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STATE FISCAL YEAR 2021MODEL PURCHASE OF SERVICE PROVIDER AGREEMENTBETWEENSTATE OF WEST VIRGINIADEPARTMENT OF HEALTH AND HUMAN RESOURCESBUREAU FOR MEDICAL SERVICESAND(MANAGED CARE ORGANIZATION)i
STATE OF WEST VIRGINIADEPARTMENT OF HEALTH AND HUMAN RESOURCESBUREAU FOR MEDICAL SERVICESPURCHASE OF SERVICE PROVIDER AGREEMENTTable of ContentsARTICLE I: STANDARD WEST VIRGINIA TERMS .11. GENERAL TERMS AND CONDITIONS .12. CONTRACT TERM .23. ENTIRE AGREEMENT .24. CONTRACT ADMINISTRATION .25. NOTICES .2ARTICLE II: GENERAL CONTRACT TERMS FOR MANAGED CAREORGANIZATIONS .41. DEFINITIONS .42. DELEGATIONS OF AUTHORITY.153. FUNCTIONS AND DUTIES OF THE MANAGED CARE ORGANIZATION .154. FUNCTIONS AND DUTIES OF THE STATE .154.1 Eligibility Determination.154.2 Enrollment .164.3 Default Enrollee Assignment .164.4 Voluntary and Involuntary Disenrollment .164.5 Capitation Payments to Managed Care Organization .164.6 Federal Disallowance .174.7 Enrollee Eligibility Capitation Adjustments .184.8 Enrollee Reinstatement Processing .184.9 Ongoing Managed Care Organization Monitoring .184.10 Utilization Review and Control .194.11 Force Majeure .194.12 Time Is of the Essence .194.13 MCO Response Time Frames .195. DECLARATIONS AND MISCELLANEOUS PROVISIONS .205.15.2Competition Not Restricted .20Binding Authority .20i
5.3 Nonsegregated Facilities.205.4 Offer of Gratuities .205.5 Employment/Affirmative Action Clause .215.6 Hold Harmless.215.7 Confidentiality .215.8 Independent Capacity .215.9 Contract Liaison.225.10 Key Staff Positions .225.11 Location of Operations.225.12 Communication with BMS.235.13 Waivers .235.14 Compliance with Applicable Laws, Rules, And Policies .235.15 Non-discrimination.255.16 Federal Requirements and Assurances .255.18 Disclosure of Interlocking Relationships .265.19 BMS’ Data Files .265.20 Changes Due to a Section 1915(b) Freedom of Choice or 1115 Demonstration Waiver275.21 Contracting Conflict of Interest Safeguards .275.22 Prohibition Against Performance Outside the United States.275.23 Freedom of Information .276. CONTRACT REMEDIES AND DISPUTES .286.16.26.36.46.56.66.76.86.96.106.11MCO Performance .28Corrective Action Plan (CAP).29Conditions Endangering Performance.30Failure to Meet Contract Requirements.31Temporary Management .32Suspension of New Enrollment .32Payment Suspension .33Dispute Resolution .33Termination For Default .34Termination for Convenience .36Termination Due to Change in Law, Interpretation of Law, or Binding Court Decision366.12 Termination for Managed Care Organization Bankruptcy .366.13 Termination for Unavailability of Funds .366.14 Termination Obligations of Contracting Parties .37ii
6.15 MCO Operations Transition .386.16 Cooperation with Other Contractors and Prospective Contractors .396.17 Waiver of Default or Breach .396.18 Severability .396.19 Modification of the Contract in the Event of Remedies .397. POST-AWARD READINESS REVIEW .398. OTHER REQUIREMENTS .408.1 Inspection of Facilities .408.2 MCO Requirements Related to Information Systems .418.3 Maintenance and Examination of Records .418.4 Audit Accounting and Retention of Records .428.5 Subcontracts .439. SIGNATURES .49ARTICLE III: STATEMENT OF WORK .501. COVERED SERVICES .501.11.21.3Covered MCO Services .50Additional Requirements/Provisions for Certain Services.51Medicaid Benefits Covered but Excluded from Capitation that Require Coordination581.4 Non-covered Services .591.5 Other Requirements Pertaining to Covered Services .601.6 Requirements Pertaining to Medicaid Managed Care Programs .612. PROVIDER NETWORK.612.1 General Requirements .612.2 Primary Care Providers (PCPs) .692.3 Specialty Care Providers, Hospitals, and Other Providers .722.4 Publicly Supported Providers .732.5 Mainstreaming .762.6 Provider Services .762.7 Provider Reimbursement .812.8 Prohibitions on Inappropriate Physician Incentives .863. ENROLLMENT & ENROLLEE SERVICES .873.13.23.33.4Marketing .87Enrollment .88Enrollee Services Department .92Materials .92iii
