12/10/16
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
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 10
1.1 APPLICABLE LAWS, REGULATIONS, AND INTERPRETATIONS 10
1.2 COMMITMENT TO DEPARTMENT GOALS FOR DELIVERY SYSTEM REFORM AND PAYMENT TRANSFORMATION 11
SECTION 2.0 REQUIREMENTS PRIOR TO OPERATIONS 12
2.1 ORGANIZATIONAL STRUCTURE 12
2.2 READINESS REVIEW 14
2.3 LICENSURE 14
2.4 CERTIFICATION 15
2.5 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION 15
2.6 DUAL ELIGIBLE SPECIAL NEEDS PLAN (D-SNP) 15
2.7 BUSINESS ASSOCIATE AGREEMENT (BAA) 15
2.8 AUTHORIZATION TO CONDUCT BUSINESS IN THE COMMONWEALTH 16
2.9 CONFIDENTIALITY STATUTORY REQUIREMENTS 16
2.10 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST 17
2.11 PROHIBITED AFFILIATIONS WITH ENTITIES DEBARRED BY FEDERAL AGENCIES 17
2.12 EXCLUDED ENTITIES 18
2.13 CONTRACTOR COMPLIANCE PROGRAM 19
SECTION 3.0 ENROLLMENT AND ASSIGNMENT PROCESS 21
3.1 ELIGIBILITY AND ENROLLMENT RESPONSIBILITIES 21
3.2 CCC PLUS ENROLLMENT PROCESS 23
SECTION 4.0 BENEFITS AND SERVICE REQUIREMENTS 31
4.1 GENERAL BENEFITS PROVISIONS 31
4.2 BEHAVIORAL HEALTH SERVICES 31
4.3 DENTAL AND RELATED SERVICES 41
4.4 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) 43
4.5 EARLY INTERVENTION (EI) 45
4.6 EMERGENCY AND POSTSTABILIZATION SERVICES 46
4.7 LONG TERM CARE SERVICES AND SUPPORTS 46
4.8 PHARMACY SERVICES 64
4.9 TELEMEDICINE SERVICES 70
4.10 TRANSPORTATION SERVICES 71
4.11 CARVED OUT SERVICES 75
4.12 STATE PLAN SUBSTITUTED (IN LIEU OF) SERVICES 76
4.13 ENHANCED BENEFITS 76
4.14 SERVICES RELATED TO FEDERAL MORAL/RELIGIOUS OBJECTIONS 77
4.15 TRANSLATION SERVICES 77
SECTION 5.0 CCC PLUS MODEL OF CARE 79
5.1 GENERAL REQUIREMENTS AND COVERED POPULATIONS 79
5.2 HEALTH RISK ASSESSMENTS (HRA) 80
5.3 PERSON-CENTERED INDIVIDUALIZED CARE PLAN (ICP) 83
5.4 INTERDISCIPLINARY CARE TEAM (ICT) 85
5.5 REASSESSMENTS 87
5.6 CARE COORDINATION STAFFING 88
5.7 CARE COORDINATION PARTNERSHIPS 89
5.8 CARE COORDINATOR STAFFING RATIOS 90
5.9 CARE COORDINATION REQUIREMENTS 91
5.10 CARE COORDINATION WITH TRANSITIONS OF CARE 93
5.11 HOSPITAL AND EMERGENCY DEPARTMENT (ED) ALERT SYSTEM FOR CARE TRANSITIONS 95
5.12 COORDINATION WITH THE MEMBER’S MEDICARE PLAN 96
5.13 CLINICAL WORKGROUP MEETINGS 98
5.14 CONTINUITY OF CARE 98
5.15 CARE DELIVERY MODEL POLICY AND PROCEDURES 101
SECTION 6.0 UTILIZATION MANAGEMENT REQUIREMENTS 107
6.1 GENERAL UTILIZATION MANAGEMENT REQUIREMENTS 107
6.2 SERVICE AUTHORIZATION 107
6.3 PATIENT UTILIZATION MANAGEMENT & SAFETY (PUMS) PROGRAM 112
6.4 ELECTRONIC VISIT VERIFICATION (EVV) SYSTEM 113
6.5 NOTIFICATION TO THE DEPARTMENT OF SENTINEL EVENTS 113
SECTION 7.0 SUBCONTRACTOR DELEGATION AND MONITORING REQUIREMENTS 114
7.1 GENERAL REQUIREMENTS FOR SUBCONTRACTORS 114
7.2 DELEGATION REQUIREMENTS 115
7.3 MONITORING REQUIREMENTS 115
7.4 DATA SHARING CAPABILITIES 116
