CN-680000-FP083-A2.pdf

AHCA CONTRACT NO. FP083

AMENDMENT NO. 2

AHCA Contract No. FP083, Amendment No. 2, Page 1 of 2 April 2020

THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and CAREPLUS HEALTH PLANS, INC., hereinafter referred to as the "Vendor" or “Managed Care Plan,” is hereby amended as follows:

1. Standard Contract, Section III., THE VENDOR AND AGENCY HEREBY MUTUALLY

AGREE, Sub-Section B., Contract Managers, Item 1., is hereby amended to now read as follows:

1. The Agency’s Contract Manager’s contact information is as follows:

Katie Wetherington Agency for Health Care Administration 2727 Mahan Drive MS #50 Tallahassee, FL 32308

(850) 412-4066 katie.wetherington@ahca.myflorida.com

2. Effective January 1, 2022, Attachment I, Scope of Services, Exhibit C-1, MA D-SNP

Capitation Rates, is hereby deleted in its entirety and replaced with Exhibit C – Effective January 1, 2022, D-SNP Capitation Rates, attached hereto and made a part of this Contract. All references in this Contract to Exhibit C-1, shall hereinafter refer to Exhibit C – Effective January 1, 2022.

3. Effective January 1, 2023, Attachment I, Scope of Services, is hereby deleted in its entirety and replaced with Attachment I, Scope of Services – Effective January 1, 2023, attached hereto and made a part of this Contract. All references in this Contract to Attachment I, Scope of Services, shall hereinafter refer to Attachment I, Scope of Services – Effective January 1, 2023.

All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.

This Amendment and its attachment are hereby made a part of this Contract.

This Amendment cannot be executed unless all previous Amendments to this Contract have been fully executed.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

DocuSign Envelope ID: 438D9E69-6D65-47D0-B744-483DA4528286 mailto:katie.wetherington@ahca.myflorida.com

AHCA CONTRACT NO. FP083

AMENDMENT NO. 2

AHCA Contract No. FP083, Amendment No. 2, Page 2 of 2 April 2020

IN WITNESS WHEREOF, the Parties hereto have caused this fifty-eight (58) page Amendment to be executed by their officials thereunto duly authorized. This Amendment is not valid until signed and dated by both Parties.

CAREPLUS HEALTH PLANS, INC. STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

SIGNED

BY:

SIGNED

BY:

NAME: NAME:

TITLE: TITLE:

DATE: DATE:

List of Attachments included as part of this Amendment:

Specify Type Number Description Attachment I Exhibit C – Effective January 1, 2022, D-SNP

Capitation Rates (1 Page) Attachment I Scope of Services – Effective January 1, 2023

(55 pages)

Segment President, Retail

7/2/2022

Timothy A. Wheatley

7/2/2022

Secretary

Simone Marstiller

ATTACHMENT I

EXHIBIT C – EFFECTIVE JANUARY 1, 2022

AHCA Contract No. FP083, Attachment I, Exhibit C – Effective 01/01/22, Page 1 of 1

D-SNP CAPITATION RATES

DATE SPAN REGION CATEGORIES OF

MEDICAID ELIGIBILITY

RATE

01/01/2022- 12/31/2022

One (1) Two (2) Three (3) Four (4) Five (5) Six (6) Seven (7) Eight (8)

QMB $38.75

01/01/2022- 12/31/2022

Nine (9) Ten (10) Eleven (11)

QMB $8.80

01/01/2022- 12/31/2022

One (1) Two (2) Three (3) Four (4) Five (5) Six (6) Seven (7) Eight (8)

QMB Plus, SLMB Plus, and FBDE

$84.60

01/01/2022- 12/31/2022

Nine (9) Ten (10) Eleven (11)

QMB Plus, SLMB Plus, and FBDE

$123.49

SCOPE OF SERVICES – EFFECTIVE JANUARY 1, 2023

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 1 of 47

AHCA Form 2100-0003 (Rev. OCT 16)

Table of Contents

I. Service(s) to be Provided

A. Overview/Purpose

II. Manner of Service(s) Provision:

A. Services Provided by the Agency

B. Services Provided by the Managed Care Plan

C. Deliverables

D. Reporting

E. Monitoring

F. Performance Requirements

III. Method of Payment:

A. Compensation

B. Financial Consequences as Liquidated Damages

IV. Attorney’s Fees

V. Legal Action Notification

VI. Damages for Failure to Meet Contract Requirements

VII. Corrective Action Plan (CAP)

VIII. Grievance and Appeals

IX. System Functionality

X. Information Technology

XI. Emergency Management and Disaster Recovery

XII. Smartphone Applications

XIII. Social Networking

XIV. Definitions and Acronyms

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 2 of 47

I. Service(s) to be Provided

A. Overview/Purpose

The Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) (Managed Care Plan) has entered into a contract with the Centers for Medicare and Medicaid Services (CMS) to provide a D-SNP. Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) and resulting regulations, CMS requires the D-SNP to enter into a Contract with the state Medicaid agency to provide or arrange for benefits to be provided, which a dually eligible individual is entitled to receive. Medicare reimbursement for D-SNPs is provided in the same manner as for any other type of Medicare Advantage Plan (Medicare Part C).