3.6 Enrollee Rights .993.7 Enabling Services .1013.8 Grievances and Appeals .1023.9 Cost-Sharing Obligations.1093.10 Value-Added Services .1104. MEDICAID ADMINISTRATOR/CONTRACT LIAISON FUNCTIONS .1115. HEALTH CARE MANAGEMENT .1125.1 Second Opinions .1125.2 Out-of-Network Services .1125.3 Continuity and Coordination of Care .1125.4 Service Authorization (Prior Authorization) .1195.5 Rural Option.1215.7 Practice Guidelines and New Technology .1215.8 Enrollee Medical Records and Communication of Clinical Information .1225.9 Confidentiality .1245.10 Reporting Requirements .1256. QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI) PROGRAM1326.1 Required Levels of Performance .1326.2 Performance Improvement Projects (PIPs) .1336.3 Systemic Problems.1356.4 Health Information System .1366.5 Administration of the QAPI Program .1366.6 MCO Accreditation .1386.7 Performance Profiling.1387. FINANCIAL REQUIREMENTS & PAYMENT PROVISIONS .1387.1 Solvency Requirements .1387.2 Capitation Payments to MCOs .1397.3 Medicaid Medical Loss Ratio (MLR) .1407.4 Health Insurer Fee .1417.5 Third Party Liability (TPL) .1417.6 Special Payment Arrangements .1427.7 Enrollee Liability.1477.8 Managed Care Premium Tax .1478. FRAUD, WASTE, AND ABUSE (FWA) REQUIREMENTS .1488.1Fraud, Waste, and Abuse Guidelines .148iv
8.2 Credible Allegation of Fraud .1528.3 Treatment of Overpayments .1539. MHT CHILDREN’S DENTAL SERVICES .1569.1 MHT Children’s Dental Services Administration .1569.2 Covered Dental Services .1569.3 Dental Director .1579.4 Oral Health Fluoride Varnish Program .1579.5 Coordination of Care .1579.6 Continuity of Care for MCO Orthodontic Services .1579.7 Continued Care for Active Orthodontia .15710. BEHAVIORAL HEALTH SERVICES .15710.1 MCO Behavioral Services Administration .15710.2 Behavioral Health Director .15810.3 Behavioral Health Covered Services .15910.4 Services Not Covered under Managed Care .15910.5 Coordination of Care .15910.6 Adult Inpatient and Residential Care for Behavioral Health .15910.7 Children’s Inpatient Care for Behavioral Health .16010.8 Court Ordered Services .16010.9 Behavioral Health Provider Network .16110.10 Behavioral Health Service Authorization .16111. DELEGATION .16512. EMERGENCY AND DISASTER DECLARATION .165APPENDIX A: DESCRIPTION OF MCO COVERED AND EXCLUDED SERVICES .1APPENDIX B: OVERVIEW OF WEST VIRGINIA’S SFY 2020 MOUNTAIN HEALTHTRUST AND WEST VIRGINIA HEALTH BRIDGE PAYMENT METHODOLOGY ANDCAPITATION RATES.1APPENDIX C: SERVICE AREAS .1APPENDIX D: MARKETING POLICIES .1APPENDIX E: SUMMARY OF MHT AND WVHB MCO REPORTINGREQUIREMENTS.1APPENDIX F 1: DATA CERTIFICATION FORM .1APPENDIX F 2: DATA CERTIFICATION FOR MONTHLY AND WEEKLYENCOUNTER DATA REPORT SUBMISSION .2APPENDIX G: SERVICE LEVEL AGREEMENTS (SLA) AND LIQUIDATEDDAMAGES MATRIX .1v
APPENDIX H: MEDICAL LOSS RATIO (MLR) REPORTING METHODOLOGY .1APPENDIX I: ALTERNATIVE PAYMENT MODEL (APM) REPORTING TEMPLATE 1APPENDIX J: PROVIDER NETWORK STANDARDS .4GENERAL NETWORK REQUIREMENTS .4Medical Provider Access Standards .4Pediatric Dental Network Access Standards .10Behavioral Health Network Access Standards .10Essential Community Providers (ECPs) .12Network Adequacy for Additional Providers Types .13NETWORK SUBMISSION AND NETWORK ADEQUACY EVALUATION .13Provider Network Submission .13Provider Network Evaluation .15vi
STATE OF WEST VIRGINIADEPARTMENT OF HEALTH AND HUMAN RESOURCESBUREAU FOR MEDICAL SERVICESPURCHASE OF SERVICE CONTRACTARTICLE I: STANDARD WEST VIRGINIA TERMSThis CONTRACT is made and entered into by and between the STATE OF WEST VIRGINIA,DEPARTMENT OF HEALTH AND HUMAN RESOURCES (DHHR), BUREAU FORMEDICAL SERVICES (BMS), hereinafter referred to as the "BMS," and [Insert Managed CareOrganization Name], hereinafter referred to as the "Managed Care Organization (MCO)".WHEREAS, BMShas conducted an open solicitation for the services of MCOs interested inentering into a Contract to provide risk-based comprehensive health services to West VirginiaMedicaid managed care enrollees, andWHEREAS, the MCO has demonstrated the ability to provide risk-based comprehensive healthservices in compliance with the program terms and requirements, andWHEREAS, BMS