7.5 BEHAVIORAL HEALTH SERVICES ADMINISTRATOR 116
7.6 CONSUMER DIRECTION FISCAL/ EMPLOYER AGENT 117
SECTION 8.0 PROVIDER NETWORK MANAGEMENT 119
8.1 GENERAL NETWORK PROVISIONS 119
8.2 SPECIALIZED NETWORK PROVISIONS 120
8.3 CERTIFICATION OF NETWORK ADEQUACY 123
8.4 PROVIDER CREDENTIALING STANDARDS 123
8.5 PROVIDER AGREEMENTS 127
SECTION 9.0 ACCESS TO CARE STANDARDS 131
9.1 GENERAL STANDARDS 131
9.2 NATIVE AMERICAN HEALTH CARE PROVIDERS 131
9.3 CHOICE OF PROVIDER STANDARDS 132
9.4 TWENTY-FOUR HOUR COVERAGE 132
9.5 URGENT CARE ACCESS 132
9.6 EMERGENCY SERVICES COVERAGE 132
9.7 INPATIENT HOSPITAL ACCESS 132
9.8 MEMBER PRIMARY CARE ACCESS (ADULT AND PEDIATRIC) 132
9.9 APPOINTMENT STANDARDS 134
9.10 SECOND OPINIONS 135
9.11 OUT-OF-NETWORK SERVICES 135
9.12 OUT-OF-STATE SERVICES 136
9.13 MEMBER TRAVEL TIME STANDARDS 136
9.14 MEMBER TRAVEL DISTANCE STANDARDS 136
9.15 PROVIDER TRAVEL CONSIDERATIONS 137
9.16 POLICY OF NONDISCRIMINATION 137
9.17 ACCOMMODATING THE DISABLED 137
9.18 ASSURANCES THAT ACCESS STANDARDS ARE BEING MET 138
SECTION 10.0 QUALITY MANAGEMENT AND IMPROVEMENT 139
10.1 QUALITY DEFINITION AND DOMAINS 139
10.2 CONTINUOUS QUALITY IMPROVEMENT PRINCIPLES AND EXPECTATIONS 139
10.3 QUALITY INFRASTRUCTURE 139
10.4 QI PROGRAM DESCRIPTION, WORK PLAN, AND EVALUATION 141
10.5 QI STAFFING 142
10.6 PERFORMANCE MEASUREMENT 143
10.7 PERFORMANCE IMPROVEMENT PROJECTS (PIPS) 145
10.8 EXTERNAL QUALITY REVIEW (EQR) ACTIVITIES 147
10.9 WAIVER ASSURANCES 148
10.10 QI FOR UTILIZATION MANAGEMENT ACTIVITIES 148
10.11 CLINICAL PRACTICE GUIDELINES 149
10.12 QUALITY COLLABORATIVE AND OTHER WORKGROUPS 150
10.13 QUALITY PERFORMANCE INCENTIVE PROGRAM 150
10.14 BEHAVIORAL HEALTH SERVICES OUTCOMES 151
10.15 ARTS SPECIFIC MEASUREMENT AND REPORTING 151
10.16 QUALITY SYSTEM 153
10.17 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) ACCREDITATION 153
SECTION 11.0 MEMBER SERVICES AND COMMUNICATIONS 155
11.1 MEMBER CALL CENTERS 155
11.2 MEMBER INQUIRIES 158
11.3 MEMBER RIGHTS AND PROTECTIONS 158
11.4 ADVANCED DIRECTIVES 159
11.5 CULTURAL COMPETENCY 159
11.6 COST-SHARING 159
11.7 PROTECTING MEMBER FROM LIABILITY FOR PAYMENT 159
11.8 MEMBER ADVISORY COMMITTEE 160
11.9 PROTECTION OF CHILDREN AND AGED OR INCAPACITATED ADULTS 161
11.10 PROTECTION OF MEMBER-PROVIDER COMMUNICATIONS 161
11.11 MEMBER COMMUNICATIONS AND ENROLLMENT MATERIALS 161
11.12 MARKETING REQUIREMENTS 165
11.13 Prohibited Marketing and Outreach Activities 168
SECTION 12.0 PROVIDER SERVICES AND CLAIMS PAYMENT 170
12.1 PROVIDER CALL CENTER 170
12.2 PROVIDER TECHNICAL ASSISTANCE 172
12.3 PROVIDER EDUCATION 172
12.4 PROVIDER PAYMENT SYSTEM 173
SECTION 13.0 VALUE BASED PAYMENTS 180
13.1 BACKGROUND 180
13.2 CONTRACTOR ANNUAL VBP PLAN 180
13.3 VBP STATUS REPORT 181
13.4 CONTRACTOR HCP-LAN APM DATA COLLECTION SUBMISSION 182
