Amendment number 3 to Contract for Furnishing Health Services between the State of Illinois Department of Healthcare and Family Services and Harmony Health Plan of Illinois, Inc

Article I, DEFINITIONS, of the contract is amended to add the first definition and amend the second definition as follows:

 

Illinois Client Enrollment Broker (ICEB) means the entity contracted by the Department to administer the day-to-day operations of the Illinois Client Enrollment Broker for clients living in the Contractor's contracting area. The day-to-day operations include conducting client enrollment activities such as mailing choice education and enrollment materials, ensuring impartial education between the clients health plan choices, assisting with selection of a "best-fit" health plan and PCP in an unbiased manner and processing requests to change health plans.

 

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is receiving Medical Assistance under Aid to the Aged, Blind and Disabled; as provided by Title XIX of the Social Security Act (42 U.S.C. § 1383c) and 305 ILCS 5/3-1 et seq.;

 

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is under age 21 and receiving Supplemental Security Income;

 

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is eligible only through the Refugee Assistance programs under Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.);

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Pre-populated ICEB Client Enrollment Forms. The Contractor's Marketing personnel may assist a Participant in completing his or her pre-populated ICEB Client Enrollment Form. If Marketing personnel of the Contractor assists a Participant in completing the pre-populated Client Enrollment Form, he or she must ensure that the Participant identifies in the space provided on the enrollment form that the Participant has received assistance, and provide the name, title and ID (if applicable) of the Marketing personnel assisting the Participant in completing the form.

ICEB Online Enrollment via the ICEB Website. Marketing personnel of the Contractor may assist a Participant to enroll on the ICEB website if the Participant is present (in person) and requests assistance. Online enrollment of a Participant that is on the phone or via an enrollment form by Marketing personnel is strictly prohibited. The Contractor's Marketing personnel may assist a Participant to enroll online through the following process:

 

(a)     Marketing personnel of the Contractor must identify if a Participant is eligible to pick a medical home.

 

(b)

Before assisting a Participant to enroll online, the Marketing personnel of the Contractor must ensure that the Participant has received education on and understands all of their health care choices. Marketing personnel will educate the Participant by using the ICEB Information Guide and other materials made available or approved by the Department.

Marketing personnel of the Contractor must have the Participant complete and sign the "Statement of Understanding Form" when assisting a Participant to enroll online. By completing the Statement of Understanding, the Participant is confirming that he or she has requested assistance with the online enrollment process, were told about all of their health care choices, received information on all their health care choices, understand all of their health care choices and desires to enroll the family members listed with the medical home(s) they have chosen.

The Statement of Understanding Form must be kept on file by the Contractor and the Contractor must provide the original form to the Department upon request.

If Marketing personnel of the Contractor is assisting a Participant to enroll online, the Participant must also complete the online "Assistance Information Screen" by clicking on the box marked "Yes", and completing the requested fields.

 

(3)

Telephone Enrollment. Marketing personnel of the Contractor may assist a Participant to enroll via the telephone. The process for Marketing personnel to assist a Participant to enroll via the telephone is as follows:

 

Marketing personnel of the Contractor may call the ICEB Client Helpline with the Participant present.

Marketing personnel will provide his or her name, ED number and purpose of call. The ICEB will verify his or her ID number. At that point the ICEB will request to speak directly with the Participant. The call cannot be continued on a speaker phone.

The ICEB will ask the Participant if he or she has been educated on all their health care options. If not, the ICEB will provide education on their health care options.

If the Participant states he or she has been educated on their health care options or after the ICEB provides the education and the Participant has no further questions, the ICEB will request to speak to Marketing personnel of the Contractor and confirm the enrollment and anticipated effective date of enrollment.

 

(e)

Marketing personnel of the Contractor must have the Participant complete and sign the "Statement of Understanding Form" when assisting a Participant to enroll via the telephone. By completing the Statement of Understanding, the Participant is confirming that he or she has requested assistance with the telephone enrollment process, was told about all of their health care choices, received information on all their health care choices, understand all of their health care choices and desires to enroll the family members listed with the medical home(s) they have chosen.

 

Coverage shall begin as designated by the Department on the first day of a calendar month no later than three (3) calendar months from the date the enrollment is accepted by the Department's database. Enrollment other than automatic enrollment can occur only upon the Prospective Enrollee's selection of a Site, the communication of that Site by the ICEB, and acceptance of that Site by the Department.

Article IV, Section 4.4(a)(4) Termination of Coverage of the contract is amended to read as follows:

 

(4) when an Enrollee elects to terminate coverage with the Contractor, he or she is required to contact the ICEB. Enrollees may make another health care choice at any time. The Contractor shall comply with any Department policies then in effect to promote and allow interaction between the Contractor and the Enrollee seeking disenrollment prior to the disenrollment.

