[X]
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QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
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[ ]
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TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
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Delaware
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42-1406317
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(State or other jurisdiction of
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(I.R.S. Employer
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incorporation or organization)
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Identification Number)
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7700 Forsyth Boulevard
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St. Louis, Missouri
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63105
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(Address of principal executive offices)
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(Zip Code)
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Exhibits.
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EXHIBIT
NUMBER
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DESCRIPTION
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4.1
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Indenture, dated May 27, 2011, among the Company and The Bank of New York Mellon Trust Company, N.A., relating to the Company's 5.75% Senior Notes due 2017 (including Form of Global Note as Exhibit A thereto), incorporated by reference to Exhibit 4.1 to the Company's Current Report on Form 8-K filed May 27, 2011.
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10.11
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Amendment #10 to the Contract No. 0653 Between Georgia Department of Community Health and Peach State.
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10.21
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Amendment S (Version 1.18.1) to Contract between the Texas Health and Human Services Commission and Superior HealthPlan, Inc.
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12.12
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Computation of ratio of earnings to fixed charges.
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31.1
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Certification of Chairman, President and Chief Executive Officer pursuant to Rule 13(a)-14(a) under the Securities Exchange Act of 1934, as amended.
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31.2
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Certification of Executive Vice President and Chief Financial Officer pursuant to Rule 13(a)-14(a) under the Securities Exchange Act of 1934, as amended.
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32.12
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Certification of Chairman, President and Chief Executive Officer pursuant to 18 U.S.C. Section 1350, as Adopted Pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.
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32.22
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Certification of Executive Vice President and Chief Financial Officer pursuant to 18 U.S.C. Section 1350, as Adopted Pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.
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101.12 3
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XBRL Taxonomy Instance Document.
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101.22 3
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XBRL Taxonomy Extension Schema Document.
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101.32 3
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XBRL Taxonomy Extension Calculation Linkbase Document.
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101.42 3
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XBRL Taxonomy Extension Definition Linkbase Document.
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101.52 3
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XBRL Taxonomy Extension Label Linkbase Document.
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101.62 3
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XBRL Taxonomy Extension Presentation Linkbase Document.
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1 The Company has requested confidential treatment of the redacted portions of this exhibit pursuant to Rule 24b-2 under the Securities Exchange Act of 1934, as amended, and has separately filed a complete copy of this exhibit with the Securities and Exchange Commission.
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2 Previously filed or furnished with the 2011 Second Quarter Report on Form 10-Q.
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3 XBRL (Extensible Business Reporting Language) information is furnished and not filed or a part of a registration statement or prospectus for purposes of sections 11 or 12 of the Securities Act of 1933, is deemed not filed for purposes of section 18 of the Securities Exchange Act of 1934, and otherwise is not subject to liability under these sections.
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CENTENE CORPORATION
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By:
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/s/ MICHAEL F. NEIDORFF
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Chairman, President and Chief Executive Officer
(principal executive officer)
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By:
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/s/ WILLIAM N. SCHEFFEL
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Executive Vice President and Chief Financial Officer
(principal financial officer)
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By:
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/s/ JEFFREY A. SCHWANEKE
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Vice President, Corporate Controller and Chief Accounting Officer
(principal accounting officer)
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I.
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To amend Section 1.1.3, by deleting the term “Member” and replacing it with the phrase “Member and P4HB Participant” throughout this section of the Contract.
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II.
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To amend Section 1.2 ELIGIBILITY FOR GEORGIA FAMILIES, by adding the following Medicaid eligibility category to subsection 1.2.1.1:
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·
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Planning for Healthy Babies 1115 Demonstration Waiver Participants (otherwise known as P4HB Participants) – Women ages 18 through 44 who are otherwise uninsured with family income at or below two hundred percent (200%) of the Federal poverty level. This Demonstration includes two distinct groups: women eligible for Family Planning Services only and women eligible for Interpregnancy Care and Family Planning Services.
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III.
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To further amend Section 1.2 ELIGIBILITY FOR GEORGIA FAMILIES, by adding the following provision under 1.2.1 Medicaid:
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1.2.1.2 The following Medicaid eligibility categories are required to receive
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Resource Mothers Outreach through GF:
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·
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Women ages 18 through 44 who qualify under the Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State Plan and who deliver a VLBW baby on or after January 1, 2011.
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IV.
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To further amend Section 1.2 ELIGIBILITY FOR GEORGIA FAMILIES, by adding the following provision under 1.2.3 Exclusions:
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·
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Women who become pregnant while enrolled in the Demonstration.
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Women determined to be infertile (sterile) or who are sterilized while enrolled in the Demonstration.
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Women who become eligible for any other Medicaid or commercial insurance program.
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Women who no longer meet the Demonstration’s eligibility requirements
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Women who are or become incarcerated.
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V.
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To amend Section 1.3.2, by deleting the term “Members” and replacing it with the phrase “Members and P4HB Participants” throughout this section of the Contract.
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VI.
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To amend Section 1.4 DEFINITIONS, by deleting the provision in its entirety and replacing with the revised language contained in Exhibit 1 to this Amendment.
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VII.
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To amend Section 2.1 GENERAL PROVISIONS, by adding the following language:
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VIII.
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To amend Section 2.3 ELIGIBILITY AND ENROLLMENT, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout the following Sections: 2.3.4; 2.3.5; 2.3.6; 2.3.7; 2.3.9; 2.3.10; 2.3.11; and 2.3.12.
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IX.
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To amend Section 2.3 ELIGIBILITY AND ENROLLMENT, by adding the following language:
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2.3.1.1
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The State of Georgia has the sole authority for determining eligibility for the Demonstration and whether P4HB Participants are eligible for enrollment in GF. DCH or its Agent will determine eligibility for the Demonstration and will continue responsibility for the electronic eligibility verification system (EVS).
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2.3.2.1
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DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all P4HB Participants who are determined eligible for GF. A P4HB Participant shall have thirty (30) Calendar Days to select a CMO and a Family Planning Provider. A P4HB Participant eligible for IPC services under GF will have thirty (30) Calendar Days to select a CMO plan, a Family Planning Provider and a PCP. The Family Planning Provider and the PCP may be the same provider.
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2.3.3.1
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If the Potential P4HB Participant does not choose a CMO Plan within thirty (30) Calendar Days of being deemed eligible for the Demonstration, DCH or its Agent will Auto-Assign the individual to a CMO plan using the algorithm described in Section 2.3.3 for Members.
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2.3.3.2
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Women already enrolled in GF due to pregnancy will have an expedited enrollment into the Demonstration upon termination of their pregnancy benefits. Members determined to be eligible for the Demonstration must be afforded the opportunity to choose a new CMO, if desired, for the delivery of Demonstration related Services. All P4HB Participants will have thirty (30) days from the date of eligibility notification to choose a CMO.
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2.3.3.3 |
The Contractor will notify its current pregnant Members at least thirty (30) Calendar Days prior to the expected date of delivery and prior to the date upon which the Member will end RSM, that they may be eligible to enroll in the Demonstration and may choose to switch to a different CMO plan for receipt of Demonstration services. Members who do not make a choice will be deemed to have chosen to remain in their current CMO plan for receipt of the Demonstration services they are eligible to receive.
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X.
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To amend Section 2.4 DISENROLLMENT, by deleting the terms “Member” and “Members” in the following Sections and replacing them with the phrases, “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout Sections 2.4.1 and 2.4.2.
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XI.
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To amend Section 2.4 DISENROLLMENT, by adding the following provision:
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XII.
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To amend Section 2.5 MEMBER SERVICES AND MARKETING, by renaming it MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING and by adding the following provision:
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XIII.
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To amend Section 2.6 COVERED SERVICES AND SPECIAL COVERAGE PROVISIONS, by adding the following language:
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XIV.
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To amend Section 2.8 QUALITY MONITORING, by adding the following provision:
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XV.
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To amend Section 4.1 ENROLLMENT, by adding the following provisions to the subsections listed herein:
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4.1.2.1.2
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At the time of plan selection, IPC P4HB Participants, with counseling and assistance from DCH or its Agent, will be encouraged to choose an In-Network PCP. If an IPC P4HB Participant fails to select a PCP, or if the IPC P4HB Participant has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign the IPC P4HB Participant to a PCP based on the algorithm identified in 4.1.2.1. If there is no IPC P4HB Participant or immediate family member historical usage, IPC P4HB Participants shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on geographic proximity.
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4.1.2.2.1
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For IPC P4HB Participants, PCP assignment shall be effective immediately. The Contractor shall notify the IPC P4HB Participant via surface mail of her Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
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XVI.
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To amend Section 4.2 DISENROLLMENT, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout the following Sections: 4.2.1; 4.2.1.1; 4.2.2; 4.2.4.
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XVII.
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To amend Section 4.2.1, Disenrollment Initiated by the Member, by adding the following provision:
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The P4HB Participant moves out of the CMO plan’s Service Region;
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The P4HB Participant requests to be assigned to the same CMO plan as family members; and
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The P4HB Participant otherwise becomes ineligible for participation in the Demonstration.
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Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the Demonstration amendment, or lack of Demonstration Providers experienced in dealing with the P4HB Participant’s health care needs. (DCH or its Agent shall make determination of these reasons.)
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XVIII.
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To amend Section 4.2.2.1, by adding the following provision:
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XIX.
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To amend Section 4.2.2.2, by adding the following language:
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The P4HB Participant no longer meets the eligibility criteria for the Demonstration.
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The IPC P4HB Participant has reached the end of the twenty-four (24) months of eligibility for the IPC component of the Demonstration.
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The P4HB Participant becomes pregnant while enrolled in the Demonstration;
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The P4HB Participant becomes infertile through a sterilization procedure;
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The P4HB Participant moves out of the CMO plan’s Service Region;
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The P4HB Participant’s utilization of services is fraudulent or abusive;
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The Participant’s eligibility category changes to a category ineligible for participation in the P4HB program;
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The P4HB Participant has died, been incarcerated, or moved out of State, thereby making her ineligible for Medicaid.
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XX.
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To amend Section 4.3 MEMBER SERVICES, by renaming it MEMBER AND P4HB PARTICIPANT SERVICES and by adding the following language to subsection 4.3.1, General Provisions:
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XXI.
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To amend Section 4.3.2 Requirements for Written Materials, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
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XXII.
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To amend Section 4.3.3 Member Handbook Requirements, by renaming it Member Handbook and P4HB Participant Information Requirements and by adding the following language:
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4.3.3.1.1
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The Contractor shall mail to all newly enrolled P4HB Participants an information packet including but not limited to the following:
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General information pertaining to the Demonstration (eligibility, enrollment and disenrollment criteria, and information pertaining to the Demonstration’s program components – family planning only, IPC, Resource Mothers Outreach).
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A list of benefits and services available under each Demonstration component
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A list of service exclusions or limitations under each Demonstration component
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Information about the role of the Family Planning Provider
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Information about the selection of a Primary Care Provider affiliated with the Georgia Association for Primary Health Care and whose services are not covered under the Demonstration
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Information on where and how P4HB Participants may access other benefits and services not available from or not covered by the Contractor under the Demonstration
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Information about the role of the PCP for the IPC P4HB Participant only
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Information about appointment procedures
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Information on how to access Demonstration services, including non-emergency transportation (NET) available to the IPC P4HB Participants only
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A notice stating that the Contractor shall be liable only for those Demonstration services authorized by CMS under the Demonstration
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A description of all pre-certification, prior authorization or other requirements for Demonstration related Services and treatments
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The geographic boundaries of the Service Regions
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Notice of all appropriate mailing addresses and telephone numbers to be utilized by P4HB Participants seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site
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A description of the P4HB Participant’s rights and responsibilities as described in Section 4.3.4
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The policies and procedures for Disenrollment from the Demonstration
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Information on Advance Directives
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A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request
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Information on the extent to which, and how, after hours and emergency coverage are provided, including the following:
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§
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What constitutes an Urgent and Emergency Demonstration related Medical Condition, Demonstration related Emergency Services, and Demonstration related Post Stabilization Services;
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The fact that Prior Authorization is not required for Demonstration related Emergency Services;
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The process and procedures for obtaining Demonstration related Emergency Services, including the use of the 911 telephone systems or its local equivalent;
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The location of any emergency settings and other locations at which Demonstration Providers and hospitals furnish Demonstration related Emergency and Post Stabilization Services; and
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The fact that a P4HB Participant has a right to use any hospital or other setting for Demonstration related Emergency Services
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Information on the Grievance Systems policies and procedures, as described in Section 4.14 of the Contract. This description must include the following:
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The right to file a Grievance and Appeal with the Contractor;
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The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
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The availability of assistance in filing a Grievance or Appeal with the Contractor;
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The toll-free numbers P4HB Participants can use to file a Grievance or an Appeal with the Contractor by phone;
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The right to a State Administrative Law hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
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Notice that if the P4HB Participant files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the P4HB Participant may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the P4HB Participant; and
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§
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Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover the Demonstration related Service.
