EX-10.1 2 ex10_1.htm EXHIBIT 10.1

Exhibit 10.1

CONTRACT BETWEEN

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

and

TRIPLE-S SALUD, INC.

for

PROVISION OF PHYSICAL & BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT HEALTH PLAN PROGRAM

Contract No.: 2019-000052

Account No.: 256-5325 to 5330

Page 1 of 324

TABLE OF CONTENTS

ARTICLE 1
GENERAL PROVISIONS
7
     
ARTICLE 2
DEFINITIONS
10
     
ARTICLE 3
ACRONYMS
30
     
ARTICLE 4
ASES RESPONSIBILITIES
33
     
ARTICLE 5
ELIGIBILITY AND ENROLLMENT
36
     
ARTICLE 6
ENROLLEE SERVICES
52
     
ARTICLE 7
COVERED SERVICES AND BENEFITS
75
     
ARTICLE 8
INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES
130
     
ARTICLE 9
PROVIDER NETWORK
134
     
ARTICLE 10
PROVIDER CONTRACTING
162
     
ARTICLE 11
UTILIZATION MANAGEMENT
179
     
ARTICLE 12
QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM
186
     
ARTICLE 13
FRAUD, WASTE, AND ABUSE
195
     
ARTICLE 14
GRIEVANCE AND APPEAL SYSTEM
203
     
ARTICLE 15
ADMINISTRATION AND MANAGEMENT
217
     
ARTICLE 16
PROVIDER PAYMENT MANAGEMENT
219
     
ARTICLE 17
INFORMATION MANAGEMENT AND SYSTEMS
226
     
ARTICLE 18
REPORTING
238
     
ARTICLE 19
ENFORCEMENT – INTERMEDIATE SANCTIONS
252
     
ARTICLE 20
ENFORCEMENT – LIQUIDATED DAMAGES AND OTHER REMEDIES
258
     
ARTICLE 21
CONTRACT TERM
265
     
ARTICLE 22
PAYMENT FOR SERVICES
266
     
ARTICLE 23
FINANCIAL MANAGEMENT
275

Page 2 of 324

ARTICLE 24
PAYMENT OF TAXES
288
     
ARTICLE 25
RELATIONSHIP OF PARTIES
288
     
ARTICLE 26
INSPECTION OF WORK
288
     
ARTICLE 27
GOVERNMENT PROPERTY
289
     
ARTICLE 28
OWNERSHIP AND USE OF DATA AND SOFTWARE
289
     
ARTICLE 29
CRIMINAL BACKGROUND CHECKS
290
     
ARTICLE 30
SUBCONTRACTS
291
     
ARTICLE 31
REQUIREMENT OF INSURANCE LICENSE
294
     
ARTICLE 32
CERTIFICATIONS
294
     
ARTICLE 33
RECORDS REQUIREMENTS
296
     
ARTICLE 34
CONFIDENTIALITY
298
     
ARTICLE 35
TERMINATION OF CONTRACT
304
     
ARTICLE 36
PHASE-OUT AND COOPERATION WITH OTHER CONTRACTORS
311
     
ARTICLE 37
INSURANCE
312
     
ARTICLE 38
COMPLIANCE WITH ALL LAWS
313
     
ARTICLE 39
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
314
     
ARTICLE 40
CHOICE OF LAW OR VENUE
315
     
ARTICLE 41
ATTORNEY’S FEES
315
     
ARTICLE 42
SURVIVABILITY
315
     
ARTICLE 43
PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED
315
     
ARTICLE 44
WAIVER
316
     
ARTICLE 45
FORCE MAJEURE
316
     
ARTICLE 46
BINDING
316

Page 3 of 324

ARTICLE 47
TIME IS OF THE ESSENCE
316
     
ARTICLE 48
AUTHORITY
317
     
ARTICLE 49
ETHICS IN PUBLIC CONTRACTING
317
     
ARTICLE 50
CONTRACT LANGUAGE INTERPRETATION
317
     
ARTICLE 51
ARTICLE AND SECTION TITLES NOT CONTROLLING
317
     
ARTICLE 52
LIMITATION OF LIABILITY/EXCEPTIONS
317
     
ARTICLE 53
COOPERATION WITH AUDITS
318
     
ARTICLE 54
OWNERSHIP AND FINANCIAL DISCLOSURE
318
     
ARTICLE 55
AMENDMENT IN WRITING
320
     
ARTICLE 56
CONTRACT ASSIGNMENT
320
     
ARTICLE 57
SEVERABILITY
320
     
ARTICLE 58
ENTIRE AGREEMENT
321
     
ARTICLE 59
INDEMNIFICATION
321
     
ARTICLE 60
NOTICES
322
     
ARTICLE 61
OFFICE OF THE COMPTROLLER
323

ATTACHMENT 1:
DESIGNATED LAWS
   
ATTACHMENT 2:
NETWORK ADEQUACY URBAN AND NON-URBAN AREA MAP
   
ATTACHMENT 3:
GHP UNIVERSAL ENROLLEE GUIDELINES HANDBOOK
   
ATTACHMENT 4:
CPTET CENTERS AND COMMUNITY-BASED ORGANIZATIONS FOR HIV/AIDS
   
ATTACHMENT 5:
MASTER FORMULARY
   
ATTACHMENT 6:
RETAIL PHARMACY REIMBURSEMENT LEVELS
   
ATTACHMENT 7:
UNIFORM GUIDE FOR SPECIAL COVERAGE
   
ATTACHMENT 8:
COST-SHARING
   
ATTACHMENT 9:
ENROLLMENT MANUAL

Page 4 of 324

ATTACHMENT 10:
GUIDELINES FOR CO-LOCATION OF BEHAVIORAL HEALTH PROVIDERS IN PMG SETTINGS
   
ATTACHMENT 11:
PER MEMBER PER MONTH PAYMENTS
   
ATTACHMENT 12:
INITIAL DELIVERABLE DUE DATES
   
ATTACHMENT 13:
REFERENCED ASES NORMATIVE LETTERS
   
ATTACHMENT 14:
PROGRAM INTEGRITY PLAN DEVELOPMENT GUIDELINES
   
ATTACHMENT 15:
FORMULARY A-102: EVIDENCE OF LACK OF PROVIDERS AND PROVIDERS REFUSAL TO CONTRACT
   
ATTACHMENT 16:
LIST OF REQUIRED REPORTS
   
ATTACHMENT 17:
EHR ADOPTION PLAN
   
ATTACHMENT 18:
BUSINESS ASSOCIATE AGREEMENT
   
ATTACHMENT 19:
HEALTH CARE IMPROVEMENT PROGRAM (HCIP) MANUAL
   
ATTACHMENT 20:
NETWORK ADEQUACY REQUIREMENTS
   
ATTACHMENT 21:
GUIDELINES FOR REVERSE CO-LOCATION OF PRIMARY CARE PHYSICIANS IN MENTAL HEALTH SETTINGS
   
ATTACHMENT 22:
STERILIZATION CONSENT FORM
   
ATTACHMENT 23:
POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF MEDICAID OVERPAYMENTS TO PROVIDERS
   
ATTACHMENT 24:
CARRIER PATIENT VOLUME CERTIFICATON FORM EP-02-2015
   
ATTACHMENT 25:
HIGH UTILIZERS PROGRAM
   
ATTACHMENT 26:
ENCOUNTER DATA REQUIREMENTS
   
ATTACHMENT 27:
POLICY FOR MEDICATION EXCEPTION REQUESTS
   
ATTACHMENT 28:
HIGH COST HIGH NEED (HCHN) RATE CELL ASSIGNMENT
   
ATTACHMENT 29:
MATERNITY KICK PAYMENT METHODOLOGY
   
ATTACHMENT 30:
TRADING PARTNER AGREEMENT

Page 5 of 324

THIS CONTRACT, is made and entered into by and between the Puerto Rico Health Insurance Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter referred to as “ASES” or “the Administration”), a public corporation of the Government of Puerto Rico (“the Government” or “Puerto Rico”), with employer identification number 66-0500678 and (Triple-S Salud, Inc.) (“the Contractor”), a managed care organization duly organized and authorized to do business under the laws of Puerto Rico, with employer identification number 66-0555677.
 
WHEREAS, pursuant to Title XIX of the Federal Social Security Act, codified as 42 USC 1396 et seq. (“the Social Security Act”), and Act No. 72 of September 7, 1993 of the Laws of Puerto Rico (“Act 72”), a comprehensive program of medical assistance for needy persons exists in Puerto Rico;
 
WHEREAS, ASES is responsible for health care policy, purchasing, planning, and regulation pursuant to Act 72, as amended, and other sources of law of Puerto Rico designated in Attachment 1 to this Contract, and pursuant to this statutory provision, ASES has established a managed care program under the medical assistance program, known as “GHP,” “GHP Program,” “the Government Health Plan”, or “MI Salud”;
 
WHEREAS, the Puerto Rico Health Department (“the Health Department”) is the single State agency designated to administer medical assistance in Puerto Rico under Title XIX of the Social Security Act of 1935, as amended, and is charged with ensuring the appropriate delivery of health care services under the Medicaid and the Children’s Health Insurance Program (“CHIP”) in Puerto Rico, and ASES manages these programs pursuant to a delegation of authority to ASES;
 
WHEREAS, GHP serves a mixed population including not only the Medicaid and CHIP populations, but also other eligible individuals as established in Act 72;
 
WHEREAS, ASES seeks to comply with Puerto Rico’s public policy objectives of creating an integrated system of physical and Behavioral Health Services, with an emphasis on preventative services and access to quality care;
 
WHEREAS, ASES issued a Request for Proposals (“the RFP”) for physical and Behavioral Health Services on February 9-16, 2018, which, except as provided in Article 58 below, are expressly incorporated as if completely restated herein;
 
WHEREAS, ASES has received from the Contractor a proposal in response to the RFP, “Contractor’s Proposal,” which, except as provided in Article 58 below, is expressly incorporated as if completely restated herein; and,
 
WHEREAS, ASES accepts the Contractor’s Proposal to provide the services contemplated under this Contract for ASES;
 
NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, ASES and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

Page 6 of 324

ARTICLE 1
GENERAL PROVISIONS


1.1
General Provisions
 

1.1.1
The Contractor shall assist the Government by providing and delivering services under the GHP through described tasks, obligations, and responsibilities included in this Contract.
 

1.1.2
The Contractor shall maintain the staff, organizational, and administrative capacity and capabilities necessary to carry out all the duties and responsibilities under this Contract.
 

1.1.3
The Contractor shall not make any changes to the following without explicit prior written approval from the Executive Director of ASES or his or her designee:
 

1.1.3.1
Its business address, telephone number, facsimile number, and e-mail address;
 

1.1.3.2
Its corporate status or nature;
 

1.1.3.3
Its business location;
 

1.1.3.4
Its corporate structure;
 

1.1.3.5
Its ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address; and/or
 

1.1.3.6
Its incorporation status.
 

1.1.4
The Contractor shall notify ASES within five (5) Business Days of a change in the following:
 

1.1.4.1
Its solvency (as a result of a non-operational event);
 

1.1.4.2
Its corporate officers or executive employees; or
 

1.1.4.3
Its Federal employee identification number or Federal tax identification number.
 

1.1.5
Unless otherwise specified herein, all documentation, including policies and procedures that the Contractor is required to maintain, shall be given prior written approval from ASES. All documentation, including the Deliverables listed in Attachment 12 to this Contract, must be submitted to ASES in English.
 

1.1.6
Unless otherwise specified, the Contractor shall notify ASES and/or the Puerto Rico Medicaid Program of any applicable provisions Immediately.

Page 7 of 324


1.1.7
Pursuant to 42 CFR 438.602(i), the Contractor shall not be located outside of the United States.
 

1.1.8
All Administrative Functions of the Contractor must be located within the United States. The following Administrative Functions must be located in Puerto Rico:
 

1.1.8.1
Care Management;
 

1.1.8.2
Marketing;
 

1.1.8.3
Utilization Management determinations, including Prior Authorization determinations;
 

1.1.8.4
Management of Enrollee and Provider Grievances and Appeals;
 

1.1.8.5
Decision-making authority related to Enrollee Services;
 

1.1.8.6
Decision-making authority related to Provider Services, such as claims dispute resolution and credentialing activities; and
 

1.1.8.7
Network management activities.
 

1.2
Background
 

1.2.1
The Government Health Plan (“GHP”), also known as MI Salud, has the following objectives:
 

1.2.1.1
Ensure appropriate and timely access to Covered Services for Enrollees across Puerto Rico, including facilitating and promoting access to preventive care.
 

1.2.1.2
Require Contractors to provide Island-wide coverage and access to Covered Services Island-wide in all geographic areas of Puerto Rico. This may be achieved through sub-contractual relationships.
 

1.2.1.3
Encourage competition among Contractors resulting in improvements of quality outcomes.
 

1.2.1.4
Require Contractors to partner with Government-owned specialty hospitals.
 

1.2.1.5
Encourage Contractors to partner with local provider entities, such as Primary Medical Groups (PMGs), provider groups, and provider associations to leverage island-based best practices and maintain existing Enrollee-provider relationships.
 

1.2.1.6
Require Contractors to propose and demonstrate cost saving initiatives, programs, and value-based payment models for Provider reimbursement to address High Cost High Needs (HCHN) Program Enrollees in Puerto Rico.

Page 8 of 324


1.2.1.7
Establish HCHN Program cohorts with enhanced Contractor management and cost-saving requirements.
 

1.2.1.8
Promote provider-based care coordination models that address social determinants of health and are likely to reduce health care expenditures.
 

1.2.1.9
Require Contractors to implement best practices to address high utilizers of services that are more appropriately delivered in less costly settings; for example, strategies to decrease non-emergent use of the emergency room.
 

1.3
Groups Eligible for Services Under the GHP
 

1.3.1
The Contractor will be responsible for providing services to all persons determined eligible for the GHP and enrolled in the Contractor’s Plan. The groups to be served under the GHP shall hereinafter be referred to collectively as “Eligible Persons.” The groups are subject to change and currently include:
 

1.3.1.1
Medicaid and CHIP. All Medicaid and CHIP eligibility categories covered in the Puerto Rico Medicaid and CHIP State Plans are eligible to enroll in the GHP and shall be referred to hereinafter as “Medicaid and CHIP Eligibles”, also known as the “Federal population.”
 

1.3.1.2
Other Groups (Non-Medicaid and CHIP Eligibles). The following groups, which receive services under the GHP without any Federal financial participation, will be referred to hereinafter as “Other Eligible Persons.”
 

1.3.1.2.1
The “State Population,” formerly known as the “Commonwealth Population,” is currently comprised of individuals, regardless of age, who meet State eligibility standards established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP.
 

1.3.1.2.2
Any other group of Other Eligible Persons may be added during the Contract Term as a result of a change in laws or regulations.
 

1.4
Geographic Scope of the Contract
 

1.4.1
The Contractor is responsible for the delivery of services under the GHP Island-wide.

Page 9 of 324


1.5
Delegation of Authority
 

1.5.1
Federal law and Puerto Rico law limit the capacity of ASES to delegate decisions to the Contractor. All decisions relating to public policy and to the administration of the Medicaid, CHIP, and the Puerto Rico government health assistance program included in the GHP rest with the Puerto Rico Medicaid Program and ASES.
 

1.6
Availability of Funds
 

1.6.1
This Contract is subject to the availability of funds on the part of ASES, which in turn is subject to the transfer of Federal, Puerto Rico, and municipal funds to ASES. If available funds are insufficient to meet its contractual obligations, ASES reserves the right to terminate this Contract, pursuant to Section 35.5.
 

1.7
Cooperation, Assistance and Compliance with Special Projects
 

1.7.1
The Contractor shall provide to ASES and any other agency of the Government all necessary cooperation, assistance, and compliance with requirements in the development and implementation of any special project of ASES and any other agency of the Government or the Federal Government. The Contractor acknowledges that this is a sine qua non of this Contract and that it will comply with ASES change requests related to such projects as these are implemented due to State or Federal mandate.

ARTICLE 2
DEFINITIONS
 
Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.
 
Act 72: The law of Puerto Rico adopted on September 7, 1993, as subsequently amended, which created ASES and empowered ASES to administer certain government health programs.
 
Act 408: The Puerto Rico Mental Health Code (Act No. 408 of October 2, 2000, as amended), which established the public policy and procedures regarding the delivery of Behavioral Health services in Puerto Rico.
 
Abandoned Call: A call initiated to a Call Center that is ended by the caller before any conversation occurs or before a caller is permitted access to a caller-selected option.
 
Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and that result in unnecessary costs to the GHP Program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for the provision of health care. It also includes Enrollee practices that result in unnecessary costs to the GHP.

Access: Adequate availability of Benefits to fulfill the needs of Enrollees.

Page 10 of 324

Adverse Benefit Determination: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service, requirements for medical necessity appropriateness, setting or effectiveness of a covered benefit; the denial, in whole or part, of payment for a service (including in circumstances in which an Enrollee is forced to pay for a service); the failure to provide services in a timely manner (within the timeframes established by this Contract or otherwise established by ASES); the failure of the Contractor to act within the timeframes provided in 42 CFR 438.408(b); or the denial of an Enrollee’s request to dispute a financial liability, including cost-sharing, co-payments, premiums, deductibles, co-insurance, and other Enrollee financial liabilities. For a resident of a rural area, the denial of an Enrollee's request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the network.
 
Actuarial Report: Actuarial reports the Contractor is required to submit in accordance with Article 18 of this Contract.
 
Administrative Functions: The contractual obligations of the Contractor under this Contract, other than providing Covered Services; include, without limitation, Care Management, Utilization Management, Credentialing Providers, Network management, Quality Improvement, Marketing, Enrollment, Enrollee services, Claims payment, Information Systems, financial management, and reporting.
 
Administrative Law Hearing: The Appeal process administered by the Government and as required by Federal law, available to Enrollees after they exhaust the Contractor’s Grievance and Appeal System.
 
Administrative Referral: A Referral of an Enrollee by the Contractor to a Provider or facility located outside the PPN, when the Enrollee’s PCP or other PMG physician does not provide a Referral within the required time period.
 
Adult: An individual age twenty-one (21) or older unless otherwise specified.
 
Advance Directive: A written instruction, such as a living will or durable power of attorney, granting responsibility over an individual’s health care, as defined in 42 CFR 489.100, and as recognized under Puerto Rico law under Act 160 of November 17, 2001, as amended, relating to the provision of health care when the individual is incapacitated.
 
ADFAN: Families and Children Administration (Administración de Familias y Niños), which is responsible for foster care children in the custody of the Government.
 
Affiliate: Any person, firm, corporation (including, without limitation, service corporation and processional corporation), partnership (including, without limitation, general partnership, limited partnership and limited liability partnership), limited liability company, joint venture, business trust, association or other entity or organization that now or in the future directly or indirectly controls, is controlled by, or is under common control with the Contractor.
 
Agent: An entity that contracts with ASES to perform Administrative Functions, including but not limited to: fiscal Agent activities; Outreach, eligibility, and Enrollment activities; and systems and technical support.

Page 11 of 324

Aggregate Lifetime Dollar Limit: For purposes of compliance with Behavioral Health parity requirements in 42 CFR part 438, subpart K, a dollar limitation on the total amount of specified benefits that may be paid under a contractor.
 
Ambulatory Services Units: Ambulatory clinics that mainly provide health services to children, families, and adults, which are staffed by an interdisciplinary team responsible for the appropriate treatment and referral processes.
 
Ancillary Services: Professional services, including laboratory, radiology, physical therapy, and respiratory therapy, which are provided in conjunction with other medical or hospital care.
 
Annual Dollar Limit: For purposes of compliance with Behavioral Health parity requirements in 42 CFR part 438, subpart K, a dollar limitation on the total amount of specified benefits that may be paid in a twelve (12) month period under a contractor.
 
Annual Open Enrollment Period: The annual period of three (3) months from November 1 through January 31 during which Enrollees have one (1) opportunity to select a different contractor, without cause.
 
Appeal: An Enrollee request for a review of an Adverse Benefit Determination. It is a formal petition by an Enrollee, an Enrollee’s Authorized Representative, or the Enrollee’s Provider, acting on behalf of the Enrollee with the Enrollee’s written consent, to reconsider a decision in the case that the Enrollee or Provider does not agree with an Adverse Benefit Determination taken.
 
ASES: Administración de Seguros de Salud de Puerto Rico (the Puerto Rico Health Insurance Administration), the Government entity responsible for oversight and administration of the GHP Program, or its Agent.
 
ASES Data: All Data created from Information, documents, messages (verbal or electronic), reports, or meetings involving, arising out of or otherwise in connection with this Contract.
 
ASES Information: All proprietary Data and/or Information generated from any Data requested, received, created, provided, managed and stored by Contractors, - in hard copy, digital image, or electronic format - from ASES and/or Enrollees (as defined in Article 2) necessary or arising out of this Contract, except for the Contractor’s Proprietary Information.
 
ASSMCA: Administración de Servicios de Salud Mental y Contra la Adicción (the Puerto Rico Mental Health and Anti-Addiction Services Administration), the government agency responsible for the planning and establishment of mental health and substance abuse policies and procedures and for the coordination, development, and monitoring of all Behavioral Health Services rendered to Enrollees in the GHP.
 
At Risk: When a Provider agrees to accept responsibility to provide, or arrange for, any service in exchange for the Per Member Per Month Payment (PMPM).
 
Authorized Certifier: The Contractor’s CEO, CFO, or an individual with delegated authority to sign for and who reports directly to the CEO and/or CFO.