The Bipartisan Budget Act of 2018 requires a minimum level of Medicare-Medicaid integration for all D-SNPs. CMS-4185-F requires that D-SNPs meet at least one of the following criteria:

• Be a Fully Integrated D-SNP (FIDE SNP);

• Be a Highly Integrated D-SNP (HIDE SNP); or

• Notify the state Medicaid agency, or its designee, of hospital and skilled nursing facility inpatient admissions for some high-risk enrollees as determined by the state.

Under this Contract, it is the Managed Care Plan's responsibility to: (i) Coordinate the delivery of Medicaid benefits for enrollees who are eligible for such services;

and (ii) Provide coverage of Medicaid services, including behavioral health services, for enrollees eligible for such services.

The legal entity holding a contract with CMS for the Managed Care Plan(s) covered under this Contract receives direct capitation from the Florida Agency for Health Care Administration (Agency) to provide coverage of the Medicaid benefits described in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services.

The Managed Care Plan shall provide services in accordance with the terms and conditions set forth in this Contract and all applicable federal and state laws, rules and regulations including but not limited to the following:

1. 42 Code of Federal Regulations (CFR) Part 422;

2. Health Insurance Portability and Accountability Act (HIPAA) of

1996;

3. Chapter 409, Florida Statutes (FS);

4. Chapter 624, FS;

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 3 of 47

5. Chapter 636, FS;

6. Chapter 641, FS; and

7. 59G-8.100, Florida Administrative Code (FAC).

The Managed Care Plan shall comply with any applicable changes in federal and state law, rules, or regulations.

The enrollees of plans subject to this Contract must be fully or partially dually eligible for Medicare and Medicaid. Such enrollees must have the following Medicaid eligibility categories: Qualified Medicare Beneficiary (QMB), Qualified Medicare Beneficiary Plus (QMB Plus), Specified Low-Income Medicare Beneficiary (SLMB), Specified Low-Income Medicare Beneficiary Plus (SLMB Plus), Qualifying Individual (QI), Qualified Disabled and Working Individual (QDWI), or Full Benefit Dual Eligible (FBDE).

Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act (Act) forbid Medicare providers and suppliers from billing QMB or QMB Plus recipients for cost-sharing. Rule 59G- 1.056(5) forbids Florida Medicaid providers from denying services to a recipient based solely on the recipient’s inability to pay a Florida Medicaid copayment or coinsurance amount. The following eligibility categories are cost-share-protected:

QMB, QMB Plus, SLMB Plus, and FBDE. The following eligibility categories are not cost-share-protected: SLMB, QI, and QDWI.

II. Manner of Service(s) Provision:

A. Services Provided by the Agency

1. The Agency will maintain continuing and regular oversight of the requirements of this Contract.

2. Agency expenditures shall be subject to authorization and funding by the state legislature.

3. Provider Network File Exchange

a. The Agency lists all providers with whom the Agency has active Medicaid agreements on the Medicaid Web Portal. The Managed Care Plan will identify in its provider directory those providers that accept both Medicare and Medicaid and that are also within the Managed Care Plan’s network. The Managed Care Plan shall electronically transmit the provider network file to the Agency Contract Manager monthly, in a manner determined by the Agency.

The Managed Care Plan shall include in the provider network file all network providers contracted by the Managed Care Plan to serve its enrollees.

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 4 of 47

4. Eligibility Verification

a. Initial Eligibility Verification. The Agency shall provide the Managed

Care Plan access to information for verifying the eligibility of enrollees through the use of the Medicaid Fiscal Agent’s Provider Secured Web Portal. The Managed Care Plan shall ensure individuals enrolled in the Managed Care Plan are eligible for both Medicare and Medicaid.

b. Ongoing Eligibility Verification. The Managed Care Plan shall review its X12-834 enrollment files to ensure that all enrollees are eligible to receive services from the Managed Care Plan. The Managed Care Plan shall notify the Agency of any discrepancies in enrollment, including enrollees not residing in the same region in which they were enrolled and enrollees not eligible for the Managed Care Plan, within sixty (60) calendar days of receipt of the enrollment file. (42 CFR 438.608(a)(3))

5. Cost-Sharing Obligations

a. Cost-Sharing Obligations by Plan Design. The Agency acknowledges and agrees that based on the Managed Care Plan’s benefit package design and its bid to CMS, the Managed Care Plan determines varying levels of cost-sharing obligations for certain enrollees. The Agency further acknowledges and agrees that as a result of these benefit package designs, the Managed Care Plan’s actual cost-sharing obligations for such enrollees may be reduced or equal zero.

B. Services Provided by the Managed Care Plan

1. The Managed Care Plan shall ensure individuals enrolled in the Managed

Care Plan are eligible for both Medicare and Medicaid. The Managed Care Plan shall facilitate eligibility redeterminations, by providing assistance with applications for medical assistance on behalf of its enrollees, conducting enrollee education regarding maintaining Medicaid eligibility, or other activities designed to facilitate the process.

2. The Managed Care Plan shall ensure the provision of Medicaid covered services specified in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services, in sufficient amount, duration, and scope to be reasonably expected to achieve the purpose for which the services are furnished. The Managed Care Plan shall enter into provider agreements with a sufficient number of providers to provide all covered services to enrollees and ensure that each medically necessary covered service is accessible and provided to the enrollee with reasonable promptness (within the meaning of that term as set forth in 42 U.S.C.

