Transcription
RFA OHA-4690-19 – CCO 2.0Appendix B: Sample ContractOREGON HEALTH PLANHEALTH PLAN SERVICES CONTRACTCoordinated Care OrganizationContract # xxxxxxxwithxxxxxxxxPage 1 of 207RFA OHA-4690-19-0 tlhAppendix B – Sample ContractPage 1 of 207
RFA OHA-4690-19 – CCO 2.0Coordinated Care OrganizationEffective: January 1, 2020Table of ContentsI.Effective Date and Duration . 7II.Contract in its Entirety . 8III.Vendor or Sub-Recipient Determination . 8IV.Status of Contractor . 9V.Enrollment Limits and Service Area. 9VI.Interpretation and Administration of Contract . 9VII. Contractor Data and Certification . 11VIII. Signatures . 13Exhibit A - Definitions. 14Exhibit B –Statement of Work - Part 1 – Governance and Organizational Relationships . 151. Governing Board and Governance Structure . 152. Clinical Advisory Panel . 153. Innovator Agent and Learning Collaborative . 15Exhibit B –Statement of Work - Part 2 – Covered and Non-Covered Services . 161. Covered Services . 162. Provision of Covered Service . 163. Authorization or Denial of Covered Services . 184. Covered Service Components . 205. Non-Covered Health Services with Care Coordination . 316. Non-Covered Health Services without Care Coordination . 32Exhibit B –Statement of Work - Part 3 – Patient Rights and Responsibilities, Engagement and Choice . 331. Member and Member Representative Engagement and Activation . 332. Member Rights under Medicaid . 333. Provider’s Opinion . 354. Informational Materials and Education of Members and Potential Members . 355. Grievance System . 376. Enrollment and Disenrollment . 377. Identification Cards . 428. Marketing to Potential Members . 429. Member Communications . 43Exhibit B –Statement of Work - Part 4 – Providers and Delivery System . 441. Integration and Coordination . 442. Access to Care. 443. Delivery System and Provider Capacity . 474. Provider Workforce Development . 485. Provider Selection . 486. Credentialing . 497. Patient Centered Primary Care Homes (PCPCH) . 518. Care Coordination . 539. Care Integration . 5410. Delivery System Dependencies . 5511. Evidence-Based Clinical Practice Guidelines . 5612. Health Promotion and Prevention . 5613. Subcontract Requirements . 5714. Minority-Owned, Woman-Owned and Emerging Small Business (“MWESB”) Participation. . 6015. Adjustments in Service Area or Enrollment . 60Contract # (XXXXXX)RFA OHA-4690-19-0 tlhTable of ContentsAppendix B – Sample ContractPage 2 of 207Page 2 of 207
RFA OHA-4690-19 – CCO 2.0Coordinated Care OrganizationEffective: January 1, 2020Exhibit B –Statement of Work - Part 8 – Operations . 641. Accountability and Transparency of Operations . 642. Privacy, Security and Retention of Records . 654. Payment Procedures . 665. Claims Payment . 676. Medicare Payers and Providers . 697. Eligibility Verification for Fully Dual Eligible Members . 698. All Payers All Claims (APAC) Reporting Program . 709. Administrative Performance Program . 7010. Encounter Claims Data . 7112. Encounter Claims Data (Non-Pharmacy) . 7313. Encounter Pharmacy Data. 7314. Drug Rebate Program . 7416. Third Party Liability and Personal Injury Liens . 7518. Disclosure of Ownership Interest. 7819. Upon renewal or extension of the Contract . 7920. Subrogation . 8021. Contractor’s Board of Directors. 80Exhibit B –Statement of Work - Part 9 – Program Integrity . 811. Monitoring and Compliance Review . 812. Conditions that may Result in Sanctions . 813. Range of Sanctions Available . 834. Corrective Action Plan. 845. Liquidated Damages . 856. Intermediate Sanctions . 867. Sanction Process . 878. Notice to CMS of Contractor Sanction . 889. Compliance Plan . 8810. Assessment of Compliance Activities . 8911. Fraud Waste and Abuse Policies. 9012. Review of Compliance Plan and Fraud, Waste and Abuse Policies . 9113. Treatment of Overpayment Recoveries Due to Fraud, Waste and Abuse . 9114. Audits of Network Providers . 9215. Referral Policy . 9216. Reporting Fraud, Waste and Abuse . 93Exhibit B –Statement of Work - Part 10– Quality, Transformation, Performance Outcomes and Accountability961. Overview . 962. Transformation and Quality Strategy Requirements . 963. Revised Transformation and Quality Strategy. 974. Transformation and Quality Strategy Monitoring and Compliance Review . 975. Transformation and Quality Strategy Deliverables . 986. Goals for Transformation and Quality Strategy Amendments . 987. Quality and Performance Outcomes . 988. Performance Measurement and Reporting Requirements . 989. Quality Performance Improvement Projects . 9910. Program Requirements. 10011. External Quality Review . 10012. Quality Pool . 101Contract # (XXXXXX)RFA OHA-4690-19-0 tlhTable of ContentsAppendix B – Sample ContractPage 3 of 207Page 3 of 207