has approved the MCO to provide risk-based comprehensive health servicesto West Virginia Medicaid managed care enrollees,NOW THEREFORE, in consideration of the foregoing recitals and of the mutual covenantscontained herein, BMS and the MCO hereby agree as follows.1. GENERAL TERMS AND CONDITIONSWritten MCO responses to a Request for Quotes and the Mountain Health Trust (MHT) andWest Virginia Health Bridge (WVHB) Medicaid MCO Provider Application, (including BMS’written responses to oral and written questions, appendices, amendments, and addenda) and/or toother formal requests by BMS’ for information and documents are hereby incorporated byreference as part of the Contract having the full force and effect as if specifically containedherein. In the event of a conflict in language between this Contract and other documentsmentioned above, the following order of precedence will apply:A. The terms of this Contract;B. MCO responses to the RFQ; andC. Written MCO responses to formal BMS requests for information and documents,including MCO responses, supplemental responses, and clarifications of responses to theMCO Provider Application.1
In construing this Contract, whenever appropriate, the singular tense will also be deemed tomean the plural and vice-versa. Titles of paragraphs used herein are for the purpose offacilitating ease of reference only and will not be construed to be a part of this Contract.2. CONTRACT TERMThe initial term of this Contract will commence on July 1, 2020 and will be effective throughJune 30, 2021.Any modification to this Contract will be subject to the terms of the RFP with the capitation ratesbeing adjusted to reflect the corresponding Fiscal Year (FY).Using actuarially sound standards, BMS will calculate capitation payments to the MCO on theannual basis for the State Fiscal Year (SFY) time period (i.e., SFY21 begins July 1, 2020, andends June 30, 2021).Notwithstanding the foregoing, the State of West Virginia, Department of AdministrationPurchasing Division approval is not required on BMS’ delegated or exempt purchases.3. ENTIRE AGREEMENTThis Contract (including all provisions incorporated by reference in Article I, Section 1 and anyappendices, exhibits, rate matrices and schedules hereto) constitutes the entire agreementbetween the parties. No amendment or other modification changing this Contract will have anyforce or effect unless it is in writing and duly executed by the parties. Said modification will beincorporated as a written amendment to the Contract.4. CONTRACT ADMINISTRATIONThis Contract will be administered for the State by BMS within the DHHR. The ContractingOfficer will be the Director of the Office of Managed Care upon the execution of the Contract.The Contracting Officer will be the primary contact for all matters related to this Contract.5. NOTICESAny notice required under this Contract must be deemed sufficiently given upon delivery, ifdelivered by hand (signed receipt obtained) or three (3) calendar days after posting if properlyaddressed and sent certified mail return receipt requested. Notices must be addressed as follows:Managed Care OrganizationBMS2
Susan Hall, DirectorOffice of Managed CareBureau for Medical ServicesWest Virginia Department of Health and Human Resources350 Capitol Street, Rm 251Charleston, WV 25301304-356-4073 (office phone)Susan.L.Hall@wv.govSaid notices will become effective on the date of receipt or the date specified within the notice,whichever comes later. Either party will be notified of an address change in writing.All questions, requests, and other matters related to the administration of this Contract must beaddressed with Susan Hall and copied to Jeff Wiseman to be considered. Their contactinformation is below.Susan Hall, DirectorOffice of Managed CareBureau for Medical ServicesWest Virginia Department of Health and Human Resources350 Capitol Street, Rm 251Charleston, WV 25301304-356-4073 (office phone)Susan.L.Hall@wv.govCC: Jeff WisemanAssistant to the Deputy SecretaryWest Virginia Department of Health and Human Resources1 Davis Square, Suite 100ECharleston, WV 25301304-558-6052 (office phone)Jeff.A.Wiseman@wv.gov3
