Amendment number 5 to the Medicaid Managed Care Eastern Region contract between the State of Missouri Office of Administration Division of Purchasing and Materials Management and Harmony Health Plan of Illinois, Inc

(U.S. Mail)

(Courier Service)

Harmony Health Plan of Illinois Inc., d/b/a/ Harmony Health Plan of Missouri

Harmony Health Plan of Illinois, Inc.

23 Public Square, Suite 400

200 West Adams Street, Suite 800

Belleville, IL 62220

Chicago, IL 60606

Ms. Tina Gallagher

***@***

(800) 608-8158 Ext. 2405

(800) 608-8157

36 ###-###-####

            _X__ FEIN       ___ SSN

 _X__ Corporation         ___ Individual         ___ State/Local Government         ___ Partnership         ___ Sole Proprietor         ___Other ________________

  /s/   Thaddeus Bereday                 

September 24, 2007

Thaddues Bereday

Secretary

1.  

Effective September 1, 2007, the State of Missouri's medical assistance program on behalf of needy persons shall be known as "MO HealthNet".  All references to Medicaid shall hereinafter be referred to as "MO HealthNet".  The Division of Medical Services (DMS) is hereinafter referred to as the "MO HealthNet Division (MHD)".  Individuals eligible under "MO HealthNet" shall be referred to as participants.

2.  

Subparagraphs a. through c. of paragraph 1.1.1 of the RFP portion of the contract is hereby amended effective January 1, 2008 as follows:

 

1.1.1

This document constitutes a request for competitive, sealed proposals from the health plan provider community for becoming providers in the Missouri managed care program, hereinafter referred to as "MC+ managed care" in the following regions of the State of Missouri:

 

a.

Central Region: Audrain, Benton, Boone, Callaway, Camden, Chariton, Cole, Cooper,   Dallas, Gasconade, Hickory, Howard, Laclede, Linn, Macon, Maries, Marion, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Phelps, Pulaski, Ralls, Randolph, Saline and Shelby counties.

 

b.

Eastern Region:  Crawford, Franklin, Iron, Jefferson, Lincoln, Madison, Perry, Pike, St. Charles, St. Francois, Ste. Genevieve, St. Louis, Warren and Washington counties and St. Louis City.

 

c.

Western Region:  Bates, Cass, Cedar, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Polk, Ray, St. Clair, and Vernon counties.

3.

Paragraph 1.5.1 of the RFP portion of the contract is hereby amended effective January 1, 2008 as follows:

 

1.5.1

Effective July 1, 2006, the State of Missouri will continue a health care delivery program in Audrain, Boone, Callaway, Camden, Cass, Chariton, Clay, Cole, Cooper, Franklin, Gasconade, Henry , Howard, Jackson, Jefferson, Johnson, Lafayette, Lincoln, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis, Platte, Randolph, Ray, Saline, St. Charles, St. Clair, St. Francois, Ste, Genevieve, St. Louis, Warren and Washington counties and St. Louis City to serve MC+ managed care eligibles meeting specified eligibility criteria.  Effective January 1, 2008, the State of Missouri will introduce the MC+ Managed Care Program in twenty-one (21) counties contiguous to the existing MC+ Managed Care regions.  The new counties are:  Bates, Benton, Cedar, Crawford, Dallas, Hickory, Iron, Laclede, Linn, Macon, Madison, Maries, Marion, Perry, Phelps, Pike, Polk, Pulaski, Ralls, Shelby, and Vernon.  The goal is to improve the accessibility and quality of health care services for Missouri's MC+ managed care and State aid eligible populations, while controlling the program's rate of cost increase.

4.

Paragraph 2.1.3 and subparagraphs a. through j. of the RFP portion of the contract is hereby amended and subparagraphs k. through o. are hereby added effective January 1, 2008 as follows:

 

2.1.3

The health plan awarded a contract for the Eastern region shall provide services to individuals determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of the following fifteen areas in the State of Missouri:

 

a.

Crawford County

 

b.

Franklin County

 

c.

Iron County

 

d.

Jefferson County

 

e.

Lincoln County

 

f.

Madison County

 

g.

Perry County

 

h.

Pike  County

 

i.

St. Charles County

 

j.

St. Francois County

 

k.

Ste. Genevieve County

 

l.

St. Louis County

 

n.

Washington County

 

o.

St. Louis City

5.

Paragraph 2.1.4 and subparagraphs a. through r. of the RFP portion of the contract is hereby amended and subparagraphs s. through dd. are hereby added effective January 1, 2008 as follows:

 

2.1.4

The health plan awarded a contract for the Central region shall provide services to individuals determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of the following thirty areas in the State of Missouri:

 

a.

Audrain County

 

b.

Benton County

 

c.

Boone County

 

d.

Callaway County

 

e.

Camden County

 

f.

Chariton County

 

g.

Cole County

 

h.

Cooper County

 

i.

Dallas County

 

j.

Gasconade County

 

k.

Hickory County

 

l.

Howard County

 

o.

Macon County

 

p.