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Authorized Representative: A person given written authorization by an Enrollee to make health-related decisions on behalf of an Enrollee, including, but not limited to: Enrollment and Disenrollment decisions, filing Complaints, Grievances and Appeals, and the choice of a PCP or PMG.
 
Auto-Assignment: The assignment of an Enrollee to a PMG and a PCP by ASES, the Contractor or the Puerto Rico Medicaid Program.
 
Auto-Enrollment: The Enrollment of a Potential Enrollee in a GHP Plan without any action by the Potential Enrollee, as provided in Article 5 of this Contract.
 
Basic Coverage: The physical and Behavioral Health Services available to all GHP Enrollees (as distinguished from Special Coverage, which is available only to Enrollees with certain diagnoses after a registration process). The GHP Covered Services are listed in Article 7 of this Contract.
 
Behavioral Health: The umbrella term for mental health conditions (including psychiatric illnesses and emotional disorders) and substance use disorders (involving addictive and chemical dependency disorders). The term also refers to preventing and treating co-occurring mental health conditions and substance use disorders (“SUDs”).
 
Behavioral Health Facility: A facility for the delivery of outpatient, inpatient or stabilization Behavioral Health Services, which houses at least two (2) Providers. These facilities include:

(i)
Psychiatric hospitals (or a unit within a general hospital)
(ii)
Emergency or stabilization units
(iii)
Partial hospitalization units
(iv)
Intensive ambulatory services units
(v)
Ambulatory services units/clinics
(vi)
Residential units
(vii)
Addiction service units (detoxification, ambulatory, inpatient, and residential)
 
Benefits: The services set forth in this Contract, for which the Contractor has agreed to provide, arrange, and be held fiscally responsible, including Basic Coverage, dental services, Special Coverage, High Cost High Needs Program, and Administrative Functions.
 
Blocked Call: A call that cannot be connected Immediately because no circuit is available at the time the call arrives or because the telephone system is programmed to block calls from entering the queue when the queue is backed up beyond a defined threshold.
 
Breach: As defined in 45 CFR 164.402, the acquisition, access, use, or disclosure of Protected Health Information in a manner not permitted under 45 CFR 164, subpart E which compromises the security or privacy of such Information.
 
Business Continuity and Disaster Recovery (“BC-DR”) Plan: A documented plan (process) to restore vital and critical Information/health care technology systems in the event of business interruption due to human, technical, or natural causes. The plan focuses mainly on technology systems, encompassing critical hardware, operating and application software, and tertiary elements required to support the operating environment. It must support the process requirement to restore vital business Data inside the defined business requirement, including an emergency mode operation plan as necessary. The BC-DR also provides for continuity of health care in the event of plan terminations.

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Business Days: Traditional workdays, including Monday, Tuesday, Wednesday, Thursday, and Friday. Puerto Rico Holidays, as defined in the Law for Compliance with the Fiscal Plan, Act No. 26 of April 29, 2017, or any other law enacted during the duration of this Contract regarding this subject, are excluded.
 
Calendar Days: All seven days of the week.
 
Call Center: A telephone service facility equipped to handle a large number of inbound and outbound calls. This facility must meet all requirements set forth in Section 6.8 of this Contract.
 
Capitation: A contractual agreement through which a Contractor or Provider agrees to provide specified health care services to Enrollees for a fixed amount per month.
 
Care Management: An Administrative Function comprised of a set of Enrollee-centered steps to ensure that an Enrollee with intensive needs, including catastrophic or high-risk conditions, receives the necessary services in a supportive, effective, efficient, timely, and cost-effective manner.
 
Care Manager: A professional with at least a Bachelor of Arts or a Bachelor of Science in a health or Behavioral Health-related field who helps Enrollees access the services they need for their recuperation and for the implementation of their individual treatment plans.
 
Centers for Medicare & Medicaid Services (“CMS”): The agency within the US Department of Health and Human Services with responsibility for the Medicare, Medicaid, and the Children’s Health Insurance Programs (“CHIP”).
 
Center for the Collection of Municipal Revenues: A municipal entity, independent from any other governmental agency, in charge of notifying, assessing, collecting, receiving, and distributing the public funds arising from property tax, state subsidy, electronic lottery and any other fund created by law in favor of the municipalities of Puerto Rico.
 
Certification: As provided in Section 5.1.2 of this Contract, a decision by the Puerto Rico Medicaid Program that a person is eligible for services under the GHP Program because the person is Medicaid Eligible, CHIP Eligible, or a member of the State Population. Some public employees and pensioners may enroll in GHP without first receiving a Certification.
 
Children’s Health Insurance Program (“CHIP”): Puerto Rico’s Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.
 
CHIP Eligible: A child eligible to enroll in the GHP Program because he or she is eligible for CHIP.
 
Chronic Condition: An ongoing physical, behavioral, or cognitive disorder, with a duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive devices, etc.) and service use or need beyond that which is normally considered routine.

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Claim: Whether submitted manually or electronically, a bill for services, a line item of services, or a bill detailing all services for one (1) Enrollee.
 
Clean Claim: A Claim received by the Contractor for adjudication, which can be processed without obtaining additional information from the Provider of the service or from a Third Party. It includes a Claim with errors originating in the Contractor’s Claims system. It does not include a Claim from a Provider who is under investigation for Fraud, Waste, or Abuse, or a Claim under review to determine Medical Necessity.
 
Cold-Call Marketing: Any unsolicited personal contact by the Contractor with a Potential Enrollee, for the purposes of Marketing.
 
Co-Location: An integrated care model in which Behavioral Health Services are provided in the same site as Primary Care.
 
Complaint: An expression of dissatisfaction about any matter other than an Adverse Benefit Determination that is resolved at the point of contact rather than through filing a formal Grievance.
 
Contract: The written agreement between ASES and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.
 
Contract Term: The duration of time that this Contract is in effect, as defined in Article 21 of this Contract.
 
Contractor: The Managed Care Organization that is a Party of this Contract, licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts hereunder with ASES under the GHP program for the provision of Covered Services and Benefits to Enrollees on the basis of PMPM Payments.
 
Co-Payment: A cost-sharing requirement which is a fixed monetary amount paid by the Enrollee to a Provider for certain Covered Services as specified by ASES.
 
Corrective Action Plan: The detailed written plan required by ASES from the Contractor to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the Contractor.
 
Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance, and other sources of Third Party Liability, have been exhausted.
 
Countersignature: An authorization provided by the Enrollee’s PCP, or another Provider within the Enrollee’s PMG, for a prescription written by another Provider to be dispensed. No Countersignature shall be required if the Provider writing the prescription is within the PPN.
 
Covered Services: Those Medically Necessary health care services (listed in Article 7 of this Contract) provided to Enrollees by Providers, the payment or indemnification of which is covered under this Contract.

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Credentialing: The Contractor’s determination as to the qualification of a specific Provider to render specific health care services.
 
Credible Allegation of Fraud: Any allegation of Fraud that has been verified by another State, the Government, or ASES, or otherwise has been preliminary investigated by the Contractor, as the case may be, and that has indicia of reliability that comes from any source.
 
Cultural Competency: A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among, and between groups and the sensitivity to know how these differences influence relationships with Enrollees. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Enrollee needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.
 
Daily Basis: Each Business Day.
 
Data: A series of meaningful electrical signals that may be manipulated or assigned.
 
Data Set: Demographic, health, or other Informational elements suitable for specific use.
 
Deductible: In the context of Medicare, the dollar amount of Covered Services that must be incurred before Medicare will pay for all or part of the remaining Covered Services.
 
Deemed Newborn: A newborn whose mother is Medicaid or CHIP Eligible on the date of delivery and is eligible from the date of birth.
 
Deliverable: A document, manual, or report submitted to ASES by the Contractor to exhibit that the Contractor has fulfilled the requirements of this Contract.
 
Disenrollment: The termination of an individual’s Enrollment in the Contractor’s Plan.
 
Domestic Violence Population: Certain survivors of domestic violence referred by the Office of the Women’s Advocate.
 
Dual Eligible Beneficiary: An Enrollee or Potential Enrollee eligible for both Medicaid and Medicare.
 
Durable Medical Equipment: Equipment, including assistive technology, which: (i) can withstand repeated use; (ii) is used to service a health-related or functional purpose; (iii) is ordered by a Health Care Provider to address an illness, injury, or disability; and (iv) is appropriate for use in the home, work place, or school.
 
Early and Periodic Screening, Diagnostic, and Treatment (“EPSDT”) Program: A Medicaid-mandated program that covers screening and diagnostic services to determine physical and mental deficiencies in Enrollees less than twenty-one (21) years of age, and health care, prevention, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered.

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Effective Date of Contract: The day the Contract is executed by both Parties.
 
Effective Date of Disenrollment: The date, as defined in Section 5.3.3 of this Contract, on which an Enrollee ceases to be covered under the Contractor’s Plan.
 
Effective Date of Eligibility: The eligibility period specified for each population covered under the GHP as described in Section 5.1.3 of the Contract.
 
Effective Date of Enrollment: shall have the meaning prescribed to it in Section 5.2.2 of the Contract.
 
Electronic Funds Transfer (“EFT”): Transfer of funds between accounts using electronic means such as a telephone or computer rather than paper-based payment methods such as cash or checks.
 
Electronic Health Record (“EHR") System: An electronic record of health-related information on an individual that is created, gathered, managed, and consulted upon by authorized health care clinicians and staff and certified by The Office of the National Coordinator’s Authorized Testing and Certification Bodies (“ONC-ATCBs”).
 
Eligible Person: A person eligible to enroll in the GHP Program, as provided in Section 1.3.1 of this Contract, by virtue of being Medicaid Eligible, CHIP Eligible, or an Other Eligible Person.
 
Emergency Medical Condition: As defined in 42 CFR 438.114, a medical or Behavioral Health condition, regardless of diagnosis or symptoms, manifesting itself in acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or other due to an alcohol or drug abuse emergency, serious injury to self or bodily harm to others, or the lack of adequate time for a pregnant women having contractions to safely reach a another hospital before delivery. The Contractor may not impose limits on what constitutes an Emergency Medical Condition based only, or exclusively, on diagnoses or symptoms.
 
Emergency Services: As defined in 42 CFR 438.114, any Physical or Behavioral Health Covered Services (as described in Section 7.5.9) furnished by a qualified Provider in an emergency room that are needed to evaluate or stabilize an Emergency Medical Condition or a Psychiatric Emergency that is found to exist using the prudent layperson standard.
 
Encounter: A distinct set of services provided to an Enrollee in a face-to-face setting on the dates that the services were delivered, regardless of whether the Provider is paid on a Fee-for-Service, Capitated, salary, or alternative payment methodology basis. Encounters with more than one (1) Provider, and multiple Encounters with the same Provider, that take place on the same day in the same location will constitute a single Encounter, except when the Enrollee, after the first Encounter, suffers an illness or injury requiring an additional diagnosis or treatment.
 
Encounter Data: (i) All Data captured during the course of a single Encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices, and equipment associated with the Enrollee receiving services during the Encounter; (ii) The identification of the Enrollee receiving and the Provider(s) delivering the health care services during the single Encounter; and (iii) A unique (i.e., unduplicated) identifier for the single Encounter.
 
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Enrollee: A person who is currently enrolled in the Contractor’s GHP Plan, as provided in this Contract, and who, by virtue of relevant Federal and Puerto Rico laws and regulations, is an Eligible Person listed in Section 1.3.1 of this Contract.
 
Enrollment: The process by which an Eligible Person becomes an Enrollee of the Contractor’s Plan.
 
Experience of Care and Health Outcomes (“ECHO”) Survey: A survey constructed to merge the most desirable aspects of the Mental Health Statistics Program’s Consumer Survey (“MHSIP”) and the Consumer Assessment of Behavioral Health Services (“CABHS”) Instrument in order to capture as many unique aspects of mental health and substance abuse-related services while limiting redundancy. The survey is a product of nearly six (6) years of research and testing by CAHPS grantees at the Harvard Medical School, with extensive input from behavioral health care experts.
 
External Quality Review Organization (“EQRO”): An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs analyses and evaluations on the quality, timeliness, and Access to Covered Services and Benefits that the Contractor furnishes to Enrollees.
 
Federally Qualified Health Center (“FQHC”): An entity that provides outpatient health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.
 
Fee-for-Service: A method of reimbursement based on payment for specific Covered Services on a service-by-service basis rendered to an Enrollee.
 
Formulary of Medications Covered (“FMC”): A published subset of pharmaceutical products used for the treatment of physical and Behavioral Health conditions developed by the PPA after clinical recommendations from the Pharmacy and Therapeutics (P&T) Committee and financial review from the Pharmacy Benefits Financial Committee.
 
Foster Care Population: Children who are in the custody of the Department of Family’s ADFAN Program and enrolled in the GHP.
 
Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable Federal or Puerto Rico law.
 
General Network: The entire group of Providers with Provider Contracts with the Contractor, including those that are and those that are not members of the Contractor’s Preferred Provider Network.
 
GHP Plan: A Managed Care Organization under contract with ASES that offers services under the Government Health Plan (“GHP”) Program.
 
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GHP Service Line: The Enrollee support Call Center that the Contractor shall operate as described in Section 6.8 of this Contract, containing two components: the Information Service and the Medical Advice Service.
 
The Government Health Plan (or “the GHP”): The government health services program (also referred to as “MI Salud”) offered by the Government, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical and Behavioral Health services.
 
Grievance: An expression of dissatisfaction about any matter other than an Adverse Benefit Determination.
 
Grievance and Appeal System: The overall system that includes Complaints, Grievances, and Appeals at the Contractor level, as well as access to the Administrative Law Hearing process.
 
Health Care Acquired Conditions: A medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in Section 1886(d)(4)(D)(iv) of the Social Security Act.
 
Health Care Provider: An individual engaged in the delivery of health care services as licensed or certified by Puerto Rico in which he or she is providing services, including but not limited to physicians, podiatrists, optometrists, chiropractors, psychologists, psychiatrists, licensed Behavioral Health practitioners, dentists, physician assistant, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians.
 
Health Certificate: Certificate issued by a physician after an examination that includes Venereal Disease Research Laboratory (“VDRL”) and tuberculosis (“TB”) tests if the individual suffers from a contagious disease that could incapacitate him or her or prevent him or her from doing his or her job, and does not represent a danger to public health.
 
Health Information Exchange (“HIE”): The secure and effective electronic transmission (push–pull) of the Protected Health Information of patients between Providers, across organizations, community or hospital system, within a jurisdiction and/or between jurisdictions. HIE is also an entity that provides services to enable the electronic sharing of health Information.
 
Health Information Organization (“HIO”): “An organization that oversees and governs services related to the exchange of health-related Information among organizations according to nationally recognized standards,” as defined in The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology.
 
Health Information Technology for Economic and Clinical Health (“HITECH”) Act: Public Law 111-5 (2009). When referenced in this Contract, it includes all related rules, regulations, and procedures.
 
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Health Care Effectiveness Data and Information Set (“HEDIS”): A set of standardized performance measures developed by the National Committee for Quality Assurance (“NCQA”) to measure and compare MCO performance.
 
Health Insurance Portability and Accountability Act (“HIPAA”): A law enacted in 1996 by the US Congress. When referenced in this Contract, it includes all related rules, regulations, and procedures.
 
High Cost High Needs (HCHN) Program: A set of contractual obligations specific to a cohort of Enrollees, as specified in Section 7.8.3 and Attachment 28 to this Contract, with specific conditions that require specialized care management and a dedicated team of Providers due to the cost or elevated needs associated with treatment of the condition.
 
Immediately: Within twenty-four (24) hours, unless otherwise provided in this Contract.
 
Implementation Date of the Contract: The date on which the Contractor shall commence providing Covered Services and other Benefits under this Contract after it has passed a readiness review; the expected implementation date of this Contract is November 1, 2018.
 
Incident: The attempted or successful unauthorized access, use, disclosure, modification, or destruction of Information or interference with system operations in an Information System.
 
Incurred-But-Not-Reported (“IBNR”): Estimate of unpaid Claims liability, including received but unpaid Claims.
 
Indian: An individual, defined in Title 25 of the U.S.C. sections 1603(c), 1603(f), 1603(f) or who has been determined eligible, as an Indian, pursuant to 42 C.F.R. 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian Health Care Providers (Indian Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization-I/T/U) or through Referral under Contract Health Services.
 
Information: Data to which meaning is assigned, according to context and assumed conventions; meaningful fractal Data for decision support purposes.
 
Information Service: The component of the GHP Service Line, a Call Center operated by the Contractor (described in Section 6.9), intended to assist Enrollees with routine inquiries, which shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. (Atlantic Time), Monday through Friday, excluding Puerto Rico holidays.
 
Information System(s): A combination of computing and communications hardware and software that is used in: (i) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of Information, i.e., structured Data (which may include digitized audio and video) and documents; and/or (ii) the processing of such Information for the purposes of enabling and/or facilitating a business process or a related transaction.
 
Initial Auto-Enrollment: The process by which an Eligible Person enrolled with a GHP contractor prior to November 1, 2018 is Auto-Enrolled with a contractor by ASES with an effective date of November 1, 2018.
 
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Initial Auto-Enrollment Enrollee: An Eligible Person enrolled prior to November 1, 2018 with a GHP contractor who is Auto-Enrolled with a Contractor’s Plan during Initial Auto-Enrollment.
 
Integration Plan: The service delivery plan under the GHP Program, providing physical and Behavioral Health Services in close coordination, to ensure optimum detection, prevention, and treatment of physical and Behavioral Health conditions.
 
International Statistical Classification of Diseases and Related Health Problems Tenth Revision (“ICD-10”): A medical classification list created by the World Health Organization that notes various Medical Records including those used for coding diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease.
 
Island-wide: All geographic areas that comprise the entirety of Puerto Rico, including Vieques and Culebra, for which the Contractor is responsible for the delivery of Covered Services.
 
List of Excluded Individuals and Entities (“LEIE”): A database of individuals and entities excluded from Federally-funded health care programs maintained by the Department of Health and Human Services Office of the Inspector General.
 
List of Medications by Exception (“LME”): List of medications that are not included in the FMC, but that have been evaluated and approved by ASES’s Pharmacy and Therapeutics (P&T) Committee to be covered only through an exception process if certain clinical criteria are met. Covered outpatient drugs that are not included on the LME may still be covered under an Exception Request in compliance with Section 7.5.12.10.1.2 and Attachment 27 to this Contract, unless statutorily excluded.
 
MA-10: Form issued by the Puerto Rico Medicaid Program, entitled “Notice of Action Taken on Application and/or Recertification,” containing the Certification decision (whether a person was determined eligible or ineligible for Medicaid, CHIP, or the State Population).
 
Managed Care Organization (“MCO”): An entity that is organized for the purpose of providing health care and is licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts with ASES for the provision of Covered Services and Benefits Island-wide on the basis of PMPM Payments, under the GHP program.
 
Marketing: Any communication from the Contractor to any Eligible Person or Potential Enrollee that can reasonably be interpreted as intended to influence the individual to enroll in the Contractor’s Plan, or not to enroll in another plan, or to disenroll from another plan.
 
Marketing Materials: Materials that are produced in any medium, by or on behalf of the Contractor that can reasonably be interpreted as intended to market to Potential Enrollees.
 
Medicaid: The joint Federal/state program of medical assistance established by Title XIX of the Social Security Act.
 
Medicaid Eligible: An individual eligible to receive services under Medicaid, who is eligible, on this basis, to enroll in the GHP Program.
 
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Medicaid Fraud Control Unit (“MFCU”): The Unit created by the Puerto Rico Department of Justice under Administrative Order 2018-002 to investigate and prosecute Medicaid Provider Fraud as well as patient abuse and neglect in health care facilities, as defined in Section 1903(q) of the Social Security Act, found at 42 USC 1396b(q).
 
Medicaid Management Information System (“MMIS”): Computerized system used for the processing, collecting, analyzing, and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.
 
Medical Advice Service: The twenty-four (24) hour emergency medical advice toll-free phone line operated by the Contractor through its GHP Service Line service, described in Section 6.8 of this Contract.
 
Medical Record: The complete, comprehensive record of an Enrollee including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Enrollee’s PCP, or Network Provider, that documents all health care services received by the Enrollee, including inpatient care, outpatient care, Ancillary, and Emergency Services, prepared in accordance with all applicable Federal and Puerto Rico rules and regulations, and signed by the Provider rendering the services.
 
Medically Necessary Services: Those services that meet the definition found in Section 7.2 of this Contract.
 
Medicare: The Federal program of medical assistance for persons age sixty-five (65) and over, certain disabled persons under Title XVIII of the Social Security Act, and persons with End Stage Renal Disease.
 
Medicare Part A: The part of the Medicare program that covers inpatient hospital stays, skilled nursing facilities, home health, and hospice care.
 
Medicare Part B: The part of the Medicare program that covers physician, outpatient, home health, and Preventive Services.
 
Medicare Part C: The part of the Medicare program that permits Medicare recipients to select coverage among various private insurance plans.
 
Medicare Part D: The part of the Medicare programs that covers prescription drugs.
 
Medicare Platino: A program administered by ASES for Dual Eligible Beneficiaries, in which MCOs or other insurers under contract with ASES function as Medicare Part C plans to provide services covered by Medicare, and also to provide a “wrap-around” Benefit of Covered Services and Benefits under the GHP.
 
National Provider Identifier (“NPI”): The 10-digit unique-identifier numbering system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System.
 