§1396a(a)(8)) and 42 CFR 438.3(q)(1) and (3). The Managed Care Plan shall take any and all necessary action to ensure that all medically

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 5 of 47 necessary covered services are provided to enrollees with reasonable promptness.

3. The Managed Care Plan shall cover all costs of the Medicaid State Plan benefits listed in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services, which are incurred by enrollees who meet the eligibility criteria for full Medicaid benefits as outlined in the Medicare Managed Care Manual Chapter 16b and applicable laws and regulations.

4. The Managed Care Plan shall track and pay all eligible providers the cost-sharing obligations incurred on behalf of enrollees with applicable Medicaid eligibility categories covered under this Contract.

5. The Managed Care Plan shall comply with all current Florida Medicaid

Handbooks (Handbooks) as noticed in the Florida Administrative Register (FAR). In addition, the Managed Care Plan shall comply with the limitations and exclusions in the Handbooks, unless otherwise specified by this Contract. In no instance may the limitations or exclusions imposed by the Managed Care Plan be more stringent than those specified in the Handbooks including the definition of medical necessity. The Managed Care Plan shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.

6. Managed Care Plan Enrollee Protections

a. Cost-Sharing Protections. The Managed Care Plan and its contracted providers are prohibited from imposing cost-sharing requirements on enrollees that would exceed the amounts permitted under the Florida Medicaid State Plan for Medical Assistance, per section 1852(a)(7) of the Act and 42 CFR §422.504(g)(1)(iii).

b. Hold Harmless Enrollee Cost-Sharing. Section 1902(n)(3)(B) of the Act prohibits a Medicare provider from billing a dual-eligible beneficiary with QMB benefits for Medicare cost-sharing amounts, including deductibles, coinsurance, and copayments. A dual-eligible beneficiary with QMB benefits has no legal obligation to make further payment to a provider or to the Managed Care Plan for Medicare Part A or Part B cost sharing amounts. The Managed Care Plan’s provider agreements shall specify that a contracted Medicare provider agrees to accept the Managed Care Plan’s Medicare reimbursement as payment in full for services rendered to enrollees, or to bill the appropriate Agency source if the Managed Care Plan has not assumed the Agency’s financial responsibility under an agreement between the Managed Care Plan and the Agency.

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 6 of 47

c. Enrollee Held Harmless from Managed Care Plan and Agency Financial Responsibility. Notwithstanding any provision in this Contract to the contrary, the Managed Care Plan shall prohibit providers, under any circumstance including but not limited to non-payment by the Managed Care Plan, insolvency of the Managed Care Plan or breach of the Managed Care Plan’s agreement with provider, from billing, charging, collecting a deposit from, seeking compensation or remuneration from, or having any recourse against any enrollee for fees that are the responsibility of the Managed Care Plan or Agency.

7. The Managed Care Plan shall maintain a sufficient number, mix and geographic distribution of providers, including providers who are accepting new Medicaid patients as specified in s. 1932(b)(7) of the Social Security Act, as enacted by s.4704(a) of the Balanced Budget Act of 1997 to provide the covered services described in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services.

8. The Managed Care Plan shall have sufficient facilities, service locations and personnel within its provider network to provide the covered services described in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services, for the population being served.

9. The Managed Care Plan is not precluded from entering into agreements with network providers that vary the amount or method of payment for the cost-sharing and Medicaid State Plan benefits or from using the Managed Care Plan’s coordination of benefits procedures.

10. The Managed Care Plan shall ensure that all providers, services, and product standards specified in the Agency’s Medicaid Services Coverage and Limitations Handbooks, and the Managed Care Plan’s own provider handbooks are incorporated in the Managed Care Plan’s provider agreements, including professional licensure and certification standards for all service providers.

11. The Managed Care Plan shall provide coordination of care for its enrollees.

Coordination of care shall include, but not be limited to the following:

a. Assist its enrollees in obtaining required services;

b. Coordinate the delivery of benefits and services to its enrollees;

c. Inform network providers of benefits and services which are to be provided to its enrollees;

d. Train network providers on available benefits and services in order to ensure its enrollees receive benefits and services; and

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 7 of 47

e. Cover all costs incurred for benefits by its enrollees as indicated in Attachment I, Scope of Services, Exhibit D – Effective January 1, 2023, D-SNP Type And Applicable Service Areas.

12. The Managed Care Plan shall submit all requests to subcontract to the

Agency for review and approval at least ninety (90) calendar days before the effective date of the subcontract or change.

13. The Managed Care Plan shall transmit to the Agency or its agent, in a periodicity schedule, format, and data exchange method to be determined by the Agency, specific data it may garner from an enrollee including third party liability data. The Managed Care Plan shall comply with Rule 59G- 1.052, FAC, with regard to payment of third-party liability and Medicare co-insurance and deductibles for covered services. The Managed Care Plan shall identify and seek recovery up to the Managed Care Plan’s full legal ability from any third party, as defined by 409.901(27), FS, to pay for services rendered to enrollees under this Contract and notify the Agency of when any third party was identified and when recovery was made. The Managed Care Plan shall assume full responsibility for all third-party recovery actions initiated within one (1) year of identification. All recovery actions not initiated by the Managed Care Plan within one (1) year of identification may be pursued by the Agency, at the Agency’s sole discretion.

