Amendment No. 08 to Contract YH04-0001-06 between Arizona Health Care Cost Containment System and Phoenix Health Plan/Community Connection

Contract Categories: Business Finance › Modification Agreements
Summary

This amendment updates the contract between the Arizona Health Care Cost Containment System (AHCCCS) and Phoenix Health Plan/Community Connection, effective October 1, 2004. It revises definitions, clarifies requirements for services, enrollment, provider responsibilities, grievance procedures, and compliance. The amendment also introduces new obligations for identifying members with special health care needs, provider training, and business continuity planning. All other terms of the original contract remain unchanged. Both parties have agreed to these updates as indicated by their signatures.

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EX-10.23 104 y67817exv10w23.txt CONTRACT AMENDMENT NUMBER 08 EXHIBIT 10.23 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION DIVISION OF BUSINESS AND FINANCE CONTRACT AMENDMENT Page 1 ============================================================================== 1. AMENDMENT NO.: 2. CONTRACT NO.: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM 08 YH04-0001-06 OCTOBER 1, 2004 DHCM- ACUT - ------------------------------------------------------------------------------- 5. CONTRACTOR/PROVIDER NAME AND ADDRESS: Phoenix Health Plan / Community Connection 7878 N. 16th street suite 105 Phoenix, Arizona 85020 - ------------------------------------------------------------------------------- 6. PURPOSE: =============================================================================== 7. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS: A. CHANGES IN REQUIREMENTS: In accordance with Section E, Paragraph 30, "Changes", various changes in contract requirements are indicated in this contract amendment. B. By signing this contract amendment, the Contractor is agreeing to the terms of the contract as amended. NOTE: Please sign, date and Gary L. Callahan, Contract Management Supervisor return one original to: AHCCCS CONTRACTS AND PURCHASING 701 E. JEFFERSON, MD 5700 PHOENIX, AZ 85034 ================================================================================ 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT. IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT. ================================================================================ 9. NAME OF CONTRACTOR: 10. ARIZONA HEALTH CARE COST PHOENIX HEALTH PLAN/COMMUNITY CONNECTION CONTAINMENT SYSTEM - -------------------------------------------------------------------------------- SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE: - -------------------------------------------------------------------------------- TYPED NAME: TYPED NAME: NANCY NOVICK MICHAEL VEIT - -------------------------------------------------------------------------------- TITLE: TITLE: CHIEF EXEUTIVE OFFICER CONTRACTS AND PURCHASING ADMINISTRATOR - -------------------------------------------------------------------------------- DATE DATE: August 27, 2004 AUGUST 23, 2004 ================================================================================ SUMMARY OF CHANGES - AMENDMENT 10/1/04 This summary is provided as a convenience to the Contractor and is not to be construed as superseding or limiting the revised text of the renewal document. This summary is believed to be an accurate and complete summary of changes in the attached document that take effect October 1, 2004; however, any conflict between the summary and the text will be resolved in favor of the text. All text revisions summarized below are considered either an actual change to contract requirements or a clarification of existing requirements. Finally, punctuation, grammar and style changes have been made throughout the revised text which have no effect on the contract requirements and which may not be otherwise identified.
PARAGRAPH SECTION -PARA #: TITLE: SUMMARY OF CHANGE OR CLARIFICATION: PG.# - ---------------- ----------------- ---------------------------------------------------- ---- Def Definitions Added definition for Appeal Resolution "The written determination by the Contractor concerning an appeal." Claim Dispute "A dispute involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance." Post Stabilization Services - added italicized language "Medically necessary services, related to an emergency medical condition, provided after the member's condition is sufficiently stabilized in order to maintain, improve or resolve the member's condition so that the member could alternatively be safely discharged or transferred to another location." D-3 Enrollment and The Contractor will share with AHCCCSA the cost of Disenrollment providing information about the acute care contractors to potential members and to those eligible for annual enrollment choice. D-8 Mainstreaming First sentence changed to read..."national origin of AHCCCS (to include those with limited English Members proficiency), ancestry, marital...' Second paragraph changed to read "Examples of prohibited practices include, but are not limited to, the following, in accordance with Title VI of the US Civil Rights Act of 1964, 42 USC, Section 2001, Executive Order 13166, and rules and regulation promulgated according to, or as otherwise provided by law:" D-10 Scope of Children's Rehabilitative System paragraph - added Services italicized language: "The Contractor remains ultimately responsible for the provision of all covered services to its members, including emergency services not related to a CRS condition and emergency services related to a CRS condition rendered outside of the CRS network. The Contractor is not responsible for these services in instances for which the CRS eligible member refuses to receive CRS covered services through the CRS program." Under the Prescription Drug paragraph, removed "as well as restrictions for immunosuppressant drugs addressed in the AHCCCS medical policies for transplantation."