SECTION 14.0 PROGRAM INTEGRITY (PI) AND OVERSIGHT 183
14.1 GENERAL PRINCIPLES 183
14.2 PROGRAM INTEGRITY PLAN, POLICIES, & PROCEDURES 183
14.3 COMPLIANCE OFFICER 185
14.4 PROGRAM INTEGRITY LEAD 185
14.5 TRAINING AND EDUCATION 185
14.6 EFFECTIVE LINES OF COMMUNICATION BETWEEN CONTRACTOR STAFF 186
14.7 ENFORCEMENT OF STANDARDS THROUGH WELL-PUBLICIZED DISCIPLINARY GUIDELINES 186
14.8 PROGRAM INTEGRITY COMPLIANCE AUDIT (PICA) 186
14.9 DEVELOPMENT OF CORRECTIVE ACTION INITIATIVES 188
14.10 REPORTING AND INVESTIGATING SUSPECTED FRAUD, AND ABUSE TO THE DEPARTMENT 189
14.11 QUARTERLY FRAUD/WASTE/ABUSE REPORT 189
14.12 COOPERATION WITH STATE AND FEDERAL INVESTIGATIONS 190
14.13 MEDICAID FRAUD CONTROL UNIT (MFCU) 190
14.14 MINIMUM AUDIT REQUIREMENTS 190
14.15 PROVIDER AUDITS, OVERPAYMENTS, AND RECOVERIES 190
SECTION 15.0 MEMBER AND PROVIDER GRIEVANCES AND APPEALS 192
15.1 GENERAL REQUIREMENTS 192
15.2 GRIEVANCES 192
15.3 GENERAL APPEALS REQUIREMENTS 193
15.4 CONTRACTOR LEVEL APPEALS 194
15.5 STATE FAIR HEARING PROCESS 196
15.6 PROVIDER APPEALS 197
15.7 EVALUATION OF GRIEVANCES AND APPEALS 198
15.8 GRIEVANCE AND APPEAL REPORTING 199
15.9 DOCUMENT PRESERVATION 199
SECTION 16.0 INFORMATION MANAGEMENT SYSTEMS 200
16.1 GENERAL REQUIREMENTS 200
16.2 DESIGN REQUIREMENTS 200
16.3 SYSTEM ACCESS MANAGEMENT AND INFORMATION ACCESSIBILITY REQUIREMENTS 200
16.4 SYSTEM AVAILABILITY AND PERFORMANCE REQUIREMENTS 200
16.5 ELECTRONIC CARE COORDINATION SYSTEM 201
16.6 CENTRAL DATA REPOSITORY 202
16.7 DATA INTERFACES SENT TO AND RECEIVED FROM DMAS 203
16.8 INTERFACE AND CONNECTIVITY TO THE VIRGINIA MEDICAID MANAGEMENT INFORMATION SYSTEM (VAMMIS) AND MEDICAID ENTERPRISE SYSTEM (MES) 203
16.9 DATA QUALITY REQUIREMENTS 204
16.10 DATA SECURITY AND CONFIDENTIALITY OF RECORDS 211
SECTION 17.0 REPORTING REQUIREMENTS 217
17.1 GENERAL REQUIREMENTS 217
17.2 ALL PAYERS CLAIM DATABASE 218
17.3 CRITICAL INCIDENT REPORTING AND MANAGEMENT 219
SECTION 18.0 ENFORCEMENT, REMEDIES, AND COMPLIANCE 220
18.1 CCC PLUS PROGRAM EVALUATION ACTIVITIES 220
18.2 PROGRAM INTEGRITY COMPLIANCE AUDIT (PICA) 220
18.3 COMPLIANCE MONITORING PROCESS (CMP) 220
18.4 OTHER – SPECIFIC PRE-DETERMINED SANCTIONS 223
18.5 REMEDIAL ACTIONS 223
18.6 CORRECTIVE ACTION PLAN 228
18.7 INTERMEDIATE SANCTIONS AND CIVIL MONETARY PENALTIES 229
SECTION 19.0 CONTRACTOR PAYMENT AND FINANCIAL PROVISIONS 231
19.1 FINANCIAL STATEMENTS 231
19.2 REPORTING OF REBATES 232
19.3 FINANCIAL RECORDS 232
19.4 FINANCIAL SOLVENCY 232
19.5 CHANGES IN RISK based capital requirements 232
19.6 HEALTH INSURER FEE 232
19.7 MINIMUM MEDICAL LOSS RATIO (MLR) 233
19.8 REINSURANCE 234
19.9 CAPITATION RATES 235
19.10 CERTIFICATION (NON-ENCOUNTERS) 239
SECTION 20.0 APPEAL RIGHTS OF THE CONTRACTOR 240
20.1 CONTRACTOR RIGHT TO APPEAL 240
20.2 DISPUTES ARISING OUT OF THE CONTRACT 240
20.3 INFORMAL RESOLUTION OF CONTRACT DISPUTES 240
