act, which provides health care to low-income individuals, including children, the elderly, and those with disabilities. Medicaid is funded through federal grants to states, which must meet specific requirements detailed in federal statute and regulations to receive matching funds. |
| Medicaid Advisory Committee (MAC) |
| A public committee to NVHA that advises on matters of concern related to Medicaid program policy development and matters related to the effective administration of the Medicaid program, per 42 CFR 431.12. |
| Medicaid Fraud Control Unit (MFCU) |
| The Medicaid Fraud Control Unit within the Office of the Nevada Attorney General is the federally funded and mandated fraud unit, independent of the Nevada Health Authority, that investigates and prosecutes Provider fraud in the Nevada Medicaid program. |
| Medicaid Services Manual (MSM) |
| A compilation of regulations adopted under NRS 422.2368 and 422.2369 regarding the operation of the Nevada Medicaid program. The Medicaid Services Manual is updated and accessible via the Nevada Health Authority website. |
| Medicaid State Plan (aka “State Plan”) |
| A comprehensive written commitment by the State, submitted to the U.S. Health and Human Services under section 1902(a) of the Act, to administer or supervise the administration of Nevada’s Medicaid program in accordance with federal requirements. |
| Medical Assistance to the Aged, Blind and Disabled (MAABD) |
| A Medicaid eligibility category which provides medical coverage for certain persons who are eligible for and/or may be receiving Supplemental Security Income (SSI), persons who qualify for Home and Community Based Services (HCBS) 1915(c) waivers, children who would be eligible for nursing facility placement but who are being cared for in their home for less cost than what would be incurred in such placement. |
| Medical Expenditures |
| Spending by the Contractor on Covered Services under the Contract, net of any recoveries, rebates, third-party obligations, and Provider contract discounts. Includes spending on ILOS approved under the Contract and any incentives, rate increases, or bonuses provided to Providers for covered services and alternative payment models (APM). Medical expenditures exclude spending on items or services not qualifying as Covered Services under the Contract, such as value-added services, administrative activities, quality- or APM-related administrative activities, non-covered benefits and services, and any other services and activities for which the Contractor is not at risk under the Contract. |
| Medically Necessary |
| In accordance with NRS 695G.055, health care services or products that a prudent physician would provide to a patient to prevent, diagnose, or treat an illness, injury, or disease, or any symptoms thereof, that are necessary and: |
1. Provided in accordance with generally accepted standards of medical practice;
2. Clinically appropriate with regard to type, frequency, extent, location and duration;
3. Not primarily provided for the convenience of the patient, physician or other provider of health care;
4. Required to improve a specific health condition of an insured or to preserve the existing state of health of the insured; and
5. The most clinically appropriate level of health care that may be safely provided to the insured.
| Member |
| A term for an individual who is a Medicaid Beneficiary and may also be an Enrollee of a managed care entity. In this SOW, the terms Beneficiary and Enrollee are used specifically. |
| Mobile Crisis Response Team |
| A team of two individuals to include a master’s level qualified mental health professional and a second team member who may be another professional or a paraprofessional (which may include family and youth peer support) who provide mobile crisis response and stabilization services to Enrollees of the Specialty Managed Care Plan. |
| Network Provider |
| Any Provider, group of providers, or entity that has a Participating Provider Agreement with the Contractor, or its subcontractor, and receives Medicaid funding directly or indirectly to order, refer, or render Covered Services as a result of the State's Contract with the Contractor. A Network Provider is not a subcontractor by virtue of the Participating Provider Agreement. |
| Nevada Administrative Code (NAC) |
| Contains regulations regarding the operation of Nevada State agencies. Applicable NAC documentation is available online at: www.leg.state.nv.us. |
| Nevada Check Up (NCU) |
| Nevada’s CHIP provided under Title XXI of the Act to children whose families have incomes that exceed Medicaid eligibility limits but that are equal to or less than 205% of the federal poverty level. |
| Nevada Division of Child & Family Services (DCFS) |
| The single state agency in Nevada authorized to administer Child and Family Services pursuant to Title IV of the Act. DCFS determines eligibility for children in the agency’s custody and provides eligibility information to DSS for the Nevada Medicaid program. |
| Nevada Division of Supportive Services (DSS) |
| The division of the State of Nevada’s Executive Branch that determines applicants’ eligibility for the Nevada Medicaid program. |
| Nevada Early Intervention Services (NEIS) |
| Services provided for children ages zero (0) to three (3) years old with known or suspected developmental delays, and their families, that are funded by Title V of the Act. |
| Nevada Health Authority (NVHA) |
| The single state agency in Nevada authorized to administer the Medicaid and CHIP program pursuant to Title XIX and XXI of the Act. |
| Nevada Revised Statutes (NRS) |
| Current codified laws of the State of Nevada. All applicable NRS documentation is available online at: www.leg.state.nv.us. |
| Nevada Standard MCO |
| The five (5) MCOs contracted by the State to provide Medicaid and CHIP services to Beneficiaries pursuant to Contract #S3037 beginning January 1, 2026. |
| Noncompliance |
| A situation in which the Contractor has failed to adequately meet the terms of the Contract and is subject to the sanctions, monetary penalties, and other remedies outlined in Section 16. |
| Non-Emergency Medical Transportation (NEMT) Broker |
| A NEMT broker manages, authorizes, and coordinates NEMT services for eligible recipients by contracting with individual transportation companies. |
| Orthodontics |
| The branch of dentistry used to correct malocclusions (the "bite") of the mouth and restore it to proper alignment and function. |
| Outcomes |
| Changes in patient health, functional status, satisfaction or goal achievement that result from health care or supportive services. |
| Out-of-Network Provider |
| Providers who do not have Participating Provider Agreements with the Contractor to deliver Covered Services to the Contractor’s Enrollees, but who may still render services to Enrollees in certain circumstances. |
| Participating Provider |
| A network Provider who has a contractual agreement with the Contractor. |
| Participating Provider Agreement |
| The contractual agreement between a Network Provider and the Contractor for the provision of Covered Services to Specialty Managed Care Plan Enrollees. |
| Performance Improvement Project (PIP) |
| As part of NVHA’s Managed Care Quality Strategy and the Contractor’s Quality Assessment and Performance Improvement program, NVHA must require that the Contractor conduct PIPs including any PIPs required by CMS that focus on both clinical and nonclinical areas. Each PIP must be designed to achieve significant improvement, sustained over time, in health outcomes and Enrollee satisfaction, and must include the following elements: |