D-11 Special Health Added the following to the first paragraph: "The Care Needs Contractor shall have in place a mechanism to identify and stratify all members with special health care needs." Added the following: "The Contractor shall have a methodology to identify providers willing to provide medical home services and make reasonable efforts to offer access to these providers. The American Academy of Pediatrics (AAP) describes care from a medical home as: - Accessible - Continuous - Coordinated - Family-centered - Comprehensive - Compassionate - Culturally effective D-12 Behavioral Numerous changes - see Paragraph Health Services D-14 Medicaid in the Title changed to Medicaid School Based Claiming - Public Schools language cleaned up to reflect new title and acronym D-15 Pediatric Added "The Contractor shall not reimburse Immunizations providers for the administration of the vaccines and the Vaccine in excess of the maximum allowable as set by CMS." for Children Program D-16 Staff Added the italicized language in the following Requirements and "The Contractor is responsible for maintaining a Support Services significant local (within the State of Arizona) presence. This presence would include staff as described in a., b., d., e., f., h., j., m., n., o., and p. below. Added "See Paragraph 62, Corporate Compliance, for more information." to item n., Corporate Compliance Officer Added q. BUSINESS CONTINUITY PLANNING COORDINATOR as noted in the DHCM Business Continuity and Recovery Policy. D-19 Member Surveys Changed title to Surveys and added provider survey language. See paragraph. D-20 Cultural Added last sentence to read: "This plan should Competency address all services and settings." D-23 QM/UM Numerous changes - please see paragraph. D-24 Performance Numerous changes - please see paragraph. Standards D-25 Grievance System Changed first sentence to read: "The Contractor may delegate the grievance system to subcontractors, however..." Added "Unless there is an agreement with the State in advance, the Contractor shall be responsible for all attorney fees and costs awarded to the claimant in a judicial proceeding." D-26 Quarterly Added Enrollee Grievance Report - see paragraph Grievance Reports
D-27 Network Numerous changes - see paragraph. Development D-29 Network Added bullets g. and h. Management g. Recruit, select, credential, re-credential and contract with providers in a manner that incorporate quality management, utilization, office audits and provider profiling; and h. Provide training for its providers and maintain records of such training. Added: "Contractors shall give hospitals and physician groups 90 days notice prior to contract termination without cause. All affected contracts shall include this provision by July 1, 2005. Contracts between the Contractor and single practitioners are exempt from this requirement." D-30 Primary Care Added: Beginning in CYE '05, AHCCCSA may develop a Physicians methodology to reimburse providers, such as clinics for the homeless and school based clinics, who provide primary care services to acute care members enrolled with the Contractor, but who are unable to fulfill the requirements to obtain a contract as a PCP. The Contractors will be responsible for payment of these services to either the clinics directly or to AHCCCSA. D-34 FQHCs Added Morenci Health Care Center Changed title to Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) and added Copper Queen RHCs
D-37 Subcontracts Added ".....prior review and written approval...." Added: "unless otherwise specified" to the sentence "The following subcontracts, unless otherwise specified, shall be submitted to AHCCCS...." Deleted item d. Model Subcontracts, deleted item f. Hospitals Added "Before entering into a subcontract which delegates Contractor duties or responsibilities to a subcontractor, the Contractor must evaluate the prospective subcontractor's ability to perform the activities to be delegated." Added "The Contractor must submit annually (within 90 days from the start of the contract year) a statement whether any Contractor duties or responsibilities have been delegated to subcontractors. If duties or responsibilities have been delegated to a subcontractor, the Contractor must submit annually (within 90 days from the start of the contract year) a report listing the following: - Subcontractor's name - Delegated duties and responsibilities - Most recent review date of the duties and responsibilities of the subcontractor - Next scheduled review date - Identified areas of deficiency - Contractor's corrective action plan The Contractor shall promptly inform AHCCCS, Division of Health Care Management, in writing if a subcontractor is in significant non-compliance that would affect their abilities to perform the duties and responsibilities of the subcontract." Added: o. Provision(s) that allow the Contractor to suspend, deny, refuse to renew or terminate any subcontractor in accordance with the terms of this contract and applicable law and regulation. p. A provision that the subcontractor may provide the member with factual information, but is prohibited from recommending or steering a member in the member's selection of a Contractor. Removed italicized language from the following sentence "A subcontract is voidable and subject to immediate cancellation by AHCCCSA in the event any subcontract subject to "a" through "g" above is implemented without the prior written approval of AHCCCSA. D-38 Claims Numerous changes - see paragraph. Payment/Health Information System
D-40 Hospital Adjusted the second sentence to read as follows: Subcontracting "The Program is defined in the Arizona Revised and Reimbursement Statutes (A.R.S.) 36-2905.01, and requires hospital subcontracts to be negotiated between health plans and hospitals in Maricopa and Pima counties to establish reimbursement levels, terms and conditions." Added the following sentence to the end of the paragraph: "In accordance with R9-22-718, unless otherwise negotiated by both parties, the reimbursement for inpatient services provided at a non-contracted hospital shall be based on the rates as defined in A.R.S. Section 36-2903.01, multiplied by 95%." Added: OUTPATIENT HOSPITAL SERVICES: With passage of SB 1410 (Laws of 2004, Chapter 279), effective for dates of service on and after July 1, 2005, in absence of a contract, the default payment rate for outpatient hospital services billed on a UB-92 will be based on the AHCCCS outpatient hospital fee schedule, rather than a hospital-specific cost-to-charge ratio (pursuant to ARS 36-2904). D-43 Management Removed "The Contractor may be placed on monthly Services financial reporting, and/or" and added "In Subcontractors addition....." D-53 Compensation Changed item b. to read "Both Audited and unaudited financial statements reported by Contractors" Added item k. Member share of cost amounts D-56 Incentives Changed Incentive Fund language to read as follows: Beginning in CYE '05, AHCCCS will create a $1.5 million dollar pool to be distributed by September 2005. This financial incentive funding will be paid out as a reward for good performance and to reimburse for additional costs incurred to achieve a higher level of performance and/or better care for members. AHCCCS will distribute this pool of funds to Contractors based on the following criteria and performance measures: 1. Reaching the CYE '05 goal for EPSDT Well-child Visits (based on CYE '04 data) 2. Consistently meeting administrative measure standards as defined in Section D, Paragraph 24, Performance Standards, of this contract 3. Achievement and/or continuation of disease management activities 4. Participation with Residency programs AHCCCSA will share the methodology for allocation and distribution of the fund with Contractors prior to finalization.