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The Contractor shall submit to DCH for review and approval any changes and edits to the P4HB Participant Information Packet at least thirty (30) Calendar Days before the effective date of change.
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XXIII.
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To amend Section 4.3.4 Member Rights, by renaming it Member and P4HB Participant Right, and by adding the following language:
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4.3.4.2
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The Contractor shall have written policies and procedures regarding the rights of P4HB Participants and shall comply with any applicable federal and State laws and regulations that pertain to P4HB Participant rights. These rights shall be included in the P4HB Participant Information Packet. At a minimum, said policies and procedures shall specify the P4HB Participant’s right to:
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Receive information pursuant to 42CFR 438.10;
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Be treated with respect and with due consideration for the P4HB Participant’s dignity and privacy;
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Have all records and medical and personal information remain confidential;
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Receive information on available Demonstration related treatment options and alternatives, presented in a manner appropriate to the P4HB Participant’s condition and ability to understand;
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Participate in decisions regarding her Demonstration services;
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Request and receive a copy of her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
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Be furnished Demonstration related Services in accordance with 42 CFR 438.206 through 438.210 as appropriate;
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Freely exercise her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the P4HB Participant is treated;
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Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Demonstration related Services provided to the P4HB Participant for which DCH does not pay the Contractor; not be held liable for Demonstration related Services provided to the P4HB Participant for which neither DCH nor the CMO pays the Demonstration Provider that furnishes the Demonstration related Services; and not be held liable for payments of Demonstration related Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of the amount the P4HB Participant would owe if the Contractor provided the services directly; and
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Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.
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XXIV.
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To amend Section 4.3.5 Provider Directory, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
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XXV.
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To further amend Section 4.3.5 Provider Directory, by deleting Section 4.3.5.2 in its entirety and replacing it with the following language:
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4.3.5.2 The Provider Directory shall include names, locations, office hours, telephone numbers of and non-English language spoken by, current contracted Providers. This includes, at a minimum, information on PCPs, specialists, Family Planning Providers, dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse Providers, and hospitals. The Provider Directory shall also identify Providers that are not accepting new patients.
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XXVI.
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To amend Section 4.3.6 Member Identification (ID) Card, by renaming it Member and P4HB Participant Identification (ID) Card and by adding the following provisions:
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4.3.6.5
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The Contractor shall mail via surface mail a P4HB Participant ID Card to all new P4HB Participants in the Demonstration within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The P4HB Participant’s ID Card must meet all requirements as specified in Sections 4.3.6.2, 4.3.6.3 and 4.3.6.4. The P4HB Participant’s ID Card will identify the Demonstration component in which the P4HB Participant is enrolled:
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A Pink color will signify the P4HB Participants as eligible for Family Planning Services Only.
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A Purple color will signify the P4HB Participants as eligible for Interpregnancy Care Services and Family Planning Services.
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A Yellow color will signify the P4HB Participant as eligible for Case Management - Resource Mothers Outreach Only.
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XXVII.
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To amend Section 4.3.7 Toll-free Member Services Line, by renaming it Toll-free Member and P4HB Participant Services Line, and by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
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XXVIII.
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To amend Section 4.3.8 Internet Presence/Web Site, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract, and by adding the following provisions:
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XXIX.
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To amend Section 4.3.9 Cultural Competency, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
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XXX.
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To amend Section 4.3.10, Translation Services, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
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XXXI.
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To amend Section 4.4. MARKETING, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
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XXXII.
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To amend Section 4.5 COVERED BENEFITS AND SERVICES, by adding the following provision:
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4.5.1.2
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The Contractor shall at a minimum provide to P4HB Participants Demonstration related Services and Benefits pursuant to the CMS SPECIAL TERMS AND CONDITIONS (STCs), NUMBER: 11-W-00249/4 Document pertaining to the Planning for Healthy Babies 1115 Demonstration Waiver Program. These STCs have been incorporated into this Contract as Attachment Q.
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XXXIII.
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To amend Section 4.6.1 Emergency Services, by adding the following provisions:
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4.6.1.3.1
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The Contractor shall provide payment for Demonstration related Emergency Services when furnished by a qualified Provider, regardless of whether that Provider is in the Contractor’s network. These services shall not be subject to prior authorization requirements. The Contractor shall be required to pay all Demonstration related Emergency Services that are Medically Necessary until the P4HB Participant is stabilized. The Contractor shall also pay for any screening examination services conducted to determine whether a Demonstration related Emergency Medical Condition exists.
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4.6.1.5.1
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The attending emergency room physician, or the Provider actually treating the P4HB Participant, is responsible for determining when the P4HB Participant is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor, who shall be responsible for coverage and payment. The Contractor, however, may establish arrangements with a hospital whereby the Contractor may send one of its own physicians with appropriate emergency room privileges to assume the attending physician’s responsibilities to stabilize, treat, and transfer the P4HB Participant, provided that such arrangement does not delay the provision of Demonstration related Emergency Services.
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4.6.1.6.1
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The Contractor shall not retroactively deny a Claim for a Demonstration related emergency screening examination because the Condition, which appeared to be a Demonstration related Emergency Medical Condition under the prudent layperson standard, turned out to be non-emergency in nature. If a Demonstration related emergency screening examination leads to a clinical determination by the examining physician that an actual Demonstration related Medical Condition does not exist, then the determining factor for payment liability shall be whether the P4HB Participant had acute symptoms of sufficient severity at the time of presentation. In this case, the Contractor shall pay for all Demonstration related emergency screening and care services provided. Payment shall be at either the rate negotiated under the Provider Contract, or the rate paid by DCH under the Fee for Service Medicaid Program.
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4.6.1.7.1
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The Contractor may establish guidelines and timelines for submittal of notification regarding provision of Demonstration related Emergency Services, but, the Contractor shall not refuse to cover a Demonstration related Emergency Service based on the emergency room Provider, hospital, or fiscal agent’s failure to notify the P4HB Participant’s Family Planning Provider and/or PCP (in the case of the IPC P4HB Participant), CMO plan representative, or DCH of the P4HB Participant’s Demonstration related screening and treatment within said timeframes.
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4.6.1.8.1
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When a representative of the Contractor instructs the P4HB Participant to seek Emergency Services, the Contractor shall be responsible for payment for the Demonstration related Medical Screening examination without regard to whether the Condition meets the prudent layperson standard.
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4.6.1.9.1
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The P4HB Participant who has a Demonstration related Emergency Medical Condition shall not be held liable for payment of subsequent Demonstration related screening and treatment needed to diagnose the specific Condition or stabilize the P4HB Participant.
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4.6.1.10.1
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Once the P4HB Participant’s condition is stabilized, the Contractor may require Pre-Certification for hospital admission or prior authorization for follow up care.
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XXXIV.
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To amend Section 4.6.2 Post-Stabilization Services, by adding the following provisions:
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·
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The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour;
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The Contractor cannot be contacted; or
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The Contractor’s Representative and the attending physician cannot reach an agreement concerning the P4HB Participant’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the P4HB Participant until a CMO plan physician is reached or one of the criteria in Section 4.6.2.11 is met.
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·
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An In-Network Provider with privileges at the treating hospital assumes responsibility for the P4HB Participant’s care;
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An In-Network Provider assumes responsibility for the P4HB Participant’s care through transfer;
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The Contractor’s Representative and the treating physician reach an agreement concerning the P4HB Participant’s care; or
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·
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The P4HB Participant is discharged.
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XXXV.
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To amend Section 4.6.3 Urgent Care Services, by deleting this section in its entirety and replacing it with the following language:
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XXXVI.
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To amend Section 4.6.4.1 Family Planning Services, by deleting it in its entirety and replacing it with the following language:
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XXXVII.
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To amend Section 4.6.4.2, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
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XXXVIII.
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To amend Section 4.6.4.3, by deleting it in its entirety and replacing it with the following language:
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·
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Education and counseling necessary to make informed choices and understand contraceptive methods;
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Initial and annual complete physical examinations including a pelvic examination and Pap test;
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Follow up, brief and comprehensive visits – up to four (4) such visits for P4HB Participants;
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·
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Pregnancy testing;
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·
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Contraceptive supplies and follow up care;
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·
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Diagnosis of sexually transmitted infections;
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·
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Treatment of sexually transmitted infections with the following exception - P4HB Participants are excluded from receiving drugs for the treatment of HIV/AIDS and hepatitis under the Demonstration;
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For P4HB Participants - Drugs, supplies, or devices related to the women’s health services described above that are prescribed by a health care provider who meets the State’s provider enrollment requirement; (subject to the national drug rebate program requirements).
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·
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Infertility assessments with the following exception – P4HB Participants are excluded from receiving this benefit.
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XXXIX.
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To amend Section 4.6.5 Sterilizations, Hysterectomies and Abortions, by adding
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·
|
The P4HB Participant is at least twenty-one (21) years of age at the time consent is obtained;
|
·
|
The P4HB Participant is mentally competent;
|
·
|
The P4HB Participant voluntarily gives informed consent in accordance with the State Policies and Procedures for Family Planning Clinic Services. This includes the completion of all applicable documentation.
|
·
|
At least thirty (30) Calendar Days, but not more than one hundred and eight (180) Calendar Days, have passed between the date of informed consent and the date of sterilization.
|
·
|
An interpreter is provided when language barriers exist. Arrangements are to be made to effectively communicate the required information to a P4HB Participant who is visually impaired, hearing impaired or otherwise disabled; and
|
·
|
The P4HB Participant is not institutionalized in a correctional facility, mental hospital or other rehabilitative facility.
|
XL.
|
To amend Section 4.6.5.2, by adding the following provision:
|
XLI.
|
To amend Section 4.6.5.4, by adding the following provision:
|
XLII.
|
To amend Section 4.6.6 Pharmacy, by adding the following provision:
|
XLIII.
|
To amend Section 4.6.7 Immunizations, by adding the following provision:
|
XLIV.
|
To amend Section 4.6.8 Transportation, by adding the following provision:
|
|
4.6.8.2.1
|
The Contractor shall coordinate with the NET vendors for services required by P4HB Participants in the IPC component of the Demonstration.
|
XLV.
|
To amend Section 4.6.11 Mental Health and Substance Abuse, by adding the following provision:
|
XLVI.
|
To amend Section 4.6.12 Advance Directives, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
|
XLVII.
|
To amend Section 4.8.2 Primary Care Providers (PCPs), by adding the following provision:
|
XLVIII.
|
To further amend Section 4.8.2 Primary Care Providers (PCPs), by deleting
|
|
4.8.2.4
|
The Contractor may require that Members and IPC P4HB Participants are assigned to the same PCP for a period of up to six (6) months. In the event the Contractor requires that Members and IPC P4HB Participants are assigned to the same PCP for a period of six (6) months or less, the following exceptions shall be made:
|
|
4.8.2.4.1
|
Members and IPC P4HB Participants shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection;
|
|
4.8.2.4.2
|
Members and IPC P4HB Participants shall be allowed to change PCPs with cause at any time. The following constitute cause for change:
|
·
|
The PCP no longer meets the geographic access standards as defined in Section 4.8.14;
|
·
|
The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and
|
·
|
The Member or IPC Participant requests to be assigned to the same PCP as other family members.
|
|
4.8.2.4.3
|
Members and IPC P4HB Participants shall be allowed to change PCPs every six (6) months.
|
XLIX.
|
To further amend Section 4.8.2 Primary Care Providers (PCPs), by adding the following provision:
|
L.
|
To amend Section 4.8.4 Pharmacies, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
|
LI.
|
To amend Section 4.8.5 Hospitals, by adding the following provision:
|
|
4.8.5.1.1
|
The Contractor shall maintain a comprehensive Provider network of hospitals such that they are available and accessible for Demonstration related Service and Benefit delivery to all P4HB Participants.
|
LII.
|
To amend Section 4.8.6 Laboratories, by adding the following provision:
|
4.8.6.1
|
The Contractor shall maintain a comprehensive Provider network of laboratories that ensures laboratories are accessible to all P4HB Participants for Demonstration related Services. The Contractor shall ensure that all laboratory testing sites providing services under this Contract have either a clinical laboratory (CLIA) certificate or a waiver of a certificate of registration, along with a CLIA number, pursuant to 42 CFR 493.3.