14. The Managed Care Plan shall have written policies and procedures in place to ensure an adequate provider network for its enrollees that complies with federal rules regarding network adequacy, including, but not limited to access standards to determine effectiveness. Copies of these policies and procedures shall be provided to the Agency prior to execution of this Contract, upon request, and upon modification.

15. A copy of each type of agreement between the Managed Care Plan and providers regarding coverage of Medicaid State Plan Services listed in Attachment I, Scope of Services, Exhibit A – Effective January 1, 2023, Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) Medicaid Covered Services must be submitted to the Agency Contract Manager for review prior to any payment being made to the Managed Care Plan. The Agency shall complete its review within forty-five (45) days of receipt.

16. The Managed Care Plan shall ensure that claims are processed and comply with the federal and state requirements set forth in 42 CFR 447.45 and 447.46 and s. 409.982(5) and 641.3155, F.S.

17. The Managed Care Plan shall require in its credentialing with network providers an agreement that network providers will not file additional claims for Medicaid deductibles or co-payment reimbursement and that the network providers will not balance bill their enrollees covered under this Contract as identified in the Medicare Managed Care Manual Chapter 16b and applicable laws and regulations. A standard copy of this agreement must be submitted to the Agency Contract Manager for review prior to any payment being made to the Managed Care Plan. Upon modification, the

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 8 of 47 new standard agreement must be submitted to the Agency Contract Manager for review prior to implementation. The Agency shall complete its review within forty-five (45) days of receipt.

18. The Managed Care Plan agrees to ensure that network providers serving its enrollees will be required in their written provider agreements to not file claims for Medicaid reimbursement to the Medicaid Fiscal Agent for its enrollees covered under this Contract as identified in the Medicare Managed Care Manual Chapter 16b and applicable laws and regulations.

The Managed Care Plan must submit copies of its provider agreements and training information to the Agency Contract Manager for review prior to any payment being made to the Managed Care Plan. Upon modification, the new provider agreements and training information must be submitted to the Agency Contract Manager for review prior to implementation. The Agency shall complete its review within forty-five (45) days of receipt.

19. Encounter Data

a. General Provisions

(1) Encounter data collection and submission is required from the Managed Care Plan for all services funded wholly or partially by Medicaid, rendered to its enrollees (excluding services paid directly by the Agency or paid directly by CMS on a fee-for-service (FFS) basis). The Managed Care Plan shall submit encounter data that meets established Agency data quality standards as defined herein. These standards are defined by the Agency to ensure receipt of complete and accurate data for program administration and to set actuarially sound capitation rates. These standards are closely monitored and enforced. (42 CFR 438.242(b)(1); 42 CFR 438.604(a)(1); 42 CFR 438.606; 42 CFR 438.818)

(2) The Managed Care Plan shall receive amended standards with advance notice as described in this Section to ensure continuous quality improvement. The Managed Care Plan shall make changes or corrections to any systems, processes, or data transmission formats as needed to comply with the Agency’s data quality standards. The Managed Care Plan shall receive:

(a) No notice for Medicaid Companion Guide updates that are informational and/or limited to clarification of existing standards, or setting an edit from deny to pay.

(b) Thirty (30) days’ notice for setting a pay edit to deny or informing the plan of new claim adjustment reason code (CARC) and remittance advice reason code (RARC) combinations.

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 9 of 47

(c) Sixty (60) days’ notice for adding a new and unique plan-related edit.

(d) Ninety (90) days’ notice of a system change resulting in a process change for the Managed Care Plan.

The Managed Care Plan must be capable of sending and receiving any claims information directly to the Agency meeting the above standards and timeframes.

(3) The Managed Care Plan must certify all data to the extent required in 42 CFR 438.606. Such certification must be submitted to the Agency concurrently with the data and must be based on the knowledge, information and belief of the chief executive officer (CEO), chief financial officer (CFO), Chief Medical Officer or an individual who has written delegated authority to sign for, and directly reports to the CEO or CFO that all data submitted in conjunction with the encounter data and all documents requested by the Agency are accurate, truthful, and complete. (42 CFR 438.604(a)(2); 42 CFR 438.606; 42 CFR 438.3; 42 CFR 438.5(c))

(4) The Managed Care Plan shall have the capacity to identify encounter data anomalies and shall provide a description of that process to the Agency for review and approval.

(5) The Managed Care Plan shall designate sufficient information technology (IT) and staffing resources to perform these encounter functions as determined by generally accepted best industry practices.

(6) The Managed Care Plan shall retain submitted encounter data for a period not less than ten (10) years. (42 CFR 438.3(u))

(7) The Managed Care Plan shall participate in Agency-sponsored workgroups directed at continuous improvements in encounter data quality and processes.

b. Requirements for Complete and Accurate Encounters

The Managed Care Plan shall establish and maintain a comprehensive automated and integrated encounter data system capable of capturing, storing, and transmitting complete, accurate and timely encounter data to the Agency.

