Commonwealth of virginia department of medical assistance services



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12/10/16

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

DRAFT



COMMONWEALTH COORDINATED CARE PLUS MCO CONTRACT

FOR MANAGED LONG TERM SERVICES AND SUPPORTS


July 1, 2017 – December 31, 2017


SECTION 1.0 SCOPE OF CONTRACT  3

1.1 APPLICABLE LAWS, REGULATIONS, AND INTERPRETATIONS 3

1.2 COMMITMENT TO DEPARTMENT GOALS FOR DELIVERY SYSTEM REFORM AND PAYMENT TRANSFORMATION 4

SECTION 2.0 REQUIREMENTS PRIOR TO OPERATIONS 5

2.1 ORGANIZATIONAL STRUCTURE 5

2.2 READINESS REVIEW 7

2.3 LICENSURE 7

2.4 CERTIFICATION 8

2.5 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION 8

2.6 DUAL ELIGIBLE SPECIAL NEEDS PLAN (D-SNP) 8

2.7 BUSINESS ASSOCIATE AGREEMENT (BAA) 8

2.8 AUTHORIZATION TO CONDUCT BUSINESS IN THE COMMONWEALTH 9

2.9 CONFIDENTIALITY STATUTORY REQUIREMENTS 9

2.10 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST 10

2.11 PROHIBITED AFFILIATIONS WITH ENTITIES DEBARRED BY FEDERAL AGENCIES 11

2.12 EXCLUDED ENTITIES 11

2.13 CONTRACTOR COMPLIANCE PROGRAM 12

SECTION 3.0 ENROLLMENT AND ASSIGNMENT PROCESS 14

3.1 ELIGIBILITY AND ENROLLMENT RESPONSIBILITIES 14



3.2 CCC PLUS ENROLLMENT PROCESS 16

SECTION 4.0 BENEFITS AND SERVICE REQUIREMENTS 24

4.1 GENERAL BENEFITS PROVISIONS 24

4.2 BEHAVIORAL HEALTH SERVICES 24

4.3 DENTAL AND RELATED SERVICES 34

4.4 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) 36

4.5 EARLY INTERVENTION (EI) 38

4.6 EMERGENCY AND POSTSTABILIZATION SERVICES 39

4.7 LONG TERM CARE SERVICES AND SUPPORTS 39

4.8 PHARMACY SERVICES 57

4.9 TELEMEDICINE SERVICES 63

4.10 TRANSPORTATION SERVICES 64

4.11 CARVED OUT SERVICES 68

4.12 STATE PLAN SUBSTITUTED (IN LIEU OF) SERVICES 69

4.13 ENHANCED BENEFITS 69

4.14 SERVICES RELATED TO FEDERAL MORAL/RELIGIOUS OBJECTIONS 70

4.15 TRANSLATION SERVICES 70

SECTION 5.0 CCC PLUS MODEL OF CARE 72

5.1 GENERAL REQUIREMENTS AND COVERED POPULATIONS 72

5.2 HEALTH RISK ASSESSMENTS (HRA) 73

5.3 PERSON-CENTERED INDIVIDUALIZED CARE PLAN (ICP) 76

5.4 INTERDISCIPLINARY CARE TEAM (ICT) 78

5.5 REASSESSMENTS 80

5.6 CARE COORDINATION STAFFING 81

5.7 CARE COORDINATION PARTNERSHIPS 82

5.8 CARE COORDINATOR STAFFING RATIOS 83

5.9 CARE COORDINATION REQUIREMENTS 84

5.10 CARE COORDINATION WITH TRANSITIONS OF CARE 86

5.11 HOSPITAL AND EMERGENCY DEPARTMENT (ED) ALERT SYSTEM FOR CARE TRANSITIONS 88

5.12 COORDINATION WITH THE MEMBER’S MEDICARE PLAN 89

5.13 CLINICAL WORKGROUP MEETINGS 91

5.14 CONTINUITY OF CARE 91