|
LIII.
|
To amend Section 4.8.12.2 Dental Practitioners, by adding the following provision:
|
LIV.
|
To amend Section 4.8.13 Geographic Access Requirements, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
|
LV.
|
To amend Section 4.8.16 Mainstreaming, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
|
LVI.
|
To amend Section 4.8.17.3, by deleting the term “Members” and replacing it with the phrase “Members or P4HB Participants” throughout this section of the Contract.
|
LVII.
|
To amend Section 4.8.17.6, by deleting the term “Member’s” and replacing it with the phrase “Member’s or P4HB Participant’s” throughout this section of the Contract.
|
LVIII.
|
To amend Section 4.8.18 Network Changes, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
|
LIX.
|
To amend Section 4.9.2.1, by adding the following language:
|
·
|
Description of the Demonstration;
|
·
|
Practice protocols for the Demonstration;
|
·
|
Other Provider responsibilities pertaining to the Demonstration;
|
·
|
Coding requirements pertaining to the Demonstration;
|
·
|
Prior Authorization, Pre-Certification, and Referral procedures pertaining to the Demonstration;
|
·
|
P4HB Participant rights and responsibilities
|
LX.
|
To amend Section 4.9.3 Education and Training, by adding the following
|
LXI.
|
To amend Section 4.10 PROVIDER CONTRACTS AND PAYMENTS, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
|
LXII.
|
To amend Section 4.10.4.4.1, by adding the following language:
|
·
|
Demonstration related Services as a separate report
|
LXIII.
|
To amend Section 4.11.4, by adding the following provisions:
|
|
4.11.4.1.1
|
The Contractor shall identify and facilitate transitions for P4HB Participants that are moving from one CMO to another and require additional or distinctive assistance during the period of transition. When relinquishing P4HB Participants, the Contractor shall cooperate with the receiving CMO plan regarding the course of ongoing care.
|
|
4.11.4.1.2
|
The Contractor will monitor Providers to ensure transition of care from one entity to another. Demonstration related procedures that are scheduled to occur after a P4HB Participant’s new CMO effective date, but that were authorized by the P4HB Participant’s original CMO prior to her new CMO effective date will be covered by the P4HB Participant’s new CMO for thirty (30) days.
|
|
4.11.4.1.3
|
P4HB Participants that are in ongoing Demonstration related outpatient treatment or that are receiving Demonstration related medication that has been covered by another CMO prior to their new CMO effective date will be covered by the new CMO for at least thirty (30) days to allow time for clinical review, and if necessary, transition of care. If it is determined the P4HB Participant is still in need of those treatments and/or medications, the CMO will be obligated to cover those Demonstration related Services beyond thirty (30) days.
|
|
4.11.4.2.1.7
|
A P4HB Participant that is hospitalized in an acute inpatient hospital facility will remain the responsibility of that P4HB Participant’s original CMO until she is discharged from the facility, even if she changes to a different CMO or becomes eligible for other coverage during her inpatient stay. The CMO is not required to cover Demonstration related Services for a P4HB Participant that has no Demonstration benefits. If the P4HB Participant remains an acute inpatient and loses Demonstration eligibility during the stay, the CMO is only responsible for payment until the last day of Demonstration eligibility.
|
LXIV.
|
To amend Section 4.11.9 Case Management, by adding the following provisions:
|
·
|
Early identification of P4HB IPC Participants who have or may have special needs;
|
·
|
Assessment of a P4HB IPC Participant’s risk factors;
|
·
|
Development of a plan of care;
|
·
|
Referrals and assistance to ensure timely access to Providers included and external to the Contractor’s network;
|
·
|
Coordination of care actively linking the P4HB IPC Participant to In-Network and out of network Providers, medical services, residential, social and other support services where needed;
|
·
|
Resource Mothers Outreach
|
·
|
Monitoring;
|
·
|
Continuity of care;
|
·
|
Follow up; and
|
·
|
Documentation
|
LXV.
|
To amend Section 4.11.12 Reporting Requirements, by adding the following provision:
|
|
4.11.12.3
|
The Contractor shall submit to DCH all reports as outlined in the Demonstration Quality Strategy identified in Attachment O of this Contract.
|
LXVI.
|
To amend Section 4.14 INTERNAL GRIEVANCE SYSTEM, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
|
LXVII.
|
To amend Section 4.16 CLAIMS MANAGEMENT, by deleting the term “Medicaid claims” as well as any reference thereto and replacing it with the phrase “Medicaid and Demonstration claims”. (Demonstration claims will be processed as all other Medicaid claims are processed.)
|
LXVIII.
|
To amend Section 4.17 INFORMATION MANAGEMENT AND SYSTEMS, by deleting the terms “Member” and “Members” and replacing them with the phrases “Member or P4HB Participant” and “Members or P4HB Participants” respectively throughout this section of the Contract.
|
LXIX.
|
To amend Section 5.8 CONTRACT REPORTS, by adding Demonstration Reports with a Due Date as – per Attachments O and Q.
|
LXX.
|
To amend Section 7.1.1, by adding the following language:
|
|
7.1.1.1
|
DCH will compensate the Contractor on a per member per month basis for each P4HB Participant enrolled in the Contractor’s plan (See Attachment R). The number of enrolled P4HB Participants in each rate cell category will be determined by the records maintained in the Medicaid Member Information System (MMIS) maintained by DCH’s fiscal agent. The monthly compensation will be the final negotiated rate for each rate cell multiplied by the number of enrolled P4HB Participants in each rate cell category. The Contractor must provide to DCH, and keep current, its tax identification number, billing address, and other contact information. Pursuant to the terms of this Contract, should DCH assess liquidated damages or other remedies or actions for noncompliance or deficiency with the terms of this Contract, such amount shall be withheld from the monthly compensation for the following month, and for continuous consecutive months thereafter until such noncompliance or deficiency is corrected.
|
LXXI.
|
To amend Section 23.4.1 by adding the following language:
|
·
|
Failure to comply with the required Demonstration Reports and Deliverables as prescribed in Attachments O and Q.
|
·
|
Failure to achieve annual targeted reductions in the Pregnancy Rate as identified in Attachment O.
|
·
|
Failure to deliver effective Demonstration services as evidenced by lack of achievement of annual targeted LBW and VLBW reduction targets as identified in Attachment O.
|
LXXII.
|
To amend the Contract by appending Exhibits 2, 3, 4, 5, 6 and 7 hereto as Attachments N, O, P, Q, and R respectively, to the Contract.
|
LXXIII.
|
DCH and Contractor agree that they have assumed an obligation to perform the covenants, agreements, duties and obligations of the Contract, as modified and amended herein, and agree to abide by all the provisions, terms and conditions contained in the Contract as modified and amended.
|
LXXIV.
|
This Amendment shall be binding and inure to the benefit of the parties hereto, their heirs, representatives, successors and assigns. Whenever the provisions of this Amendment and the Contract are in conflict, the provisions of this Amendment shall take precedence and control.
|
·
|
Education and counseling necessary to make informed choices and understand contraceptive methods;
|
·
|
Initial and annual complete physical examinations;
|
·
|
Follow-up, brief and comprehensive visits;
|
·
|
Pregnancy testing;
|
·
|
Contraceptive supplies and follow-up care;
|
·
|
Diagnosis and treatment of sexually transmitted diseases; and
|
·
|
Infertility assessment
|
·
|
Direct Cause: The cause that directly resulted in the event (the first cause in the chain).
|
·
|
Corrective Action: actions taken to correct the root cause generally a reactive process used to address problems after they have occurred
|
|
• Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
|
|
Exhibit 2
|
Family Planning Demonstration Services: Services provided to P4HB Participants must be provided by a physician or an advanced practice nurse.
|
Services Include:
|
·
|
Family planning initial or annual exams
|
·
|
Follow up, brief and comprehensive visits – up to four (4) such visits
|
·
|
Contraceptive services and supplies
|
·
|
Patient education and counseling
|
·
|
Counseling and referrals to:
|
o
|
Social services
|
o
|
Primary health care providers
|
·
|
Family planning lab tests:
|
o
|
Pregnancy tests
|
o
|
Pap Smear and Pelvic exam
|
§
|
A colposcopy (and procedures done with/during a colposcopy) or repeat Pap smear performed as a follow-up to an abnormal Pap smear which is done as part of a routine/periodic family planning visit. Only those colposcopies which can generally be performed in the office or clinic setting are coverable as a family planning-related service under this Demonstration. Colposcopies which are generally provided in an ambulatory surgery center/facility, a special procedure room/suite, an emergency room, an urgent care center or a hospital are not covered under this waiver as family planning-related services
|
·
|
Screening, treatment and follow up for sexually transmitted infections (STIs), except HIV/AIDS and Hepatitis
|
o
|
Antibiotic treatment for STIs when the infections are identified during a routine family planning visit.
|
o
|
A follow up visit for the treatment/drugs may be covered
|
o
|
Subsequent follow-up visits to re-screen for STIs based on the Centers for Disease Control and Prevention guidelines
|
·
|
Drugs for the treatment of lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection/disorder is identified or diagnosed during a routine/periodic family planning visit. A follow-up visit for the treatment/ drugs may be covered.
|
·
|
Treatment of major complications related to the delivery of Demonstration related services such as:
|
o
|
Treatment of a perforated uterus due to an intrauterine device insertion;
|
o
|
Treatment of severe menstrual bleeding caused by a Depo-Provera injection requiring a dilation and curettage; or,
|
o
|
Treatment of surgical or anesthesia-related complications during a sterilization procedure.
|
·
|
Tubal Ligation (Sterilization)
|
o
|
Treatment and follow-up of an STI diagnosed at the time of sterilization.
|
·
|
Family Planning pharmacy visits
|
·
|
Folic acid and/or a multivitamin with folic acid.
|
·
|
Select immunizations for P4HB Participants aged 19 and 20. The Contractor shall provide all P4HB Participants ages nineteen (19) and twenty (20) with Hepatitis B, Tetanus-Diphtheria (Td) and combined Tetanus, Diphtheria, Pertussis vaccinations according to the Advisory Committee on Immunization Practices (ACIP) guidelines as needed
|
·
|
P4HB Participants age 18 receive vaccines at no cost under the Vaccines for Children (VFC) program
|
·
|
Additionally women who have delivered a very low birth weight baby following implementation of the Demonstration will be eligible for Interpregnancy Care services including the Resource Mother Outreach benefit.
|
·
|
Primary Care services, up to 5 office/outpatient visits
|
·
|
Limited Dental Services
|
·
|
Management and treatment of chronic diseases
|
·
|
Substance abuse treatment including detoxification and intensive outpatient rehabilitation
|
·
|
Case Management/Resource Mother Outreach
|
·
|
Prescription drugs (non-family planning) for the treatment of chronic conditions that may increase the risk of a subsequent VLBW delivery
|
·
|
Non emergency transportation
|
|
Exhibit 3
|
·
|
Key Goals, Objectives and Performance Targets
|
·
|
Program Hypotheses
|
·
|
Performance Measures
|
·
|
Analysis pertaining to the achievement of the Performance Targets
|
·
|
Assessment of the rate at which the Demonstration was implemented
|
·
|
Assessment of the Demonstration Providers’ understanding of program eligibility, service coverage and payment rates across sites of care
|
·
|
Assessment of the Providers’ and P4HB Participants satisfaction with the Demonstration
|
·
|
Assessment of the per Demonstration year changes in family planning visits regardless of payer source, per poor and near poor women in Georgia
|
·
|
Determination of averted births among P4HB Participants and tests of budget neutrality
|
·
|
The relationship between the Demonstration implementation and changes in pregnancy and birth rates, low birth weight rate and inter-pregnancy interval for “targeted” versus control group women
|
·
|
The relationship between the Demonstration and changes in pregnancies, unintended births, intra-partum intervals and post-partum birth control use among “targeted” and control groups
|
·
|
The relationship of the Demonstration to changes in inter-pregnancy intervals, rate of repeat very low birth weight and preterm delivery rates
|
·
|
Reduction of Georgia’s low birth weight and very low birth weight rates over the course of the Demonstration period
|
·
|
Reduction in the number of unintended pregnancies in Georgia
|
·
|
Reduction in Georgia’s Medicaid costs by reducing the number of unintended pregnancies in women who otherwise would be eligible for Medicaid pregnancy related services.