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Negative Determination or Redetermination Decision: The decision by the Puerto Rico Medicaid Program that a person is not initially eligible or no longer eligible for services under the GHP Program (because the person no longer meets the eligibility requirements for Medicaid, CHIP, or Puerto Rico’s government health assistance program).
 
Network Adequacy Standards: The Provider-to-Enrollee Ratios; Provider Per Municipality requirements; Required Network Provider requirements, and Time and Distance requirements developed in accordance with 42 CFR 438.68, as defined by ASES in Section 9.4 to measure the adequacy and appropriateness of the Contractor’s provider network to meet the needs of the enrolled population.
 
Network Provider: A Medicaid-enrolled Provider that has a Provider Contract with a Contractor under the GHP Program. This term includes Providers in the General Network and Providers in the PPN.
 
New Enrollee: An Eligible Person who became a Potential Enrollee after November 1, 2018.
 
Non-Emergency Medical Transportation (“NEMT”): A ride, or reimbursement for a ride, provided so that an Enrollee with no other transportation resources can receive Covered Services from a Provider. NEMT does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.
 
Non-Urban Area: For purposes of measuring Network Adequacy, defined by ASES as municipalities with populations at or below 49,999 people.
 
Notice of Adverse Benefit Determination: The written notice described in Section 14.4.3, in which the Contractor notifies both the Enrollee and the Provider of an Adverse Benefit Determination.
 
Notice of Disposition: The notice in which the Contractor explains in writing the results and the date of resolution of a Complaint, Grievance, or Appeal to the Enrollee and the Provider.
 
Office of the Inspector General: The Federal office within the Department of Health & Human Services tasked with protecting the integrity of federal health care programs as well as the health and welfare of program beneficiaries.
 
Office of the Patient Advocate: An office of the Government created by Act 11 of April 11, 2001, as amended by Act 77 of June 24, 2013, which is tasked with protecting the patient rights and protections contained in the Patient’s Bill of Rights Act.
 
Office of the Women’s Advocate: An office of the Government created by Act 20 of April 11, 2001, as amended, which is tasked, among other responsibilities, with protecting victims of domestic violence.
 
Open Enrollment Period: A period of ninety (90) Calendar Days during which Enrollees have one (1) opportunity to select a different contractor, without cause, as set forth in Section 5.2.5.
 
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Other Eligible Person: A person eligible to enroll in the GHP Program under Section 1.3.1.2 of this Contract who is not Medicaid- or CHIP Eligible. This group is comprised of the State Population and certain public employees and pensioners.
 
Outreach: Means, among other things, of educating or informing the Contractor’s Enrollees about GHP, managed care, and health issues.
 
Out-of-Network Provider: A Provider that does not have a Provider Contract with the Contractor under GHP; i.e., the Provider is not in either the General Network or the PPN.
 
Overpayment: Any funds that a person or entity receives which that person or entity is not entitled to under Title XIX of the Social Security Act as defined in 42 CFR 438.2. Overpayments shall not include funds that have been subject to a payment suspension or that have been identified as a Third Party Liability as set forth in Section 23.4.
 
Patient’s Bill of Rights Act: Act 194 of August 25, 2000, a law of Puerto Rico relating to patient rights and protection.
 
Patient Protection and Affordable Care Act (“PPACA”): Public Law 111-148 (2010) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 (2010), including any and all rules and regulations thereunder.
 
Payment Hold: The situation when a Provider who owes funds to Puerto Rico, such Provider cannot be paid until the amounts owed to Puerto Rico are repaid or an acceptable repayment plan is in place, as determined by ASES.
 
Pediatric Enrollee: An Enrollee aged zero (0) through twenty (20) (inclusive) unless otherwise specified.
 
Performance Improvement Projects (“PIPs”): Projects consistent with 42 CFR 438.330.
 
Per Member Per Month (“PMPM”) Payment: The fixed monthly amount, developed in accordance with actuarially sound principles and practices as specified in 42 CFR 438.4, that the Contractor is paid by ASES for each Enrollee to ensure that Benefits under this Contract are provided. This payment is made regardless of whether the Enrollee receives Benefits during the period covered by the payment.
 
Protected Health Information (“PHI”): As defined in 45 CFR 160.103, individually identifiable health Information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium.
 
Pharmacy Benefit Manager (“PBM”): An entity under contract with ASES under the GHP Program, responsible for the administration of pharmacy Claims processing, formulary management, drug Utilization review, pharmacy network management, and Enrollee Information Services relating to pharmacy services.
 
Pharmacy Program Administrator (“PPA”): An entity, under contract with ASES, responsible for implementing and offering support to ASES and the contracted PBMs in the negotiation of rebates and development of the Maximum Allowable Cost (“MAC”) List.
 
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Physician Incentive Plan: Any compensation arrangement between a Contractor and a physician or PMG that is intended to advance Utilization Management and is governed by 42 CFR 438.3(i).
 
Plan: The Contractor’s Managed Care Organization offering services to Enrollees under the GHP.
 
Post-Stabilization Services: Covered Services, relating to an Emergency Medical Condition or Psychiatric Emergency, that are provided after an Enrollee is stabilized, in order to maintain the stabilized condition or to improve or resolve the Enrollee’s condition.
 
Potential Enrollee: A person who has been Certified by the Puerto Rico Medicaid Program as eligible to enroll in the GHP (whether on the basis of Medicaid eligibility, CHIP eligibility, or eligibility as a member of the State Population), but who has not yet enrolled with the Contractor.
 
Preferential Turns: The policy of requiring Network Providers to give priority in treating Enrollees from the island municipalities of Vieques and Culebra, so that they may be seen by a Provider within a reasonable time after arriving at the Provider’s office. This priority treatment is necessary because of the remote locations of these municipalities, and the greater travel time required for their residents to seek medical attention.
 
Preferred Provider Network (“PPN”): A group of Network Providers that (i) GHP Enrollees may access without any requirement of a Referral or Prior Authorization; (ii) provides services to GHP Enrollees without imposing any Co-Payments on Medicaid or CHIP-Eligible populations; and (iii) meets the Network requirements described in Article 9 of this Contract.
 
Prevalent Non-English Language: A non-English language spoken by a significant number or percentage of Potential Enrollees and current Enrollees in Puerto Rico, as determined by the Government.
 
Preventive Services: Health care services provided by a physician or other Provider within the scope of his or her practice under Puerto Rico law to detect or prevent disease, disability, Behavioral Health conditions, or other health conditions; and to promote physical and Behavioral Health and efficiency.
 
Primary Care: All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by ASES, to the extent the furnishing of those services is legally authorized where the practitioner furnishes them.
 
Primary Care Physician: A licensed medical doctor (MD) who is a Provider and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for providing all required Primary Care to Enrollees. The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.
 
Primary Medical Group (“PMG”): A grouping of associated Primary Care Physicians and other Providers for the delivery of services to GHP Enrollees using a coordinated care model. PMGs may be organized as Provider care organizations, or as another group of Providers who have contractually agreed to offer a coordinated care model to GHP Enrollees under the terms of this Contract.
 
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Prior Authorization: Authorization granted by the Contractor to determine whether the service is Medically Necessary. In some instances, this process is a condition for receiving the Covered Service.
 
Provider: Any physician, hospital, facility, or other Health Care Provider who is licensed or otherwise authorized to provide physical or Behavioral Health Services in the jurisdiction in which they are furnished.
 
Provider Per Municipality Requirements: Required number of specified Providers per municipality that must be included in the Contractor’s provider network per Section 9.4.3.3.
 
Provider-to-Enrollee Ratio: Ratios established in Section 9.4 as part of the Network Adequacy Standards that are applicable to the Contractor’s General Network and PPN.
 
Provider Contract: Any written contract between the Contractor and a Provider that requires the Provider to order, refer, provide or render Covered Services under this Contract. The execution of a Provider Contract makes the Provider a Network Provider.
 
Psychiatric Emergency: A set of symptoms characterized by an alteration in the perception of reality, feelings, emotions, actions, or behavior, requiring immediate therapeutic intervention in order to avoid immediate damage to the patient, other persons, or property. A Psychiatric Emergency shall not be defined on the basis of lists of diagnoses or symptoms.
 
Puerto Rico Health Department (“the Health Department”): The Single State Agency charged with administration of the Puerto Rico Medicaid Program, which (through the Puerto Rico Medicaid Program) is responsible for Medicaid and CHIP eligibility determinations.
 
Puerto Rico Insurance Commissioner’s Office (“PRICO”): The Government agency responsible for regulating, monitoring, and licensing insurance business.
 
Puerto Rico Medicaid Program: The subdivision of the Health Department that conducts eligibility determinations under GHP for Medicaid, CHIP, and the State Population.
 
Quality Assessment and Performance Improvement Program (“QAPI”): A set of programs aimed at increasing the likelihood of desired health outcomes of Enrollees through the provision of health care services that are consistent with current professional knowledge; the QAPI Program includes incentives to comply with HEDIS standards, to provide adequate Preventive Services, and to reduce the unnecessary use of Emergency Services.
 
Quality Management/Quality Improvement (“QM/QI”): The process of developing and implementing strategies to ensure the delivery of available, accessible, timely, and Medically Necessary Services that meet optimal clinical standards. This includes the identification of key measures of performance, discovery and Data collection processes, identification and remediation of issues, and systems improvement activities.
 
Recertification: A determination by the Puerto Rico Medicaid Program that a person is again eligible for services under the GHP Program.
 
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Reconsideration: The process for an Enrollee to request that ASES re-evaluate a denial of a Disenrollment request from a contractor that precedes the Administrative Law Hearing process, as provided by Act 72 of September 7, 1993, as amended.
 
Redetermination: The periodic re-evaluation of eligibility of an individual for Medicaid, CHIP, or the State Population, conducted by the Puerto Rico Medicaid Program.
 
Referral: A request by a PCP, Psychiatrist, Psychologist, or any other type of Provider in the PMG for an Enrollee to be evaluated and/or treated by a different Provider, usually a specialist. Referrals shall be required only for services outside the Contractor’s PPN.
 
Reinsurance: An agreement whereby the Contractor transfers risk or liability for losses, in whole or in part, sustained under this Contract. A Reinsurance agreement may also exist at the Provider level.
 
Remedy: ASES’s means to enforce the terms of the Contract through liquidated damages and other sanctions.
 
Request for Proposals (“RFP”): The Request for Proposals issued by the Government on February 9-16, 2018.
 
Required Network Providers: Specific Providers or types of Providers that must be included in the Contractor’s provider network per Section 9.4.3.4.
 
Retention Fund: The amount of Withhold by ASES of the monthly PMPM Payments otherwise payable to the Contractor in order to incentivize the Contractor to meet performance targets under the Health Care Improvement Program described in Section 12.5.3. This amount shall be equal to the percent of that portion of the total PMPM Payment that is determined to be attributable to the Contractor’s administration of the Health Care Improvement Program described in Sections 12.5 and 22.4. Amounts withheld will be reimbursed to the Contractor in whole or in part (as set forth in Sections 12.5 and 22.4) in the event of a determination by ASES that the Contractor has complied with the quality standards and criteria established by Section 12.5.
 
Reverse Co-location: An integrated care model in which physical health services are available to Enrollees being treated in Behavioral Health settings.
 
Runoff Period: The period of time as explained in Section 35.1.5.
 
Rural Health Clinic or Center (“RHC”): A clinic that is located in an area that has a Provider shortage. An RHC provides primary Care and related diagnostic services and may provide optometric, podiatry, chiropractic, and Behavioral Health Services. An RHC employs, contracts, or obtains volunteer services from Providers to provide services.
 
Serious Emotional Disturbance (“SED”): Children and youth who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder to meet diagnostic criteria in the following ICD-10 codes: F-20 Schizophrenia, F-31 Bipolar Disorder, F-33 Major Depressive Disorder, F-41 Other Anxiety Disorders, and F-50 Eating Disorders.
 
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Serious Mental Illness (“SMI”): Individuals eighteen (18) years of age or older, who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder to meet diagnostic criteria in the following categories of ICD-10: F20.0 Paranoid schizophrenia; F20.1 Disorganized schizophrenia; F20.2 Catatonic schizophrenia; F20.3 Undifferentiated schizophrenia; F20.9 Schizophrenia, unspecified; F25 Schizoaffective Disorder; F28 Other non-organic psychotic disorders; F31.2 Bipolar disorder, current episode manic, sever, with psychotic symptoms; F31.5 Bipolar disorder, current episode depressed, severe, with psychotic symptoms; F31.6 Bipolar disorder, current episode mixed, severe, with psychotic symptoms; F33.3 Major Depressive disorder, recurrent, severe with psychotic symptoms.
 
Service Authorization Request: An Enrollee’s request for the provision of a service.
 
Span of Control: Information Systems and telecommunications capabilities that the Contractor operates or for which it is otherwise legally responsible according to the terms and conditions of this Contract. The Contractor’s Span of Control also includes systems and telecommunications capabilities outsourced by the Contractor.
 
Special Coverage: A component of Covered Services provided by the Contractor, described in Section 7.7, which are more extensive than the Basic Coverage services, and for which Enrollees are eligible only by “registering.” Registration for Special Coverage is based on intensive medical needs occasioned by serious illness.
 
“State Population” (formerly known as the “Commonwealth Population”): A group eligible for participation in the GHP as Other Eligible Persons, with no Federal financial participation supporting the cost of their coverage, which is comprised of low-income persons and other groups listed in Section 1.3.1.2.1.
 
Subcontract: Any written contract between the Contractor and Subcontractor to perform a specified part of the Contractor’s obligations under this Contract.
 
Subcontractor: Any organization or person, including the Contractor’s parent, subsidiary or Affiliate, who has a Subcontract with the Contractor to provide any function or service for the Contractor specifically related to securing or fulfilling the Contractor’s obligations to the Government under the terms of this Contract. Subcontractors do not include Providers unless the Provider is responsible for services other than providing Covered Services pursuant to a Provider Contract.
 
Systems Unavailability: As measured within the Contractor’s Information Systems’ Span of Control, when a system user does not get the complete, correct full-screen response to an input command within three (3) minutes after pressing the “Enter” or any other function key.
 
Telecommunication Device for the Deaf (“TDD”): Special telephone devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.
 
Terminal Condition: A condition caused by injury, illness, or disease, from which, to a reasonable degree of certainty, will lead to the patient’s death in a period of, at most, six (6) months.
 
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Termination Date of the Contract: The dated designated by ASES as the date that services under this Contract shall end, pursuant to Article 35 of this Contract.
 
Termination Plan: The plan referenced in Article 35.
 
Third Party: Any person, institution, corporation, insurance company, public, private, or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease, or disability of an Enrollee.
 
Third Party Liability (“TPL”): Legal responsibility of any Third Party to pay for health care services.
 
Time and Distance Standards: A standardized measure of mileage and travel time for Enrollees in Urban and Non-Urban Areas to access a set of identified Network Providers as specified in Section 9.4 and developed by ASES in accordance with 42 CFR 438.68.
 
Urban Area: For purposes of measuring Network Adequacy, defined by ASES as municipalities with populations of at least 50,000 people. Urban Areas are San Juan, Carolina, Trujillo Alto, Caguas, Guaynabo, Bayamón, Toa Alta, Toa Baja, Vega Baja, Rio Grande, Humacao, Arecibo, Ponce, Aguadilla, Mayaguez. ASES will notify Contractors if this list of Urban Areas changes.
 
Utilization: The rate patterns of service usage or types of service occurring within a specified time frame.
 
Utilization Management (“UM”): A service performed by the Contractor which seeks to ensure that Covered Services provided to Enrollees are in accordance with, and appropriate under, the standards and requirements established by the Contract, or a similar program developed, established, or administered by ASES.
 
Warm Transfer: A telecommunications mechanism in which the person answering the call facilitates the transfer to a Third Party, announces the caller and issue, and remains engaged as necessary to provide assistance.
 
Waste: Health care spending that can be eliminated without reducing quality of care.
 
Week: The traditional seven-day week, Sunday through Saturday.
 
Well Baby Care: The battery of screenings (listed in Section 7.5.3.1) provided to children as part of Puerto Rico’s (“EPSDT”) Program.
 
Withhold: A percentage of payments or set dollar amounts that ASES deducts from its payment to the Contractor as a penalty, or that a Contractor deducts from its payment to a Network Provider, depending on specific predetermined factors.

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ARTICLE 3
ACRONYMS

The acronyms included in this Contract stand for the following terms:

ACH
Automated Clearinghouse
ACIP
Advisory Committee on Immunization Practices
ADAP
AIDS Drug Assistance Program
ADFAN
Puerto Rico Administración de Familias y Niños, or Families and Children Administration
AHRQ
Agency for Health Care Research and Quality
AICPA
American Institute of Certified Public Accountants
ASES
Administración de Seguros de Salud, or Puerto Rico Health Insurance Administration
ASSMCA
Puerto Rico Mental Health and Anti-Addiction Services Administration or Administración de Servicios de Salud Mental y Contra la Adicción
ASUME
Minor Children Support Administration
BC-DR
Business Continuity and Disaster Recovery
CAHPS
Consumer Assessment of Health Care Providers and Systems
CEO
Chief Executive Officer
CFO
Chief Financial Officer
CFR
Code of Federal Regulations
CHIP
Children's Health Insurance Program
CLIA
Clinical Laboratory Improvement Amendment
CMS
Centers for Medicare & Medicaid Services
CPTET
Centro de Prevención y Tratamiento de Enfermedades Transmisibles, or Communicable Diseases Prevention and Treatment Center
DME
Durable Medical Equipment
DOJ
The Puerto Rico Department of Justice
DSM
Diagnostic and Statistical Manual for Mental Disorders
ECHO
Experience of Care and Health Outcomes Survey
ECM
Electronic Claims Management
EDI
Electronic Data Interchange
EFT
Electronic Funds Transfer
EIN
Employer Identification Number
EMTALA
Emergency Medical Treatment and Labor Act

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EPLS
Excluded Parties List System
EPSDT
Early and Periodic Screening, Diagnostic, and Treatment
EQRO
External Quality Review Organization
ER
Emergency Room
FAR
Federal Acquisition Regulation
FMC
Formulary of Medications Covered
FDA
Food and Drug Administration
FFS
Fee-for-Service
FQHC
Federally Qualified Health Center
FTP
File Transfer Protocol
GHP
Government Health Plan
HEDIS
The Health Care Effectiveness Data and Information Set
HCIP
Health Care Improvement Program
HHS
US Department of Health & Human Services
HHS-OIG
US Department of Health & Human Services Office of the Inspector General
HIE
Health Information Exchange
HIO
Health Information Organization
HIPAA
Health Insurance Portability and Accountability Act of 1996
HITECH
The Health Information Technology for Economic and Clinical Health Act of 2009, 42 USC 17391 et. seq
IBNR
Incurred-But-Not-Reported
ICD-10
International Statistical Classification of Diseases and Related Health Problems (10th edition)
LEIE
List of Excluded Individuals and Entities
LME
List of Medications by Exception
MAC
Maximum Allowable Cost
M-CHAT
Modified Checklist for Autism in Toddlers
MCO
Managed Care Organization
MD
Medical Doctor
MHSIP
Mental Health Statistics Improvement Program
MMIS
Medicaid Management Information System
NCQA
National Committee for Quality Assurance
NEMT
Non-Emergency Medical Transportation

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NPI
National Provider Identifier
NPL
National Provider List
NPPES
National Plan and Provider Enumeration System
NQMC
National Quality Measures Clearinghouse
ONCHIT
Office of the National Coordinator for Health Information Technology
P&T
Pharmacy and Therapeutics
PBM
Pharmacy Benefit Manager
PCP
Primary Care Physician
PHI
Protected Health Information
PIP
Performance Improvement Projects
PMG
Primary Medical Group
PPA
Pharmacy Program Administrator
PPACA
Patient Protection and Affordable Care Act
PPN
Preferred Provider Network
PRHIEC
Puerto Rico Health Information Exchange Corporation
QAPI
Quality Assessment Performance Improvement Program
RFP
Request for Proposals
Rh
Rhesus
RHC
Rural Health Clinic/Center
SAMHSA
Substance Abuse and Mental Health Services Administration
SAS
Statements on Auditing Standards
SMI
Serious Mental Illness
SED
Serious Emotional Disturbance
SSN
Social Security Number
SUDs
Substance Use Disorders
TDD
Telecommunication Device for the Deaf
TPL
Third Party Liability
UM
Utilization Management
US or USA
United States of America
USC
United States Code

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ARTICLE 4
ASES RESPONSIBILITIES
 

4.1
General Provision
 

4.1.1
ASES will be responsible for administering the GHP. ASES will administer contracts, monitor Contractors’ performance, and provide oversight of all aspects of the Contractors’ operations.
 

4.2
Legal Compliance
 

4.2.1
ASES will comply with, and will monitor the Contractor’s compliance with, all applicable Puerto Rico and Federal laws and regulations, including but not limited to those listed in Attachment 1 to this Contract.
 

4.3
Coordination with Contractor’s Key Staff
 

4.3.1
ASES will make diligent, good-faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of the GHP operations.
 

4.3.2
Specifically, ASES will designate individuals within ASES who will serve as liaisons to corresponding individuals on the Contractor’s staff, including:
 

4.3.2.1
A program integrity staff member;
 

4.3.2.2
A quality oversight staff member;
 

4.3.2.3
A financial management staff member;
 

4.3.2.4
A Grievance and Appeal System staff member; and
 

4.3.2.5
An Information Systems coordinator.
 

4.4
Information Systems and Reporting
 

4.4.1
ASES reserves the right to modify, expand, or delete the requirements contained in Article 17 with respect to the Data that Contractor is required to submit to ASES, or to issue new requirements, subject to consultation with Contractor and to cost negotiation, if necessary. Unless otherwise stipulated in the Contract or mutually agreed upon by the Parties, the Contractor shall have ninety (90) Calendar Days from the day on which ASES issues notice of a required modification, addition, or deletion, to comply with the modification, addition, or deletion. Any payment made by ASES that is based on data submitted by the Contractor is contingent upon the Contractor’s compliance with the Certification requirements contained in 42 CFR 438.606.
 