1. Measurement of performance using objective quality indicators.
2. Implementation of interventions to achieve improvement in the access to and quality of care.
3. Evaluation of the effectiveness of the interventions based on the performance measures in 42 CFR 438.330(d)(2)(i).
4. Planning and initiation of activities for increasing or sustaining improvement.
| Performance Withhold Arrangement |
| Any payment mechanism under which a portion of a capitation rate is withheld from the Contractor and a portion of or all of the withheld amount will be paid to the Contractor for meeting targets specified in the Contract. The targets for a withhold arrangement are distinct from general operational requirements under the Contract. Arrangements that withhold a portion of a capitation rate for noncompliance with general operational requirements are a penalty and not a withhold arrangement. |
| Personal Care Services (PCS) |
| Services performed in accordance with a written service plan developed with the Enrollee or their representative, based on the needs of the Enrollee as determined by a functional assessment. Assistance may be in the form of direct hands-on assistance or coaching the individual to perform the task, and relates to the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). |
| Personal Representative |
| A parent, including a parent who is an emancipated minor; a guardian of a person as defined in NRS Chapter 159, an executor, or administrator; a person who has authority to make health care decisions under a power of attorney for health care; or a person designated in writing as a personal representative for a Beneficiary, by the Beneficiary or, in the case of a minor child or adult who is adjudicated incompetent, their parent or guardian. |
| Pharmacy Services |
| Pharmaceuticals, supplies, and devices covered on the Nevada Medicaid pharmacy benefit, as well as physician administered drugs (PADs) covered on the Nevada Medicaid medical benefit. |
| Physician Services |
| Services furnished by a physician, whether furnished in the office, the Beneficiary's home, a hospital, a skilled nursing facility, or elsewhere, — |
1. Within the scope of practice of medicine or osteopathy as defined by state law; and
2. By or under the personal supervision of an individual licensed under state law to practice medicine or osteopathy.
| Plan |
| A Nevada MCO that creates a network of health care providers that deliver medical services to Beneficiaries that have enrolled with that MCO. |
| Plan of Care |
| A comprehensive, individualized plan that outlines treatment goals for Enrollees receiving care management and a strategy for achieving those goals. The plan of care will be informed by the comprehensive assessment and any other assessments, and take into consideration the strengths, culture, and needs of the Enrollee and family and be signed by the family. The plan of care should at a minimum, identify: 1) supports and services available to the family, 2) the frequency with which certain services should be provided to the Enrollee, and a plan for necessary transportation, and 3) any referrals necessary to specific providers and resources in support of the plan of care. |
| Post-Stabilization Services |
| Covered services, related to an emergency medical condition that are provided after an Enrollee is stabilized to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e) to improve or resolve the Enrollee's condition. |
| Potential Enrollee |
| A Beneficiary who is subject to mandatory enrollment or may voluntarily elect to enroll with a MCO but is not yet an Enrollee of a specific MCO. |
| Prescription Drug Coverage |
| The Nevada Medicaid policy that provides coverage for prescription drugs under the State Plan in accordance with NRS 689A.405. |
| Prescription Drugs |
| Simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are— |
1. Prescribed by a physician or other licensed practitioner of the healing arts within the scope of this professional practice as defined and limited by federal and state law;
2. Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the Nevada Medical Practice Act; and
3. Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records. Prescription Drugs are further defined in NRS 453.3628.