|
·
|
Improve access to family planning services by extending eligibility for family planning services to all women aged 18 – 44 years who are at or below 200% of the federal poverty level (FPL) during the three year term of the Demonstration. Achievement of this objective will be measured by:
|
o
|
Total family planning visits pre and post the Demonstration;
|
o
|
Use of contraceptive services/supplies pre and post the Demonstration;
|
·
|
Provide access to inter-pregnancy primary care health services for eligible women who have previously delivered a very low birth weight infant. Achievement of this objective will be measured by:
|
o
|
Use of inter-pregnancy care services (primary care and Resource Mothers Outreach) by women with a very low birth weight delivery;
|
·
|
Decrease unintended and high-risk pregnancies among Medicaid eligible women and increase child spacing intervals through effective contraceptive use to foster reduced low birth weight rates and improved health status of women. Achievement of this objective will be measured by:
|
o
|
Average inter-pregnancy intervals for women pre and post the Demonstration;
|
o
|
Average inter-pregnancy intervals for women with a very low birth weight delivery pre and post the Demonstration;
|
·
|
Decrease in late teen pregnancies by reducing the number of repeat teen births among Medicaid eligible women. Achievement of this objective will be documented by:
|
o
|
The number of repeat teen births assessed annually
|
·
|
Decrease the number of Medicaid-paid deliveries beginning in the second year of the Demonstration, thereby reducing annual pregnancy-related expenditures. Achievement of this objective will be measured by:
|
o
|
The number of Medicaid paid deliveries assessed annually
|
·
|
Increase consistent use of contraceptive methods by incorporating care coordination and patient-directed counseling into family planning visits. Achievement of this objective will be measured by:
|
o
|
Utilization statistics for family planning methods
|
o
|
Number of Deliveries to P4HB Participants
|
·
|
Increase family planning utilization among Medicaid eligible women by using an outreach and public awareness program designed with input from family planning patients and providers as well as women who are in need of services but who are not receiving them. Achievement of this objective will be measured by:
|
o
|
Enrollment statistics for the Demonstration.
|
·
|
Increase the overall savings in Medicaid spending attributable to this Demonstration. Achievement of this objective will be measured by:
|
o
|
Documentation of achievement of financial savings targets
|
·
|
That the Demonstration will bring sufficient numbers of women into the program to increase the overall use of family planning services/supplies and will promote the more consistent use of effective contraceptive methods among program users.
|
·
|
That increased use of contraceptives will lead to reduced unintended pregnancies and in turn, unintended births among this population of women (as well as improved inter-pregnancy intervals).
|
·
|
That teens are at high risk of unintended pregnancy a related hypothesis is that the rate of unintended births and repeat teen births will also fall post implementation of the waiver.
|
·
|
That these changes will be sufficient to lower the number of overall Medicaid paid deliveries/births and hence, costs, such that the state and federal government will realize a net cost savings despite increased spending on family planning services.
|
I.
|
Assessment of the rate at which the Demonstration was implemented using Enrollment, Participation and Use of Services as Performance Measures:
|
·
|
Total number of Demonstration Enrollees per CMO stratified by Demonstration component – Family Planning only; IPC; Resource Mothers only
|
·
|
Total number of Demonstration Enrollees per CMO stratified by age, race and ethnicity, county;
|
·
|
Average months enrolled per CMO by Age, Race/Ethnicity and County;
|
·
|
Proportion of LIM population per CMO enrolled in Resource Mothers Outreach
|
·
|
Total number of P4HB Participants per CMO stratified by age, race , ethnicity, county;
|
·
|
Number of IPC P4HB Participants per CMO stratified by age, race and ethnicity, county;
|
·
|
Number of P4HB Participants per CMO in the Resource Mothers only Outreach
|
·
|
Overview of the Geographic variations in enrollment per CMO;
|
·
|
Rate of use per CMO of:
|
§
|
All Family Planning Services by type;
|
§
|
All Contraceptives by type (inclusive of hormonal and non-hormonal contraceptives);
|
§
|
Counts of primary care visits for those in the IPC component of the Demonstration.
|
·
|
Utilization statistics per CMO for all IPC services and IPC services by type
|
II.
|
Assessment of the Demonstration Providers’ and P4HB Participants’ understanding of program eligibility, service coverage and payment rates across sites of care
|
·
|
Semi-annual CMO conducted Provider Surveys with analysis reports highlighting responses to questions regarding knowledge, understanding of the Demonstration, level of participation and training/outreach.
|
·
|
Semi-annual CMO conducted P4HB Participant Surveys with analysis reports highlighting responses to questions pertaining to: satisfaction with eligibility and enrollment processes
|
1.
|
Satisfaction with CMO selection process
|
2.
|
Satisfaction with educational materials regarding the Demonstration
|
3.
|
Satisfaction with service options and services
|
4.
|
Satisfaction with contraceptive method
|
5.
|
Contraceptive failures/unintended births
|
6.
|
Satisfaction with provider selection
|
7.
|
Results and analysis of semi-annual member satisfaction surveys
|
III.
|
Assessment of the per Demonstration year changes in family planning visits
|
·
|
Total Demonstration expenses per CMO and stratified by Demonstration component – Family Planning Only, IPC, and Resource Mothers Outreach only
|
·
|
The average per person expenditures for the IPC component per CMO
|
·
|
The total expenditures per CMO for the first year infant life costs stratified by birth weight categories
|
·
|
The average per person expenditures per CMO for the first year of life costs stratified by birth weight categories
|
·
|
The total expenditures for VLBW deliveries per CMO
|
·
|
The average per person expenditures for VLBW deliveries per CMO
|
IV. Determination of the number of averted births among P4HB Participants and tests of budget neutrality
|
·
|
Total Pregnancies per CMO stratified by age, race/ethnicity, county/region
|
·
|
Total Pregnancies per Demonstration population paid per CMO stratified by age, race/ethnicity, county/region, FP only and IPC
|
·
|
Contraceptive failures per CMO stratified by age, race/ethnicity, county/region
|
·
|
Actual Live Births per CMO stratified by Age, Race/Ethnicity, county/region and weight categories
|
V.
|
Determination of the relationship between the Demonstration implementation and changes in pregnancy and birth rates, low birth weight rate and inter-pregnancy interval for “targeted” versus control group women
|
·
|
To be calculated by the Demonstration evaluator
|
VI.
|
Assessment of the relationship between the Demonstration and changes in pregnancies, unintended births, intra-partum intervals and post-partum birth control use among “targeted” and control groups:
|
·
|
CMO documentation of events that occurred during the quarter or are anticipated to occur in the near future affecting the CMO’s health care delivery; benefits; enrollment; grievances; quality of care; access; other operational issues
|
·
|
Total Births – Live Births and Fetal Deaths stratified by age, race/ethnicity, county/region per CMO
|
·
|
Unintended Births-Percent of Births Reported as Unwanted or Mistimed per CMO
|
VII.
|
Assessment of the relationship of the Demonstration to changes in inter-pregnancy intervals, rate of repeat very low birth weight and preterm delivery rates
|
·
|
Average number of months between pregnancies to the same woman (number of months between initial birth/fetal death event and subsequent birth/fetal death event – the gestational age of the subsequent event) per CMO
|
·
|
Proportion of women with a very low birth weight delivery whose next pregnancy ends in low birth weight or very low birth weight per CMO
|
·
|
Proportion of women with a very low birth weight delivery whose next pregnancy ends in a preterm delivery per CMO
|
·
|
Reduction of Georgia’s low birth weight and very low birth weight rates over the course of the Demonstration period as measured by:
|
o
|
3.5% annual reduction from CY 2010 baseline in the Medicaid reported LBW and VLBW rates; or
|
o
|
10% cumulative reduction from CY 2010 baseline in the Medicaid LBW and VLBW rates over the Demonstration period (by December 31, 2013).
|
o
|
Reports are due from the CMOs to DCH by June 30 of each Demonstration year, beginning in Demonstration year 2 which begins January 1, 2012.
|
o
|
Reports are due from the DCH MMIS by June 30 of each Demonstration Year, beginning in Demonstration Year 2 which begins January 1, 2012.
|
·
|
Reduction in the number of unintended pregnancies in Georgia as measured by:
|
o
|
Percent births reported as unintended in the Medicaid population compared with baseline; and
|
o
|
4% annual reduction in the Pregnancy Rate in the Medicaid population
|
·
|
Reduction in Georgia’s Medicaid costs by reducing the number of unintended pregnancies in women who otherwise would be eligible for Medicaid pregnancy related services. Projected state fund savings due to reductions in pregnancies and subsequent care for normal weight, low birth weight and very low birth weight infants are:
|
o
|
$9.3M in FY 12;
|
o
|
$15.5M in FY 13
|
o
|
$24.9M in FY 14
|
·
|
Demonstration expenditures including administrative costs;
|
·
|
Total number of Demonstration enrollees;
|
·
|
Total number of P4HB Participants
|
·
|
Total number of Demonstration enrollees stratified by age, race and ethnicity;
|
·
|
Total number of P4HB Participants stratified by age, race and ethnicity
|
·
|
Total number of IPC enrollees stratified by age, race and ethnicity
|
·
|
Total number of IPC P4HB Participants stratified by age, race and ethnicity
|
·
|
Total number of Family Planning only enrollees stratified by age, race and ethnicity
|
·
|
Total number of Family Planning only P4HB Participants stratified by age, race and ethnicity
|
·
|
Total number of Resource Mothers Outreach only Enrollees stratified by age, race and ethnicity
|
·
|
Total number of Resource Mothers Outreach only P4HB Participants stratified by age, race and ethnicity
|
·
|
Total number of P4HB Participants utilizing services
|
·
|
Utilization statistics for Family Planning only services by type
|
·
|
IPC Problem and Strength Identification Quarterly Summary
|
·
|
Total number of Care Plans for IPC Participants
|
·
|
Utilization statistics for IPC Services by type;
|
·
|
Contraceptive types utilized;
|
·
|
Geographic variations in enrollment;
|
·
|
Total number of P4HB Participants (Participants include all individuals who obtain one or more covered family planning services through the Demonstration);
|
·
|
Events occurring during the quarter, or anticipated to occur in the near future that affect:
|
§
|
health care delivery
|
§
|
benefits
|
§
|
enrollment
|
§
|
grievances
|
§
|
quality of care
|
§
|
access
|
§
|
pertinent legislative activity
|
§
|
eligibility verification activities
|
§
|
other operational issues;
|
·
|
Action plans for addressing any policy and administrative issues identified; and
|
·
|
Evaluation activities and interim findings.
|
·
|
Top five (5) Chronic Diseases/Conditions affecting P4HB Participants in the IPC Demonstration component ;
|
·
|
The total number of deliveries to Contractor’s Medicaid Members;
|
·
|
The pregnancy rate for Contractor’s Medicaid Members;
|
·
|
The number of deliveries to the P4HB Participants stratified by Demonstration component: FP Only; FP and IPC; Resource Mothers Only.
|
·
|
The number of total births to the Contractor’s Medicaid Members stratified by birth weight categories;
|
·
|
The number of live births to P4HB Participants in the FP only component of the Demonstration stratified by birth weight categories – Normal (2,500 grams or more), LBW (1,500 grams to 2,499 grams), VLBW (less than 1,500 grams);
|
·
|
The number of live births to P4HB Participants in the IPC component of the Demonstration stratified by birth weight category;
|
·
|
The number of stillbirths to the IPC P4HB Participants;
|
·
|
IPC Problem and Strength Identification Yearly Summary
|
·
|
The number of estimated averted births (using the baseline fertility rate) in the waiver application;
|
·
|
The total and average per person Medicaid expenditures for the Demonstration;
|
·
|
The total and average per person Medicaid expenditures for the IPC component of the Demonstration;
|
·
|
The total and average per person Medicaid expenditures for the first year infant life costs stratified by birth weight categories;
|
·
|
The number of VLBW deliveries to Contractor’s P4HB participants;
|
·
|
The number of VLBW deliveries that occur to P4HB Participants in the IPC component of the Demonstration;
|
·
|
The total and average per person Medicaid expenditures for VLBW deliveries;
|
·
|
Results of P4HB Participant and Provider satisfaction surveys.
|
|
Exhibit 4
|
ATTACHMENT P
|
·
|
Complete P4HB Participant intakes based on interviews with P4HB Participants, their families, significant others and appropriate community agencies.
|
·
|
Demonstrate skillful use of observation and assessment tools to evaluate the P4HB Participant’s needs and monitor the P4HB Participant’s progress towards treatment goals.