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Podiatric services;

 

Pharmaceutical products provided by an entity other than a pharmacy;

 

Services to Prevent Illness and Promote Health in accordance with subsection (d) hereof;

Transplants covered under 89 111. Adm. Code 148.82 (using transplant providers certified by the Department, if the procedure is performed in the State); and

Article IX, Section 9.54, the following provision is added to the contract as follows: 

Article IX, Section 9.55, the following provision is added to the contract as follows:

Article IX, Section 9.56, the following provision is added to the contract as follows:

Article IX, Section 9.57, the following provision is added to the contract as follows:

Article IX, Section 9.58, the following provision is added to the contract as follows:

Article IX, Section 9.59, the following provision is added to the contract as follows:

Article IX, Section 9.60, the following provision is added to the contract as follows:

Article IX, Section 9.61, the following provision is added to the contract as follows:

Article IX, Section 9.62, the following provision is added to the contract as follows:

Article IX, Section 9.63, the following provision is added to the contract as follows:

Article IX, Section 9.64, the following provision is added to the contract as follows:

Article IX, Section 9.65, the following provision is added to the contract as follows:

Article IX, Section 9.66, the following provision is added to the contract as follows:

Article IX, Section 9.67, the following provision is added to the contract as follows:

Article IX, Section 9.68, the following provision is added to the contract as follows:

 

c) the contract is with a firm, partnership, association or corporation in which a person referenced in b) above, together with their spouse or minor child, receives more than 15% in the aggregate of the total distributable income or an amount in excess of 2 times the salary of the Governor (currently $354,824.00) from the firm, partnership, association or corporation.

Attachment I shall be deleted and replaced by the attached Third Amended Attachment 1. Each reference to Attachment I in the Contract shall be replaced with a reference to the Third Amended Attachment 1.

Exhibit A, Quality Assurance, Page A-12 Year 2, Effectiveness of Care: Adolescent Immunization Status HEDIS, has been revised as follows: Year 2, Effectiveness of Care: Adolescent Immunization Status HEDIS Like.

Exhibit C, Summary of Required Reports and Submissions, Under Quality Assurance, Medical, the Behavioral Health report is deleted and the second Case Management Enrollees report is deleted.

46.

Attachment 1A is added to the contract to add Kane County as a contracted area, effective January 1,2009.

a)

The bid/proposal as initially submitted must contain an acknowledgement of this Attachment and a verification that the Utilization Plan has been provided at the time of proposal submission. Failure to submit a Utilization Plan shall render the bid non-responsive.

b)

The Utilization Plan must demonstrate that the Vendor has either met the contract goal or that it has made good faith efforts to do so.

c)

The Utilization Plan must provide the name and contact information of the Vendor's official responsible for compliance with this Attachment.

d)

 

The Utilization Plan shall include, for each certified vendor proposed for the performance of work to achieve the contract goal, the following:

 

(1)

The name and address of each certified vendor to be used;

 

(2)

The name of the agency/organization that has certified the vendor as disadvantaged, minority or woman business enterprise (i.e., CMS Business Enterprise Program, Women's Business Development Center, etc.). At the time of proposal submission, the Certified Vendor may not yet be certified with CMS Business Enterprise Program; however, the Certified Vendor must meet the eligibility requirements and be fully certified in the BEP Program before contract award. (The criteria for eligibility: The business is at least 51% owned and controlled by a minority, woman, or person with disability, the owner is a U.S. citizen or resident alien, and the annual gross sales and receipts of the business are under $27 million.)

 

(3)

A detailed description of the commercially useful work to be done by each certified vendor;

 

(4)

The price to be paid to each certified vendor for the identified work specifying the quantity, unit price and total subcontract price;

 

(5)

A letter of intent (Attachment F) between the Vendor and the certified vendor(s) detailing the work to be performed by the certified vendor and the agreed upon rates or prices, conforming to the Utilization Plan;

 

(6)

If applicable, an executed Joint Venture agreement specifying the terms and conditions of the relationship between the partners and their relationship and responsibilities to the contract. The joint venture agreement must clearly evidence that the certified vendor will be responsible for a clearly defined portion of the work and that its responsibilities, risks, profits and contributions of capital and personnel are proportionate to its ownership percentage. It must include specific details related to the parties' contributions of capital, personnel and equipment and share of the costs of insurance and other items; the scopes to be performed by the certified vendor's own forces and under its supervision; and the commitment of management, supervisory personnel and operative personnel employed by the certified vendor to be dedicated to the performance of the contract. Each joint venture partner must execute the proposal to the Agency.

e)

An agreement between a Vendor and a certified vendor in which the certified vendor promises not to provide subcontracting quotations to other vendors is prohibited.

f)

The Agency may request additional information to demonstrate compliance. The Vendor agrees to cooperate promptly with the Agency in submitting to interviews, allowing entry to places of business, providing further documentation, or soliciting the cooperation of a proposed certified vendor. Failure to cooperate may render the proposal non-responsive.