(1) All Managed Care Plan encounters shall be submitted to the

Agency in the standard HIPAA transaction formats, namely the American Nation Standards Institute (ANSI) X12N 837

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 10 of 47 transaction formats (P — Professional; I — Institutional; D

— Dental), and, for pharmacy services, in the current National Council for Prescribed Drug Programs (NCPDP) format. The Managed Care Plan’s encounters shall also follow the standards in the Agency’s 5010 Companion Guides, the Florida D.0 Payer Specification – Encounters and in this Section. Encounters must include Managed Care Plan amounts paid to the providers and shall be submitted for all providers (capitated and non-capitated).

(2) The Managed Care Plan shall follow the instructions in the

User Guide and Report Guide regarding the reporting of pharmacy encounter data using the NCPDP standard D. 0.

Format and field definitions. Additionally, the Managed Care Plan shall submit all denied pharmacy encounter data and the reason code(s) for denial of prescriptions. The NCPDP edits are described in the National Council for Prescription Drug Programs Telecommunications Standard Guides.

Pharmacy benefits system edits are defined on the following website:

http://portal.flmmis.com/FLPublic/Provider_ManagedCare/ Provider_ManagedCare_Encounter/Provider_ManagedCar e_Pharmacy/tabId/82/Default.aspx.

(3) The Managed Care Plan shall convert all information that enters its claims system via hard copy paper claims or other proprietary formats to encounter data to be submitted in the appropriate HIPAA-compliant formats.

(4) For any services in which a Managed Care Plan has entered into capitation reimbursement arrangements with providers, the Managed Care Plan shall comply with all encounter data submission requirements in this Section. The Managed Care Plan shall require timely submissions from its providers as a condition of the capitation payment.

(5) The Managed Care Plan shall implement and maintain review procedures to validate encounter data submitted by providers.

(6) The Managed Care Plan shall ensure all encounter data submissions include the actual amount paid to providers.

(7) For all services rendered to its enrollees (excluding services paid directly by the Agency or paid directly by CMS on a FFS basis), the Managed Care Plan shall submit encounter data, without alteration or omission of provider submitted data, no later than thirty (30) days following the date on which the Managed Care Plan completed adjudication of the Florida Medicaid portion of the claims. The Managed Care

DocuSign Envelope ID: 438D9E69-6D65-47D0-B744-483DA4528286 http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabId/82/Default.aspx http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabId/82/Default.aspx http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabId/82/Default.aspx

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 11 of 47

Plan shall append to the provider-submitted data the Managed Care Plan data required by the Agency as described in the Medicaid Companion Guides.

(8) For Non-Pharmacy Encounters (X12):

(a) The Managed Care Plan shall submit encounters for no less than one hundred percent (100%) of the covered services provided by participating and non-participating providers.

(b) No less than ninety-five percent (95%) of the

Managed Care Plan’s encounter lines submission shall pass Florida Medicaid Management Information System (FMMIS) system edits as specified by the Agency.

(9) For encounter data acceptance purposes the Managed Care Plan must ensure the provider information it supplies to the Agency is sufficient to ensure providers are recognized in FMMIS.

c. Encounter Data Submission

(1) The Managed Care Plan shall collect and submit encounter data to the Agency’s fiscal agent. The Managed Care Plan shall be held responsible for errors or noncompliance resulting from their own actions or the actions of an agent authorized to act on its behalf.

(2) The encounter data submission standards required to support encounter data collection and submission are defined by the Agency in the Medicaid Companion Guides, Pharmacy Payer Specifications and this Section. In addition, encounter data reporting requirements shall be posted on the following websites:

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_E

DI_CompanionGuides/tabId/62/Default.aspx http://portal.flmmis.com/flpublic/Provider_ManagedCare/Pr ovider_ManagedCare_Encounter/Provider_ManagedCare _Pharmacy/tabid/82/desktopdefault/+/Default.aspx.

(3) The Managed Care Plan shall implement and maintain review procedures to validate the successful loading of encounter files by the Agency’s fiscal agent’s Electronic Data Interchange (EDI) clearinghouse. The Managed Care Plan shall use the EDI response (acknowledgement) files to determine if files were successfully loaded. Within seven (7)

DocuSign Envelope ID: 438D9E69-6D65-47D0-B744-483DA4528286 http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_CompanionGuides/tabId/62/Default.aspx http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_CompanionGuides/tabId/62/Default.aspx http://portal.flmmis.com/flpublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabid/82/desktopdefault/+/Default.aspx http://portal.flmmis.com/flpublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabid/82/desktopdefault/+/Default.aspx http://portal.flmmis.com/flpublic/Provider_ManagedCare/Provider_ManagedCare_Encounter/Provider_ManagedCare_Pharmacy/tabid/82/desktopdefault/+/Default.aspx

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 12 of 47 days of the original submission attempt, the Managed Care Plan shall correct and resubmit files that fail to load.

(4) Encounter Resubmission – Adjustments, Reversals or

Corrections

(a) Within thirty (30) days after encounters fail NCPDP edits, X12 (EDI) edits or FMMIS system edits, the Managed Care Plan shall correct and resubmit all encounters for which errors can be remedied.

(b) The Managed Care Plan shall correct and resubmit one hundred percent (100%) of previously submitted X12 encounter data transactions to reflect the most current and accurate payment adjustments or reversals that resulted in a recoupment or additional payment within thirty (30) days of the respective action.