|
·
|
Meet with P4HB Participants via phone or in person to increase participants’ adoption of healthy behaviors, including healthy eating choices and smoking cessation; increase participants’ adoption of health behaviors such as healthy eating choices and smoking cessation.
|
·
|
Support P4HB Participants’ compliance with primary care medical appointments including assistance with non-emergency transportation arrangements; serve as the liaison between P4HB Participants and family members, significant others, nurses, physicians, and organizational components to facilitate communication, linkage and continuity of service.
|
·
|
Consult with physicians, nurses, social workers, and case managers about problems identified and assist in the development of an appropriate action plan.
|
·
|
Document compliance with appointments and enrollment and participation in planned services and benefits in the P4HB Participant’s case management record and/or required Demonstration forms.
|
·
|
Prepare and disseminate pertinent reports for/to supervisors, colleagues and other appropriate individuals. Maintain program statistics for purposes of evaluation and research.
|
·
|
Submit all data, forms and documentation per Demonstration guidelines.
|
·
|
Provide short-term case management and referral services to P4HB Participants with emergency situations.
|
·
|
Support P4HB Participants’ compliance with medications to treat chronic health conditions including assisting the P4HB Participant with obtaining needed medications and reinforcing the need for medication compliance;
|
·
|
Assist the P4HB Participant with the coordination of social services support for family and life issues; implement and organize the delivery of specific social services within the community and maintain an updated resource file.
|
·
|
Assists Participants in locating and utilizing community resources including legal, medical, financial assistance, and other referral services; assist with linking mothers to community resources such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
|
·
|
Provide emotional support for P4HB Participants following substance abuse treatment;
|
·
|
Provide mentoring for P4HB Participants;
|
·
|
Assist mothers of VLBW babies to obtain regular preventive health visits and appropriate immunizations for their child;
|
·
|
Link the VLBW infant’s mother with community resources such as WIC;
|
·
|
Provide the mother with the peer and emotional support needed to meet the health demands of her VLBW infant;
|
·
|
Encourage the VLBW infant’s mother to implement the parenting and child safety concepts taught during classes the mother will be encouraged to attend.
|
|
Exhibit 5
|
ATTACHMENT Q
|
AWARDEE:
|
Georgia Department of Community Health
|
I. | Preface |
II. | Program Description and Objectives |
III. | General Program Requirements |
IV. | Eligibility |
V. | Benefits and Delivery Systems |
VI. | General Reporting Requirements |
VII. | General Financial Requirements |
VIII. | Monitoring Budget Neutrality |
IX. | Evaluation of the Demonstration |
X. | Schedule of State Deliverables for the Demonstration |
II.
|
PROGRAM DESCRIPTION AND OBJECTIVES
|
·
|
Reduce Georgia’s low birth weight (LBW) and VLBW rates;
|
·
|
Reduce the number of unintended pregnancies in Georgia;
|
·
|
Reduce Georgia’s Medicaid costs by reducing the number of unintended pregnancies by women who otherwise would be eligible for Medicaid pregnancy-related services;
|
·
|
Provide access to IPC health services for eligible women who have previously delivered a VLBW baby; and
|
·
|
Increase child spacing intervals through effective contraceptive use.
|
III.
|
GENERAL PROGRAM REQUIREMENTS
|
1.
|
Compliance with Federal Non-Discrimination Statutes. The State must comply with all applicable Federal statutes relating to non-discrimination. These include, but are not limited to, the Americans with Disabilities Act of 1990, title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.
|
2.
|
Compliance with Medicaid Law, Regulation, and Policy. All requirements of the Medicaid programs expressed in law, regulation, court order, and policy statement not expressly waived or identified as not applicable in the waiver and expenditure authority documents (of which these terms and conditions are part), must apply to the Demonstration.
|
3.
|
Changes in Medicaid Law, Regulation, and Policy. The State must, within the timeframes specified in law, regulation, court order, or policy statement, come into compliance with any changes in Federal law, regulation, court order, or policy affecting the Medicaid programs that occur during this Demonstration approval period, unless the provision being changed is explicitly waived or identified as not applicable.
|
4.
|
Impact on Demonstration of Changes in Federal Law, Regulation, and Policy Statements.
|
a)
|
To the extent that a change in Federal law, regulation, final court order, or policy requires either a reduction or an increase in Federal financial participation (FFP) for expenditures made under this Demonstration, the State must adopt, subject to CMS approval, a modified budget neutrality agreement for the Demonstration as necessary to comply with such change. The modified agreement will be effective upon the implementation of the change.
|
b)
|
If mandated changes in Federal law require State legislation, the changes must take effect on the day such State legislation becomes effective, or on the last day such legislation was required to be in effect under the law.
|
5.
|
State Plan Amendments. The State will not be required to submit title XIX or title XXI State plan amendments for changes affecting any populations made eligible solely through the Demonstration. If a population eligible through the Medicaid State plan is affected by a change to the Demonstration, a conforming amendment to the appropriate State plan may be required, except as otherwise noted in these STCs.
|
6.
|
Changes Subject to the Amendment Process. Changes related to eligibility, enrollment, benefits, delivery systems, cost sharing, sources of non-Federal share of funding, budget neutrality, and other comparable program elements in these STCs must be submitted to CMS as amendments to the Demonstration. All amendment requests are subject to approval at the discretion of the Secretary of the Department of Health and Human Services in accordance with section 1115 of the Act. The State must not implement changes to these elements without prior approval by CMS. Amendments to the Demonstration are not retroactive and FFP will not be available for changes to the Demonstration that have not been approved through the amendment process set forth in paragraph 7 below. The State will notify CMS of proposed Demonstration changes during the quarterly monitoring call, as well as in the written quarterly report, to determine if a formal amendment is necessary.
|
7.
|
Amendment Process. Requests to amend the Demonstration must be submitted to CMS for approval no later than 120 days prior to the planned date of implementation of the change and may not be implemented until approved. CMS reserves the right to deny or delay approval of a Demonstration amendment based on non-compliance with these STCs, including, but not limited to, failure by the State to submit required reports and other deliverables in a timely fashion according to the deadlines specified therein. Amendment requests must include, but are not limited to, the following:
|
a)
|
An explanation of the public process used by the State consistent with the requirements of paragraph 12 to reach a decision regarding the requested amendment;
|
b)
|
A data analysis which identifies the specific “with waiver” impact of the proposed amendment on the current budget neutrality expenditure limit. Such analysis must include current “with waiver” and “without waiver” status on both a summary and detailed level through the current extension approval period using the most recent actual expenditures, as well as summary and detailed projections of the change in the “with waiver” expenditure total as a result of the proposed amendment which isolates (by Eligibility Group) the impact of the amendment;
|
c)
|
A detailed description of the amendment, including impact on beneficiaries, with sufficient supporting documentation; and
|
d)
|
If applicable, a description of how the evaluation design must be modified to incorporate the amendment provisions.
|
8.
|
CMS Right to Terminate or Suspend. CMS may suspend or terminate the Demonstration, in whole or in part, at any time before the date of expiration, whenever it determines, following a hearing, that the State has materially failed to comply with the terms of the project. CMS will promptly notify the State in writing of the determination and the reasons for the suspension or termination, together with the effective date.
|
9.
|
Finding of Non-Compliance. The State does not relinquish its rights to challenge the CMS finding that the State materially failed to comply.
|
10.
|
Withdrawal of Waiver Authority. CMS reserves the right to withdraw waivers or expenditure authorities at any time it determines that continuing the waivers or expenditure authorities would no longer be in the public interest or promote the objectives of title XIX. CMS must promptly notify the State in writing of the determination and the reasons for the withdrawal, together with the effective date, and must afford the State an opportunity to request a hearing to challenge CMS’ determination prior to the effective date. If a waiver or expenditure authority is withdrawn, FFP is limited to normal closeout costs associated with terminating the waiver or expenditure authorities, including services and administrative costs of disenrolling participants.
|
11.
|
Adequacy of Infrastructure. The State must ensure the availability of adequate resources for implementation and monitoring of the Demonstration, including education, outreach, and enrollment; maintaining eligibility systems; compliance with cost sharing requirements to the extent they apply; and reporting on financial and other Demonstration components.
|
12.
|
Public Notice, Tribal Consultation, and Consultation with Interested Parties. The State must continue to comply with the State Notice Procedures set forth in 59 Fed. Reg. 49249 (September 27, 1994) and the tribal consultation requirements pursuant to section 1902(a)(73) of the Act as amended by section 5006(e) of the ARRA, when any program changes to the Demonstration, including, but not limited to, those referenced in STC 7, are proposed by the State. In States with Federally recognized Indian Tribes, Indian health programs, and/or Urban Indian organizations, the State is required to submit evidence to CMS regarding the solicitation of advice from these entities prior to submission of any Demonstration proposal, amendment and/or renewal of this Demonstration.
|
13.
|
FFP. No Federal matching funds for expenditures for this Demonstration will take effect until the effective date identified in the Demonstration approval letter.
|
14.
|
Citizenship Documentation Requirements. For individuals who have declared that they are United States citizens or nationals, the State must only enroll individuals into the Demonstration who document citizenship or nationality in accordance with sections 1902(a)(46) and 1903 of the Act. The State may establish citizenship or nationality using the process set out in section 1902(ee) of the Act in lieu of the documentation requirements set forth in sections 1902(a)(46) and 1903 of the Act to the extent permitted by that section.
|
IV. ELIGIBILITY
|
15.
|
Eligibility Requirements. The State must enroll only individuals meeting the following eligibility criteria into the family planning component of the Demonstration:
|
1.
|
Uninsured women, ages 18 through 44, losing Medicaid pregnancy coverage at the conclusion of 60 days postpartum, who are not otherwise eligible for Medicaid or CHIP; and
|
2.
|
Uninsured women, ages 18 through 44, who have family income up to and including 200 percent of the FPL, who are not otherwise eligible for Medicaid or CHIP.
|
·
|
Uninsured women, ages 18 through 44, who deliver a VLBW baby on or after January 1, 2011, who have family income up to and including 200 percent of the FPL, who are not otherwise eligible for Medicaid or CHIP.
|
·
|
Women, ages 18 through 44, who qualify under the Low Income Medicaid Class of Assistance or Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State plan and deliver a VLBW baby on or after January 1, 2011.
|
16.
|
Demonstration Enrollment. Women already enrolled in a Georgia Families Care Management Organization (CMO) due to pregnancy will have an expedited enrollment into the plan with which they are currently affiliated. These women will be afforded the opportunity to choose a new CMO if desired. The enrollment processes for each component of the Demonstration are described below:
|
a)
|
FP Component. The State will follow applicable Federal law and regulations for determining eligibility and enrolling those deemed eligible into one of the CMOs. Individuals must enroll in a managed care plan to receive family planning and family planning-related services.
|
b)
|
IPC Component. Women in the IPC component must enroll in a managed care plan to receive Family Planning and IPC services.
|
c)
|
Resource Mothers Outreach.
|
i.
|
Women ages 18 through 44 who qualify under the Low Income Medicaid Class of Assistance under the Georgia Medicaid State plan are mandatorily enrolled into one of the CMOs per the Medicaid State plan. These women will receive Resource Mothers Outreach through the CMOs in which they are enrolled at the time of delivery of their VLBW baby. The State will follow standard Medicaid managed care rules regarding choice of plans.
|
ii.
|
Women ages 18 through 44 who qualify under the Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State Plan and who deliver a VLBW baby on or after January 1, 2011, will receive Resource Mothers Outreach
|
17.
|
Demonstration Disenrollment. If a woman becomes pregnant while enrolled in the Demonstration, she may be determined eligible for Medicaid under the State plan. An individual who is enrolled in a Medicaid State plan eligibility category will only be eligible for Resource Mothers Outreach services under the Demonstration if they have had a VLBW delivery on or after January 1, 2011.
|
18.
|
Redeterminations. The State must ensure that redeterminations of eligibility for the Demonstration are conducted at least every 12 months.
|
19.
|
Primary Care Referral. The State assures CMS that providers of family planning services will make appropriate referrals to primary care providers as medically indicated. The State also assures that individuals enrolled in this Demonstration receive information about how to access primary care services.
|
V. BENEFITS AND DELIVERY SYSTEMS
|
20.
|
Benefits. Family planning services and supplies described in section 1905(a)(4)(C) of the Act are reimbursable at the 90 percent matching rate, including:
|
a)
|
Approved methods of contraception;
|
b)
|
Sexually transmitted infection testing, including Pap tests and pelvic exams;
|
c)
|
Drugs, supplies, or devices related to women’s health services described above that are prescribed by a health care provider who meets the State’s provider enrollment requirements; (subject to the national drug rebate program requirements); and,
|
d)
|
Contraceptive management, patient education, and counseling.