4.4.2
ASES will make available a secure FTP server, accessible via the Internet, for receipt of electronic files and reports from the Contractor. The Contractor shall provide a similar system for ASES to transmit files and reports deliverable by ASES to the Contractor. When such systems are not operational, ASES and the Contractor shall agree mutually on alternate methods for the exchange of files.
 
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4.4.3
ASES will deliver to the Contractor the following information:
 

4.4.3.1
On a Daily Basis:
 

4.4.3.1.1
Certifications and Negative Redetermination Decisions;
 

4.4.3.1.2
Enrollment rejections and errors.
 

4.4.3.2
On a Daily and monthly Basis: Eligibility Data (including Certification and Negative Redetermination Decisions); and
 

4.4.3.3
On a monthly Basis: PMPM Payments.
 

4.5
Readiness Review
 

4.5.1
ASES shall conduct readiness reviews of the Contractor’s operations three (3) months before the start of a new managed care program and when the Contractor will provide or arrange for the provision of Covered Services to new eligibility groups. Such review will include, at a minimum, one (1) on-site review, at dates and times to be determined by ASES. These reviews may include, but are not limited to, desk and on-site reviews of documents provided by the Contractor, walk-through(s) of the Contractor’s facilities, Information System demonstrations, and interviews with the Contractor’s staff. ASES will conduct the readiness review to confirm that the Contractor is capable and prepared to perform all Administrative Functions and to provide high-quality services to GHP Enrollees.
 

4.5.2
The Contractor shall submit policies and procedures and other Deliverables specified by ASES in accordance with Attachment 12 to this Contract. The Contractor shall make any changes requested by ASES to policies and procedures or other Deliverables in the timeframes specified by ASES.
 

4.5.3
ASES’s review will document the status of the Contractor’s compliance with the program standards set forth in this Contract. A multidisciplinary team appointed by ASES will conduct the readiness review. The scope of the readiness review will include, but not be limited to, the review and/or verification of:
 

4.5.3.1
Provider Network composition and Access;
 

4.5.3.2
Staff;
 

4.5.3.3
Provider Credentialing;
 
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4.5.3.4
Call Center;
 

4.5.3.5
Care Management;
 

4.5.3.6
Marketing Materials;
 

4.5.3.7
Content of Provider contracts;
 

4.5.3.8
EPSDT plan;
 

4.5.3.9
Enrollee services capability;
 

4.5.3.10
Comprehensiveness of Quality and Utilization Management strategies;
 

4.5.3.11
Policies and procedures for the Grievance and Appeal System;
 

4.5.3.12
Financial management, including financial reporting and monitoring and financial solvency;
 

4.5.3.13
Contractor litigation history, current litigation, audits and other government investigations both in Puerto Rico and in other jurisdictions;
 

4.5.3.14
Information Systems management, including claims management, encounter data and enrollment information management, systems performance, interfacing capabilities, and security management functions and capabilities; and
 

4.5.3.15
All other matters which ASES may deem reasonable in order to determine the Contractor’s compliance with the requirements of this Contract.
 

4.5.4
The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.
 

4.5.5
Potential Enrollees may not be enrolled in a GHP Plan until ASES has determined that the Contractor is capable of meeting these standards. A Contractor’s failure to pass the readiness review may result in immediate Contract termination. If the Contract is terminated in accordance with this Section 4.5.5 of this Contract, ASES shall not make any payments to the Contractor and shall have no liability for any costs incurred by the Contractor.
 

4.5.6
ASES will provide the Contractor with a summary of findings from the readiness review, as well as areas requiring remedial action with the timeframes to correct the findings.

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ARTICLE 5
ELIGIBILITY AND ENROLLMENT
 

5.1
Eligibility
 

5.1.1
The Government has sole authority to determine eligibility for the GHP, as provided in Federal law and Puerto Rico’s State Plan, with respect to the Medicaid and CHIP Eligibles; and, with respect to the Other Eligible Persons listed in Section 1.3.1.2, as provided in Article VI, Section 5 of Act 72 and other Puerto Rico law and regulation.
 

5.1.2
The Puerto Rico Medicaid Program’s determination that a person is eligible for the GHP is contained on Form MA-10, titled “Notification of Action Taken on Application and/or Recertification.” A person who has received an MA-10 shall be referred to hereinafter as a “Potential Enrollee.” The Potential Enrollee may access Covered Services using the MA-10 as a temporary Enrollee ID Card from the first day of the eligibility period specified on the MA-10 even if the person has not received an Enrollee ID Card. Only Medicaid, CHIP, and State Enrollees receive an MA-10 and may access Covered Services with the MA-10 as a temporary Enrollee ID Card.
 

5.1.3
Effective Date of Eligibility. ASES shall provide the Effective Date of Eligibility for services under the GHP to the Contractor for all Potential Enrollees as follows:
 

5.1.3.1
Effective Date of Eligibility for Medicaid and CHIP Eligibles (see Section 1.3.1.1) is the eligibility period specified on the Form MA-10 which is the first day of the month in which the Potential Enrollee submits its eligibility application with the Medicaid Program Office and they shall be eligible to be enrolled as of that date. For Medicaid and Chip populations, the eligibility period specified on the MA-10 may be retroactive up to three (3) months before the first day of the month in which the Potential Enrollee submits its eligibility application with the Medicaid Program Office. Retroactive eligibility is calculated independently for each of the three (3) months for which retroactive eligibility may be granted and during which services may be retroactively covered.
 

5.1.3.2
Effective Date of Eligibility for the State Population (see Section 1.3.1.2.1) is the eligibility period specified on the Form MA-10 and they shall be eligible to be enrolled as of that date.
 

5.1.3.3
Public employees and pensioners (see Section 1.3.1.2) shall be eligible to enroll in the GHP according to policies determined by the Government and their eligibility, Enrollment and Disenrollment processes and timeframes shall be determined through such policies. The Puerto Rico Medicaid Program and ASES do not play a role in determining the eligibility for public employees and pensioners, except in cases where the employee or pensioner seeks coverage based on income and the Medicaid Program evaluates whether income eligibility standards are met.
 
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5.1.3.4
Effective Date of Eligibility for Enrollees that have been Recertified is the date immediately following the expiration of the twelve (12) month period.
 

5.1.4
Termination of Eligibility
 

5.1.4.1
A Medicaid, CHIP, or State Enrollee who is determined ineligible for the GHP after a Redetermination conducted by the Puerto Rico Medicaid Program shall remain eligible for services under the GHP until the eligibility expiration date specified in the MA-10 issued by the Puerto Rico Medicaid Program for the current period of eligibility. This rule applies unless the Enrollee notifies the Puerto Rico Medicaid Program that their circumstances of eligibility have changed or as otherwise stated in Attachment 9 to this Contract.
 

5.1.4.2
An Enrollee who is a public employee or pensioner (see Section 1.3.1.2) shall remain eligible until disenrolled from the GHP by the applicable Government agency.
 

5.1.5
ASES Notice to Contractor
 

5.1.5.1
ASES will receive a file with Certification and Negative Redetermination Decision Data from the Puerto Rico Medicaid Program on a Daily Basis concerning the Enrollment status of the Medicaid, CHIP, and State Populations, and shall notify the Contractor of a Certification or Negative Redetermination Decision within one (1) Business Day of receiving notice of it via said file. ASES shall forward these Data to the Contractor in an electronic format agreed to between the Parties (the “Daily Update/Carrier Eligibility File Format”).
 

5.1.5.2
The applicable Government agency will directly notify the Contractor of the Enrollment and Disenrollment status of public employees and pensioners.
 

5.2
Enrollment
 

5.2.1
The Contractor shall coordinate with ASES as necessary for all Enrollment and Disenrollment functions.
 

5.2.1.1
The Contractor shall accept all Potential Enrollees into its Plan without restrictions, unless otherwise authorized by ASES. The Contractor shall not discriminate against individuals eligible to enroll on the basis of religion, race, color, national origin, sex, sexual orientation, gender identity, or disability, and will not use any policy or practice that has the effect of discriminating on the basis of religion, race, color, national origin, sex, sexual orientation, gender identity, or disability on the basis of health, health status, pre-existing condition, or need for health care services.
 
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5.2.1.2
The Contractor shall maintain adequate capacity to ensure prompt and voluntary Enrollment of all Potential Enrollees on a Daily Basis and in the order in which they apply or are Auto-Enrolled by ASES per Section 5.2.4.
 

5.2.1.3
The Contractor shall provide Potential Enrollees with specific Information allowing for prompt, voluntary, and reliable Enrollment.
 

5.2.1.4
The Contractor guarantees the maintenance, functionality, and reliability of all systems necessary for Enrollment and Disenrollment.
 

5.2.2
Effective Date of Enrollment
 

5.2.2.1
Except as provided below, Enrollment, whether chosen or automatic, will be effective (hereinafter referred to as the “Effective Date of Enrollment”) the same date as the period of eligibility specified on the MA-10.
 

5.2.2.1.1
The Effective Date of Enrollment for all Initial Auto-Enrollment Enrollees is November 1, 2018.
 

5.2.2.2
Changes in Enrollment requested by the Enrollee received during the first twenty (20) Calendar Days of the month will be effective the first Calendar Day of the following month (e.g., requests received January 10th will be effective February 1st). Changes in Enrollment received after the first twenty (20) Calendar Days of the month will be effective the first Calendar Day of the second month following the request to change Enrollment (e.g., requests received January 25th will be effective March 1st).
 

5.2.2.3
Effective Date of Enrollment for Newborns. The Effective Date of Enrollment for a newborn whose mother is Medicaid or CHIP Eligible on the date of delivery (Deemed Newborn) is the date of his or her birth. The Effective Date of Enrollment for a newborn whose mother is a State Population Enrollee is the Effective Date of Eligibility established by the Puerto Rico Medicaid Program. A newborn shall be Auto-Enrolled pursuant to the procedures set forth in Section 5.2.6.
 
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5.2.3
Term of Enrollment. The Term of Enrollment with Contractor shall be a period of twelve (12) consecutive months for all GHP Enrollees, unless a different contractor is selected during the applicable Open Enrollment Period described in Section 5.2.5, and except in cases in which the Puerto Rico Medicaid Program has designated an eligibility period shorter than twelve (12) months for an Enrollee who is a Medicaid or CHIP Eligible or a member of the State Population, in which case that same period shall also be considered the Enrollee’s Term of Enrollment. Such a shortened eligibility period may apply, at the discretion of the Puerto Rico Medicaid Program, when an Enrollee is pregnant, is homeless, or anticipates a change in status (such as receipt of unemployment benefits or in family composition). Notwithstanding this Section, Section 5.3.3 controls the Effective Date of Disenrollment.
 

5.2.3.1
Deemed Newborns have a Term of Enrollment of up to thirteen (13) months.
 

5.2.3.2
Pregnant Enrollees with a Term of Enrollment that expires during pregnancy or within sixty (60) Calendar Days of the post-partum period shall have an extended Term of Enrollment that expires on the last day of the month after sixty (60) Calendar days counted from the beginning of the post-partum period.
 

5.2.3.3
Except as otherwise provided in this Section 5.2, and notwithstanding the Term of Enrollment provided in Section 5.2.3, Enrollees shall remain enrolled in the Contractor’s Plan until the occurrence of an event listed in Section 5.3 (Disenrollment).
 

5.2.4
Auto-Enrollment. ASES shall apply an algorithm developed in accordance with the requirements in 42 CFR 438.54 to conduct Initial Auto-Enrollment prior to November 1, 2018. The Contractor shall have the policies and procedures necessary, and as shall be approved in writing by ASES, to comply with Initial Auto-Enrollment as of the Effective Date of the Contract for the Medicaid and CHIP Eligibles and members of the State Population, excluding State Employees eligible under Law 95.
 

5.2.4.1
The Foster Care Population and Domestic Violence Population will be Auto-Enrolled in one contractor’s plan and are not eligible to enroll into another contractor’s plan.
 

5.2.5
Open Enrollment Periods
 

5.2.5.1
Initial Auto-Enrollment Enrollees. Initial Auto-Enrollment Enrollees will have one (1) opportunity to change contractors without cause during their Open Enrollment Period, which shall begin on November 1, 2018 and end on January 31, 2019.
 

5.2.5.2
New Enrollees. New Enrollees to the GHP will have the opportunity to select a contractor during the Medicaid eligibility process with the Puerto Rico Medicaid Program. If the New Enrollee does not select a contractor, the Puerto Rico Medicaid Program will select a contractor on behalf of the New Enrollee. New Enrollees shall be permitted to select a different contractor once without cause, regardless of how the initial selection of contractor was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Effective Date of Enrollment.
 
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5.2.5.3
All Enrollees. All Enrollees will have the opportunity to select a contractor without cause during the Annual Open Enrollment period.
 

5.2.5.3.1
If a New Enrollee’s Open Enrollment Period in Section 5.2.5.2 coincides with the Annual Open Enrollment Period, the Open Enrollment Period in Section 5.2.5.2 controls.
 

5.2.5.4
When an Enrollee ceases to be part of the Domestic Violence or Foster Care Populations but continues to be an Eligible Person, the Enrollee may select a new contractor during an Open Enrollment Period.
 

5.2.5.5
When an Enrollee ceases to be eligible for the Platino Program but continues to be an Eligible Person, the Enrollee may select a new contractor during an Open Enrollment Period.
 

5.2.5.6
If the Enrollee does not make a change in contractor during the Open Enrollment Period, the Enrollee will remain enrolled with his/her current contractor.
 

5.2.6
Enrollment Procedures for All Enrollees Except Newborns
 

5.2.6.1
Upon receipt of notices in accordance with Section 5.1.5 of this Contract, the Contractor shall comply with the Auto-Enrollment process and issue to the Enrollee a notice informing the Enrollee of the PMG and PCP they are assigned to and their rights to change the PMG or PCP without cause during the applicable Open Enrollment Period. Effective November 1, 2018, such changes may be requested through ASES’s designated enrollment counselor.
 

5.2.6.2
The Contractor shall issue to the Enrollee an Enrollee ID Card and a notice of Enrollment, as well as an Enrollee Handbook and Provider Directory either in paper or electronic form, subject to the requirements of Section 6.10.8 and 6.10.9; or, such notice of Enrollment, an ID Card, an Enrollee Handbook, and a Provider Directory may be sent to the Enrollee via surface mail or electronically, subject to the requirements of Section 6.10.8 and 6.10.9 within five (5) Business Days of Enrollment.
 
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5.2.6.3
The notice of Enrollment that the Contractor issues will clearly state the Effective Date of Enrollment that applies per Section 5.2.2. The notice of Enrollment will explain that the Enrollee is entitled to receive Covered Services through the Contractor. The notice will inform the Enrollee of his or her limited right to disenroll, per Section 5.3 of this Contract. The notice shall advise the Enrollee of the Enrollee’s right to select a different PCP or to change PMGs, as described in Section 5.4, and will encourage the Enrollee to pursue this option if he or she is dissatisfied with care or services.
 

5.2.6.3.1
All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56. Such notification must clearly explain the process for exercising this disenrollment right, as well as the alternatives available to the Enrollee based on their specific circumstance.
 

5.2.7
Procedures for Auto-Enrollment of Newborns
 

5.2.7.1
The Contractor shall notify ASES and the Puerto Rico Medicaid Program in writing of any Enrollees who are expectant mothers Immediately at the moment of diagnosis of the pregnancy or at least sixty (60) Calendar Days before the expected date of delivery.
 

5.2.7.2
The Contractor shall promptly, upon learning that an Enrollee is an expectant mother, mail a newborn Enrollment packet to the expectant mother (i) instructing her to register the newborn with the Puerto Rico Medicaid Program within ninety (90) Calendar Days of birth by providing evidence of the newborn’s birth; (ii) notifying an expectant mother that is a Medicaid or CHIP Enrollee that the Deemed Newborn will be Auto-Enrolled in the GHP; (iii) informing an expectant mother that is a Medicaid or CHIP Enrollee that unless she visits the Contractor’s office to select a PMG and PCP, the Deemed Newborn will be Auto-Assigned to the mother’s PMG and to a PCP who is a pediatrician; and (iv) informing the expectant mother that she will have ninety (90) Calendar Days after the date in which the Puerto Rico Medicaid Program notifies that the Deemed Newborn has been registered to disenroll from Plan or to change the child’s PMG and PCP, without cause.
 

5.2.7.3
The Contractor shall provide assistance to any expectant mother or guardian who contacts the Contractor wishing to make a PCP and PMG selection for her newborn and record that selection, per Section 5.4.
 

5.2.7.4
If the mother or guardian has not made a PCP and PMG selection at the time of the Deemed Newborn’s birth, the Contractor shall, within one (1) Business Day of the birth, Auto-Assign the Deemed Newborn to a PCP who is a pediatrician and to the Contact Member’s PMG.
 
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5.2.7.5
Within one (1) Business Day of acknowledging, either by concurrent review or hospital notification of the birth of a Deemed Newborn to a Medicaid or CHIP Enrollee, the Contractor shall ensure the submission of a newborn notification form to ASES and to the Puerto Rico Medicaid Program; such form shall be given prior written approval by ASES and the Puerto Rico Medicaid Program.
 

5.2.7.6
The Contractor shall participate in any meeting, working group, or other mechanism requested by ASES in order to ensure coordination among the Contractor, ASES, and the Puerto Rico Medicaid Program in order to implement Deemed Newborn Auto-Enrollment.
 

5.2.8
Contractor Notification Procedures Related to Redeterminations and Open Enrollment Periods
 

5.2.8.1
The Contractor shall inform Enrollees who are Medicaid- and CHIP Eligibles and members of the State Population of an impending Redetermination through written notices. Such notices shall be provided ninety (90) Calendar Days, sixty (60) Calendar Days, and thirty (30) Calendar Days before the scheduled date of the Redetermination.
 

5.2.8.1.1
The written notices shall inform the Enrollee that, if he or she is Recertified, his or her Term of Enrollment with the Contractor’s Plan will automatically renew unless a different contractor is selected during the Open Enrollment Period described in Section 5.2.5.3. The written notices must also specify that the Enrollee may change his or her PMG and/or PCP selection without cause during the applicable Open Enrollment Period.
 

5.2.8.2
The Contractor shall provide Enrollees and their representatives with sixty (60) Calendar Days written notice before the start of the Open Enrollment Period described in Section 5.2.5.3 of the right to disenroll or to change PMG or PCP without cause during such Open Enrollment Period.
 

5.2.8.3
Upon the receipt of written request from ASES, the Contractor shall provide a report for a specific period of time containing documentation that the Contractor has furnished the notices required in this Section 5.2.7.
 
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5.2.8.4
The form letters used for the notices in this Section 5.2.8 shall fall within the requirements in Section 6.2.1 that the Contractor seek advance written approval from ASES of certain documents.
 

5.2.9
Specific Contractor Responsibilities Regarding Dual Eligible Beneficiaries. At the time of Enrollment, the Contractor shall provide Potential Enrollees who are Medicaid-eligible and are also eligible for Medicare Part A or Medicare Part A and Part B (“Dual Eligible Beneficiaries”) with the information about their Covered Services and Co-Payments that is listed in Section 6.13. Members of the State Population (see section 1.3.1.2.1) who are Medicare-eligible shall not be considered Dual Eligible Beneficiaries.
 

5.3
Disenrollment
 

5.3.1
Disenrollment occurs only when the Medicaid Program determines that an Enrollee is no longer eligible for the GHP; or when Disenrollment is requested by the Contractor or Enrollee, and approved by ASES, as provided in Sections 5.3.4 and 5.3.5. The Foster Care Population and Domestic Violence Populations may not disenroll from their Auto-Enrolled GHP Plan.
 

5.3.2
All Disenrollments will be processed by ASES, and ASES will issue notification to the Contractor. Such notice shall be delivered via file transfer to the Contractor on a Daily Basis simultaneously with Information on Potential Enrollees within five (5) Calendar Days of a final determination on Disenrollment.
 

5.3.2.1
Disenrollment decisions and processing are the responsibility of the Puerto Rico Medicaid Program and ASES; however, notice to Enrollees of Disenrollment shall be issued by the Contractor. The Contractor shall issue such notice in person or via surface mail to the Enrollee within five (5) Business Days of a final Disenrollment decision, as provided in Sections 5.3.4 and 5.3.5.
 

5.3.2.2
Each notice of Disenrollment shall include information concerning:
 

5.3.2.2.1
The Effective Date of Disenrollment;
 

5.3.2.2.2
The reason for the Disenrollment;
 

5.3.2.2.3
The Enrollee’s right to request a Reconsideration from ASES and of ASES’s Administrative Law Hearing process, as provided by Act 72 of September 7, 1993;
 

5.3.2.2.4
The right to re-enroll in the GHP upon receiving a Recertification from the Puerto Rico Medicaid Program, if applicable; and
 
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5.3.2.2.5
Disenrollment shall occur according to the timeframes in Section 5.3.3 (the “Effective Date of Disenrollment”).
 