(c) The Managed Care Plan shall correct and resubmit one hundred percent (100%) of previously submitted NCPDP encounter data transactions to reflect the most current and accurate payment adjustments or reversals that resulted in a recoupment or additional payment within thirty (30) days of the respective action.

(5) If the Managed Care Plan fails to comply with the encounter data reporting requirements of this Contract, the Managed Care Plan may be subject to sanctions, pursuant to Section III.B.2., or liquidated damages, pursuant to Section III.B.1., Performance Standards and Liquidated Damages.

C. Deliverables

1. The Managed Care Plan shall provide documentation of the following to the Agency Contract Manager prior to any payment being made to the Managed Care Plan. In addition, the Managed Care Plan shall maintain current documentation throughout the term of this Contract to be provided to the Agency upon request.

a. Valid certificate of authority issued by the State of Florida

Department of Financial Services Office of Insurance Regulation as a risk bearing entity (either a health maintenance organization or a health insurer) and notification within five (5) business days of status change.

b. Approval from CMS qualifying as a D-SNP for each calendar year of this Contract and notification within five (5) business days of status change.

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 13 of 47

c. Certificate of Liability Insurance within five (5) business days of renewal or status change.

2. Prior to Contract execution, upon request, and upon modification, the

Managed Care Plan shall submit to the Agency Contract Manager:

a. For review and approval: the grievance and appeal enrollee notice templates, to include the notice of adverse benefit determination, notice of plan appeal resolution, grievance acknowledgement and resolution.

b. For review: the Summary of Benefits, Enrollee Handbook, Explanation of Coverage, Provider Handbook, and Provider Termination Templates.

The Agency shall complete its review within forty-five (45) days of receipt.

3. The Managed Care Plan shall provide the Agency with the service area(s) covered by this Contract as provided in Attachment I, Scope of Services, Exhibit D – Effective January 1, 2023, D-SNP Type and Applicable Service Areas. Attachment I, Scope of Services, Exhibit D – Effective January 1, 2023, D-SNP Type and Applicable Service Areas, shall be submitted to the Agency Contract Manager for review prior to any payment being made to the Managed Care Plan. The Agency shall complete its review within forty-five (45) days of receipt.

4. The Managed Care Plan shall refer to Attachment I, Scope of Services, Exhibit B – Effective January 1, 2023, Required Documentation and Reporting, for a listing of deliverable requirements.

D. Reporting

1. The Managed Care Plan shall comply with all reporting requirements, including submission timeframes as prescribed by the Agency when requested by the Agency.

2. The Managed Care Plan shall be required to provide to the Agency or its agents any other information, documentation, or data relative to this Contract in accordance with 42 CFR 438.604(b). In such instances, and at the direction of the Agency, the Managed Care Plan shall fully cooperate with such requests and furnish all data or information in a timely manner, in the format in which it is requested. The Managed Care Plan shall have at least thirty (30) days to fulfill such ad hoc requests, unless the Agency directs the Managed Care Plan to provide data or information in less than thirty (30) days. The Managed Care Plan shall certify that data and information it submits to the Agency is accurate, truthful, and complete in accordance with 42 CFR 438.606.

3. The Managed Care Plan is responsible for assuring the accuracy, completeness, and timely submission of each report.

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4. The Managed Care Plan’s chief executive officer (CEO), chief financial officer (CFO), or an individual who directly reports to the CEO or CFO and who has delegated authority to certify the Managed Care Plan’s reports, must attest, based on his/her best knowledge, information, and belief, that all data submitted in conjunction with the reports and all documents requested by the Agency are accurate, truthful, and complete (42 CFR 438.606(a) and (b)) under penalty of perjury. The Managed Care Plan shall submit its certification at the same time it submits the certified data reports (42 CFR 438.606(c)). The certification page shall be scanned and submitted electronically to the Agency.

5. The Managed Care Plan shall submit to the Agency the Unaudited D-SNP

Financial Report annually by July 1st.

6. The Managed Care Plan shall submit to the Agency the Independently Audited D-SNP Financial Report annually by September 15th.

7. The Managed Care Plan shall submit to the Agency the Medicare Contract number, Plan Benefit Package (PBP) number, and service areas for each PBP in Florida. Approved PBPs and service areas must be submitted to the Agency annually by October 15th. Any proposed amendments to the PBPs or service areas must be submitted to the Agency upon initial submission to CMS for review.

8. The Managed Care Plan shall submit to the Agency the Managed Care

Plan’s policies and procedures for ensuring compliance with HIPAA prior to Contract execution, upon request, and upon modification.

9. The Managed Care Plan shall submit to the Agency the Managed Care

Plan’s policies and procedures for subcontractors upon request.

10. Prior to Contract execution, the Managed Care Plan shall provide the Agency a copy of its policies and procedures for approval relating to the following: (i) How the Managed Care Plan will determine eligibility for each enrollee and what type of transportation to provide that enrollee; (ii) The Managed Care Plan's procedure for providing prior authorization to enrollees requesting transportation services; (iii) How the Managed Care Plan will review transportation providers to prevent and/or identify those who falsify encounter or service reports, overstate reports or upcode service levels, or commit any form of fraud or abuse as defined in s.