g)

The goal is also applicable to change orders and allowances within the scope of work provided by the certified vendor.

a)

The value of the work actually performed by the certified vendor's forces shall be counted towards the goal. The entire amount of that portion of the contract that is performed by the certified vendor's forces, including supplies purchased or equipment leased by the BEP vendor shall be counted, except supplies purchased and equipment rented from the Vendor.

b)

A joint venture shall count the portion of the total dollar value of the contract equal to the distinct, clearly defined portion of the work of the contract that the certified vendor performs with its forces toward the goal. A joint venture shall also count the dollar value of work subcontracted to other certified vendors. Work performed by the forces of a non-certified joint venture partner shall not be counted toward the goal.

d)

A Vendor shall count towards the goal 100% of its expenditures for materials and supplies required under the contract and obtained from a certified vendor manufacturer, regular dealer or supplier.

e)

A Vendor shall count towards the goal the following expenditures to certified vendors that are not manufacturers, regular dealers or suppliers:

 

(1)

The fees or commissions charged for providing a bona fide service, such as professional, technical, consultant or managerial services and assistance in the procurement of essential personnel, facilities, equipment, materials or supplies required for performance of the contract, provided that the fee or commission is determined by the Agency to be reasonable and not excessive as compared with fees customarily allowed for similar services.

 

(2)

The fees charged for delivery of materials and supplies required by the contract (but not the cost of the materials and supplies themselves) when the hauler, trucker, or delivery service is not also the manufacturer of or a regular dealer in the materials and supplies, provided that the fee is determined by the Agency to be reasonable and not excessive as compared with fees customarily allowed for similar services. The certified vendor trucking firm must be responsible for the management and supervision of the entire trucking operation for which it is responsible on the contract, and must itself own and operate at least one fully licensed, insured and operational truck used on the contract.

 

(3)

The fees or commissions charged for providing any bonds or insurance specifically required for the performance of the contract, provided that the fee or commission is determined by the Agency to be reasonable and not excessive as compared with fees customarily allowed for similar services.

f)

 

 

(1)

A firm is considered to perform a commercially useful function when it is responsible for execution of a distinct element of the work of a contract and carries out its responsibilities by actually performing, managing, and supervising the work involved. The certified vendor must also be responsible, with respect to materials or supplies used on the contract, for negotiating price, determining quality and quantity, ordering the materials or supplies, and installing the materials (where applicable) and paying for the material or supplies. To determine whether a firm is performing a commercially useful function, the Agency shall evaluate the amount of work subcontracted, whether the amount the firm is to be paid under the contract is commensurate with the work it is actually performing and the credit claimed for its performance of the work, industry practices, and other relevant factors.

 

(2)

A certified vendor does not perform a commercially useful function if its role is limited to that of an extra participant in a transaction or contract through which funds are passed in order to obtain certified vendor participation. In determining whether a certified vendor is such an extra participant, the Agency shall examine similar transactions,  particularly those  in  which  certified vendors  do  not participate, and industry practices.

g)

A Vendor shall not count towards the goal expenditures that are not direct, necessary and proximately related to the work of the contract. Only the amount of sendees or goods that are directly attributable to the performance of the contract shall be counted. Ineligible expenditures include general office overhead or other Vendor support activities.

a)

The following is a list of types of action that the Agency will consider as evidence of the Vendor's good faith efforts to meet the goal. Other factors or efforts brought to the attention of the Agency may be relevant in appropriate cases.

 

(1)

Soliciting through all reasonable and available means (e.g., attendance at pre-bid meetings, advertising and/or written notices) the interest of all certified vendors that have the capability to perform the work of the contract. The Vendor must solicit this interest within sufficient time to allow the certified vendors to respond to the solicitation. The Vendor must determine with certainty if the certified vendors are interested by taking appropriate steps to follow up initial solicitations and encourage them to bid.

 

(2)

Selecting portions of the work to be performed by certified vendors in order to increase the likelihood that the goal will be achieved. This includes, where appropriate, breaking out contract work items into economically feasible units to facilitate certified vendor participation, even when the Vendor might otherwise prefer to perform these work items with its own forces.

 

(3)

Providing interested certified vendors with adequate information about the plans, specifications, and requirements of the contract in a timely manner to assist them in responding promptly to the solicitation.

 

(4)

Making a portion of the work available to certified vendors and selecting those portions of the work or material needs consistent with their availability, so as to facilitate certified vendor participation.

 

(5)

a.

Negotiating in good faith with interested certified vendors.   Evidence of such negotiation includes the names, addresses, and telephone numbers of certified vendors that were considered; a description of the information provided regarding the plans and specifications for the work selected for subcontracting and evidence as to why additional agreements could not be reached for certified vendors to perform the work.