5.3.3
The Effective Date of Disenrollment is as follows:
 

5.3.3.1
Except as otherwise provided in this Section 5.3, Disenrollment will take effect as of the Effective Date of Disenrollment specified in the daily eligibility file sent to the Contractor by ASES as set forth in Attachment 9 to this Contract.
 

5.3.3.2
When Disenrollment is effectuated at the Contractor’s or the Enrollee’s request, as provided in Sections 5.3.4 and 5.3.5 of this Contract, Disenrollment shall take effect no later than the first day of the second month following the month that the Contractor or Enrollee requested the Disenrollment. If ASES fails to make a decision on the Enrollee’s request before this date, the Disenrollment will be deemed granted. If the Enrollee’s request is denied by ASES, the Enrollee may request, verbally or in writing, a Reconsideration by ASES and the Reconsideration process shall be completed in time to permit the Disenrollement (if approved) to take effect in accordance with this timeframe.
 

5.3.3.3
If an Enrollee is no longer eligible under the GHP, and Disenrollment under this Section 5.3.3 falls:
 

5.3.3.3.1
When the Enrollee is an inpatient at a hospital, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the Enrollee is discharged from the hospital, or the last day of the month following the month in which Disenrollment would otherwise be effective, whichever occurs earlier;
 

5.3.3.3.2
During a month in which a Medicaid, CHIP or State Enrollee is pregnant, or on the date the pregnancy ends, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the 60-day post-partum period ends;
 

5.3.3.3.3
When the Enrollee is in the process of appealing a denial of a Disenrollment request by ASES through either ASES’s Reconsideration process, ASES’s Administrative Law Hearing process (after exhausting the Reconsideration process), or the Puerto Rico Medicaid Department’s dedicated hearing process on Disenrollments due to loss of eligibility, as applicable, then ASES shall postpone the Effective Date of Disenrollment until a decision is rendered after the hearing; or
 
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5.3.3.3.4
During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the following month.
 

5.3.3.4
For the public employees and pensioners who are Other Eligible Persons referred to in Section 1.3.1.2.2, Disenrollment shall occur according to the timeframes set forth in a Normative Letter issued by ASES annually.
 

5.3.4
Disenrollment Initiated by the Contractor
 

5.3.4.1
The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee’s consent. The Contractor shall notify ASES upon identification of an Enrollee who it knows or believes meets the criteria for Disenrollment.
 

5.3.4.2
The Contractor shall submit Disenrollment requests to ASES, and the Contractor shall honor all Disenrollment determinations made by ASES. ASES’s decision on the matter shall be final, conclusive, and not subject to appeal by the Contractor.
 

5.3.4.3
The following are acceptable reasons for the Contractor to request Disenrollment:
 

5.3.4.3.1
The Enrollee’s continued Enrollment in the Contractor’s Plan seriously impairs the ability to furnish services to either this particular Enrollee or other Enrollees;
 

5.3.4.3.2
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness;
 

5.3.4.3.3
The Enrollee’s use of services is fraudulent or abusive (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services);
 

5.3.4.3.4
The Enrollee is placed in a long-term care nursing facility or intermediate care facility for the intellectually disabled;
 

5.3.4.3.5
The Enrollee’s Medicaid or CHIP eligibility category changes to a category ineligible for the GHP; or
 

5.3.4.3.6
The Enrollee has died or moved out of Puerto Rico, thereby making him or her ineligible for Medicaid or CHIP or is otherwise ineligible for the GHP.
 
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5.3.4.4
ASES will approve a Disenrollment request by the Contractor, in ASES’s discretion, only if ASES determines:
 

5.3.4.4.1
That it is impossible for the Contractor to continue to provide services to the Enrollee without endangering the Enrollee or other GHP Enrollees; and
 

5.3.4.4.2
That an action short of Disenrollment, such as transferring the Enrollee to a different PCP or PMG, will not resolve the problem.
 

5.3.4.5
The Contractor may not request Disenrollment for any discriminatory reason including, but not limited, to the following:
 

5.3.4.5.1
Adverse changes in an Enrollee’s health status;
 

5.3.4.5.2
Missed appointments;
 

5.3.4.5.3
Utilization of medical services;
 

5.3.4.5.4
Diminished mental capacity;
 

5.3.4.5.5
Pre-existing medical condition;
 

5.3.4.5.6
The Enrollee’s attempt to exercise his or her rights under the Grievance and Appeal System; or
 

5.3.4.5.7
Uncooperative or disruptive behavior resulting from the Enrollee’s special needs.
 

5.3.4.6
The request of one (1) PMG to have an Enrollee assigned to a different PMG, per Section 5.4, shall not be sufficient cause for the Contractor to request that the Enrollee be disenrolled from the Plan. Rather, the Contractor shall, if possible, assign the Enrollee to a different and available PMG within the Plan.
 

5.3.4.7
When requesting Disenrollment of an Enrollee for reasons described in Section 5.3.4.3, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment and Care Management to resolve any difficulty leading to the request. The Contractor shall also provide evidence of having given at least one (1) written warning to the Enrollee, with a certified return receipt requested, regarding implications of his or her actions.
 

5.3.4.8
If the Enrollee has demonstrated abusive or threatening behavior as defined by ASES, only one (1) Contractor intervention, and a subsequent written attempt to resolve the difficulty, are required.
 
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5.3.4.9
In the event that the Contractor seeks Disenrollment of an Enrollee, the Contractor shall notify the Enrollee of the availability of ASES’s Reconsideration process and Administrative Law Hearing process, as provided by Act 72 of September 7, 1993, as amended.
 

5.3.4.10
The Contractor shall maintain policies and procedures to comply with the Puerto Rico Patients’ Bill of Rights Act and with the Medicaid Regulations of 42 CFR 438.100, to ensure that the Enrollee’s exercise of Grievance rights does not adversely affect the services provided to the Enrollee by the Contractor or by ASES.
 

5.3.5
Disenrollment Initiated by the Enrollee
 

5.3.5.1
All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56. Such notification shall clearly explain the process for exercising this disenrollment right, as well as the coverage alternatives available to the Enrollee based on their specific circumstance.
 

5.3.5.2
An Enrollee wishing to request Disenrollment must submit an oral or written request to ASES or to the Contractor. If the request is made to the Contractor, the Contractor shall forward the request to ASES, within five (5) Business Days of receipt of the request, with a recommendation of the action to be taken.
 

5.3.5.3
An Enrollee may request Disenrollment from the Contractor’s Plan without cause once during the applicable Open Enrollment Period in accordance with Section 5.2.5.
 

5.3.5.4
An Enrollee may request Disenrollment from the Contractor’s Plan for cause at any time. ASES shall determine whether the reason constitutes a valid cause. The following constitute cause for Disenrollment by the Enrollee:
 

5.3.5.4.1
The Enrollee moves outside of Puerto Rico;
 

5.3.5.4.2
The Contractor’s Plan does not, due to moral or religious objections, cover the health service the Enrollee seeks.
 

5.3.5.4.3
The Enrollee needs related services to be performed at the same time, and not all related services are available within the network. The Enrollee’s PCP or another Provider in the Contractor’s Network have determined that receiving services separately would subject the Enrollee to unnecessary risk.
 

5.3.5.4.4
Other acceptable reasons for Disenrollment at Enrollee request, per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care, lack of Access to Covered Services, or lack of Providers experienced in dealing with the Enrollee’s health care needs; and
 
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5.3.5.4.5
The Enrollee has become eligible for a Platino Program, or has experienced a change in his or her eligibility as a member of the Domestic Violence or Foster Care Populations.
 

5.3.5.5
If the Contractor fails to refer a Disenrollment request within the timeframe specified in Section 5.3.3, or if ASES fails to make a Disenrollment determination so that the Enrollee may be disenrolled by the first day of the second month following the month when the Disenrollment request was made, per Section 5.3.3, the Disenrollment shall be deemed approved for the effective date that would have been established had ASES or the Contractor complied with Section 5.3.3.
 

5.3.5.6
ASES shall make the final decision on Enrollees’ requests for Disenrollment. ASES may approve or disapprove the request based on the reasons specified in the Enrollee’s request, or upon any relevant Information provided to ASES by the Contractor about the Disenrollment request.
 

5.3.5.7
If the Enrollee’s request for Disenrollment under this Section is denied, the Contractor shall provide the Enrollee with a notice of the decision in a format and content consistent with Section 14.5.15. The notice shall include the grounds for the denial and shall inform the Enrollee of his or her right to use the Reconsideration process, and to have access to an Administrative Law Hearing after first exhausting ASES’s Reconsideration process.
 

5.3.5.8
Use of the Contractor’s Grievance and Appeal System. ASES may at its option require that the Enrollee seek redress through the Contractor’s Grievance and Appeal System before ASES makes a determination on the Enrollee’s request for Disenrollment. The Contractor shall Immediately inform ASES of the outcome of the Grievance process. ASES may take this Information into account in making a determination regarding the request for Disenrollment. The Grievance process shall be completed in time to permit the Disenrollment (if approved) to be effective in accordance with the timeframe specified in Section 5.3.3; if the process is not completed within the specified timeframe, then the Disenrollment will be deemed approved by ASES.
 

5.3.6
Disenrollment During Termination Hearing Process. If ASES notifies the Contractor of its intention to terminate the Contract as provided in Article 35, ASES may allow Enrollees to disenroll Immediately without cause. In the event of such a Termination, ASES must provide Enrollees with the notice required by 42 CFR 438.10, listing their options for receiving services following the Termination Date of the Contract.
 
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5.3.7
ASES shall ensure, through the obligations of the Contractor under this Contract that Enrollees receive the notices contained in Section 5.2.7 (Re-Enrollment Procedures). While these notices shall be issued by the Contractor, per Section 5.2.7, ASES shall provide the Contractor with the information on Certifications and Negative Redetermination Decisions (see Section 5.1.5.1) needed for the Contractor to carry out this responsibility.
 

5.3.8
Enrollment Database
 

5.3.8.1
The Contractor shall maintain an Enrollment database that includes all Enrollees, and contains, for each Enrollee, the Information specified in the Carrier Billing File/Carrier Eligibility File format.
 

5.3.8.2
The Contractor shall notify the Puerto Rico Medicaid Program Immediately when the Enrollment database is updated to reflect a change in the place of residence of an Enrollee.
 

5.3.8.3
The Contractor shall secure any authorization required from Enrollees under the laws of Puerto Rico in order to allow the US Department of Health and Human Services, the Medicaid Fraud Control Unit, ASES, and its Agents to review Enrollee Medical Records, in order to evaluate the Information and determine quality, appropriateness, timeliness, and cost of services performed under this Contract; provided that such authorization shall be limited by the Contractor’s obligation to observe the confidentiality of Enrollees’ Protected Health Information, as provided in Article 34.
 

5.3.9
Notification to ASES and the PBM of New Enrollees and of Completed Disenrollments
 

5.3.9.1
The Contractor shall notify ASES and the PBM of new Enrollees and of completed Disenrollments on a routine Daily Basis; or at any time, if requested by ASES. Such notification will be made through electronic transmissions.
 

5.3.9.2
The notification will include all new Enrollees as of the Business Day before the notification is issued, and will be sent no later than the following Business Day after the Enrollment process has been completed (as signified by issuance of the Enrollee ID Card, either in person or by surface mail) or the Disenrollment process has been completed (as signified by the issuance of a Disenrollment notice).
 

5.3.10
In the event that the Contractor must update information previously submitted to ASES about a new Enrollment, including a change in coverage code, or that the Contractor must add a new Enrollee who was previously omitted, such update must occur the next Business Day after the information is updated or a new Enrollee is added. ASES reserves the authority not to accept any new additions or corrections to a particular month’s Enrollment Data after two (2) Business Days past the date on which ASES notifies the Contractor of the rejected subscriptions, as set forth in Attachment 9 to this Contract.
 
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5.4
Change of a Primary Medical Group (“PMG”) and Primary Care Physician (“PCP”)
 

5.4.1
Change of a PMG and PCP
 

5.4.1.1
During the ninety (90) Calendar Days period following the Effective Date of Enrollment (the Open Enrollment Period), the Enrollee can change his/her Auto-Assigned or selected PMG and PCP without cause. The Contractor can offer counseling and assistance to the Enrollee in selecting a different PCP and PMG. Enrollees under the Foster Care Population and Domestic Violence Population classification are not assigned to a PCP or PMG.
 

5.4.1.2
The Contractor shall advise certain Enrollees to choose a physician other than, or in addition to, a general practice physician as their PCP, as follows:
 

5.4.1.2.1
Female Enrollees age twelve (12) and older will be recommended to choose an obstetrician/gynecologist as a PCP.
 

5.4.1.2.2
Enrollees under twenty-one (21) years of age will be recommended to choose a pediatrician as a PCP.
 

5.4.1.2.3
Enrollees with conditions that are included in HCHN Program in Section 7.8.3 will be recommended to choose an internist or other appropriate specialist as a PCP.
 

5.4.1.3
Per Section 5.2.7, following the Contractor’s notice to an expectant mother of a Deemed Newborn’s upcoming Auto-Enrollment in the Contractor’s Plan, the Contractor shall record any notice it receives from the mother or guardian concerning the selection of a PCP or PMG for the Deemed Newborn. The Contractor shall ensure that such selections take effect as of the date of the Deemed Newborn’s birth.
 

5.4.1.4
In order to comply with the PMG Capitation payment process, if an Enrollee changes PCP/PMG during the first five (5) Calendar Days of the month, the change will be effective in the next subsequent month of the change. If Enrollee changes PCP/PMG after the fifth (5th) day of the month, the change will be effective in the second (2nd) subsequent month of the change. The Enrollee can still receive services until the change is effective from the originally assigned PCP/PMG
 
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5.4.1.5
The Contractor shall permit Enrollees to change their PMG or PCP at any time with cause. The following shall constitute cause for change of PMG or PCP:
 

5.4.1.5.1
The Enrollee’s religious or moral convictions conflict with the services offered by Providers in the PMG;
 

5.4.1.5.2
The Enrollee needs related services to be provided concurrently; not all services are available within the Preferred Provider Network associated with a PMG; and the Enrollee’s PCP or any other Provider has determined that receiving the services separately could expose the Enrollee to an unnecessary risk; or
 

5.4.1.5.3
Other reasons, including a deterioration of the Provider-Enrollee relationship where the Enrollee no longer feels comfortable receiving services from the Provider, poor quality of care, unavailability of appointments, inaccessibility to Covered Services, and inaccessibility to Providers with the experience to address the health care needs of the Enrollee.
 

5.4.1.6
The Contractor shall permit Enrollees to change their PMG and/or PCP for any reason, within certain timeframes:
 

5.4.1.6.1
During the ninety (90) Calendar Days following the Effective Date of Enrollment (Open Enrollment Period);
 

5.4.1.6.2
At least every twelve (12) months, following the ninety (90) Calendar Days after the Effective Date of Enrollment; or
 

5.4.1.6.3
At any time, during time periods in which the Contractor is subject to intermediate sanctions, as defined in 42 CFR 438.702(a)(3).
 

5.4.1.7
A Contractor may change an Enrollee’s PMG at the request of the PCP or another Provider within that PMG, in limited situations, when appropriately documented, as follows:
 

5.4.1.7.1
The Enrollee’s continued participation in the PMG seriously impairs the PMG’s ability to furnish services to either this particular Enrollee or other Enrollees;
 
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5.4.1.7.2
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and that is not caused by a presenting illness; or
 

5.4.1.7.3
The Enrollee’s use of services is fraudulent or abusive (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services).
 

5.5
Transition of Care During Contractor Change
 

5.5.1
The Contractor must ensure continued access to services during an Enrollee’s transition from one Contractor to another by complying with the following:
 

5.5.1.1
Ensure the Enrollee has access to services consistent with the access they previously had, and is permitted to retain their current Provider for ninety (90) Calendar Days if that Provider is not a Network Provider;
 

5.5.1.2
Refer Enrollee to appropriate Network Providers;
 

5.5.1.3
Fully and timely comply with requests for historical utilization data from the new contractor or other entity in compliance with Federal and State laws;
 

5.5.1.4
Ensure that the Enrollee’s new Provider is able to obtain copies of the Enrollee’s medical records, as appropriate;
 

5.5.1.5
Comply with any other necessary procedures specified by CMS or ASES to ensure continued access to services to prevent serious detriment to the Enrollee’s health or reduce the risk of hospitalization or institutionalization.

ARTICLE 6
ENROLLEE SERVICES
 

6.1
General Provisions
 

6.1.1
The Contractor shall have policies and procedures, prior approved by ASES and submitted in accordance with Attachment 12 to this Contract, that explain how it will ensure that Enrollees and Potential Enrollees:
 

6.1.1.1
Are aware of their rights and responsibilities;
 

6.1.1.2
How to obtain physical and Behavioral Health Services;
 

6.1.1.3
What to do in an emergency or urgent medical situation;
 
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6.1.1.4
How to request a Grievance, Appeal, or Administrative Law Hearing;
 

6.1.1.5
How to report suspected Incident of Fraud, Waste, and Abuse;
 

6.1.1.6
Have basic information on the basic features of managed care; and
 

6.1.1.7
Understand the Contractor’s responsibilities to coordinate Enrollee care.
 

6.1.2
The Contractor’s informational materials must convey to Enrollees and Potential Enrollees that GHP is an integrated program that includes both physical and Behavioral Health Services, and must also explain the concepts of Primary Medical Groups and Preferred Provider Networks.
 

6.1.3
The information conveyed in the Contractor’s written materials shall conform with ASES’s Universal Enrollee Handbook, included as Attachment 3 to this Contract.
 

6.1.4
The Contractor shall convey Information to Enrollees and Potential Enrollees via written materials and via telephone, internet, and face-to-face communications, and shall allow Enrollees to submit questions and to receive responses from the Contractor.
 

6.1.5
The Contractor shall ensure that the informational materials disseminated to all GHP Enrollees accurately identify differences among the categories of Eligible Persons.
 

6.1.6
The Contractor shall provide Enrollees with at least thirty (30) Calendar Days written notice of any significant change in policies concerning Enrollees’ Disenrollment rights (see Section 5.3), right to change PMGs or PCPs (see Section 5.4), or any significant change to any of the items listed in the Enrollee Handbook (Section 6.4) or Enrollee Rights and Responsibilities (section 6.5), regardless of whether ASES or the Contractor caused the change to take place. This Section 6.1.6 shall not be construed as giving the Contractor the right to change its policies and procedures without prior written approval from ASES.
 

6.1.7
The Contractor shall use the definitions for managed care terminology set forth by ASES in all of its written and verbal communications with Enrollees, in accordance with 42 CFR 438.10(c)(4)(i).
 

6.1.8
The Contractor shall provide instructions to Enrollees and Potential Enrollees on how to access continued services pursuant to its transition of care process as specified in Section 5.5 and in accordance with 42 CFR 438.62.
 
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6.2
ASES Approval of All Written Materials
 

6.2.1
The Contractor shall submit to ASES for review and prior written approval all materials meant for distribution to Enrollees, including but not limited to, Enrollee Handbooks, Provider Directories, ID cards and, upon request, any other additional, but not required, materials and Information provided to Enrollees designed to promote health and/or educate Enrollees.
 

6.2.2
All materials must be submitted to ASES in paper and electronic file media, in the format prescribed by ASES. The Contractor shall submit the reading level and the methodology used to measure it concurrent with all submissions of written materials and include a plan that describes the Contractor’s intent for the use of the materials.
 

6.2.3
ASES reserves the right to notify the Contractor to discontinue or modify written materials after approval.
 

6.2.4
Except as otherwise provided below, written materials described in this Article 6 must be submitted to ASES for review at least forty-five (45) Calendar Days before their printing and distribution, as required by Act 194 of August 2000. This requirement applies to:
 

6.2.4.1
The materials described in this Article 6 distributed to all Enrollees, including the Enrollee Handbook;
 

6.2.4.2
Policy letters, coverage policy statements, or other communications about Covered Services under the GHP distributed to Enrollees; and
 

6.2.4.3
Standard letters and notifications, such as the notice of Enrollment required in Section 5.2.6.3, the notice of Redetermination required in Section 5.2.8.1, and the notice of Disenrollment required in Section 5.3.2. The Contractor shall use model Enrollee notices developed by ASES whenever available.
 

6.2.5
The Contractor shall provide ASES with advance notice of any changes made to written materials that will be distributed to all Enrollees. Notice shall be provided to ASES at least forty-five (45) Calendar Days before the effective date of the change. Within fifteen (15) Business Days of receipt of the materials, ASES will respond to the Contractor’s submission with either an approval of the materials, recommended modifications, or a notification that more review time is required. If the Contractor receives no response from ASES within fifteen (15) Business Days of ASES’s receipt of the materials, the materials shall be deemed approved. Except as otherwise provided in this Section 6.2.5, the Contractor may distribute the revised written materials only upon written approval of the changes from ASES.
 
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6.3
Requirements for Written Materials
 

6.3.1
The Contractor shall maintain written policies and procedures governing the development and distribution of written materials including how the Contractor will meet the requirements in this Section 6.3, with such policies and procedures to be submitted in accordance with Attachment 12 to this Contract for prior written approval from ASES. The Contractor shall, at a minimum, have policies and procedures regarding the process for developing/creating, proofing, approving, publishing, and mailing the (i) Enrollee Handbook, (ii) Provider Directory, and (iii) form letters within contractual standards and timeframes. The Contractor shall include a separate set of policies and procedures for the items listed above.
 