RFA OHA-4690-19 – CCO 2.0Coordinated Care OrganizationEffective: January 1, 2020Exhibit C – Consideration. 1041. Payment Types and Rates . 1042. Payment in Full . 1043. Changes in Payment Rates . 1044. Timing of CCO Payments . 1055. Settlement of Accounts . 1066. CCO Risk Corridor . 1087. Global Payment Rate Methodology . 1118. Administrative Performance Penalty . 1119. Quality Pool . 11110. Minimum Medical Loss Ratio: . 111Exhibit C – Consideration - Attachment 1 – CCO Payment Rates. 113Exhibit D – Standard Terms and Conditions . 1141. Governing Law, Consent to Jurisdiction . 1142. Compliance with Applicable Law . 1143. Independent Contractor . 1154. Representations and Warranties . 1155. (Reserved) . 1156. Funds Available and Authorized; Payments . 1157. Recovery of Overpayments. 1168. Indemnity . 1169. Default; Remedies; and Termination . 11710. Limitation of Liabilities . 12411. Insurance . 12412. Access to Records and Facilities. 12413. Information Privacy/Security/Access . 12514. Force Majeure . 12515. Foreign Contractor . 12616. Assignment of Contract, Successors in Interest . 12617. Subcontracts . 12618. No Third Party Beneficiaries . 12619. Amendments . 12620. Waiver . 12721. Severability . 12722. Survival . 12723. Notices . 12924. Construction . 13025. Headings . 13026. Merger Clause . 13027. Counterparts . 13028. Equal Access . 13029. Media Disclosure . 13030. Mandatory Reporting . 130Exhibit E - Required Federal Terms and Conditions . 1311. Miscellaneous Federal Provisions. 1312. Equal Employment Opportunity . 1313. Clean Air, Clean Water, EPA Regulations . 1314. Energy Efficiency . 1325. Truth in Lobbying . 132Contract # (XXXXXX)RFA OHA-4690-19-0 tlhTable of ContentsAppendix B – Sample ContractPage 4 of 207Page 4 of 207
RFA OHA-4690-19 – CCO 2.0Coordinated Care OrganizationEffective: January 1, 20206. HIPAA Compliance . 1337. Resource Conservation and Recovery . 1348. Audits . 1349. Debarment and Suspension . 13410. Pro-Children Act . 13511. Additional Medicaid and CHIP . 13512. Agency-based Voter Registration . 13513. Clinical Laboratory Improvements . 13514. Advance Directives . 13615. Practitioner Incentive Plans (PIP) . 13616. Risk HMO . 13617. Conflict of Interest Safeguards . 13618. Non-Discrimination . 13819. OASIS . 13820. Patient Rights Condition of Participation . 13821. Federal Grant Requirements . 13822. Mental Health Parity . 138Exhibit F – Insurance Requirements . 140Exhibit G – Reporting of Delivery System Network Providers, Cooperative Agreements, and HospitalAdequacy . 1421. Delivery System Network (DSN) Reports . 1422. DSN Provider Report . 1423. Provider Capacity. 1444. Cooperative Agreements with Publicly Funded Programs Report: . 1455. Cooperative Agreements with Community Social and Support Service and Long Term Care Report:. 1456. Hospital Network Adequacy . 146Exhibit H – Value Based Payment. 1481. VBP minimum threshold . 1482. Expanding . 1483. Patient-Centered Primary Care Home (PCPCH) VBP requirements . 1494. VBP Targets by Year . 1495. Contractor Data Reporting . 149Exhibit I – Grievance and Appeal System . 1511. Grievance and Appeal System . 1512. Grievances. 1523. Notice of Adverse Benefit Determination . 1534. Handling of Appeals . 1565. Contested Case Hearings . 1596. Continuation of Benefits: . 1597. Implementation of Reversed Appeal Resolution . 1618. Final Order on Contested Case Hearings . 1619. Record Keeping and Quality Improvement . 161Exhibit J - Health Information Technology . 1641. Health Information Technology Requirements . 1642. Health Information Technology (HIT) Roadmap . 165Exhibit L – Solvency Plan and Financial Reporting and Cost . 1681. Overview of Solvency Plan and Financial Reporting . 1682. Solvency Plan and Financial Reporting . 1683. Assumption of Risk/Private Market Reinsurance . 170Contract # (XXXXXX)RFA OHA-4690-19-0 tlhTable of ContentsAppendix B – Sample ContractPage 5 of 207Page 5 of 207
RFA OHA-4690-19 – CCO 2.0Coordinated Care OrganizationEffective: January 1, 20204. Restricted Reserve and Financial Solvency Requirement . 170Exhibit M-Behavioral Health. 1721. Contractor Responsibilities . 1722. Covered Services . 1733. Care Coordinati
HEALTH PLAN SERVICES CONTRACT . COORDINATED CARE ORGANIZATION . This Health Plan Services Contract, Coordinated Care Organization Contract # xxxxx ("Contract") is between the State of Oregon, acting by and through its Oregon Health Authority, hereinafter referred to as "OHA", and . xxxxx. xxxx . xxxx . hereinafter referred to as .