5.15 CARE DELIVERY MODEL POLICY AND PROCEDURES 94

SECTION 6.0 UTILIZATION MANAGEMENT REQUIREMENTS 100

6.1 GENERAL UTILIZATION MANAGEMENT REQUIREMENTS 100

6.2 SERVICE AUTHORIZATION 100

6.3 PATIENT UTILIZATION MANAGEMENT & SAFETY (PUMS) PROGRAM 105

6.4 ELECTRONIC VISIT VERIFICATION (EVV) SYSTEM 106

6.5 NOTIFICATION TO THE DEPARTMENT OF SENTINEL EVENTS 106

SECTION 7.0 SUBCONTRACTOR DELEGATION AND MONITORING REQUIREMENTS 107

7.1 GENERAL REQUIREMENTS FOR SUBCONTRACTORS 107

7.2 DELEGATION REQUIREMENTS 108

7.3 MONITORING REQUIREMENTS 108

7.4 DATA SHARING CAPABILITIES 109

7.5 BEHAVIORAL HEALTH SERVICES ADMINISTRATOR 109

7.6 CONSUMER DIRECTION FISCAL/ EMPLOYER AGENT 110

SECTION 8.0 PROVIDER NETWORK MANAGEMENT 112

8.1 GENERAL NETWORK PROVISIONS 112

8.2 SPECIALIZED NETWORK PROVISIONS 113

8.3 CERTIFICATION OF NETWORK ADEQUACY 116

8.4 PROVIDER CREDENTIALING STANDARDS 116

8.5 PROVIDER AGREEMENTS 120

SECTION 9.0 ACCESS TO CARE STANDARDS 125

9.1 GENERAL STANDARDS 125

9.2 NATIVE AMERICAN HEALTH CARE PROVIDERS 125

9.3 CHOICE OF PROVIDER STANDARDS 127

9.4 TWENTY-FOUR HOUR COVERAGE 127

9.5 URGENT CARE ACCESS 127

9.6 EMERGENCY SERVICES COVERAGE 127

9.7 INPATIENT HOSPITAL ACCESS 127

9.8 MEMBER PRIMARY CARE ACCESS (ADULT AND PEDIATRIC) 128

9.9 APPOINTMENT STANDARDS 129

9.10 SECOND OPINIONS 130

9.11 OUT-OF-NETWORK SERVICES 130

9.12 OUT-OF-STATE SERVICES 131

9.13 MEMBER TRAVEL TIME STANDARDS 131

9.14 MEMBER TRAVEL DISTANCE STANDARDS 131

9.15 PROVIDER TRAVEL CONSIDERATIONS 132

9.16 POLICY OF NONDISCRIMINATION 132

9.17 ACCOMMODATING THE DISABLED 132

9.18 ASSURANCES THAT ACCESS STANDARDS ARE BEING MET 133

SECTION 10.0 QUALITY MANAGEMENT AND IMPROVEMENT 134

10.1 QUALITY DEFINITION AND DOMAINS 134

10.2 CONTINUOUS QUALITY IMPROVEMENT PRINCIPLES AND EXPECTATIONS 134

10.3 QUALITY INFRASTRUCTURE 134

10.4 QI PROGRAM DESCRIPTION, WORK PLAN, AND EVALUATION 136

10.5 QI STAFFING 137

10.6 PERFORMANCE MEASUREMENT 138

10.7 PERFORMANCE IMPROVEMENT PROJECTS (PIPS) 140

10.8 EXTERNAL QUALITY REVIEW (EQR) ACTIVITIES 142

10.9 WAIVER ASSURANCES 143

10.10 QI FOR UTILIZATION MANAGEMENT ACTIVITIES 143

10.11 CLINICAL PRACTICE GUIDELINES 144

10.12 QUALITY COLLABORATIVE AND OTHER WORKGROUPS 145

10.13 QUALITY PERFORMANCE INCENTIVE PROGRAM 145

10.14 BEHAVIORAL HEALTH SERVICES OUTCOMES      146

10.15 ARTS SPECIFIC MEASUREMENT AND REPORTING 146

10.16 QUALITY SYSTEM 148

10.17 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION 148

SECTION 11.0 MEMBER SERVICES AND COMMUNICATIONS 150

11.1 MEMBER CALL CENTERS 150

11.2 MEMBER INQUIRIES 153