409.913, FS; (iv) How the Managed Care Plan will deal with providers who alter, falsify or destroy records before the end of the retention period; make false statements about credentials; misrepresent medical information to justify referrals; fail to provide scheduled transportation; or charge enrollees for covered services; and (v) How the Managed Care Plan will provide transportation services outside its region.

11. The Managed Care Plan shall submit to the Agency all non-patient-level reporting exchanged with CMS or the National Committee for Quality Assurance (NCQA), including but not limited to the Finalized Special Needs Plan Model of Care (MOC) with MOC score and all summary-level

AHCA Contract No. FP083, Attachment I – Effective 01/01/23, Page 15 of 47 performance reporting exchanged with CMS or NCQA, within five (5) business days of exchange with CMS or NCQA.

E. Monitoring

1. The Managed Care Plan shall comply with all requirements as specified in this Contract. The Agency shall utilize the Manage Care Plan’s submissions specified in Attachment I, Scope of Services, Exhibit B – Effective January 1, 2023, Required Documentation and Reporting, for monitoring progress or performance of the contractual services as specified in this Contract.

2. The Managed Care Plan shall permit persons duly authorized by the Agency to inspect any records, papers, documents, facilities, goods and services of the Managed Care Plan which are relevant to this Contract. The Managed Care Plan shall require providers to cooperate fully with the Agency (or its designee), CMS, the Office of the Inspector General (OIG), the Comptroller General, and Attorney General’s Office for the inspection, evaluation, and auditing of any records or documents (medical or financial) of the Managed Care Plan or its subcontractors at any time, related to this Contract (42 CFR 438.3(h)). The State, CMS, and Department of Health & Human Services (DHHS) may inspect and audit any financial records of the Managed Care Plan or its subcontractors, as well as financial records from parent companies relating to corporate or administrative charges included on financial reports submitted by the Managed Care Plan to the Agency. Pursuant to s. 1903(m)(4)(A) of the Act and the State Medicaid Manual 2087.6(A-B), non-federally qualified Managed Care Plans shall report to the State, upon request, and to the Secretary and the Inspector General of DHHS, a description of certain transactions with parties of interest as defined in s. 1318(b) of the Act. The Managed Care Plan shall make any reports of transactions between the Managed Care Plans and parties in interest that are provided to the State or other agencies to its enrollees, upon reasonable request, as provided at Section 1903(m)(4)(A)-

(B) of the Act.

3. The Managed Care Plan will be reviewed each quarter for the documents required under Exhibit B – Effective January 1, 2023, Required Documentation and Reporting, of this Contract. The Managed Care Plan will be notified of any deficiencies in writing. The escalation process will involve liquidated damages and/or sanctions up to Contract termination.

F. Performance Requirements

1. The Managed Care Plan shall timely submit to the Agency all requirements specified in Exhibit B – Effective January 1, 2023, Required Documentation and Reporting, of this Contract.

2. The Managed Care Plan agrees to participate in meetings with the Agency to foster enhanced communication, strategic planning, and collaboration in coordinating benefits and to address any major organizational challenges and/or barriers during the implementation process. If the Managed Care

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Plan fails to comply with the requirements of this section, the Managed Care Plan may be subject to sanctions, pursuant to Section III.B.2., Sanctions, or liquidated damages, pursuant to Section III.B.1., Performance Standards and Liquidated Damages, as determined by the

3. The Managed Care Plan shall complete all Health Risk Assessments (HRAs) within the timeframes required by CMS. Such HRAs shall include assessments of social determinants of health (SDOH); at the time of the HRA, the Managed Care Plan shall initiate closed-loop referrals to community-based organizations to address unmet social needs that are consistent with beneficiary and/or caregiver priorities. The Agency reserves the right to request evidence of this activity on an ad-hoc basis.

4. The Managed Care Plan shall complete Follow-Up After Hospitalization for Mental Illness within thirty (30) days, as specified by NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) measure.

III. Method of Payment:

A. Compensation

1. The Managed Care Plan shall be compensated a rate per member per month found in Attachment I, Scope of Services, Exhibit C – Effective January 1, 2023, D-SNP Capitation Rates.

2. Any changes to the monthly per enrollee payment shall be incorporated into this Contract via formal amendment.

3. There shall be no other payment to the Managed Care Plan under this

Contract.

4. The Agency will establish for each calendar year, through actuarial consultation, the monthly per member payment.

5. The Managed Care Plan shall provide the Agency with all necessary and pertinent information, as determined necessary by the Agency, so the Agency may consult with the actuaries in establishing payment rates for services provided to enrollees eligible under Title XIX of the Act.

6. The Managed Care Plan agrees to accept the Agency’s monthly per member payment as payment in full for Medicaid services covered under this Contract.

7. Any claims processed by the Agency for enrollees shall be deducted from future per member payments. The Agency will provide a list of any such claims paid, which will identify the enrollee, the health care provider who submitted the claim for the service provided, and the amount paid by the

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8. The Managed Care Plan agrees that any Medical Loss Ratio calculations will be as specified in 42 CFR 438.8.

9. In the event of overpayment, the Managed Care Plan shall refund the full amount overpaid. An overpayment includes any amount paid by the Medicaid program as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

10. Adjustments to funds previously paid and to be paid may be required.

Funds previously paid shall be adjusted when payment calculations are determined to have been in error, or when payments have been made for individuals who are determined to be ineligible for enrollment during the period for which the payments were made. In such events, the Managed Care Plan agrees to refund any overpayment and the Agency agrees to pay any underpayment.