 

(6)

Thoroughly investigating the capabilities of certified vendors and not rejecting them as unqualified without sound reasons. The certified vendor's memberships in specific groups, organizations, or associations and political or social affiliations are not legitimate causes for the rejection or non-solicitation of bids in the Vendor's efforts to meet the goal.

 

(7)

Making efforts to assist interested certified vendors in obtaining lines of credit or insurance as required by the Agency, the Vendor or to perform the scope of work.

 

(8)

Making efforts to assist interested certified vendors in obtaining necessary equipment, supplies, materials, or related assistance or services.

 

(9)

Effectively using the services of available minority/women community organizations; minority/women vendors' groups; local, state, and federal minority/women business assistance offices; and other organizations that provide assistance in the recruitment and placement of certified vendors.

b)

In evaluating the Vendor's good faith efforts, the good faith efforts of other vendors to meet the goal on this solicitation or similar contracts may be considered.

c)

If the Agency determines that the Vendor has made good faith efforts to meet the goal, the Agency will award the contract provided that the Vendor is otherwise eligible for award. If the Agency determines that the Vendor has not made good faith efforts, the Agency will notify the Vendor of that preliminary determination. The preliminary determination shall include a statement of reasons why good faith efforts have not been found, and may include additional good faith efforts that the Vendor could take. The Vendor shall have 5 business days to make the suggested good faith efforts and any other additional good faith efforts to meet the goal. The Vendor shall submit an amended Utilization Plan if additional certified vendor commitments to meet the goal are secured. If additional certified vendor commitments sufficient to meet the goal are not secured, the Vendor shall report the final good faith efforts made in the time allotted. All additional efforts taken by the Vendor will be considered. If the Agency determines that good faith efforts have not been made, it will notify the Vendor in writing of the reasons for its determination within 5 business days of receipt of the final Utilization Plan.

b)

The Vendor may not make changes to its contractual BEP certified vendor commitments or substitute BEP certified vendors without the prior written approval of the Agency. Unauthorized changes or substitutions, including performing the work designated for a certified vendor with the Vendor's own forces, shall be a violation of this Attachment and a breach of the contract, and shall be cause to terminate the contract, and/or seek other contract remedies or sanctions. The facts supporting the request for changes must not have been known nor reasonably should have been known by the parties prior to entering into the subcontract. The Vendor must negotiate with the certified vendor to resolve the problem. Where there has been a mistake or disagreement about the scope of work, the certified vendor can be substituted only where agreement cannot be reached for a reasonable price or schedule for the correct scope of work.

 

(5)

Material mistake of fact or law about the elements of the scope of work of a solicitation where a reasonable price cannot be agreed;

 

d)

If it becomes necessary to substitute a certified vendor or otherwise change the Utilization Plan, the Vendor must notify the Agency in writing of the request to substitute a certified vendor or otherwise change the Utilization Plan.   The request must state specific reasons for the substitution or change. The Agency will approve or deny a request for substitution or other change in the Utilization Plan within 5 business days of receipt of the request.

e)

Where the Vendor has established the basis for the substitution to the Agency's satisfaction, it must make good faith efforts to meet the contract goal by substituting a certified vendor. Documentation of a replacement vendor, or of good faith efforts to replace the certified vendor, must meet the requirements of the initial Utilization Plan. If the goal cannot be reached and good faith efforts have been made, the Vendor may substitute with a non-certified vendor.

f)

If a Vendor plans to hire a subcontractor for any scope of work that was not previously disclosed in the Utilization Plan, the Vendor must obtain the approval of the Agency to modify the Utilization Plan and must make good faith efforts to ensure that certified vendors have a fair opportunity to bid on the new scope of work.

g)

A new subcontract must be executed and submitted to the Agency within 5 business days of the Vendor's receipt of the Agency's approval for the substitution or other change.

h)

The Vendor shall maintain a record of all relevant data with respect to the utilization of certified vendors, including but without limitation, payroll records, invoices, canceled checks and books of account for a period of at least 5 years after the completion of the contract. Full access to these records shall be granted by the Vendor upon 48 hours written demand by the Agency to any duly authorized representative thereof, or to any municipal, state or federal authorities. The Agency shall have the right to obtain from the Vendor any additional data reasonably related or necessary to verify any representations by the Vendor. After the performance of the final item of work or delivery of material by a certified vendor and final payment to the certified vendor by the Vendor, but not later than 30 calendar days after such payment, the Vendor shall submit a statement confirming the final payment and the total payments made to the BEP vendor under the contract.

 

 

 

_*_ Harmony will use good faith efforts throughout this contract term to accomplish these items where necessary to meet its goal.

 

(a)

Contractor Name:

Address:

Harmony Health Plan of Illinois, Inc.

200 West Adams Street, Suite 800

Chicago, EL 60606-5520