11.3 MEMBER RIGHTS AND PROTECTIONS 153

11.4 ADVANCED DIRECTIVES 154

11.5 CULTURAL COMPETENCY 154

11.6 COST-SHARING 154

11.7 PROTECTING MEMBER FROM LIABILITY FOR PAYMENT 154

11.8 MEMBER ADVISORY COMMITTEE 155

11.9 PROTECTION OF CHILDREN AND AGED OR INCAPACITATED ADULTS 156

11.10 PROTECTION OF MEMBER-PROVIDER COMMUNICATIONS 156

11.11 MEMBER COMMUNICATIONS AND ENROLLMENT MATERIALS 156

11.12 MARKETING REQUIREMENTS 160

11.13 Prohibited Marketing and Outreach Activities 163

SECTION 12.0 PROVIDER SERVICES AND CLAIMS PAYMENT 165

12.1 PROVIDER CALL CENTER 165

12.2 PROVIDER TECHNICAL ASSISTANCE 167

12.3 PROVIDER EDUCATION 167

12.4 PROVIDER PAYMENT SYSTEM 168

SECTION 13.0 VALUE BASED PAYMENTS 175

13.1 BACKGROUND 175

13.2 CONTRACTOR ANNUAL VBP PLAN 175

13.3 VBP STATUS REPORT 176

13.4 CONTRACTOR HCP-LAN APM DATA COLLECTION SUBMISSION 177

SECTION 14.0 PROGRAM INTEGRITY (PI) AND OVERSIGHT 178

14.1 GENERAL PRINCIPLES 178

14.2 PROGRAM INTEGRITY PLAN, POLICIES, & PROCEDURES 178

14.3 COMPLIANCE OFFICER 180

14.4 PROGRAM INTEGRITY LEAD 180

14.5 TRAINING AND EDUCATION 180

14.6 EFFECTIVE LINES OF COMMUNICATION BETWEEN CONTRACTOR STAFF 181

14.7 ENFORCEMENT OF STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES 181

14.8 PROGRAM INTEGRITY COMPLIANCE AUDIT (PICA) 181

14.9 DEVELOPMENT OF CORRECTIVE ACTION INITIATIVES 183

14.10 REPORTING AND INVESTIGATING SUSPECTED FRAUD, AND ABUSE TO THE DEPARTMENT 184

14.11 QUARTERLY FRAUD/WASTE/ABUSE REPORT 184

14.12 COOPERATION WITH STATE AND FEDERAL INVESTIGATIONS 185

14.13 MEDICAID FRAUD CONTROL UNIT (MFCU) 185

14.14 MINIMUM AUDIT REQUIREMENTS 185

14.15 PROVIDER AUDITS, OVERPAYMENTS, AND RECOVERIES 185

SECTION 15.0 MEMBER AND PROVIDER GRIEVANCES AND APPEALS 187

15.1 GENERAL REQUIREMENTS 187

15.2 GRIEVANCES 187

15.3 GENERAL APPEALS REQUIREMENTS 188

15.4 CONTRACTOR LEVEL APPEALS 189

15.5 STATE FAIR HEARING PROCESS 191

15.6 PROVIDER APPEALS 192

15.7 EVALUATION OF GRIEVANCES AND APPEALS 193

15.8 GRIEVANCE AND APPEAL REPORTING 194

15.9 DOCUMENT PRESERVATION 194

SECTION 16.0 INFORMATION MANAGEMENT SYSTEMS 195

16.1 GENERAL REQUIREMENTS 195

16.2 DESIGN REQUIREMENTS 195

16.3 SYSTEM ACCESS MANAGEMENT AND INFORMATION ACCESSIBILITY REQUIREMENTS 195

16.4 SYSTEM AVAILABILITY AND PERFORMANCE REQUIREMENTS 196

16.5 ELECTRONIC CARE COORDINATION SYSTEM 196

16.6 CENTRAL DATA REPOSITORY 197

16.7 DATA INTERFACES SENT TO AND RECEIVED FROM DMAS 198

16.8 INTERFACE AND CONNECTIVITY TO THE VIRGINIA MEDICAID MANAGEMENT INFORMATION SYSTEM (VAMMIS) AND MEDICAID ENTERPRISE SYSTEM (MES) 198