| Primary Care Physician |
| Practitioners licensed and authorized by the State of Nevada to provide all health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner. |
| Primary Care Provider (PCP) |
| The participating physician, other licensed practitioner (e.g., physician assistant, nurse practitioner, certified nurse midwife), group practice, health center, clinic, or other individual or entity selected by or assigned to the Enrollee to provide and coordinate all of the Enrollee's health care needs and to initiate and monitor referrals for specialized services, when required. |
| Primary Care Services |
| All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State of Nevada to provide primary care services, to the extent the furnishing of those services is legally authorized in the state in which the practitioner furnishes them. |
| Prior Authorization |
| A process in which an Enrollee or Provider submits a request to the Contractor for a provisional affirmation of coverage before a service, treatment plan, prescription drug, or durable medical equipment is rendered to the Enrollee and before a claim is submitted for payment. |
| Private Duty Nursing (PDN) Services |
| Nursing services for Enrollees who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or nursing facility. These services are provided through a HHA; |
1. By a Registered Nurse or a Licensed Practical Nurse;
2. Under the direction of the Enrollee physician; and
3. At the State’s option, to an Enrollee in one or more of the following locations: their own home, any setting outside of the home where normal life activities take place, a hospital, or a nursing facility.
| Profit |
| A Contractor’s underwriting gain, or the allowable operating income minus the allowable operating expenses divided by the allowable operating income |
| Provider |
| Any individual or entity that is engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the state in which it delivers the services. |
| Provider Dispute |
| A grievance or appeal made by a Provider in regards to one or more actions taken by the Contractor, regardless of whether the grievance or appeal requests any remedial actions. |
| Provider Preventable Conditions (PPCs) |
| Certain reasonably preventable conditions caused by medical accidents or errors in the health care setting. Federal payments for PPCs are prohibited by the Patient Protection and Affordable Care Act Section 2702 and implementing regulations at 42 CFR 447.26. |
| Provider Type |
| A category of Provider as defined by the State. Provider types and specialties are listed in the Provider Enrollment Information Booklet available on the Nevada Medicaid Provider Portal at https://www.medicaid.nv.gov/providers/enroll.aspx. |
| Prudent Layperson |
| A person with an average knowledge of health and medicine. |
| Public Option |
| A health benefit plan available on Nevada Health Link established pursuant to NRS 695K.200. |
| Quality |
| The degree to which an MCO, PIHP, PAHP, or PCCM entity (described in 42 CFR 438.310(c)(2) increases the likelihood of desired outcomes of its Enrollees through: |
1. Its structural and operational characteristics.
2. The provision of services that are consistent with current professional, evidenced-based-knowledge.
3. Interventions for performance improvement.
| Quality Assurance (QA) |
| A formal set of activities to review and affect the quality of Contractor operations and services provided to Enrollees. Quality assurance includes assessment of services, administrative processes, and data systems; implementation of corrective actions; and ongoing efforts to improve Contractor operations and Enrollee care. |
| Quality Assurance and Performance Improvement (QAPI) |
| The Contractor’s required program for the services it furnishes to its Enrollees that includes the elements identified in 42 CFR 438.330(b). |
| Quality Indicator |
| A measurable variable relating to a specified clinical or health services delivery area, which is reviewed over a period of time to monitor the process or outcomes of care delivered in that area. |
| Rate Cell |
| A set of mutually exclusive categories of Enrollees that is defined by one or more characteristics for the purpose of determining the capitation rate and making a capitation payment; such characteristics may include age, gender, eligibility category, and region or geographic area. Each Enrollee should be categorized in one of the rate cells for each unique set of mutually exclusive benefits under the contract. |
| Referral |
| The recommendation by a Provider and/or the Contractor, and in certain instances a parent, legal guardian, and/or authorized representative, for an Enrollee to receive medically necessary care from a different Provider. |
| Rehabilitation Services and Devices |
| An optional Medicaid benefit recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under State law, for the reduction of a physical or mental disability and the restoration of the individual to the best possible functional level. |
| Remote Patient Monitoring |
| A form of telehealth that allows health care providers to use devices that gather and analyze health information without a face-to-face appointment or in-person testing. |
| Residential Treatment Facilities |
| Structured 24-hour non-acute group care treatment settings for Enrollees with significant behavioral health needs. |
| Respite Care |
| Provides families with short-term care for Enrollees by natural supports or formal Providers. |
| Rural Health Clinic (RHC) |
| A clinic that is located in a rural area designated as a shortage area, not including rehabilitation agencies or facilities primarily established for the care and treatment of mental diseases. |
| Rural Service Area |
| All ZIP codes in Nevada other than the urban ZIP codes in Clark and Washoe counties. See the Geographic Service Areas exhibit for more information. |
| Serious Emotional Disturbance (SED) |
| Per the DOJ Settlement, refers to a diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional impairment that substantially interferes with or limits the Enrollee’s role or functioning in family, school, or community activities. The term used for Enrollees under the age of 18. |
| Serious Mental Illness (SMI) |
| Per the DOJ Settlement, refers to a diagnosable mental, behavior, or emotional disorder within the past year that causes serious functional impairment that substantially interferes with or limits one or more major life activities and is a term used for Enrollees over the age of 18. |
This is the start of the file's text. The full file is on GovTribe.