D-57 Reinsurance Under Encounter Submission and Payments for Reinsurance, letter d); Removed: "While encounter data is not currently used to determine reinsurance payments for transplant services, in the future, encounters may be required in order for Contractors to receive reinsurance payments for transplants. Contractors are required to encounter all medical services provided for which a financial liability is incurred." Added: "Effective for dates of service on or after October 1, 2004, Contractors are required to submit all supporting service encounters for transplant services. Reinsurance payments will be linked to transplant encounter submissions." D-58 Coordination of Numerous changes, see paragraph. Benefits/Third Party Liability D-62 Corporate Numerous Changes - see paragraph. Compliance D-65 Encounter Changed sentence to read: "The Contractor shall Data Reporting submit encounter data to AHCCCSA for all services for which the Contractor incurred a financial liability and claims for services eligible for processing by the contractor where no financial liability was incurred, including services provided during prior period coverage." D-72 Sanctions Added item "p. Failure to report third party liability cases as described in Paragraph 58" Changed last sentence from "will proceed to "......may proceed with the imposition of sanctions." D-73 Business Changed title of policy to be "Business Continuity Continuity Plan and Recovery Plan" Removed bullet "Healthcare facility closure/loss of major provider" Added bullet requiring "Periodic Testing: D-74 Technological Removed #3. Policies Advancement D-75 Pending Added pending issues for: Legislative/Other AzEIP Issues Medicare Modernization Act Transportation Hemophilia RFP D-76 Balanced Budget Revised paragraph to read as follows: Act of 1997 (BBA) "In August 2002, CMS issued final regulations for the implementation of the BBA. AHCCCS continues to review all areas of the regulations to ensure full compliance with the BBA; however, there are some issues that may require further clarification from CMS. Any program changes due to the resolution of the issues will be reflected in amendments to the contract. Capitation rates may also be adjusted to reflect the financial impact of the program changes." Section E Contract Clauses Added Executive order 13166 to item 10 Changed item 24 to read "The effective date of this contract shall be the date referenced on page 1 of this contract." Added Item 44 "Data Certification" and Item 45 "Offshore Performance of Work Prohibited"
Attachment A Minimum Removed duplicative language from item #4: "No Subcontract payment due the Contractor under this subcontract Provisions may be assigned without the prior approval of AHCCCSA. No assignment or delegation of the duties of this subcontract shall be valid unless prior written approval is received from AHCCCSA." Attachment F Periodic Changed the Prescription Drug Utilization Report Reporting to be on a quarterly basis, due 45 days after Requirements quarter end, rather than due monthly. Added: Claims reporting Administrative Measures Report of all subcontracts which delegate Contractor duties and responsibilities QM Quarterly Reporting UM Quarterly Reporting HIV Specialty Provider List Business Continuity and Recovery Plan Attachments H Provider and Numerous changes - please see attachments: (1) and (2) Member Grievance System Standards Added "e.) for decisions regarding claims and Policy disputes, the requirement that the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the decision." to Item 9. Added Item 12 as follows: 12. If the Contractor's decision regarding a claim denial is reversed through the appeal process, the Contractor shall reprocess the claims(s) in a manner consistent with the decision within 15 business days of the date of the decision. Attachment I Encounter Changed encounter timeliness language from all Submission encounters to 95%... "Ninety-five percent (95%) of all encounters must be received by AHCCCSA no later than 240 days after the end of the month in which the service was rendered, or the effective date of enrollment with the Contractor, whichever is later." Attachment L Cost Sharing Revised Title XIX Waiver Group copayments - see Copayments Attachment L.