11. If after preparation and electronic submission, either the Managed Care

Plan or the Agency discover an error, including but not limited to errors resulting in eligibility or enrollment errors, errors resulting in incorrect identification of enrollees, errors resulting in incorrect claims payments, and errors resulting in rate payments above the Managed Care Plan’s authorized enrollment levels, the Managed Care Plan has thirty (30) calendar days after its discovery of the error, or from its receipt of Agency notice of the error, to correct the error and re-submit accurate reports.

Failure to respond within the thirty (30) calendar day period shall result in a loss of any money due the Managed Care Plan for such errors and/or liquidated damages against the Managed Care Plan.

B. Financial Consequences as Liquidated Damages

1. Performance Standards and Liquidated Damages

a. The Managed Care Plan shall comply with all requirements and performance standards set forth in this Contract.

b. The Agency reserves the right to impose liquidated damages upon the Managed Care Plan for failure to perform any of the required components of this Contract. The Agency may base its determinations on liquidated damages from findings regarding onsite surveys, complaints from enrollees or other complaints, financial status, Managed Care Plan reports, or any other source.

c. The Agency’s Contract Manager will monitor the Managed Care

Plan’s performance in accordance with the monitoring requirements of this Contract. Failure by the Managed Care Plan to meet the established minimum performance standards may result in the Agency, in its sole discretion, finding the Managed Care Plan to be out of compliance, and all remedies provided in this Contract and under law, shall become available to the Agency.

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d. The Agency reserves the right to impose liquidated damages upon the Managed Care Plan for failure to comply with the performance standard requirements set forth in this Contract. The maximum amounts of liquidated damages to be imposed for failure to comply are set forth in Table 1-B, Liquidated Damages Issues and Amounts, below. The total amount of liquidated damages imposed shall not exceed twenty (20) percent of the Managed Care Plan’s capitation payments in the Calendar Year.

e. Liquidated damages are due from the Managed Care Plan within twenty-one (21) calendar days from receipt of the notice of liquidated damages.

f. The Agency reserves the right to withhold all or a portion of the

Managed Care Plan’s monthly per member payment for any amount owed to the Agency.

TABLE 1-B

LIQUIDATED DAMAGES ISSUES AND AMOUNTS

# Program Issues Damages

HIPAA

1 Failure to comply with provisions of Health Insurance Portability and Accountability Act (HIPAA) / Health Information Technology for Economic and Clinical Health (HITECH).

$500.00 to $5,000.00, per incident, per occurrence, depending upon the severity. In addition, Federal penalties may apply in accordance with the HIPAA Act of 1996.

Records 2 Failure to comply with public records laws, in accordance with Section 119.0701, F.S.

$5,000.00 for each incident in which the Managed Care Plan does not comply with a public records request.

Background Screening 3 Failure to complete initial and renewal background screenings within required timeframes.

$250.00 per occurrence.

4 Failure to submit background screening policies and procedures within thirty (30) calendar days of Contract execution.

$250.00 per calendar day beyond the due date.

Reporting 5 Failure to timely submit complete and accurate unaudited and audited annual financial statements as described in this Contract

$500.00 per day for each day that reporting requirements are not met.

6 Failure to submit inappropriate report certifications and/or failure to submit report attestations as described in this Contract

$250.00 per occurrence.

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TABLE 1-B

LIQUIDATED DAMAGES ISSUES AND AMOUNTS

# Program Issues Damages 7 Failure to file required reports timely as described in this Contract $500.00 per occurrence.

8 Failure to file accurate reports as described in this Contract

$1000.00 per occurrence.

Services 9 Failure to implement the approved

Corrective Action Plan (CAP) by the Agency specified date.

$500.00 per calendar day for each calendar day that the approved CAP is not implemented to the satisfaction of the Agency.

10 Failure to respond to an Agency communication within the time prescribed by the Agency as described in this Contract.

$500.00 for each day beyond the due date until provided to the Agency.

11 Failure to provide covered services with reasonable promptness.

$2,500.00 per occurrence.

12 Failure by the Managed Care Plan to timely report violations in the access, use and disclosure of Protected Health Information (PHI) or timely report a security incident or timely make a notification of breach or notification of provisional breach as described in this Contract. See also ancillary Business Associate Agreement (BAA) between the parties.

$500.00 per enrollee per occurrence, not to exceed $10,000,000.00.

13 Failure to timely complete health risk assessment (HRA), as required by this Contract

$500.00 per occurrence

14 Failure to Follow-Up After Hospitalization for Mental Illness within thirty (30) days, as required by this Contract

$2,500.00 per occurrence

15 Failure to comply with the grievance and appeal notice requirements described in this Contract.

$1,000.00 per day

16 Failure to comply with timeframes for the grievance and appeal system.

$500.00 per occurrence

17 Failure to comply with all orders/official decisions relating to claim disputes, grievances, appeals and/or fair hearings, as they are issued.

$10,000.00 per occurrence.

18 Failure to provide continuation of services during the pendency of a Medicaid fair hearing and/or the Managed Care Plan’s appeal process where the enrollee has challenged a reduction or elimination of services as required by this…