16.9 DATA QUALITY REQUIREMENTS 199

16.10 DATA SECURITY AND CONFIDENTIALITY OF RECORDS 206

SECTION 17.0 REPORTING REQUIREMENTS 212

17.1 GENERAL REQUIREMENTS 212

17.2 ALL PAYERS CLAIM DATABASE 213

17.3 CRITICAL INCIDENT REPORTING AND MANAGEMENT 214

SECTION 18.0 ENFORCEMENT, REMEDIES, AND COMPLIANCE 215

18.1 CCC PLUS PROGRAM EVALUATION ACTIVITIES 215

18.2 PROGRAM INTEGRITY COMPLIANCE AUDIT (PICA) 215

18.3 COMPLIANCE MONITORING PROCESS (CMP) 215

18.4 OTHER – SPECIFIC PRE-DETERMINED SANCTIONS 218

18.5 REMEDIAL ACTIONS 218

18.6 CORRECTIVE ACTION PLAN 223

18.7 INTERMEDIATE SANCTIONS AND CIVIL MONETARY PENALTIES 224

SECTION 19.0 CONTRACTOR PAYMENT AND FINANCIAL PROVISIONS 226

19.1 FINANCIAL STATEMENTS 226

19.2 REPORTING OF REBATES 227

19.3 FINANCIAL RECORDS 227

19.4 FINANCIAL SOLVENCY 227

19.5 CHANGES IN RISK based capital requirements 227

19.6 HEALTH INSURER FEE 227

19.7 MINIMUM MEDICAL LOSS RATIO (MLR) 228

19.8 REINSURANCE 229

19.9 CAPITATION RATES 230

19.10 CERTIFICATION (NON-ENCOUNTERS) 234

SECTION 20.0 APPEAL RIGHTS OF THE CONTRACTOR 235

20.1 CONTRACTOR RIGHT TO APPEAL 235

20.2 DISPUTES ARISING OUT OF THE CONTRACT 235

20.3 INFORMAL RESOLUTION OF CONTRACT DISPUTES 235

20.4 PRESENTATION OF DOCUMENTED EVIDENCE 235

SECTION 21.0 RENEWAL/TERMINATION OF CONTRACT 237

21.1 CONTRACT RENEWAL 237

21.2 SUSPENSION OF CONTRACTOR OPERATIONS 237

21.3 TERMS OF CONTRACT TERMINATION 237

21.4 TERMINATION PROCEDURES 240

SECTION 22.0 GENERAL TERMS AND CONDITIONS 243

22.1 NOTIFICATION OF ADMINISTRATIVE CHANGES 243

22.2 ASSIGNMENT 243

22.3 INDEPENDENT CONTRACTORS 243

22.4 BUSINESS TRANSACTION REPORTING 243

22.5 LOSS OF LICENSURE 243

22.6 INDEMNIFICATION 244

22.7 CONFLICT OF INTEREST 244

22.8 INSURANCE FOR CONTRACTOR'S EMPLOYEES 244

22.9 IMMIGRATION AND CONTROL ACT OF 1986 244

22.10 SEVERABILITY 244

22.11 ANTI-BOYCOTT COVENANT 244

22.12 RECORD RETENTION, INSPECTION, AND AUDITS 245

22.13 OPERATION OF OTHER CONTRACTS 245

22.14 PREVAILING CONTRACT 246

22.15 NO THIRD-PARTY RIGHTS OR ENFORCEMENT 246

22.16 EFFECT OF INVALIDITY OF CLAUSES 246

22.17 APPLICABLE LAW 246

22.18 SOVEREIGN IMMUNITY 246

22.19 WAIVER OF RIGHTS 246

22.20 INSPECTION 247

22.21 DEBARMENT STATUS 247

22.22 ANTITRUST 247

22.23 DRUG-FREE WORKPLACE 247

SECTION 23.0 DEFINITIONS AND ACRONYMS 248

23.1 DEFINITIONS 248

23.2 ACRONYMS 278

ATTACHMENTS 283

ATTACHMENT 1 - CCC PLUS CONTRACTOR SPECIFIC CONTRACT TERMS 283

ATTACHMENT 2 - BUSINESS ASSOCIATE AGREEMENT 286

ATTACHMENT 3 - BHSA/CCC PLUS MCO COORDINATION AGREEMENT 294

ATTACHMENT 4 - SAMPLE CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION 298

ATTACHMENT 5 - CCC PLUS COVERAGE CHART 299

ATTACHMENT 6 - DMAS DEVELOPMENTAL DISABILITY WAIVER SERVICES 364

ATTACHMENT 7 - CCC PLUS PROGRAM REGIONS AND LOCALITIES 365

ATTACHMENT 8 - COMMON DEFINITIONS FOR MANAGED CARE TERMS 366

ATTACHMENT 9 - CERTIFICATION OF DATA (NON-ENCOUNTER) 369

ATTACHMENT 10 – EI FAMILY DECLINING TO BILL PRIVATE INSURANCE 370

ATTACHMENT 11 - MOC ASSESSMENT AND INDIVIDUALIZED CARE PLAN (ICP) EXPECTATIONS 371

ATTACHMENT 12 - INDIVIDUALIZED CARE PLAN (ICP) REQUIREMENTS CHECKLIST (PER CMS FINAL RULE) 373

ATTACHMENT 13 - NOTIFICATION OF PROVIDER INVESTIGATION 374


CCC Plus Contract Table of Contents

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