|
21.
|
Family Planning-Related Benefits. Family planning-related services are provided as part of, or as follow-up to, a family planning visit and are reimbursable at the State’s regular FMAP rate. The following are examples of family-planning related services:
|
a)
|
Drugs for the treatment of sexually-transmitted infections (STIs), except for HIV/AIDS and hepatitis, when the STI is identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/drugs may be covered. In addition, subsequent follow-up visits to rescreen for STIs based on the Centers for Disease Control and Prevention guidelines may be covered.
|
b)
|
Drugs for the treatment of lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection/disorder is identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/ drugs may be covered.
|
22.
|
Primary Care Referrals. Primary care referrals to other social service and health care providers as medically indicated are provided; however, the costs of those primary care services are only covered for women enrolled in the IPC component of the Demonstration. These primary care services are not covered for enrollees who are not in the IPC component of this Demonstration.
|
23.
|
Vitamins. Participants will have access to folic acid and/or a multivitamin with folic acid, and this benefit will be reimbursable at the State’s FMAP rate.
|
24.
|
Immunization Benefits. Participants ages 19 and 20, will be eligible to receive the Hepatitis B, tetanus-diphtheria (Td), and combined tetanus, diphtheria, and pertussis (TdAP) vaccinations. Participants who are 18 years old are eligible to receive immunizations at no cost via the Vaccines for Children (VFC) Program. These services are reimbursable at the State’s FMAP rate.
|
25.
|
IPC Component Benefits. In addition to the family planning and family planning-related services described above, women who are enrolled in the IPC component of the Demonstration are also eligible for the benefits described in the table below. These services are reimbursable at the State’s FMAP rate.
|
Services
|
Notes/ Limitations
|
Primary care
|
|
5 office/outpatient visits
|
|
Management and treatment of chronic diseases
|
|
Substance use disorder treatment (detoxification and intensive outpatient rehabilitation)
|
Referral required
|
Case management/ Resource Mother Outreach
|
|
Limited Dental
|
|
Prescription Drugs (non-family planning)
|
26.
|
Resource Mother Outreach. Women served under the IPC and Resource Mother components of the Demonstration, will have access to Resource Mother Outreach. The CMOs will employ or contract with Resource Mothers, and the Resource Mothers will assist nurse case managers to achieve the following goals:
|
a)
|
Increase the participant’s adoption of healthy behaviors such as healthy eating choices and smoking cessation;
|
b)
|
Support the participant’s compliance with primary care medical appointments, including assisting with arranging non-emergency medical transportation;
|
c)
|
Assist the mother of a VLBW baby to obtain regular preventive health visits and appropriate immunizations for her child;
|
d)
|
Support the participant’s compliance with medications to treat chronic health conditions
|
e)
|
Assist with coordination of social services support; and,
|
f)
|
Assist with linking mothers to community resources such as the Special Supplemental Nutrition Program for Women, Infants, and Children.
|
27.
|
Delivery System. Services provided through this Demonstration are paid via a managed care delivery system via CMOs. Standard Medicaid managed care rules will apply including freedom of choice of provider for family planning services as specified in 42 CFR 431.51(a)(5).
|
VI.GENERAL REPORTING REQUIREMENTS
|
28.
|
General Financial Requirements. The State must comply with all general financial requirements under title XIX set forth in section VII of these STCs.
|
29.
|
Reporting Requirements Relating to Budget Neutrality. The State must comply with all reporting requirements for monitoring budget neutrality as set forth in section VIII of these STCs.
|
30.
|
Compliance with Managed Care Reporting Requirements. The State must comply with all managed care reporting regulations at 42 CFR Part 438 et seq., except as expressly waived or referenced in the expenditure authorities incorporated into these STCs.
|
31.
|
Monitoring Calls. CMS will schedule quarterly monitoring calls with the State, unless CMS determines that more frequent calls are necessary to adequately monitor the Demonstration. The purpose of these calls is to discuss any significant actual or anticipated developments affecting the Demonstration. Areas to be addressed include, but are not limited to, health care delivery, enrollment, quality of care, access, benefits, audits, lawsuits, financial reporting and budget neutrality issues, progress on evaluations, State legislative developments, quarterly reports, and any Demonstration amendments the State is considering submitting.
|
32.
|
Quarterly Progress Reports. The State must submit progress reports no later than 60 days following the end of each quarter. The intent of these reports is to present the State’s data along with an analysis of the status of the various operational areas under the Demonstration. These quarterly reports must include, but are not limited to:
|
a)
|
An updated budget neutrality monitoring worksheet;
|
b)
|
Expenditures including administrative costs;
|
c)
|
Total number of enrollees;
|
d)
|
Total number of participants (Participants include all individuals who obtain one or more covered family planning services through the Demonstration);
|
e)
|
Events occurring during the quarter, or anticipated to occur in the near future that affect health care delivery, benefits, enrollment, grievances, quality of care, access, pertinent legislative activity, eligibility verification activities, and other operational issues;
|
f)
|
Action plans for addressing any policy and administrative issues identified; and
|
g)
|
Evaluation activities and interim findings.
|
33.
|
Annual Report. The annual report is due 120 days following the end of the fourth quarter of each Demonstration year, and must include a summary of the year’s preceding activity as well as the following:
|
a)
|
The number of actual births that occur to participants in the FP component of the Demonstration broken out by birth weight category;
|
i.
|
Normal (2,500 grams or more)
|
ii.
|
LBW (1,500 grams to 2,499 grams)
|
iii.
|
VLBW (less than 1,500 grams)
|
b)
|
The number of total Medicaid births broken out by birth weight category;
|
c)
|
The number of actual births that occur to women in the IPC component of the Demonstration broken out by birth weight category;
|
d)
|
The average total Medicaid expenditures for the first-year infant life costs broken out by birth weight category;
|
e)
|
Results of member and provider satisfaction surveys; and
|
f)
|
An interim evaluation report as described in paragraph 54 of these STCs.
|
34.
|
Transition Plan. The State is required to prepare, and incrementally revise a Transition Plan, consistent with the provisions of the Affordable Care Act, for individuals enrolled in the Demonstration, including how the State plans to coordinate the transition of these individuals to a coverage option available under the Affordable Care Act without interruption in coverage to the maximum extent possible. The State must submit a draft to CMS by
|
35.
|
Final Report. The State must submit a final report to CMS to describe the impact of the Demonstration, including the extent to which the State met the goals of the Demonstration. The draft report will be due to CMS 6 months after the expiration of the Demonstration. The State must submit a final report within 60 days of receipt of CMS comments.
|
VII.GENERAL FINANCIAL REQUIREMENTS
|
36.
|
Quarterly Expenditure Reports. The State must provide quarterly expenditure reports using the form CMS-64 to report total expenditures for services provided under the Medicaid program, including those provided through the Demonstration under section 1115 authority. This project is approved for expenditures applicable to services rendered during the Demonstration period. CMS must provide FFP for allowable Demonstration expenditures only as long as they do not exceed the pre-defined limits on the costs incurred as specified in Section VIII of these STCs.
|
37.
|
Reporting Expenditures Subject to the Title XIX Budget Neutrality Agreement. The following describes the reporting of expenditures subject to the budget neutrality limit:
|
a)
|
Tracking Expenditures. In order to track expenditures under this Demonstration, Georgia must report Demonstration expenditures through the Medicaid and CHIP Budget and Expenditure System (MBES/CBES); following routine CMS-64 reporting instructions outlined in section 2500 of the State Medicaid Manual. All Demonstration expenditures claimed under the authority of title XIX of the Act and subject to the budget neutrality expenditure limit must be reported each quarter on separate Forms CMS-64.9 Waiver and/or CMS-64.9P Waiver, identified by the Demonstration project number assigned by CMS, including the project number extension, which indicates the Demonstration Year (DY) in which services were rendered or for which capitation payments were made.
|
b)
|
Cost Settlements. For monitoring purposes, cost settlements attributable to the Demonstration must be recorded on the appropriate prior period adjustment schedules (Form CMS-64.9P Waiver) for the Summary Sheet Line 10B, in lieu of Lines 9 or 10C. For any other cost settlements not attributable to this Demonstration, the adjustments should be reported on lines 9 or 10C as instructed in the State Medicaid Manual.
|
c)
|
Use of Waiver Forms. The following 3 waiver forms CMS-64.9 Waiver and/or
|
(i)
|
“FP Benefits” expenditures – This includes expenditures for all family planning and family planning-related benefits for women enrolled in the Demonstration.
|
(ii)
|
“IPC Benefits” expenditures – This includes only expenditures for IPC benefits for women enrolled in the IPC component of the Demonstration.
|
(iii)
|
“Outreach” expenditures – This includes only expenditures for the Resource Mother Outreach that women eligible under the Medicaid State plan receive.
|
d)
|
Pharmacy Rebates. The State may propose a methodology for assigning a portion of pharmacy rebates to the Demonstration, in a way that reasonably reflects the actual rebate-eligible pharmacy utilization of the Demonstration population, and which reasonably identifies pharmacy rebate amounts with DYs. Use of the methodology is subject to the approval in advance by the CMS Regional Office, and changes to the methodology must also be approved in advance by the Regional Office. The portion of pharmacy rebates assigned to the Demonstration using the approved methodology will be reported on the appropriate Form CMS-64.9 Waiver for the Demonstration, and not on any other CMS-64.9 form (to avoid double-counting). Each rebate amount must be distributed as State and Federal revenue consistent with the Federal matching rates under which the claim was paid.
|
e)
|
Title XIX Administrative Costs. Administrative costs will not be included in the budget neutrality agreement, but the State must separately track and report additional administrative costs that are directly attributable to the Demonstration. All administrative costs must be identified on the Forms CMS-64.10.
|
f)
|
Claiming Period. All claims for expenditures subject to the budget neutrality agreement (including any cost settlements) must be made within 2 years after the calendar quarter in which the State made the expenditures. All claims for services during the Demonstration period (including any cost settlements) must be made within 2 years after the conclusion or termination of the Demonstration. During the latter 2-year period, the State must continue to identify separately net expenditures related to dates of service during the operation of the Demonstration on the CMS-64 waiver forms in order to properly account for these expenditures in determining budget neutrality.
|
38.
|
Standard Medicaid Funding Process. The standard Medicaid funding process must be used during the Demonstration. The State must estimate matchable Demonstration expenditures (total computable and Federal share) subject to the budget neutrality expenditure limit and separately report these expenditures by quarter for each Federal fiscal year on the Form CMS-37 for both the Medical Assistance Payments (MAP) and State and
|
39.
|
Extent of FFP for Family Planning and Family Planning Related Services. CMS shall provide FFP for services (including prescriptions) provided to women at the following rates:
|
a)
|
For procedures or services clearly provided or performed for the primary purpose of family planning (i.e., contraceptive initiation, periodic or inter-periodic contraceptive management, and sterilizations), and which are provided in a family planning setting, FFP will be available at the 90 percent Federal matching rate. Reimbursable procedure codes for office visits, laboratory tests, and certain other procedures must carry a primary diagnosis or a modifier that specifically identifies them as a family planning service. Note: The laboratory tests performed during an initial family planning visit for contraception include a Pap smear, screening tests for STIs, blood counts, and pregnancy test. Additional screening tests may be performed depending on the method of contraception desired and the protocol established by the clinic, program, or provider. Additional laboratory tests may be needed to address a family planning problem or needed during an inter-periodic family planning visit for contraception.
|
b)
|
In order for family planning-related services to be reimbursed at the FMAP rate they must be defined as those services generally performed as part of, or as follow-up to, a family planning service for contraception. Such services are provided because a “family planning-related” problem was identified/diagnosed during a routine/periodic family planning visit. These expenditures should be entered in Column (B) on the appropriate waiver sheets. Four kinds of family planning related services are recognized:
|
i.
|
A colposcopy (and procedures done with/during a colposcopy) or repeat Pap smear performed as a follow-up to an abnormal Pap smear which is done as part of a routine/periodic family planning visit.
|
ii.
|
Treatment/drugs for STIs, except for HIV/AIDS and hepatitis, where the STIs are identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/drugs may be covered at the applicable Federal matching rate for the State. Subsequent follow-
|
iii.
|
Treatment/drugs for vaginal infections/disorders, other lower genital tract and genital skin infections/disorders, and urinary tract infections, where these conditions are identified/diagnosed during a routine/periodic family planning visit. A follow-up visit/encounter for the treatment/drugs may be covered at the applicable Federal matching rate for the State.