20.4 PRESENTATION OF DOCUMENTED EVIDENCE 240
SECTION 21.0 RENEWAL/TERMINATION OF CONTRACT 242
21.1 CONTRACT RENEWAL 242
21.2 SUSPENSION OF CONTRACTOR OPERATIONS 242
21.3 TERMS OF CONTRACT TERMINATION 242
21.4 TERMINATION PROCEDURES 245
SECTION 22.0 GENERAL TERMS AND CONDITIONS 248
22.1 NOTIFICATION OF ADMINISTRATIVE CHANGES 248
22.2 ASSIGNMENT 248
22.3 INDEPENDENT CONTRACTORS 248
22.4 BUSINESS TRANSACTION REPORTING 248
22.5 LOSS OF LICENSURE 248
22.6 INDEMNIFICATION 249
22.7 CONFLICT OF INTEREST 249
22.8 INSURANCE FOR CONTRACTOR'S EMPLOYEES 249
22.9 IMMIGRATION AND CONTROL ACT OF 1986 249
22.10 SEVERABILITY 249
22.11 ANTI-BOYCOTT COVENANT 249
22.12 RECORD RETENTION, INSPECTION, AND AUDITS 250
22.13 OPERATION OF OTHER CONTRACTS 250
22.14 PREVAILING CONTRACT 251
22.15 NO THIRD-PARTY RIGHTS OR ENFORCEMENT 251
22.16 EFFECT OF INVALIDITY OF CLAUSES 251
22.17 APPLICABLE LAW 251
22.18 SOVEREIGN IMMUNITY 251
22.19 WAIVER OF RIGHTS 251
22.20 INSPECTION 252
22.21 DEBARMENT STATUS 252
22.22 ANTITRUST 252
22.23 DRUG-FREE WORKPLACE 252
SECTION 23.0 DEFINITIONS AND ACRONYMS 253
23.1 DEFINITIONS 253
23.2 ACRONYMS 283
ATTACHMENTS 288
ATTACHMENT 1 - CCC PLUS CONTRACTOR SPECIFIC CONTRACT TERMS 288
ATTACHMENT 2 - BUSINESS ASSOCIATE AGREEMENT 290
ATTACHMENT 3 - BHSA/CCC PLUS MCO COORDINATION AGREEMENT 296
ATTACHMENT 4 - SAMPLE CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION 300
ATTACHMENT 5 - CCC PLUS COVERAGE CHART 302
ATTACHMENT 6 - DMAS DEVELOPMENTAL DISABILITY WAIVER SERVICES 366
ATTACHMENT 7 - CCC PLUS PROGRAM REGIONS AND LOCALITIES 367
ATTACHMENT 8 - COMMON DEFINITIONS FOR MANAGED CARE TERMS 369
ATTACHMENT 9 - CERTIFICATION OF DATA (NON-ENCOUNTER) 372
ATTACHMENT 10 – EI FAMILY DECLINING TO BILL PRIVATE INSURANCE 373
ATTACHMENT 11 - MOC ASSESSMENT AND INDIVIDUALIZED CARE PLAN (ICP) EXPECTATIONS 374
ATTACHMENT 12 - INDIVIDUALIZED CARE PLAN (ICP) REQUIREMENTS CHECKLIST (PER CMS FINAL RULE) 376
ATTACHMENT 13 - NOTIFICATION OF PROVIDER INVESTIGATION 377
SECTION 1.0 SCOPE OF CONTRACT
This Contract, by and between the Department of Medical Assistance Services (hereinafter referred to as the Department or DMAS) and the Contractor, is for the provision of Medicaid managed long term services and supports to individuals enrolled in the Department’s Commonwealth Coordinated Care Plus (CCC Plus) Program. In accordance with MLTSS RFP-2016-01, the initial period of this Contract is from July 1, 2017 through December 31, 2017, and automatically renews annually thereafter (per calendar year) for an period of five (5) calendar years with the potential for up to five (5) 12-month extensions. Refer to Section 21.0 Renewal/Termination of Contract for terms and conditions. All Contracts and rates will be renewed annually as needed, subject to CMS and Virginia legislative approval.