6.3.2
The Contractor shall make all written materials available through auxiliary aids and services or alternative formats, and in a manner that takes into consideration the Enrollee’s or Potential Enrollee’s special needs, including Enrollees and Potential Enrollees who are visually impaired or have limited reading proficiency. The Contractor shall notify all Enrollees and Potential Enrollees that Information is available in alternative formats, and shall instruct them on how to access those formats. Consistent with Section 1557 of PPACA and 42 CFR 438.10(d)(3), all written materials must also include taglines in the prevalent languages, as well as large print, with a font size of no smaller than 18 point, to explain the availability of written and oral translation to understand the Information provided and the toll-free and TTY/TDD telephone number of the GHP Service Line.
 

6.3.3
Once an Enrollee has requested a written material in an alternative format or language, the Contractor shall at no cost to the Enrollee or Potential Enrollee (i) make a notation of the Enrollee or Potential Enrollee’s preference in the Contractor’s system and (ii) provide all subsequent written materials to the Enrollee or Potential Enrollee in such format unless the Enrollee or Potential Enrollee requests otherwise.
 

6.3.4
Except as provided in Sections 1.1.5 and 6.4 (Enrollee Handbook) and subject to Section 6.3.8, the Contractor shall make all written information available in Spanish or other applicable Prevalent Non-English Language, as defined in Section 6.3.8 below, with a language block in English, explaining that (i) Enrollees may access an English translation of the Information if needed, and (ii) the Contractor will provide oral interpretation services into any language other than Spanish or English, if needed. Such translation or interpretation shall be provided by the Contractor at no cost to the Enrollee. The language block and all other content shall comply with 42 CFR 438.10(d)(2) and Section 1557 of PPACA.
 

6.3.5
If oral interpretation services are required in order to explain the Benefits covered under the GHP to a Potential Enrollee who does not speak either English or Spanish, the Contractor must, at its own cost, make such services available in a third language, in compliance with 42 CFR 438.10(d)(4).
 
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6.3.6
All written materials shall be worded such that they are understandable to a person who reads at the fourth (4th) grade level.
 

6.3.7
All written materials must be clearly legible with a minimum font of size twelve (12) point with the exception of Enrollee ID cards and unless otherwise approved in writing by ASES.
 

6.3.8
Within ninety (90) Calendar Days of a notification from ASES that ASES has identified a Prevalent Non-English Language other than Spanish or English (with “Prevalent Non-English Language” defined as a language that is the primary language of more than five percent (5%) of the population of Puerto Rico), all written materials provided to Enrollees and Potential Enrollees shall be translated into and made available in such language.
 

6.3.9
The Contractor shall provide written notice to Enrollees of any material changes to written materials previously distributed to Enrollees at least thirty (30) Calendar Days before the effective date of the change.
 

6.4
Enrollee Handbook Requirements
 

6.4.1
The Contractor shall produce at its sole cost, and shall mail or make electronically available, subject to the requirements of Section 6.10.8 and 6.10.9, to all new Enrollees, an Enrollee Handbook including information on physical health, Behavioral Health, and all other Covered Services offered under the GHP. The Contractor shall distribute the Enrollee Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.5.3 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.
 

6.4.2
Upon request of an Enrollee or his/her Authorized Representative for a replacement or additional copy of the Enrollee Handbook, the Contractor shall send an Enrollee Handbook within ten (10) Calendar Days. The Contractor shall give the person requesting an Enrollee Handbook the option to get the Information from the Contractor’s website or to receive a printed document.
 

6.4.3
The Contractor shall either:
 

6.4.3.1
Mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees an Enrollee Handbook on at least an annual basis, after the initial distribution of the Enrollee Handbook at Enrollment; or
 

6.4.3.2
At least annually, as required by 42 CFR 438.10, mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees a Handbook supplement that includes Information on the following:
 
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6.4.3.2.1
The Contractor’s service area;
 

6.4.3.2.2
Benefits covered under the GHP;
 

6.4.3.2.3
Any cost-sharing imposed by the Contractor; and
 

6.4.3.2.4
To the extent available, quality and performance indicators, including Enrollee satisfaction.
 

6.4.3.3
The Contractor is not required to mail an Enrollee Handbook to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided an Enrollee Handbook within the past year. The Contractor is also not required to mail an Enrollee Handbook to new Enrollees under the age of twenty-one (21) if an Enrollee Handbook has been mailed within the past year to a member of that Enrollee’s household. However, this exception does not apply to pregnant Enrollees under the age of twenty-one (21).
 

6.4.4
The Contractor shall use the Universal Beneficiary Guide, provided by ASES and included as Attachment 3 to this Contract, as a model for its Enrollee Handbook; however, the Contractor shall ensure that its Enrollee Handbook meets all the requirements listed in this Section 6.4.
 

6.4.5
Pursuant to the requirements set forth in 42 CFR 438.10, the Enrollee Handbook shall include, at a minimum, the following:
 

6.4.5.1
A table of contents;
 

6.4.5.2
An explanation of the purpose of the Enrollee ID Card and a warning that transfer of the card to another person constitutes Fraud;
 

6.4.5.3
Information about the role of the PCP and how to choose a PCP;
 

6.4.5.4
Information about the PMG, how to choose a PMG, and which Benefits may be accessed through the PMG;
 

6.4.5.5
Information about the PPN associated with the Enrollee’s PMG, and the benefits of seeking services within the PPN;
 

6.4.5.6
Information about the circumstances under which Enrollees may change to a different PMG;
 

6.4.5.7
Information about what to do when family size changes, including the responsibility of new mothers who are Medicaid Eligible to register their newborn with the Puerto Rico Medicaid Program and to apply for the Enrollment of the newborn;
 
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6.4.5.8
Appointment procedures;
 

6.4.5.9
Information on the amount, duration and scope of Benefits and Covered Services, including how the scope of Benefits and services differs between Medicaid and CHIP Eligibles and Other Eligible Persons. This must include Information on the EPSDT Benefit and how Enrollees under the age of twenty-one (21) and entitled to the EPSDT Benefit may access component services;
 

6.4.5.10
An explanation of how physical health and Behavioral Health services are integrated under the GHP, and how to access specialized Behavioral Health Services;
 

6.4.5.11
Information on how to access local resources for Non-Emergency Medical Transportation (“NEMT”);
 

6.4.5.12
An explanation of any service limitations or exclusions from coverage, including any restrictions on the Enrollee’s freedom of choice among network Providers;
 

6.4.5.13
Information on where and how Enrollees may access Benefits not available from or not covered by the Contractor’s Plan;
 

6.4.5.14
The Medical Necessity definition used in determining whether services will be covered (see Section 7.2);
 

6.4.5.15
A description of all pre-certification, Prior Authorization, or other requirements for treatments and services;
 

6.4.5.16
The policy on Referrals for specialty care and for other Covered Services not provided by the Enrollee’s PCP;
 

6.4.5.17
Information on how to obtain after-hours coverage;
 

6.4.5.18
An explanation of cost-sharing, including:
 

6.4.5.18.1
The differences in cost-sharing responsibilities between Medicaid- and CHIP Eligibles and Other Eligible Persons, and
 

6.4.5.18.2
The cost-sharing responsibilities of Dual Eligible Beneficiaries, as well as the other information for Dual Eligible Beneficiaries listed in Section 6.13;
 
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6.4.5.19
Notice of all appropriate mailing addresses and telephone numbers to be utilized by Enrollees seeking Information or authorization, including the Contractor’s toll-free telephone line and website address;
 

6.4.5.20
A description of Utilization Management policies and procedures used by the Contractor;
 

6.4.5.21
A description of Enrollee rights and responsibilities as described in Section 6.5;
 

6.4.5.22
The policies and procedures for Disenrollment, including when Disenrollment may be requested without Enrollee consent by the Contractor and Information about Enrollee’s right to request Disenrollment, and including notice of the fact that the Enrollee will lose Access to services under the GHP if the Enrollee chooses to disenroll;
 

6.4.5.23
Information on Advance Directives, including the right of Enrollees to file directly with ASES or with the Puerto Rico Office of the Patient Advocate, Complaints concerning Advance Directive requirements listed in Section 7.10 of this Contract;
 

6.4.5.24
A statement that additional Information, including the Provider Guidelines (see Section 10.2.1 of the Contract) and Information on the structure and operations of the GHP and Physician Incentive Plans, shall be made available to Enrollees and Potential Enrollees upon request;
 

6.4.5.25
Information on the extent to which, and how, after-hours and emergency coverage are provided, including:
 

6.4.5.25.1
What constitutes an Emergency Medical Condition and a Psychiatric Emergency;
 

6.4.5.25.2
The fact that Prior Authorization is not required for Emergency Services;
 

6.4.5.25.3
Notice that:
 

6.4.5.25.3.1
Under no circumstances will a Medicaid or CHIP Enrollee be charged a Co-Payment for the treatment of any Emergency Medical Condition or Psychiatric Emergency;
 

6.4.5.25.3.2
No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years under any circumstances.
 
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6.4.5.25.3.3
For Medicaid or CHIP Enrollees, Co-Payments may apply to non-emergency services provided in an emergency room pursuant to Attachment 8 to this Contract on Cost-Sharing; and
 

6.4.5.25.3.4
For Other Eligible Persons, Co-Payments apply to Emergency Services outside the Enrollee’s PPN, but the Enrollee may avoid a Co-Payment by using the GHP Service Line (see Section 6.8).
 

6.4.5.25.4
The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
 

6.4.5.25.5
The scope of Post-Stabilization Services offered under the GHP as detailed in Section 7.5.9.4;
 

6.4.5.25.6
The locations of emergency rooms and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered under the GHP; and
 

6.4.5.25.7
The fact that an Enrollee has a right to use any hospital or other setting for Emergency Services;
 

6.4.5.26
An explanation of the Redetermination process, including:
 

6.4.5.26.1
Disenrollment as a consequence of a Negative Redetermination Decision; and
 

6.4.5.26.2
The Re-Enrollment period that follows a new Certification.
 

6.4.5.27
Information on the Contractor’s Grievance and Appeal System policies and procedures, as described in Article 14 of this Contract. This description must include the following:
 

6.4.5.27.1
The right to file a Grievance and Appeal with the Contractor;
 

6.4.5.27.2
The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
 

6.4.5.27.3
The availability of assistance in filing a Grievance or Appeal with the Contractor;
 

6.4.5.27.4
The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal with the Contractor by phone;
 

6.4.5.27.5
The right to an Administrative Law Hearing after exhaustion of the Contractor’s Grievance and Appeal System, the method for obtaining a hearing, and the rules that govern representation at the hearing;
 
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6.4.5.27.6
Notice that if the Enrollee files an Appeal or a request for an Administrative Law Hearing and requests continuation of services, the Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee;
 

6.4.5.27.7
Any Appeal rights that ASES chooses to make available to Providers to challenge the failure of the Contractor to cover a service;
 

6.4.5.27.8
Instructions on how an Enrollee can report suspected Fraud, Waste, or Abuse, and protections that are available for whistleblowers;
 

6.4.5.27.9
Information on the family planning services and supplies, including the extent to which, and how, Enrollees may obtain such services or supplies from out-of-network providers, and that an Enrollee cannot be required to obtain a referral before choosing a family planning Provider;
 

6.4.5.27.10
Information on non-coverage of counseling or referral services based on Contractor’s moral or religious objections, as specified in Section 7.13 and how to access these services from ASES; and
 

6.4.5.27.11
Instructions on how to access oral or written translation services, Information in alternative formats, and auxiliary aids and services, as specified in Sections 6.3 and 6.11.
 

6.4.5.28
A description of the model of care for treatment of Enrollees with each HCHN condition.
 

6.4.6
The Enrollee Handbook in both English and Spanish shall be submitted to ASES for review and prior written approval. Submission of the Enrollee Handbook by the Contractor shall be in accordance with the timeframes specified in Attachment 12 to this Contract.
 

6.4.7
The Contractor shall be responsible for producing the Enrollee Handbook in both English and Spanish.
 

6.5
Enrollee Rights and Responsibilities
 

6.5.1
The Contractor shall have written policies and procedures regarding the rights of Enrollees and shall comply with any applicable Federal and Puerto Rico laws and regulations that pertain to Enrollee rights, including those set forth in 42 CFR 438.100, and in the Puerto Rico Patient’s Bill of Rights Act 194 of August 25, 2000; the Puerto Rico Mental Health Law Act 408 of October 2, 2000, as amended and implemented; and Law 77 of July 24, 2013 which created the Office of the Patient Advocate. These rights shall be included in the Enrollee Handbook. At a minimum, the policies and procedures shall specify the Enrollee’s right to:
 
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6.5.1.1
Receive information pursuant to 42 CFR 438.10;
 

6.5.1.2
Be treated with respect and with due consideration for the Enrollee’s dignity and privacy;
 

6.5.1.3
Have all records and medical and personal information remain confidential;
 

6.5.1.4
Receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee’s condition and ability to understand;
 

6.5.1.5
Participate in decisions regarding his or her health care, including the right to refuse treatment;
 

6.5.1.6
Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience, or retaliation, as specified in 42 CFR 482.13(e) and other Federal regulations on the use of restraints and seclusion;
 

6.5.1.7
Request and receive a copy of his or her Medical Records pursuant to 45 CFR Parts 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;
 

6.5.1.8
Choose an Authorized Representative to be involved as appropriate in making care decisions;
 

6.5.1.9
Provide informed consent;
 

6.5.1.10
Be furnished with health care services in accordance with 42 CFR 438.206 through 438.210;
 

6.5.1.11
Freely exercise his or 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 Enrollee is treated;
 

6.5.1.12
Receive Information about Covered Services and how to access Covered Services and Network Providers;
 
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6.5.1.13
Be free from harassment by the Contractor or its Network Providers with respect to contractual disputes between the Contractor and its Providers;
 

6.5.1.14
Participate in understanding physical and Behavioral Health problems and developing mutually agreed-upon treatment goals;
 

6.5.1.15
Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Enrollee for which ASES does not pay the Contractor; not be held liable for Covered Services provided to the Enrollee for which ASES or the Contractor’s Plan does not pay the Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of the amount the Enrollee would owe if the Contractor provided the services directly; and
 

6.5.1.16
Only be responsible for cost-sharing in accordance with 42 CFR 447.50 through 42 CFR 447.56 and as permitted by the Puerto Rico Medicaid and CHIP State Plans and Puerto Rico law as applicable to the Enrollee.
 

6.6
Provider Directory
 

6.6.1
The Contractor shall develop, maintain, and mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9 to all new Enrollees a Provider Directory in a manner reasonably calculated to reach Enrollees within five (5) Calendar Days of sending the notice of Enrollment referenced in Section 5.2.5.3.
 

6.6.1.1
The Contractor is not required to mail a Provider Directory to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided a Provider Directory within the past year. The Contractor is also not required to mail a Provider Directory to new Enrollees under the age of twenty-one (21) if a Provider Directory has been mailed to a member of that Enrollee’s household. However, this exception does not apply to pregnant Enrollees under the age of twenty-one (21).
 

6.6.2
The Contractor shall update the paper Provider Directory once a month, and distribute it to Enrollees upon Enrollee request.
 

6.6.3
The Contractor shall make the Provider Directory available on its website in a machine readable file and format as specified by CMS.
 

6.6.4
The Provider Directory shall include the names, provider group affiliations, locations, office hours, telephone numbers, websites, cultural and linguistic capabilities, completion of Cultural Competency training, and accommodations for people with physical disabilities of current Network Providers. This includes, at a minimum, Information sorted by PCPs; specialists; dentists; FQHCs and RHCs; Behavioral Health Providers/clinics, including detox clinics; pharmacies; hospitals, including locations of emergency settings and Post-Stabilization Services, with the name, location, hours of operation, and telephone number of each facility/setting. The Provider Directory shall also identify all Network Providers that are not accepting new patients. Any subcontractors of ASES, such as the PBM, will collaborate with the Contractor to provide information in a format mutually agreed upon for the generation of the Provider Directory.
 
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6.6.5
The Provider Directory shall include all Network Providers grouped by PMG.
 

6.6.6
The Provider Directory must be indexed alphabetically and by specialty.
 

6.6.7
The Contractor shall submit the Provider Directory to ASES for review and prior written approval in the timeframe specified in Attachment 12 to this Contract.
 

6.6.8
The Contractor shall update and amend the Provider Directory on its website within three (3) Calendar Days of any changes as well as produce and distribute annual updates to all Enrollees. The Contractor shall maintain on its website an updated Provider Directory that includes all identified Information above and that is searchable by Provider type, distance from Enrollee’s address, and/or whether the Network Provider is accepting new patients. Information on how to access this Information shall be clearly stated in both the Enrollee and Provider sections of the website.
 

6.6.9
On a monthly basis, the Contractor shall submit to ASES any changes and edits to the Provider Directory. Such changes shall be submitted electronically in the format specified by ASES.
 

6.7
Enrollee Monthly Utilization Report
 

6.7.1
The Contractor shall send a quarterly utilization report to Enrollees in accordance with Act 114 of July 30, 2010.
 

6.8
Enrollee Identification (ID) Card
 

6.8.1
The Contractor shall furnish to all new Enrollees an Enrollee ID card made of durable plastic material. The card shall be mailed to the Enrollee via surface mail within five (5) Business Days of sending the notice of Enrollment referenced in Section 5.2.5.3.
 

6.8.2
The Enrollee ID Card must, at a minimum, include the following information:
 

6.8.2.1
The “GHP” logo;
 
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6.8.2.2
The Enrollee’s name;
 

6.8.2.3
A designation of the Enrollee as a Medicaid Eligible, a CHIP Eligible, or an Other Eligible Person;
 

6.8.2.4
The Enrollee’s Medicaid or CHIP identification number, if applicable;
 

6.8.2.5
The Enrollee’s Plan group number, when applicable;
 

6.8.2.6
The Effective Date of Enrollment in the GHP;
 

6.8.2.7
The Master Patient Identifier, which shall not be altered in format or content by the Contractor;
 

6.8.2.8
The applicable Co-Payment levels for various services outside the Enrollee’s PPN and the assurance that no Co-Payment will be charged for a Medicaid Eligible Person and for CHIP children under twenty-one (21) years under any circumstances;
 

6.8.2.9
The PCP’s and the PMG’s names;
 

6.8.2.10
The name and telephone number(s) of the Contractor;
 

6.8.2.11
The twenty-four (24) hour, seven (7) day a Week toll-free GHP Service Line Medical Advice Service phone number;
 

6.8.2.12
A notice that the Enrollee ID Card may under no circumstances be used by a person other than the identified Enrollee; and
 

6.8.2.13
Instructions to obtain Emergency Services
 

6.8.3
The Contractor shall reissue the Enrollee ID Card in the following situations and timeframes:
 

6.8.3.1
Within ten (10) Calendar Days of notice if an Enrollee reports a lost, stolen, or damaged ID Card and requests a replacement;
 

6.8.3.2
Within ten (10) Calendar Days of notice if an Enrollee reports a name change;
 

6.8.3.3
Within twenty (20) Calendar Days of the effective date of a change of PMG or change or addition of a PCP, as provided in Section 5.4.
 

6.8.4
The Contractor may charge a fee of five dollars ($5.00) to replace lost, damaged, or stolen Enrollee ID Cards; provided, however, that the Contractor may not charge a replacement fee because of a name change or change of PMG or PCP, and that the Contractor may not charge a replacement fee in any circumstance for Medicaid and CHIP Eligibles.
 
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6.8.5
The Contractor shall submit a front and back sample Enrollee ID Card to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract.
 

6.8.6
The Contractor must require an Enrollee to surrender his or her ID Card in each of the following events:
 

6.8.6.1
The Enrollee disenrolls from the GHP;
 

6.8.6.2
The Enrollee requests a change to his or her PCP or PMG, and is therefore issued a new Enrollee ID Card; or
 

6.8.6.3
The Enrollee requests a new ID card because his or her existing card is damaged.
 

6.9
GHP Service Line (Toll Free Telephone Service)
 

6.9.1
The Contractor shall operate a toll-free telephone number, “GHP Service Line” equipped with caller identification and automatic call distribution equipment capable of handling the high expected volume of calls. The GHP Service Line shall have two components:
 

6.9.1.1
An Information Service to respond to questions, concerns, inquiries, and Complaints regarding the GHP from the Enrollee, Enrollee’s family, or Enrollee’s Authorized Representative; and
 

6.9.1.2
A Medical Advice Service to advise Enrollees about how to resolve non-emergency medical or Behavioral Health concerns.
 

6.9.2
The Contractor shall establish, operate, monitor, and support an automated call distribution system for the GHP Service Line that supports, at a minimum:
 

6.9.2.1
Capacity to handle the high call volume;
 

6.9.2.2
A daily analysis of the quantity, length, and types of calls received;
 

6.9.2.3
A daily analysis of the amount of time it takes to answer the call, including Blocked and Abandoned Calls;
 

6.9.2.4
The ability to measure average waiting time; and
 

6.9.2.5
The ability to monitor calls from a remote location by a Third Party, such as ASES.
 

6.9.3
Hours of Operation
 

6.9.3.1
The Information Service shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. (Atlantic Time). Monday through Friday, excluding Puerto Rico holidays. The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. (Atlantic Time) Monday through Friday and during all hours on weekends and holidays. This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has the required capacity to receive all messages. A Contractor’s representative shall reply to one hundred percent (100%) of messages by the next Business Day.
 
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6.9.3.2
The Medical Advice Service shall be fully staffed and available to Enrollees twenty-four (24) hours per day, seven (7) days per Week.
 

6.9.4
Staffing
 

6.9.4.1
The Contractor shall be responsible for the required staffing of the GHP Service Line with individuals who are able to communicate effectively with GHP Enrollees.
 