|
iv.
|
Treatment of major complications such as:
|
·
|
Treatment of a perforated uterus due to an intrauterine device insertion;
|
·
|
Treatment of severe menstrual bleeding caused by a Depo-Provera injection requiring a dilation and curettage; or
|
·
|
Treatment of surgical or anesthesia-related complications during a sterilization procedure.
|
c)
|
FFP will not be available for the costs of any services, items, or procedures that do not meet the requirements specified above, even if family planning clinics or providers provide them. For example, in the instance of testing for STIs as part of a family planning visit, FFP will be available at the 90 percent Federal matching rate. The match rate for the subsequent treatment would be paid at the applicable Federal matching rate for the State. For testing or treatment not associated with a family planning visit, no FFP will be available.
|
d)
|
CMS will provide FFP at the appropriate 50 percent administrative match rate for general administration costs, such as, but not limited to, claims processing, eligibility assistance and determinations, outreach, program development, evaluation, and program monitoring and reporting.
|
40.
|
Extent of FFP for IPC Services. CMS shall provide FFP for services described in paragraph 25 for women who enrolled in the IPC component of the Demonstration at the State’s regular Federal matching rate.
|
41.
|
Sources of Non-Federal Share. The State must certify that the non-Federal share of funds for the Demonstration are State/local monies. The State further certifies that such funds must not be used to match for any other Federal grant or contract, except as permitted by law. All sources of non-Federal funding must be compliant with section 1903(w) of the Act and applicable regulations. In addition, all sources of the non-Federal share of funding are subject to CMS approval.
|
a)
|
CMS reserves the right to review the sources of the non-Federal share of funding for the Demonstration at any time. The State agrees that all funding sources deemed unacceptable by CMS must be addressed within the time frames set by CMS.
|
b)
|
Any amendments that impact the financial status of the program must require the State to provide information to CMS regarding all sources of the non-Federal share of funding.
|
42.
|
State Certification of Funding Conditions. The State must certify that the following conditions for non-Federal share of Demonstration expenditures are met:
|
a)
|
Units of government, including governmentally operated health care providers, may certify that State or local tax dollars have been expended as the non-Federal share of funds under the Demonstration.
|
b)
|
To the extent the State utilizes certified public expenditures (CPEs) as the funding mechanism for title XIX (or under section 1115 authority) payments, CMS must approve a cost reimbursement methodology. This methodology must include a detailed explanation of the process by which the State would identify those costs eligible under title XIX (or under section 1115 authority) for purposes of certifying public expenditures.
|
c)
|
To the extent the State utilizes CPEs as the funding mechanism to claim Federal match for payments under the Demonstration, governmental entities to which general revenue funds are appropriated must certify to the State the amount of such tax revenue (State or local) used to satisfy Demonstration expenditures. The entities that incurred the cost must also provide cost documentation to support the State’s claim for Federal match.
|
d)
|
The State may use intergovernmental transfers to the extent that such funds are derived from State or local tax revenues and are transferred by units of government within the State. Any transfers from governmentally-operated health care providers must be made in an amount not to exceed the non-Federal share of title XIX payments. Under all circumstances, health care providers must retain 100 percent of the claimed expenditure. Moreover, no pre-arranged agreements (contractual or otherwise) exist between health care providers and State and/or local government to return and/or redirect any portion of the Medicaid payments. This confirmation of Medicaid payment retention is made with the understanding that payments that are the normal operating expenses of conducting business, such as payments related to taxes, (including health care provider-related taxes), fees, business relationships with governments that are unrelated to Medicaid and in which there is no connection to Medicaid payments, are not considered returning and/or redirecting a Medicaid payment.
|
43.
|
Monitoring the Demonstration. The State must provide CMS with information to effectively monitor the Demonstration, upon request, in a reasonable time frame.
|
44.
|
Program Integrity. The State must have processes in place to ensure that there is no duplication of Federal funding for any aspect of the Demonstration. Specifically, the State must ensure that there is no duplication of Federal funding between the State’s Maternal, Infant, and Early Childhood Home Visiting Program and the Demonstration. In addition, the State must ensure that there is no duplication of Federal funding between the State’s VFC Program and the Demonstration. The State must confirm in each quarterly and annual report that there is no duplication of funding.
|
VIII.
|
MONITORING BUDGET NEUTRALITY
|
45.
|
Limit on Title XIX Funding. The State shall be subject to a limit on the amount of Federal title XIX funding that the State may receive on selected Medicaid expenditures during the period of approval of the Demonstration. The budget neutrality expenditure targets are set on a yearly basis with a cumulative budget neutrality expenditure limit for the length of the entire Demonstration. Actual expenditures subject to the budget neutrality expenditure limit shall be reported by the State using the procedures described in section VII, paragraph 37 of these STCs.
|
46.
|
Risk. Georgia shall be at risk for the per capita cost (as determined by the method described below in this section) for Medicaid eligibles in the “FP Benefits” eligibility group, but not for the number of Demonstration eligibles in this group. By providing FFP for enrollees in this eligibility group, Georgia shall not be at risk for changing economic conditions that impact enrollment levels. However, by placing Georgia at risk for the per capita costs for enrollees in the family planning component of the Demonstration, CMS assures that Federal Demonstration expenditures do not exceed the level of expenditures that would have occurred had there been no Demonstration. Georgia will be at risk for both per capita costs and enrollment for “IPC Benefits.”
|
47.
|
Budget Neutrality Annual Expenditure Limits. For each DY, two annual limits are calculated: one for the FP component of the Demonstration and one for the IPC component of the Demonstration, as described in paragraphs 48 and 49 below.
|
48.
|
FP Component Budget Limit. The FP Component budget limit is calculated as the projected per member/per month (PMPM) cost times the actual number of member months for “FP Benefits,” multiplied by the Composite Federal Share.
|
a)
|
PMPM Cost. The following table gives the projected PMPM (Federal share) costs for the calculation described above by DY.
|
Trend
|
DY 1
|
DY 2
|
DY 3
|
|
FP Benefits
|
2.7%
|
$68.17
|
$70.01
|
$71.90
|
b)
|
Composite Federal Share. The Composite Federal Share is the ratio calculated by dividing the sum total of FFP received by the State on actual Demonstration expenditures during the 3-year approval period, as reported on the forms listed in paragraph 37 above, by total computable Demonstration expenditures for the same period as reported on the same forms. Should the Demonstration be terminated prior to the end of the 3-year approval period (see paragraph 8), the Composite Federal Share will be determined based on actual expenditures for the period in which the Demonstration was active. For the purpose of interim monitoring of budget neutrality, a reasonable Composite Federal Share may be used.
|
c)
|
The FP Component is structured as a “pass-through” or “hypothetical” population. Therefore, the State may not derive savings from this component.
|
49.
|
IPC Component Budget Limit. The annual budget limit for the IPC component of the Demonstration will be the estimated cost-savings of the VLBW and LBW births averted as described below:
|
a)
|
VLBW Birth Averted = Birth Averted * Medicaid Costs for VLBW Infants up to 1
|
·
|
The Medicaid Cost of a VLBW Infant equals (the cost of VLBW infants up to 1 year of life)/ number of VLBW live births, where the costs and number of VLBW live births pertain to the Georgia Medicaid Program.
|
b)
|
LBW Birth Averted = Birth Averted * Medicaid Costs for LBW Infants up to 1 year
|
·
|
The Medicaid Cost of a LBW Infant equals (the cost of LBW infants up to 1 year of life)/ number of LBW live births, where the costs and number of LBW live births pertain to the Georgia Medicaid Program.
|
c)
|
Application of the IPC Budget Limit. The budget limit calculated above will apply to IPC expenditures, as reported by the State on the CMS-64 forms. If, at the end of the Demonstration period, the costs of the Demonstration services exceed the IPC budget limit, the excess Federal funds will be returned to CMS.
|
50.
|
Future Adjustments to the Budget Neutrality Expenditure Limit. CMS reserves the right to adjust the budget neutrality expenditure limit to be consistent with enforcement of impermissible provider payments, health care-related taxes, new Federal statutes, or policy interpretations implemented through letters, memoranda, or regulations with respect to the provision of services covered under the Demonstration.
|
51.
|
Enforcement of Budget Neutrality. CMS will enforce budget neutrality over the life of the Demonstration, rather than annually. However, no later than 6 months after the end of each DY, or as soon thereafter as data are available, the State will calculate annual expenditure targets for the IPC component of the Demonstration for the completed year. This amount
|
a)
|
Failure to Meet Budget Neutrality Goals. The State, whenever it determines that the Demonstration is not budget neutral or is informed by CMS that the Demonstration is not budget neutral, must immediately collaborate with CMS on corrective actions, which must include submitting a corrective action plan to CMS within 21 days of the date the State is informed of the problem. While CMS will pursue corrective actions with the State, CMS will work with the State to set reasonable goals that will ensure that the State is in compliance.
|
b)
|
Use of “Savings.” The State may only use savings from averting LBW and VLBW births to provide IPC services to women who have delivered a VLBW baby.
|
c)
|
Definition of “With” and “Without” Waiver IPC Component Demonstration Costs. The “with”(WW) and “without” (WOW) Demonstration costs (Federal share) follow. The “without” Demonstration costs are estimates of the costs of VLBW and LBW births that would occur in the absence of the Demonstration. The “with” Demonstration costs are estimates of IPC services provided with the Demonstration in effect. Total “with” and “without” Demonstration costs (Federal share) including the cost of the FP Component is also shown in the table below.
|
State Plan VLBW and LBW Birth Costs (Federal share)
|
|||
YEAR
|
WOW
|
WW
|
Estimated IPC Annual Budget Limit
|
CY 2011
|
$517,383,223
|
$514,586,627
|
$2,796,596
|
CY 2012
|
$519,429,739
|
$510,813,428
|
$8,616,311
|
CY 2013
|
$521,524,925
|
$515,625,623
|
$5,899,301
|
IPC Component Demonstration Costs (Federal share)
|
|||
YEAR
|
WOW
|
WW Cost of IPC Component
|
Estimated IPC Annual Budget Limit - WW Cost of IPC Component
|
CY 2011
|
$2,482,687
|
$313,909
|
|
CY 2012
|
$5,274,512
|
$3,341,800
|
|
CY 2013
|
$4,917,388
|
$981,913
|
FP Component + IPC Component (Federal Share)
|
|||
YEAR
|
WOW
|
WW
|
Projected Margin
|
CY 2011
|
$519,645,402
|
$519,331,493
|
$313,909
|
CY 2012
|
$522,914,626
|
$519,572,826
|
$3,341,800
|
CY 2013
|
$526,495,692
|
$525,513,780
|
$981,913
|
3 Year Total
|
$1,569,055,720
|
$1,564,418,099
|
$4,637,621
|
IX.
|
PRIMARY CARE REFERRAL AND EVALUATION
|
52.
|
Access to Primary Care Services. The State must facilitate access to primary care services for enrollees in the Demonstration. The State must assure CMS that written materials concerning access to primary care services are distributed to the Demonstration participants. The written materials must explain to the participants how they can access primary care services.
|
53.
|
Submission of Draft Evaluation Design. A draft evaluation design report must be submitted to CMS for approval within 120 days from the award of the Demonstration. At a minimum, the evaluation design should include a detailed analysis plan that describes how the effects of the Demonstration will be isolated from those of other initiatives occurring in the State. The report should also include an integrated presentation and discussion of the specific hypotheses (including those that focus specifically on the target population for the Demonstration) that are being tested. The report will also discuss the outcome measures that will be used in evaluating the impact of the Demonstration, particularly among the target population. It will also discuss the data sources and sampling methodology for assessing these outcomes. The State must implement the evaluation design and report its progress in each of the Demonstration’s quarterly and annual reports.
|
1.
|
To what extent is the Demonstration reducing the LBW and VLBW rates in Georgia?
|
2.
|
To what extent is the Demonstration reducing the infant mortality rate in Georgia?
|
3.
|
To what extent is the Demonstration reducing the number of unintended pregnancies in Georgia?
|
4.
|
To what extent is the Demonstration reducing Georgia’s Medicaid costs by reducing the number of unintended pregnancies by women who otherwise would be eligible for Medicaid pregnancy-related services?\
|
5.
|
To what extent is the Demonstration increasing child spacing intervals?
|
6.
|
To what extent is the Demonstration improving the health status of women enrolled in the IPC component of the Demonstration?
|
54.