ARTICLE II: GENERAL CONTRACT TERMS FOR MANAGED CAREORGANIZATIONS1. DEFINITIONSAs used throughout this Contract, the following terms will have the meanings set forth below.Abuse – provider practices that are inconsistent with sound fiscal, business, or medical practices,and result in an unnecessary cost to the Medicaid program, or in reimbursement for services thatare not Medically Necessary or that fail to meet professionally recognized standards for healthcare. It also includes beneficiary practices that result in unnecessary cost to the Medicaidprogram.Actuary – an individual who meets the qualification standards established by the AmericanAcademy of Actuaries for an actuary and follows the practice standards established by theActuarial Standards Board. In this Contract, Actuary refers to an individual who is acting onbehalf of the State when used in reference to the development and certification of capitationrates.Advance Directive – a written instruction, such as a living will or durable power of attorney forhealth care, recognized under State law (whether statutory or as recognized by the courts of theState), relating to the provision of health care when the individual is incapacitated.Adverse Benefit Determination – the MCO’s decision to deny or limit authorization or payment(in whole or in part) for health care services, including new authorizations and previouslyauthorized services; the MCO’s reduction, suspension, or termination of a previously authorizedservice; the MCO’s failure to provide services as required by the Contract; the MCO’s failure toresolve grievances or appeals within the timeframes specified in this Contract; or the MCO’sdenial of a request by an enrollee who resides in a rural area with only one MCO to receive outof-network services; or the denial of an enrollee’s request to dispute a finnancial liability,including copayments.Agency for Healthcare Research and Quality (AHRQ) – the lead Federal agency charged withimproving the safety and quality of America's health care system. AHRQ develops theknowledge, tools, and data needed to improve the health care system and help Americans, healthcare professionals, and policymakers make informed health decisions.Appeal – a request for a review of the MCO’s adverse benefit determination as defined in thisContract and 42 CFR 438.400(b) (1-7).Authorized Agent – any corporation, company, organization, or person or their affiliates, not incompetition with the MCO for the provision of managed care services, retained by BMS toprovide assistance with administering its MCO program or any other matter.Behavioral Health Services – services used to treat a mental illness, behavioral disorder and/orsubstance use disorder which necessitates therapeutic and/or supportive treatment, such servicesinclude but not limited to psychological and psychiatric services.4
Bureau for Medical Services (BMS) – the West Virginia Bureau for Medical Services within theWest Virginia Department of Health and Human Resources, which serves as the Single StateAgency in West Virginia for Medicaid. Also referenced in this agreement as “BMS”.Business Continuity Plan (BCP) – a plan that provides for a quick and smooth restoration of theMCO information system after a disruptive event. BCP includes business impact analysis, BCPdevelopment, testing, awareness, training, and maintenance. This is a day-to-day plan.Capitation Payment – a payment the State makes periodically to the MCO on behalf of eachbeneficiary enrolled under this Contract and based on the actuarially sound capitation rate for theprovision of covered services. The State makes the payment regardless of whether the parti
services in compliance with the program terms and requirements, and WHEREAS, BMS has approved the MCO to provide risk-based comprehensive health services to West Virginia Medicaid managed care enrollees, NOW THEREFORE, in consideration of the foregoing recitals and of the mutual covenants contained herein, BMS and the MCO hereby agree as follows.