Maries County

 

q.

Marion County

 

r.

Miller County

 

s.

Moniteau County

 

t.

Monroe County

 

u.

Montgomery County

 

v.

Morgan County

 

x.

Pettis County

 

y.

Phelps County

 

z.

Pulaski County

6.

Paragraph 2.1.5 and subparagraphs a. through i. of the RFP portion of the contract is hereby amended and subparagraphs j. through m. are hereby added effective January 1, 2008 as follows:

 

2.1.5

The health plan awarded a contract for the Western region shall provide services to individuals determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of the following thirteen areas in the State of Missouri:

 

a.

Bates County

 

b.

Cass County

 

c.

Cedar County

 

d.

Clay County

 

e.

Henry County

 

f.

Jackson County

 

g.

Johnson County

 

h.

Lafayette County

 

i.

Platte County

 

j.

Polk County

 

k.

Ray County

 

l.

St. Clair County

7.

Paragraph 2.4.6 of the RFP portion of the contract is hereby amended effective July 1, 2007 as follows:

 

2.4.6

Pharmacy Dispensing Fee:  The health plan shall pay a pharmacy dispensing fee of $4.84 to each qualifying pharmacy for the first 1,000 prescriptions filled in any calendar quarter.  The reimbursement of a pharmacy dispensing fee shall be available only to corporations, partnerships, or individual proprietorships with less than 25 employees who operate pharmacies or pharmacy franchises and to public health entities owned and operated by a state, county or local government agency and where the entity is a hospital which qualifies as a first-tier 10% add-on disproportionate share hospital in accordance with 13 CSR 70-15.010.  The health plan shall identify its pharmacies that qualify.  The health plan shall supply the state agency with a list of those pharmacies identified to qualify for a pharmacy dispensing fee reimbursement upon request.

8.

Paragraph 2.4.9 of the RFP portion of the contract is hereby amended and subparagraphs a. through c. are hereby added effective July 1, 2007 as follows:

 

2.4.9

The health plan shall maintain the fee schedule for office visit services and dental services located in Attachment 14 at no lower than the Medicaid fee-for-service fee schedule in effect the time of service.  The fee schedule for office visit services included in Attachment 14 are for dates of services July 1, 2006 through June 30, 2007.

 

a.

The Missouri 94^th General Assembly approved a statutory change for the state agency to develop a four-year plan to achieve parity with Medicare reimbursement rates for physicians which was signed by the Governor on July 2, 2007.  The statutory change affects MC+ Managed Care reimbursement rates.

 

b.

A physician fee increase will be implemented effective July 1, 2007.  Physician reimbursement rates that are currently less than 55% of the Medicare reimbursement rate will increase to 55%, physician reimbursement rates currently at 55% will remain unchanged, and physician reimbursement rates currently more than 55% will be increased by 10%, but shall not exceed the Medicare rate.  The state agency’s Online Fee-For-Service Fee Schedule is available electronically at:  http//www.dss.mo.gov/mhd/providers/pages/cptagree.htm.

 

c.

Effective July 1, 2007, the health plan shall increase the rates for physician services provided to MC+ enrollees in accordance with the fee-for-service rate increases.  The health plan's capitation rates will be increased July 1, 2007 to reflect the increases for physician services.  The health plan shall request and receive proof from its health care services subcontractors that these increases have been passed on to providers beginning July 1, 2007.  Such proof shall be provided to the state agency upon request.

9.

Paragraph 2.7.1 r. of the RFP portion of the contract is hereby amended effective September 1, 2007 as follows:

 

r.

Durable medical equipment (including but not limited to: orthotic and prosthetic devices, respiratory equipment and oxygen, enteral and parenteral nutrition, wheelchairs and walkers, and diabetic supplies and equipment);

10.

Paragraph 2.7.3 e. of the RFP portion of the contract is deleted effective September 1, 2007.

11.

Paragraph 2.28.2 d. and subparagraphs 1) and 2) of the RFP portion of the contract is hereby amended effective July 1, 2007 as follows:

 

d.

The first time a health plan achieves an average of low with a value of one (1), the state agency shall notify the health plan of the health plan's rating and shall give the health plan ten (10) working days to develop an acceptable action plan to improve the substandard performance.

 

1)

If the health plan submits an action plan for correcting the rating and if the plan is acceptable to the state agency, no action shall be taken at that time, provided the health plan implements the corrective action plan as approved by the state agency.

 

2)

If the health plan fails to submit an action plan within ten (10) working days or the health plan does not implement the corrective action plan within the time frame stated in the action plan, the state agency shall inform enrollees in enrollment materials that the health plan failed to achieve the minimum performance standard.

12.

Attachment 1 is hereby revised effective July 1, 2007.

13.

Attachment 3 is hereby revised effective September 1, 2007.

14.

Attachment 5 is hereby revised effective January 1, 2008.

15.

Attachment 9 is hereby revised effective July 1, 2007.

16.

Attachment 13 is hereby revised effective July 1, 2007.

17.

Attachment 14 is hereby revised effective July 1, 2007.