|
Interim Evaluation Reports. The State must provide an interim evaluation report in each annual report as required in paragraph 33. In the event the State requests to extend the Demonstration beyond the current approval period under the authority of section 1115(a) of the Act, the State must submit an interim evaluation report as part of the State’s request for each subsequent renewal.
|
55.
|
Final Evaluation Plan and Implementation. CMS shall provide comments on the draft evaluation design within 60 days of receipt and the State must submit a final plan for the overall evaluation of the Demonstration described in paragraph 53, within 60 days of receipt of CMS comments.
|
a)
|
The State must implement the evaluation designs and report its progress in each quarterly report.
|
b)
|
The State must submit to CMS a draft of the evaluation report within 120 days after expiration of the Demonstration. CMS must provide comments within 60 days after receipt of the report. The State must submit the final evaluation report within 60 days after receipt of CMS comments.
|
Date
|
Deliverable
|
STC Reference
|
02/15/2011
|
Submit Draft Evaluation Design
|
Section IX, paragraph 53
|
07/01/2012
|
Submit Draft Transition Plan
|
Section VI, paragraph 34
|
07/01/2014
|
Submit Draft Final Report
|
Section VI, paragraph 35
|
Deliverable
|
STC Reference
|
|
Annual
|
By May 1st - Draft Annual Report
|
Section VI, paragraph 33
|
Quarterly
|
Quarterly Progress Reports
|
Section VI, paragraph 32
|
Per Member Per Month | ||
Family Planning - All Regions | $ *** | |
Interpregnancy Care - All Regions | $ *** |
Resource Mother services only - All Regions | $ *** |
Part 1: Parties to the Contract:
|
This Contract Amendment (the “Amendment”) is between the Texas Health and Human Services Commission (HHSC), an administrative agency within the executive department of the State of Texas, having its principal office at 4900 North Lamar Boulevard, Austin, Texas 78751, and Superior HealthPlan, Inc. (HMO) a corporation organized under the laws of the State of Texas, having its principal place of business at: 2100 South IH-35, Suite 202, Austin, Texas 78704. HHSC and HMO may be referred to in this Amendment individually as a “Party” and collectively as the “Parties.”
The Parties hereby agree to amend their original contract, HHSC contract number 529-06-0280-00014 (the “Contract”) as set forth herein. The Parties agree that the terms of the Contract will remain in effect and continue to govern except to the extent modified in this Amendment.
This Amendment is executed by the Parties in accordance with the authority granted in Attachment A to the HHSC Managed Care Contract document, “HHSC Uniform Managed Care Contract Terms & Conditions,” Article 8, “Amendments and Modifications.”
|
||
Part 2: Effective Date of Amendment:
|
Part 3: Contract Expiration Date
|
Part 4: Operational Start Date:
|
March 1, 2011
|
August 31, 2013
|
STAR and CHIP HMOs: September 1, 2006
STAR+PLUS HMOs: February 1, 2007
CHIP Perinatal HMOs: January 1, 2007
|
Part 5: Project Managers:
|
||
HHSC:
Scott Schalchlin
Director, Health Plan Operations
11209 Metric Boulevard, Building H
Austin, Texas 78758
Phone: 512-491-1866
Fax: 512-491-1969
HMO:
Susan Erickson
Director of Contract Management
2100 South IH-35, Suite 202
Austin, Texas 78704
Phone: 512-692-1465
Fax: 512-692-1474
E-mail: serickson@centene.com
|
||
Part 6: Deliver Legal Notices to:
|
||
HHSC:
General Counsel
4900 North Lamar Boulevard, 4th Floor
Austin, Texas 78751
Fax: 512-424-6586
HMO:
Superior HealthPlan
2100 South IH-35, Suite 202
Austin, Texas 78704
Fax: 512-692-1435
|
Part 7: HMO Programs and Service Areas:
|
This Contract applies to the following HHSC HMO Programs and Service Areas (check all that apply). All references in the Contract Attachments to HMO Programs or Service Areas that are not checked are superfluous and do not apply to the HMO.
|
Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
Service Areas:
|
þ Bexar
|
þ Nueces
|
||
o Harris
|
o Travis
|
Core Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
Optional Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
þ El Paso
|
þ Nueces
|
|||
o Harris
|
þ Travis
|
Core Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
o Dallas
|
þ Nueces
|
|||
þ El Paso
|
o Tarrant
|
|||
o Harris
|
þ Travis
|
Optional Service Areas:
|
þ Bexar
|
þ Lubbock
|
||
þ El Paso
|
þ Nueces
|
|||
o Harris
|
þ Travis
|
Part 8: Payment
|
Part 8 of the HHSC Managed Care Contract document, “Payment,” is modified to add the capitation rates for Rate Period 5.
|
Service Area: BEXAR
|
|||||||||||||||
Rate Period 5
|
Rate Period 5
|
Rate Period 5
|
|||||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-1/31/11
|
2/1/11-8/31/11
|
||||||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
3 |
TANF Adult
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
4 |
Pregnant Woman
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
8 |
Federal Mandate child
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
10. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
Service Area: EL PASO
|
|||||||||||||||
Rate Period 5
|
Rate Period 5
|
Rate Period 5
|
|||||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-1/31/11
|
2/1/11-8/31/11
|
||||||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
3 |
TANF Adult
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
4 |
Pregnant Woman
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
8 |
Federal Mandate child
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
10. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
Service Area: LUBBOCK
|
|||||||||||||||
Rate Period 5
|
Rate Period 5
|
Rate Period 5
|
|||||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-1/31/11
|
2/1/11-8/31/11
|
||||||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
3 |
TANF Adult
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
4 |
Pregnant Woman
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
8 |
Federal Mandate child
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
10. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
Service Area: NUECES
|
|||||||||||||||
Rate Period 5
|
Rate Period 5
|
Rate Period 5
|
|||||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-1/31/11
|
2/1/11-8/31/11
|
||||||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
3 |
TANF Adult
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
4 |
Pregnant Woman
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
8 |
Federal Mandate child
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
10. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
Service Area: TRAVIS
|
|||||||||||||||
Rate Period 5
|
Rate Period 5
|
Rate Period 5
|
|||||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-1/31/11
|
2/1/11-8/31/11
|
||||||||||||
1 |
TANF Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
2 |
TANF child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
3 |
TANF Adult
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
4 |
Pregnant Woman
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
5 |
Newborn ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
6 |
Expansion Child > 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
7 |
Expansion child ≤ 12 months
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
8 |
Federal Mandate child
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
9 |
Delivery Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
||||||||
10. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
$
|
***
|
STAR+PLUS Service Area: BEXAR
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Medicaid Only Standard Rate
|
$
|
***
|
$
|
***
|
||||||
2. |
Medicaid Only 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$
|
***
|
||||||
3. |
Dual Eligible Standard Rate
|
$
|
***
|
$
|
***
|
||||||
4. |
Dual Eligible 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$
|
***
|
||||||
5. |
Nursing Facility – Medicaid Only
|
$
|
***
|
$
|
***
|
||||||
6. |
Nursing Facility – Dual Eligible
|
$
|
***
|
$
|
***
|
||||||
7. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
STAR+PLUS Service Area: NUECES
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Medicaid Only Standard Rate
|
$
|
***
|
$
|
***
|
||||||
2. |
Medicaid Only 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$
|
***
|
||||||
3. |
Dual Eligible Standard Rate
|
$
|
***
|
$
|
***
|
||||||
4. |
Dual Eligible 1915(C) Nursing Facility Waiver Rate
|
$
|
***
|
$
|
***
|
||||||
5. |
Nursing Facility – Medicaid Only
|
$
|
***
|
$
|
***
|
||||||
6. |
Nursing Facility – Dual Eligible
|
$
|
***
|
$
|
***
|
||||||
7. |
Bariatric Supplemental Payment
|
$
|
***
|
$
|
***
|
Service Area: BEXAR
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
< Age 1
|
$
|
***
|
$
|
***
|
||||||
2. |
Ages 1 through 5
|
$
|
***
|
$
|
***
|
||||||
3. |
Ages 6 through 14
|
$
|
***
|
$
|
***
|
||||||
4. |
Ages 15 through 16
|
$
|
***
|
$
|
***
|
Service Area: EL PASO
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
< Age 1
|
$
|
***
|
$
|
***
|
||||||
2. |
Ages 1 through 5
|
$
|
***
|
$
|
***
|
||||||
3. |
Ages 6 through 14
|
$
|
***
|
$
|
***
|
||||||
4. |
Ages 15 through 16
|
$
|
***
|
$
|
***
|
Service Area: LUBBOCK
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-8/31/11
|
|||||||||
1. |
< Age 1
|
$
|
***
|
$
|
***
|
||||||
2. |
Ages 1 through 5
|
$
|
***
|
$
|
***
|
||||||
3. |
Ages 6 through 14
|
$
|
***
|
$
|
***
|
||||||
4. |
Ages 15 through 16
|
$
|
***
|
$
|
***
|
Service Area: NUECES
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-11/30/10
|
12/1/10-8/31/11
|
|||||||||
1. |
< Age 1
|
$
|
***
|
$
|
***
|
||||||
2. |
Ages 1 through 5
|
$
|
***
|
$
|
***
|
||||||
3. |
Ages 6 through 14
|
$
|
***
|
$
|
***
|
||||||
4. |
Ages 15 through 16
|
$
|
***
|
$
|
***
|
Service Area: TRAVIS
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
< Age 1
|
$
|
***
|
$
|
***
|
||||||
2. |
Ages 1 through 5
|
$
|
***
|
$
|
***
|
||||||
3. |
Ages 6 through 14
|
$
|
***
|
$
|
***
|
||||||
4. |
Ages 15 through 16
|
$
|
***
|
$
|
***
|
Service Area: BEXAR
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
$
|
***
|
||||||
3. |
Perinate 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
$
|
***
|
Service Area: EL PASO
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
$
|
***
|
||||||
3. |
Perinate 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
$
|
***
|
Service Area: LUBBOCK
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
$
|
***
|
||||||
3. |
Perinate 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
$
|
***
|
Service Area: NUECES
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
$
|
***
|
||||||
3. |
Perinate 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
$
|
***
|
Service Area: TRAVIS
|
|||||||||||
Rate Period 5
|
Rate Period 5
|
||||||||||
Rate Cell
|
9/1/10-1/31/11
|
2/1/11-8/31/11
|
|||||||||
1. |
Perinate Newborn 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
2. |
Perinate Newborn Above 185% to 200%
|
$
|
***
|
$
|
***
|
||||||
3. |
Perinate 0% to 185%
|
$
|
***
|
$
|
***
|
||||||
4. |
Perinate Above 185% to 200%
|
$
|
***
|
$
|
***
|
Part 9: Contract Attachments:
|
Part 10: Special Provision for Nueces Service Area
|
Part 11: Signatures:
|
The Parties have executed this Contract Amendment in their capacities as stated below with authority to bind their organizations on the dates set forth by their signatures. By signing this Amendment, the Parties expressly understand and agree that this Amendment is hereby made part of the Contract as though it were set out word for word in the Contract.
Texas Health and Human Services Commission
/s/ Charles E. Bell, M.D.
Charles E. Bell, M.D.
Deputy Executive Commissioner for Health Services
Date: 6/13/11
Superior HealthPlan, Inc.
/s/ Thomas Wise
By: Thomas Wise
Title: President and CEO
Date: 5/10/11
|
1.
|
I have reviewed this Quarterly Report on Form 10-Q/A of Centene Corporation;
|
2.
|
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;
|
3.
|
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;
|
4.
|
The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:
|
|
a.
|
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;
|
|
b.
|
Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;
|
|
c.
|
Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and
|
|
d.
|
Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and
|
5.
|
The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):
|
|
a.
|
All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and
|
|
b.
|
Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.
|
Dated: October 28, 2011
|
/s/ MICHAEL F. NEIDORFF
|
|
Chairman, President and Chief Executive Officer
(principal executive officer)
|
1.
|
I have reviewed this Quarterly Report on Form 10-Q/A of Centene Corporation;
|
2.
|
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;
|
3.
|
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;
|
4.
|
The registrant’s other certifying officer and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:
|
|
a.
|
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;
|
|
b.
|
Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;
|
|
c.
|
Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and
|
|
d.
|
Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and
|
5.
|
The registrant’s other certifying officer and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):
|
|
a.
|
All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and
|
|
b.
|
Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.
|
Dated: October 28, 2011
|
|
/s/ WILLIAM N. SCHEFFEL
|
Executive Vice President and Chief Financial Officer
(principal financial officer)
|