6.9.4.2
The Contractor shall make key staff responsible for operating the GHP Service Line available to meet with ASES staff on a regular basis, as requested by ASES, to review reports and all other obligations under the Contract relating to GHP Service Line.
 

6.9.4.3
All staff shall be hired and must complete a training program at least fifteen (15) Calendar Days before the staff provides GHP Service Line services. Such training program shall include, but will not be limited to, systems, policies and procedures, and telephone scripts.
 

6.9.4.4
For the Information Service, the Contractor shall ensure that Call Center attendants receive the necessary training to respond to Enrollee questions, concerns, inquiries, and Complaints from the Enrollee or the Enrollee’s family relating to this Contract regarding topics, including but not limited to Covered Services (both physical and Behavioral Health), Grievances and Appeals, the Provider Network, and Enrollment and Disenrollment.
 

6.9.4.5
For the Medical Advice Service, the Contractor shall ensure that Call Center attendants are registered nurses with the necessary training to advise Enrollees about appropriate steps they should take to resolve a physical or Behavioral Health complaint or concern.
 

6.9.4.6
The Contractor shall ensure that GHP Service Line Call Center staff is trained to identify Behavioral Health concerns and, where appropriate, to transfer Enrollee callers to the appropriate Call Center representative for assistance.
 
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6.9.4.7
The Contractor shall ensure that GHP Service Line Call Center staff is trained to identify situations in which an Enrollee may need services that are offered through the Department of Health rather than through the GHP, and GHP Service Line staff shall provide the Enrollee with Information on where to access these services.
 

6.9.4.8
The Contractor shall ensure that GHP Service Line Call Center staff is trained to provide to Medicaid and CHIP Eligible Enrollees Information on how to access local NEMT resources to enable an Enrollee without available transportation to receive Medically Necessary Services.
 

6.9.4.9
The Contractor shall ensure that GHP Service Line Call Center staff are trained to process and fulfill requests by Enrollees and Potential Enrollees to receive, by surface mail, the Enrollee Handbook, the Provider Directory, or the Provider Guidelines. The Contractor shall fulfill such requests by mailing the requested document within five (5) Business Days of the request.
 

6.9.5
The Contractor may provide the Information Service and the Medical Advice Service as separate phone lines with a “Warm Transfer” capability, or as separate dialing options within one (1) phone line.
 

6.9.6
The Contractor shall have the capability of making out-bound calls.
 

6.9.7
The GHP Service Line shall be equipped to handle calls in Spanish and English, as well as, through a Telecommunication Device for the Deaf (TDD) for calls from Enrollees who are hearing-impaired. For callers who speak neither English nor Spanish, the Contractor shall provide interpreter services free of charge to Enrollees. The Contractor shall not permit Enrollees’ family members, especially minor children, or friends, to provide oral interpreter services, unless specifically requested by the Enrollee.
 

6.9.8
All calls shall be recorded, identifying the date and time, the type of call, the reason for the call, and the resolution of the call.
 

6.9.9
The Contractor shall generate a call identification number for each phone call made by an Enrollee to the Medical Advice Service. Enrollees who use this service to seek advice on their health condition before visiting the emergency room will not be responsible for any Co-Payment otherwise imposed for emergency room visits (as provided under Section 7.11.4) outside the Enrollee’s PPN, provided that the Enrollee presents his or her GHP Service Line call identification number at the emergency room. Under no circumstance will a Co-Payment be imposed on a Medicaid or CHIP Eligible Enrollee for treatment of an Emergency Medical Condition or Psychiatric Emergency (regardless of whether the Enrollee uses the Medical Advice Service). The Medical Advice Service does not apply to emergency services obtained outside of Puerto Rico; however, Enrollees should be able to access both the Medical Advice Service and the Information Service lines from the US.
 
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6.9.10
The Contractor shall develop GHP Service Line policies and procedures, including staffing, training, hours of operation, Access and response standards, transfers/Referrals, monitoring of calls via recording and other means, and compliance with other performance standards to be prior approved in writing by ASES.
 

6.9.11
The Contractor shall develop GHP Service Line quality criteria and protocols. These protocols shall, at a minimum:
 

6.9.11.1
Measure and monitor the accuracy of responses and phone etiquette in GHP Service Line (including through recording phone calls) and take corrective action as necessary to ensure the accuracy of responses and appropriate phone etiquette by staff;
 

6.9.11.2
Provide for quality calibration sessions between the Contractor’s staff and ASES;
 

6.9.11.3
Require that, on a monthly basis, the average speed of answer is at least eighty percent (80%) of calls answered within thirty (30) seconds;
 

6.9.11.4
Require that, on a monthly basis, the Blocked Call rate does not exceed three percent (3%); and
 

6.9.11.5
Require that, on a monthly basis, the rate of Abandoned Calls does not exceed five percent (5%).
 

6.9.12
The above standards serve as minimum requirements for each GHP Service Line service. The Contractor may elect to establish more rigorous performance standards. The Contractor may elect to establish different quality criteria for the Medical Advice Service than for the Information Service; provided, however, the standards governing the Medical Advice Service are stricter than the standards for the Information Service.
 

6.9.13
The Contractor must develop and implement a GHP Service Line Outreach Program to educate Enrollees about the GHP Service Line service and to encourage its use. The Outreach program shall include, at a minimum, the following components:
 

6.9.13.1
A section on GHP Service Line in the Enrollee Handbook;
 

6.9.13.2
Contact information for GHP Service Line on the Enrollee ID Card and on the Contractor’s website; and
 
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6.9.13.3
Informational flyers on the GHP Service Line to be placed in the offices of the Contractor and the Network Providers.
 

6.9.14
All documents and communication materials included in this Outreach program must explain that (i) by using the Medical Advice Service before visiting the emergency room, and presenting their call identification number at the emergency room, Enrollees can avoid any emergency room Co-Payments otherwise applicable under Section 7.11.4 of this Contract for services outside the PPN; and (ii) in no event will Co-Payments be imposed for services to treat an Emergency Medical Condition or Psychiatric Emergency for Medicaid or CHIP Eligibles. All written materials included in the Outreach Program must be written at a fourth (4th) grade reading level and must be available in Spanish and English.
 

6.9.15
The Contractor shall prepare scripts addressing the questions expected to arise most often for both the Information Service and the Medical Advice Service. The Contractor shall submit these scripts to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract. It is the responsibility of the Contractor to maintain and update these scripts and to ensure that they are developed at the fourth (4th) grade reading level. The Contractor shall submit revisions to the script to ASES for written approval prior to use.
 

6.9.16
The Contractor shall submit the following written materials referred to in this Section 6.8 to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract:
 

6.9.16.1
GHP Service Line policies and procedures;
 

6.9.16.2
GHP Service Line quality criteria and protocols;
 

6.9.16.3
GHP Service Line Outreach Program; and
 

6.9.16.4
Scripts and training materials for GHP Service Line Call Center employees.
 

6.10
Internet Presence/Website
 

6.10.1
The Contractor shall provide on its website general and up-to-date information about the GHP and about the Contractor’s Plan, including the Provider Network, customer services, GHP Service Line, and its Grievance and Appeal System. The Enrollee Handbook and the Provider Directory shall be available on the website. All information must be written at a fourth (4th) grade level and must be available in Spanish and English.
 

6.10.2
The Contractor shall maintain an Enrollee portal that allows Enrollees to access a searchable Provider Directory that shall be updated within three (3) Business Days of any change to the Provider Network.
 
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6.10.3
The website must have the capability for Enrollees to submit questions and comments to the Contractor and receive responses. The Contractor shall reply to Enrollee questions within two (2) Business Days.
 

6.10.4
The website must comply with the Marketing policies and procedures and with requirements for written materials described in Sections 6.2 and 6.3 of this Contract and must be consistent with applicable Puerto Rico and Federal laws.
 

6.10.5
The Contractor shall submit website screenshots, active website URLs, and provide ASES access to website development portals upon request, for review and approval of information on the website relating to the GHP Program according to the timeframe specified in Attachment 12 to this Contract.
 

6.10.6
The Contractor’s website shall provide secured online access to the Enrollee’s historical and current information.
 

6.10.7
The Contractor’s website shall prominently feature a link to the ASES website, www.ases.pr.gov.
 

6.10.8
Any Enrollee Information required under 42 CFR 438.10, including the Enrollee Handbook, Provider Directory, FMC and LME, and Enrollee notices, may not be provided electronically or on the Contractor’s website unless such Information (1) is readily accessible, (2) is placed on the Contractor’s website in a prominent location, (3) is provided in a form that can be electronically retained and printed, and (4) includes notice to the Enrollee that the Information is available in paper form without charge and can be provided upon request within five (5) Business Days.
 

6.10.9
The Enrollee Handbook, Provider Directory, FMC and LME may be provided electronically instead of paper form if all required elements of Section 6.10.8 are satisfied. However, the Contractor must provide the Enrollee Handbook, Provider Directory, and FMC and LME in paper form upon request by the Enrollee at no charge and within five (5) Business Days. If the Enrollee Handbook is provided by e-mail, the Contractor must first obtain the Enrollee’s agreement to receive the Enrollee Handbook by e-mail. If the Enrollee Handbook is posted on the Contractor’s website, the Contractor must first advise the Enrollee in paper or electronic form that the information is available on the internet, and must include the applicable website address, provided that Enrollees with disabilities who cannot access this information online are provided auxiliary aids and services upon request and at no cost.
 

6.11
Cultural Competency
 

6.11.1
In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Enrollees. The Cultural Competency plan must describe how the Providers, individuals, and systems within the Contractor’s Plan will effectively provide services to people of all diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation, gender identity, or religion in a manner that recognizes values, affirms, and respects the worth of the individual Enrollees and protects and preserves the dignity of each individual.
 
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6.11.2
The Contractor shall submit the Cultural Competency plan to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.
 

6.11.3
The Contractor may distribute a summary of the Cultural Competency plan, rather than the entire document, to Providers if the summary includes Information on how the Provider may access the full Cultural Competency plan on the Contractor’s website. This summary shall also detail how the Provider can request a hard copy from the Contractor at no charge to the Provider.
 

6.12
Interpreter Services
 

6.12.1
The Contractor shall provide oral interpreter services to any Enrollee or Potential Enrollee who speaks any language other than English or Spanish as his or her primary language, regardless of whether the Enrollee or Potential Enrollee speaks a language that meets the threshold of a Prevalent Non-English Language. This also includes the use of auxiliary aids and services such as TTY/TDD and the use of American Sign Language. The Contractor is required to notify its Enrollees of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to an Enrollee or Potential Enrollee for interpreter services or other auxiliary aids.
 

6.13
Enrollment Outreach
 

6.13.1
The Contractor shall participate in any Enrollment Outreach activities as prescribed by ASES or the Puerto Rico Medicaid Program.
 

6.14
Special Enrollee Information Requirements for Dual Eligible Beneficiaries
 

6.14.1
The Contractor shall inform a Potential Enrollee who is a Dual Eligible Beneficiary:
 

6.14.1.1
That the Dual Eligible Beneficiary is eligible for services under the GHP with the limits stated in Section 7.12 of this Contract;
 

6.14.1.2
That the GHP Plan will cover Medicare Part B Deductibles and co-insurance subject to the requirements in Section 23.5.1, but not Medicare Part A Deductibles;
 

6.14.1.3
That the Dual Eligible Beneficiary may not be simultaneously enrolled in the GHP and in a Medicare Platino plan, for the reason that the Platino plan already includes GHP Benefits; and
 
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6.14.1.4
That as an Enrollee in the Contractor’s Plan, the Dual Eligible Beneficiary may access Covered Services only through the PMG, not through the Medicare Provider List.
 

6.15
Marketing
 

6.15.1
For purposes of this section only, “Contractor” shall also include Contractor’s Subcontractors and Network Providers to the extent that such Subcontractors and Network Providers are conducting Marketing activities.
 

6.15.2
Prohibited Activities. The Contractor is prohibited from engaging in the following activities:
 

6.15.2.1
Directly or indirectly engaging in door-to-door, telephone, e-mail, texting or other Cold-Call Marketing activities;
 

6.15.2.2
Offering any favors, inducements or gifts, promotions, or other insurance products that are designed to induce Enrollment in the Contractor’s Plan;
 

6.15.2.3
Distributing plans and materials that contain statements that ASES determines are inaccurate, false, or misleading. Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the Contractor’s Plan is endorsed by the Federal Government or Government, or similar entity;
 

6.15.2.4
Distributing materials that, according to ASES, mislead or falsely describe the Contractor’s Provider Network, the participation or availability of Network Providers, the qualifications and skills of Network Providers (including their bilingual skills); or the hours and location of network services;
 

6.15.2.5
Seeking to influence Enrollment in conjunction with the sale or offering of any private insurance; and
 

6.15.2.6
Asserting or stating in writing or verbally that the Enrollee or Potential Enrollee must enroll in the Contractor’s Plan to obtain or retain Benefits.
 

6.15.2.7
Marketing Contractor’s Plan to Enrollees or Potential Enrollees prior to October 1, 2018.
 

6.15.3
Allowable Activities. The Contractor shall be permitted to perform the following Marketing activities:
 
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6.15.3.1
Distribute general information through mass media (i.e., newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);
 

6.15.3.2
Make telephone calls, mailings and home visits only to Enrollees currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor;
 

6.15.3.3
Distribute brochures and display posters at Provider offices that inform patients that the Provider is part of the GHP Provider Network; and
 

6.15.3.4
Attend activities that benefit the entire community, such as health fairs or other health education and promotional activities.
 

6.15.4
If the Contractor performs an allowable activity, the Contractor must conduct that activity Island-wide.
 

6.15.5
All materials shall be in compliance with the informational requirements in 42 CFR 438.10.
 

6.15.6
ASES Approval of Marketing Materials
 

6.15.6.1
The Contractor shall submit a detailed description of its Marketing plan and copies of all Marketing Materials (written and oral) that it or its Subcontractors plan to distribute to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract. This requirement includes, but is not limited to posters, brochures, websites, and any materials that contain statements regarding the Benefit package and Provider Network-related materials. Neither the Contractor nor its Subcontractors shall distribute any Marketing Materials without prior written approval from ASES.
 

6.15.6.1.1
The Contractor may begin Marketing activities using the materials and marketing plan approved by ASES beginning on October 1, 2018.
 

6.15.6.2
The Contractor may not initiate Marketing or distribute Marketing Materials of its GHP Plan until ASES has granted its written authorization for all Contractors to initiate Marketing at the same time.
 

6.15.6.3
The Contractor shall submit any changes to previously approved Marketing Materials and receive written approval from ASES of the changes before distribution.
 
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6.15.6.4
The Contractor must comply with ASES’ Normative Letter 18-0807, and any superseding Normative Letters, related to the review and approval of the Contractors Marketing Materials included in Attachment 13 to this Contract.
 

6.15.7
Provider Marketing Materials
 

6.15.7.1
The Contractor is responsible for ensuring that not only its Marketing activities, but also the Marketing activities of its Subcontractors and Providers, meet the requirements of this Section 6.14.
 

6.15.7.2
The Contractor shall collect from its Providers any Marketing Materials they intend to distribute and submit these to ASES for review and written approval prior to distribution.
 

6.15.7.3
The Contractor shall provide for equitable distribution of all Marketing Materials without bias toward or against any group.

ARTICLE 7
COVERED SERVICES AND BENEFITS
 

7.1
Requirement to Provide Covered Services
 

7.1.1
The Contractor shall at a minimum provide Medically Necessary Covered Services to Enrollees as of the Effective Date of Enrollment (including the retroactive period specified in Section 5.1.3.1) pursuant to the program requirements of the GHP, and the Puerto Rico Medicaid State Plan and CHIP Plan. The Contractor shall not impose any other exclusions, limitations, or restrictions on any Covered Service, and shall not arbitrarily deny or reduce the amount, duration, or scope of a Covered Service solely because of the diagnosis, type of illness, or condition.
 

7.1.1.1
In accordance with Section 2702 of the PPACA and 42 CFR 438.3(g), the Contractor must have mechanisms in place to prevent payment for the following Provider preventable conditions and must require all providers to report on such Provider preventable conditions associated with Claims for payment or Enrollee treatments for which payment would otherwise be made. The Contractor must report all identified Provider preventable conditions to ASES as follows:
 

7.1.1.1.1
All hospital acquired conditions as identified by Medicare other than deep vein thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients for inpatient hospital services; and
 
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7.1.1.1.2
Any incorrect surgical or other invasive procedure performed on a patient; any surgical or other invasive procedure performed on the incorrect body part; or any surgical or other invasive procedure performed on the incorrect patient for inpatient and non-institutional services.
 

7.1.2
The Contractor shall not deny Covered Services based on pre-existing conditions, the individual’s genetic Information, or waiting periods.
 

7.1.3
The Contractor shall not be required to provide a Covered Service to a person who is not an Eligible Person.
 

7.1.4
The Contractor shall not be required to pay for a Covered Service if:
 

7.1.4.1
The Enrollee paid the Provider for the service. This rule does not apply in circumstances where a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the other USA jurisdictions. In such a case, the expenses will be reimbursed under the GHP; or
 

7.1.4.2
The service was provided by a person or entity that does not meet the definition of a Network Provider (with the exception of Medical Emergencies and cases where the service was Prior Authorized by the Contractor).
 

7.1.5
The Contractor shall make a best effort to conduct an initial screening of each Enrollee within ninety (90) days of the Effective Date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful.
 

7.2
Medical Necessity
 

7.2.1
Based on generally accepted medical practices specific to the medical or Behavioral Health condition of the Enrollee at the time of treatment, Medically Necessary Services are those that relate to (i) the prevention, diagnosis, and treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional capacity. The scope of Medically Necessary Services must not be any more restrictive than that of Puerto Rico’s Medicaid program. Additionally, Medically Necessary services must be:
 

7.2.1.1
Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Enrollee’s medical condition;
 

7.2.1.2
Compatible with the standards of acceptable medical practice in the medical community;
 
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7.2.1.3
Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;
 

7.2.1.4
Not provided solely for the convenience of the Enrollee or the convenience of the Provider or hospital; and
 

7.2.1.5
Not primarily custodial care (for example, foster care).
 

7.2.2
In order for a service to be Medically Necessary, there must be no other effective and more conservative or substantially less costly treatment, service, or setting available.
 

7.3
Experimental or Cosmetic Procedures
 

7.3.1
In no instance shall the Contractor cover experimental or cosmetic procedures, except as required by the Puerto Rico Patient’s Bill of Rights Act or any other Federal or Puerto Rico law or regulation. Breast reconstruction after a mastectomy and surgical procedures that are determined to be Medically Necessary to treat morbid obesity shall not be regarded as cosmetic procedures.
 

7.4
Covered Services and Administrative Functions
 

7.4.1
Benefits under the GHP are comprised of four categories: (i) Basic and Behavioral Health Coverage, (ii) dental services, (iii) Special Coverage, (iv) High Cost High Needs Program, and (v) Administrative Functions. The scope of these items is covered in Sections 7.5 – 7.8, in the order listed.
 

7.4.2
The Contractor may cover services or settings that are in lieu of those covered under the State plan if ASES has approved the in lieu of service or setting as a medically appropriate and cost effective substitute. If approved by ASES, the Contractor may offer the in lieu of service or setting to Enrollees, as appropriate, but shall not require an Enrollee to use an in lieu of service or setting. The utilization and actual cost of approved in lieu of services or settings will be taken into account in developing the component of the PMPM Payment that represents the covered Medicaid State Plan services or settings, unless a statute or regulation explicitly requires otherwise. Approved in lieu of services or settings will be communicated to Contractors via a Normative Letter or other standard method of communication of formal GHP policy.
 

7.5
Basic and Behavioral Health Coverage
 

7.5.1
Basic and Behavioral Health Coverage is available to all GHP Enrollees, except as provided in the table below. Basic Coverage includes the following categories:

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BASIC COVERAGE
SERVICES
 
GHP ELIGIBILITY
GROUPS COVERED
 
Preventive Services
 
All
 
Diagnostic Test Services
 
All
 
Outpatient Rehabilitation Services
 
All
 
Medical and Surgical Services
 
All
 
Emergency Transportation Services
 
All (Services outside Puerto Rico available only for Medicaid and CHIP Eligibles)
 
Maternity and Pre-Natal Services
 
All
 
Emergency Services
 
All (Services outside Puerto Rico available only for Medicaid and CHIP Eligibles)
 
Hospitalization Services
 
All
 
Behavioral Health Services
 
All
 
Pharmacy Services
 
All (Note: Claims processing and adjudication Services provided by PBM; not covered under this Contract.)
 

7.5.2
Exclusions from Basic Coverage
 

7.5.2.1
The following services are excluded from all Basic Coverage. In addition, exclusions specific to each category of Covered Services are noted in Sections 7.5.3 – 7.5.12 below.
 