Under this Contract, the Contractor shall operate in all 6 regions of the Commonwealth and in all localities in each region. The Contractor shall provide the full scope of services and deliverables through an integrated and coordinated system of care as required, described, and detailed herein, consistent with all applicable laws and regulations, and in compliance with service and delivery timelines as specified by this Contract.
1.1 APPLICABLE LAWS, REGULATIONS, AND INTERPRETATIONS
The documents listed herein shall constitute the Contract between the parties, and no other expression, whether oral or written, shall constitute any part of this Contract. Any conflict, inconsistency, or ambiguity among the Contract documents shall be resolved by giving legal order of precedence in the following order:
• Federal Statutes
• Federal Regulations
• 1915(b)(c) CCC Plus Waivers
• State Statutes
• State Regulations
• Virginia State Plan
• CCC Plus Contract, including all amendments and attachments including Medicaid memos and relevant manuals, as updated
• CCC Plus Program Operational Memoranda and Guidance Documents
Any ambiguity or conflict in the interpretation of this Contract shall be resolved in accordance with the requirements of Federal and Virginia laws and regulations, including the State Plan for Medical Assistance Services and Department memos, notices, and provider manuals.
Services listed as covered in any evidence of coverage or any member handbook shall not take precedence over the services required under this Contract or the State Plan for Medical Assistance.
1.1.1 Guidance Documents and Department Forms
The Department may issue guidance documents and program memoranda clarifying, elaborating upon, explaining, or otherwise relating to Contract administration and clarification of coverage. The Contractor shall comply with all such program memoranda. In addition, DMAS program policy manuals, Medicaid Memos and forms used in the administration of benefits for Medicaid individuals and referenced within this Contract are available on the DMAS web portal at: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal.
1.2 COMMITMENT TO DEPARTMENT GOALS FOR DELIVERY SYSTEM REFORM AND PAYMENT TRANSFORMATION
The Contractor shall work collaboratively with the Department on Health Information Exchange, delivery system reform, payment reform, and other future key initiatives.
SECTION 2.0 REQUIREMENTS PRIOR TO OPERATIONS
2.1 ORGANIZATIONAL STRUCTURE
2.1.1 Virginia Based Operations
The Contractor shall have a Virginia-based operation that is dedicated to this Contract. The Department does not require claims, utilization management, customer service, pharmacy management, or Member services to be physically located in Virginia; however, these service areas must be located within the United States.
2.1.2 Dedicated Project Director and Project Manager
The Contractor shall have a dedicated Virginia CCC Plus Project Director and dedicated Project Manager located in an operations/business office within the Commonwealth of Virginia. The Contractor’s Project Director and Project Manager, if desired, may provide oversight for both the Virginia CCC Plus program and the Virginia D-SNP program. The Contractor’s Project Director and Project Manager are expected to attend all meetings required by DMAS.
2.1.2.1 Project Director
The Contractor’s Project Director shall be authorized and empowered to make contractual, operational, and financial decisions including rate negotiations for Virginia business. The CCC Plus Project Director shall be solely responsible to the Contractor (not a third party administrator) and comply with all requirements of this Contract in that capacity.
2.1.2.2 Project Manager
The CCC Plus Project Manager shall have the ability to make timely decisions about the CCC Plus program issues and shall represent the Contractor at the Department’s meetings. The CCC Plus Project Manager must be able to respond to issues involving information systems and reporting, appeals, quality improvement, member services, service management, pharmacy management, medical management, care coordination, claim payment, provider relations/contracting, and issues related to the health, safety, and welfare of the Members.