7.5.2.1.1
Expenses for personal comfort materials or services, such as, telephone use, television, or toiletries;
 

7.5.2.1.2
Services rendered by close family relatives (parents, children, siblings, grandparents, grandchildren, or spouses);
 

7.5.2.1.3
Weight control treatment (obesity or weight gain) for aesthetic reasons. As noted, procedures determined to be Medically Necessary to address morbid obesity shall not be excluded;
 

7.5.2.1.4
Sports medicine, music therapy, and natural medicine;
 

7.5.2.1.5
Services, diagnostic testing, or treatment ordered or rendered by naturopaths, naturists, or iridologists;
 

7.5.2.1.6
Health Certificates, except as provided in Section 7.5.3.2.10 (Preventive Services);
 
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7.5.2.1.7
Epidural anesthesia services;
 

7.5.2.1.8
Educational tests or services;
 

7.5.2.1.9
Peritoneal dialysis or hemodialysis services (covered under Special Coverage, not Basic Coverage);
 

7.5.2.1.10
Home Health and Hospice care for Adults;
 

7.5.2.1.11
Services received outside the territorial limits of Puerto Rico, except as provided in Sections 7.5.7.11 (Emergency Transportation) and 7.5.9.3 (Emergency Services);
 

7.5.2.1.12
Expenses incurred for the treatment of conditions resulting from services not covered under the GHP (maintenance prescriptions and required clinical laboratories for the continuity of a stable health condition, as well as any emergencies which could alter the effects of the previous procedure, are covered);
 

7.5.2.1.13
Judicially ordered evaluations for legal purposes;
 

7.5.2.1.14
Travel expenses, even when ordered by the Primary Care Physician;
 

7.5.2.1.15
Psychological, psychometric, and psychiatric tests and evaluations to obtain employment or insurance, or for purposes of litigation;
 

7.5.2.1.16
Eyeglasses, contact lenses and hearing aids for Adults;
 

7.5.2.1.17
Acupuncture services;
 

7.5.2.1.18
Sex change procedures;
 

7.5.2.1.19
Organ and tissue transplants, except skin, bone and corneal transplants.; and
 

7.5.2.1.20
Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate.
 

7.5.2.1.21
Mechanical respirators and ventilators with oxygen supplies are covered without limits as required by local law to Enrollees under age twenty-one (21). The Contractor must cooperate with ASES and DOH to provide any necessary information as directed by ASES. All Durable Medical Equipment (DME) is not covered; however, DME may be covered on a case-by-case basis under an exceptions process.
 
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7.5.3
Preventive Services
 

7.5.3.1
Well Baby Care. The Contractor shall provide the following Preventive Services as Covered Services under the Well Baby Care Program:
 

7.5.3.1.1
One (1) annual comprehensive evaluation by a certified Provider, which complements other services for children and young adults provided pursuant to the periodicity scheme of the American Academy of Pediatrics and Title XIX (EPSDT); and
 

7.5.3.1.2
Other services, as needed.
 

7.5.3.2
Other Preventive Services. The Contractor shall provide the following Preventive Services as Covered Services for all GHP Enrollees:
 

7.5.3.2.1
All immunizations shall be provided for Pediatric Enrollees, and those necessary according to age, gender, and health condition of the Enrollee, including but not limited to: influenza and pneumonia, and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes and heart disease, among others.
 

7.5.3.2.1.1
The Puerto Rico Department of Health shall provide and pay for vaccines to Enrollees ages zero (0) and eighteen (18), excluding those in the State Population, through the Children’s Immunization Program. The Contractor shall cover the administration of the vaccines provided by the Puerto Rico Department of Health.
 

7.5.3.2.1.2
The Contractor shall provide and pay for the immunizations of Enrollees in the State Population ages zero (0) and eighteen (18), all Enrollees ages nineteen (19) to twenty (20), and those necessary according to age, gender and health condition of the Enrollee, including but not limited to influenza and pneumonia vaccines for Enrollees over sixty-five (65) years and adults with high risk conditions such as pulmonary, renal, diabetes, and heart disease, among others.
 
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7.5.3.2.1.3
The Contractor shall cover the administration of all the vaccines according to the fee schedule established by the Puerto Rico Health Department. The Contractor shall contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide immunization services.
 

7.5.3.2.1.4
The Contractor shall administer the immunizations without any charge or deductible.
 

7.5.3.2.2
Hearing exam, including hearing screening for newborns prior to their leaving the hospital nursery;
 

7.5.3.2.3
Evaluation and nutritional screening;
 

7.5.3.2.4
Medically Necessary laboratory exams and diagnostic tests, appropriate to the Enrollee’s age, sex, and health condition, including, but not limited to:
 

7.5.3.2.4.1
Prostate and gynecological cancer screening according to accepted medical practice, including Pap smears (for Enrollees over age eighteen (18)), mammograms (for Enrollees age forty (40) and over), and Prostate-Specific Antigen (PSA) tests when Medically Necessary; and
 

7.5.3.2.4.2
Sigmoidoscopy and colonoscopy for colon cancer detection in Adults age fifty (50) years and over, classified in risk groups according to accepted medical practice;
 

7.5.3.2.5
Nutritional, oral, and physical health education;
 

7.5.3.2.6
Reproductive health counseling and family planning. Enrollees shall be free to choose the method of family planning in accordance with 42 CFR 438.210(a)(4)(ii)(C). The Contractor shall cover the following family planning services:
 

7.5.3.2.6.1
Education and Counseling;
 

7.5.3.2.6.2
Pregnancy testing;
 

7.5.3.2.6.3
Infertility assessments;
 
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7.5.3.2.6.4
Sterilization services in accordance with 42 CFR 441.200, subpart F.
 

7.5.3.2.6.5
Laboratory services;
 

7.5.3.2.6.6
At least one of every class and category of FDA-approved contraceptive method as specified by ASES’s Normative Letter 15-1012 (Attachment 13);
 

7.5.3.2.6.7
At least one of every class of FDA-approved contraceptive medication as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);
 

7.5.3.2.6.8
Cost and insertion removal of non-oral products, such as long acting reversible contraceptives (LARC) as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract); and
 

7.5.3.2.6.9
Other FDA-approved contraceptive medications or methods not covered by sections 7.5.3.2.6.6 or 7.5.3.2.6.7 of the Contract, when it is Medically Necessary and approved through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations:
 

7.5.3.2.6.9.1
Contra-indication with drugs that are in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that the Enrollee is already taking, and no other methods available in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that can be used by the Enrollee;
 

7.5.3.2.6.9.2
History of adverse reaction by the Enrollee to the contraceptive methods covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);
 

7.5.3.2.6.9.3
History of adverse reaction by the Enrollee to the contraceptive medications covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);
 
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7.5.3.2.7
Syringes for home medicine administration, if deemed Medically Necessary;
 

7.5.3.2.8
Annual physical exam and follow-up for diabetic patients according to the Diabetic Patient Treatment Guide and Health Department protocols; and
 

7.5.3.2.9
Health Certificates are covered under the GHP, provided that cost sharing and/or deductibles applicable for necessary procedures and laboratory testing related to generating a Health Certificate will be the Enrollee’s responsibility. Such certificates shall include:
 

7.5.3.2.9.1
Venereal Disease Research Laboratory (“VDRL”) tests;
 

7.5.3.2.9.2
Tuberculosis (“TB”) tests; and
 

7.5.3.2.9.3
Any Certification for GHP Enrollees related to eligibility for the Medicaid Program (provided at no charge).
 

7.5.4
Diagnostic Test Services
 

7.5.4.1
The Contractor shall provide the following diagnostic test services as Covered Services:
 

7.5.4.1.1
Diagnostic and testing services for Enrollees under age twenty-one (21) required by EPSDT, as defined in Section 1905(r) of the Social Security Act;
 

7.5.4.1.2
Clinical labs, including but not limited to, any laboratory order for disease diagnostic purposes, even if the final diagnosis is a condition or disease whose treatment is not a Covered Service;
 

7.5.4.1.3
Hi-tech Labs;
 

7.5.4.1.4
X-Rays;
 

7.5.4.1.5
Electrocardiograms;
 

7.5.4.1.6
Radiation therapy (Prior Authorization required);
 

7.5.4.1.7
Pathology;
 
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7.5.4.1.8
Arterial gases and Pulmonary Function Test;
 

7.5.4.1.9
Electroencephalograms;
 

7.5.4.1.10
Diagnostic services for Enrollees who present learning disorder symptoms; and
 

7.5.4.1.11
Services related to a diagnostic code included in the Diagnostic and Statistical Manual of Mental Disorders (“DSM IV or DSM V”).
 

7.5.4.2
The following shall not be considered diagnostic test services covered under the GHP:
 

7.5.4.2.1
Polysomnography studies; and
 

7.5.4.2.2
Clinical labs processed outside of Puerto Rico.
 

7.5.5
Outpatient Rehabilitation Services
 

7.5.5.1
The Contractor shall provide the following outpatient rehabilitation services as Covered Services:
 

7.5.5.1.1
Medically Necessary outpatient rehabilitation services for Enrollees under age twenty-one (21), as required by EPSDT, Section 1905(r) of the Social Security Act;
 

7.5.5.1.2
Physical therapy (limited to a maximum of fifteen (15) treatments per Enrollee condition per year, unless Prior Authorization of an additional fifteen (15) treatments is indicated by an orthopedist or physiatrist or chiropractor);
 

7.5.5.1.3
Occupational therapy, without limitations; and
 

7.5.5.1.4
Speech therapy, without limitations.
 

7.5.6
Medical and Surgical Services
 

7.5.6.1
The Contractor shall provide the following medical and surgical services as Covered Services:
 

7.5.6.1.1
Early and Periodic Screening, Diagnostic and Treatment (“EPSDT”) services, as defined in Section 1905(r) of the Social Security Act;
 

7.5.6.1.2
Primary Care Physician visits, including nursing services;
 

7.5.6.1.3
Specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN;
 
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7.5.6.1.4
Sub-specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN;
 

7.5.6.1.5
Physician home visits when Medically Necessary;
 

7.5.6.1.6
Respiratory therapy, without limitations;
 

7.5.6.1.7
Anesthesia services (except for epidural anesthesia);
 

7.5.6.1.8
Radiology services;
 

7.5.6.1.9
Pathology services;
 

7.5.6.1.10
Surgery;
 

7.5.6.1.11
Outpatient surgery facility services;
 

7.5.6.1.12
Nursing services;
 

7.5.6.1.13
Voluntary sterilization of men and women of legal age and sound mind, provided that they have been previously informed about the medical procedure’s implications, and that there is evidence of Enrollee’s written consent by completing the Sterilization Consent Form included as Attachment 22 to this Contract;
 

7.5.6.1.14
Prosthetics, including the supply of all extremities of the human body including therapeutic ocular prosthetics, segmental instrument tray, and spine fusion in scoliosis and vertebral surgery;
 

7.5.6.1.15
Ostomy equipment for outpatient-level ostomized patients;
 

7.5.6.1.16
Transfusion of blood and blood plasma services, without limitations, including the following:
 

7.5.6.1.16.1
Antihemophilic recombinant factor VIII;
 

7.5.6.1.16.2
Antihemophilic recombinant factor IX;
 

7.5.6.1.16.3
Anti-inhibitor coagulant complex (Feiba); and
 

7.5.6.1.16.4
Antihemophilic factor VIII, human/Von Willebrand factor complex.
 

7.5.6.1.17
Services to patients with Level 1 or Level 2 of chronic renal disease (Levels 3 to 5 are included in Special Coverage in Section 7.7).
 
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7.5.6.1.17.1
Chronic renal disease Levels 1 and 2 are defined as follows:
 

7.5.6.1.17.1.1
Level 1. GFR (Glomerular Filtration – ml/min. per 1.73m² per corporal area surface) over 90; slight damage when protein is present in the urine.
 

7.5.6.1.17.1.2
Level 2. GFR between 60 and 89, a slight decrease in kidney function.
 

7.5.6.1.17.2
When GFR decreases to under 60 ml/min per 1.73 m², the Enrollee must be referred to a nephrologist for proper management. The Enrollee will be registered for Special Coverage.
 

7.5.6.1.18
Skin, bone and corneal transplants.
 

7.5.6.2
While cosmetic procedures shall be excluded from Covered Services, breast reconstruction after a mastectomy and surgical procedures Medically Necessary to treat morbid obesity shall not be considered to be cosmetic procedures.
 

7.5.6.3
Mechanical respirators and ventilators with oxygen supplies are covered without limits as required by local law to Enrollees under age twenty-one (21). All Durable Medical Equipment (DME) is not covered; however, DME may be covered on a case-by-case basis under an exceptions process.
 

7.5.6.4
Abortions are covered in the following instances: (i) life of the mother would be in danger if the fetus is carried to term; (ii) when the pregnancy is a result of rape or incest; and (iii) severe and long lasting damage would be caused to the mother if the pregnancy is carried to term, as certified by a physician.
 

7.5.7
Emergency Transportation Services
 

7.5.7.1
The Contractor shall provide Emergency Transportation Services, including but not limited to, maritime and ground transportation, in emergency situations as Covered Services.
 

7.5.7.2
Emergency transportation services shall be available twenty-four (24) hours a day, seven (7) days per Week throughout Puerto Rico.
 

7.5.7.3
Emergency transportation services do not require Prior Authorization.
 
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7.5.7.4
The Contractor shall ensure that adequate emergency transportation is available to transport any Enrollees experiencing an Emergency Medical Conditions or a Psychiatric Emergency, or whose conditions require emergency transportation because of their geographical location.
 

7.5.7.5
The Contractor may not impose limits on what constitutes an Emergency Medical Condition or a Psychiatric Emergency on the basis of lists of diagnoses or symptoms.
 

7.5.7.6
Aerial emergency transportation services are provided and paid for by the Government of Puerto Rico under a separate contract. The Contractor shall coordinate the provision of aerial emergency transportation on behalf of its Enrollees when Medically Necessary utilizing the Provider designated by the Government of Puerto Rico.
 

7.5.7.7
The Contractor shall bear the expenses of providing emergency transportation and shall adhere to Puerto Rico laws and regulations concerning emergency transportation, including applicable fees as established by the Public Service Commission of the Government of Puerto Rico (CSP for its acronym in Spanish).
 

7.5.7.8
The Contractor shall provide Category II and Category III Ambulance Services pursuant to Regulation No. 6737 of the Public Service Commission.
 

7.5.7.8.1
Category II Ambulances are Ambulances utilized for the transportation of ill, injured, hurt, and disabled patients equipped with the specifications set by the Department of Heath of Puerto Rico. Fees paid for Type III ambulances are set by Provision 57.37 of the Public Service Commission.
 

7.5.7.8.2
Category III Ambulances must comply with all the requirements of Category II Ambulances, have advanced stabilization equipment and are specially designed and equipped as established from time to time by the Ambulance Certification Office of the Department of Health of Puerto Rico.
 

7.5.7.9
The Contractor may not retroactively deny a Claim for emergency transportation services because the Enrollee’s condition, which at the time of service appeared to be an Emergency Medical Condition or a Psychiatric Emergency under the prudent layperson standard, was ultimately determined to be a non-emergency.
 

7.5.7.10
In any case in which an Enrollee is transported by ambulance to a facility that is not a Network Provider, and, after being stabilized, is transported by ambulance to a facility that is a Network Provider, all emergency transportation costs, provided that they are justified by prudent layperson standards, will be borne by the Contractor.
 
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7.5.7.11
The Contractor shall be responsible for timely payment for emergency transportation services in the other USA jurisdictions for Enrollees who are Medicaid or CHIP Eligibles, if the emergency transportation is associated with an Emergency Service in the other USA jurisdictions covered under Section 7.5.9.3.1.2 of this Contract. If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for emergency transportation services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be considered a Covered Service.
 

7.5.7.12
Emergency transportation services will be subject to periodic reviews and/or audits by applicable governmental agencies and ASES to ensure quality of services.
 

7.5.8
Maternity and Pre-Natal Services
 

7.5.8.1
The Contractor shall provide the following maternity and pre-natal services as Covered Services:
 

7.5.8.1.1
Pregnancy testing;
 

7.5.8.1.2
Medical services, during pregnancy and post-partum;
 

7.5.8.1.3
Physician and nurse obstetrical services during vaginal and caesarean section deliveries, and services to address any complication that arises during the delivery;
 

7.5.8.1.4
Treatment of conditions attributable to the pregnancy or delivery, when medically recommended;
 

7.5.8.1.5
Hospitalization for a period of at least forty-eight (48) hours in cases of vaginal delivery, and at least ninety-six hours (96) in cases of caesarean section;
 

7.5.8.1.6
Anesthesia, excluding epidural;
 

7.5.8.1.7
Incubator use, without limitations;
 

7.5.8.1.8
Fetal monitoring services, during hospitalization only;
 

7.5.8.1.9
Nursery room routine care for newborns;
 

7.5.8.1.10
Circumcision and dilatation services for newborns;
 
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7.5.8.1.11
Transportation of newborns to tertiary facilities when necessary;
 

7.5.8.1.12
Pediatrician assistance during delivery; and
 

7.5.8.1.13
Delivery services provided in free-standing birth centers.
 

7.5.8.2
The following are excluded from maternity and pre-natal Covered Services:
 

7.5.8.2.1
Outpatient use of fetal monitor;
 

7.5.8.2.2
Treatment services for infertility and/or related to conception by artificial means;
 

7.5.8.2.3
Services, treatments, or hospitalizations as a result of a provoked non-therapeutic abortion or associated complications are not covered. The following are considered to be provoked abortions:
 

7.5.8.2.3.1
Dilatation and curettage (CPT Code 59840);
 

7.5.8.2.3.2
Dilatation and expulsion (CPT Code 59841);
 

7.5.8.2.3.3
Intra-amniotic injection (CPT Codes 59850, 59851, 59852);
 

7.5.8.2.3.4
One or more vaginal suppositories (e.g., Prostaglandin) with or without cervical dilatation (e.g., Laminar), including hospital admission and visits, fetus birth, and secundines (CPT Code 59855);
 

7.5.8.2.3.5
One or more vaginal suppositories (e.g., Prostaglandin) with dilatation and curettage/or evacuation (CPT Code 59856); and
 

7.5.8.2.3.6
One or more vaginal suppositories (e.g., Prostaglandin) with hysterectomy (omitted medical expulsion) (CPT Code 59857); and
 

7.5.8.2.4
Differential diagnostic interventions up to the confirmation of pregnancy are not covered. Any procedure after the confirmation of pregnancy will be at the Contractor’s own risk.
 

7.5.8.3
The Contractor shall implement a pre-natal and maternal program, aimed at preventing complications during and after pregnancy, and advancing the objective of lowering the incidence of low birth weight and premature deliveries.
 
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7.5.8.3.1
The program shall include, at a minimum, the following components:
 

7.5.8.3.1.1
A pre-natal care card, used to document services utilized;
 

7.5.8.3.1.2
Counseling regarding HIV testing;
 

7.5.8.3.1.3
Pregnancy testing;
 

7.5.8.3.1.4
A RhoGAM injection for all pregnant women who have a negative Rhesus (“Rh”) factor according to the established protocol;
 

7.5.8.3.1.5
Alcohol screening of pregnant women with the 4P-Plus instrument;
 

7.5.8.3.1.6
Smoking cessation counseling and treatment;
 

7.5.8.3.1.7
Post-partum depression screening using the Edinburgh post-natal depression scale;
 

7.5.8.3.1.8
Post-partum counseling and Referral to the WIC program;
 

7.5.8.3.1.9
Dental evaluation during the second trimester of gestation; and
 

7.5.8.3.1.10
Educational workshops regarding pre-natal care topics (importance of pre-natal medical visits and post-partum care), breast-feeding, stages of childbirth, oral and Behavioral Health, family planning, and newborn care, among others.
 

7.5.8.3.2
The Contractor shall ensure that eighty-five percent (85%) of pregnant Enrollees receive services under the Pre-Natal and Maternal Program. The Contractor shall submit its pre-natal and Maternal Program maternal wellness plan to ASES according to the timeframe specified in Attachment 12 to this Contract, and shall submit reports quarterly concerning the usage of services under this program.
 

7.5.8.4
The Contractor shall provide reproductive health and family planning counseling. Such services shall be provided voluntarily and confidentially, including circumstances where the Enrollee is under age eighteen (18). Family planning services will include, at a minimum, the following:
 
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7.5.8.4.1
Education and counseling;
 

7.5.8.4.2
Pregnancy testing;
 

7.5.8.4.3
Infertility assessment;
 

7.5.8.4.4
Sterilization services in accordance with 42 CFR 441.200, subpart F;
 

7.5.8.4.5
Laboratory services;
 

7.5.8.4.6
Cost and insertion/removal of non-oral products, such as long acting reversible contraceptives (LARC) as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);
 

7.5.8.4.7
At least one of every class and category of FDA-approved contraceptive medication as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);
 

7.5.8.4.8
At least one of every class and category of FDA-approved contraceptive method as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract); and
 

7.5.8.4.9
Other FDA-approved contraceptive medications or methods not covered by sections 7.5.8.4.7 or 7.5.8.4.8 of the Contract, when it is Medically Necessary and approved through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations:
 

7.5.8.4.9.1
Contra-indication with drugs that are in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that the Enrollee is already taking, and no other methods available in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that can be used by the Enrollee.
 

7.5.8.4.9.2
History of adverse reaction by the Enrollee to the contraceptive methods covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract); or
 

7.5.8.4.9.3
History of adverse reaction by the Enrollee to the contraceptive medications that are in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract).
 
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7.5.8.5
Maternity services, including family planning and postpartum services must be covered for a sixty (60) Calendar Day period, beginning on the day the pregnancy ends. These services will also be covered for any remaining days in the month in which the sixtieth (60th) day falls.
 

7.5.9
Emergency Services
 

7.5.9.1
The Contractor shall cover and pay for Emergency Services where necessary to treat an Emergency Medical Condition or a Behavioral Health Emergency. The Contractor shall ensure that Medical and Behavioral Health Emergency Services are available twenty-four (24) hours a day, seven (7) days per Week. The Contractor shall ensure that emergency rooms and other Providers qualified to fu