ATTACHMENT I SCOPE OF SERVICES CAPITATED HEALTH PLANS

Transcription

1 ATTACHMENT I SCOPE OF SERVICES CAPITATED HEALTH PLANS A. Plan Type The Vendor (Health Plan) is approved to provide contracted services as the following health plan type as denoted by X. When the statewide Medicaid managed care program for the Managed Medical Assistance component begins, these designations will be voided on a county-by-county basis to accommodate the transition. : TABLE 1 Effective Date: 09/01/12 08/31/15 Health Maintenance Organization (HMO) Fee- for- Service (FFS) Provider Service Network (PSN) Capitated PSN Specialty Health Plan for Children with Chronic Conditions Specialty Plan for Recipients Living with HIV/AIDS HMOs that Specialize in HIV/AIDS B. Population(s) to be Served 1. Population Groups The Health Plan shall deliver covered services as defined in Attachment II to the specific population(s) approved below with X and as listed in Attachment II, Section III, Eligibility and Enrollment: TANF SSI Dually Eligible TABLE 2 Effective Date: 09/01/12 08/31/15 Frail/ Elderly* HIV/ AIDS** TANF SSI Dually Eligible Children with Chronic Conditions*** HIV/ AIDS**** TABLE 2 Effective Date: 09/01/12 08/31/15 TANF SSI Dually Eligible Frail/ Elderly* HIV/ AIDS** TANF SSI Dually Eligible Children with Chronic Conditions*** HIV/ AIDS**** AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 1 of 18

2 * Enrollees, who have been determined to be at risk for nursing home institutionalization by the Comprehensive Assessment and Review for Long Term Care (CARES) Unit, and are enrolled in an Agency-authorized plan which participates in the Frail/Elderly Program. ** Enrolled in an agency-authorized HMO that specializes in HIV/AIDSdesignated as a specialty plan for recipients with HIV/AIDS ***Enrolled in an Agency-authorized specialty plan for children with chronic conditions and screened by the Florida Department of Health as clinically eligible for Children s Medical Services using an Agency-approved screening tool as specified in Attachment II, Section III, Eligibility and Enrollment, Exhibit 3. **** Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 2 of 18

3 2. Age Restrictions The Health Plan s enrollment is restricted as indicated by X below in regard to the age range for the population groups referenced in Item 1 above that the Health Plan is authorized by the Agency to serve: TABLE 3 Effective Date: 09/01/12 08/31/15 Age Restriction Restricted None Only ages 0 up to 21 Only ages 21 and over Restricted 3. Enrollment Levels and Authorized Counties of Operation The Agency assigns the Health Plan an authorized maximum enrollment level for each operational county indicated in Exhibit 1 of this attachment for and non- populations if those populations are covered in this Contract as specified in Section B. above. The authorized maximum enrollment level listed is effective on September 1, , or upon Contract execution, whichever is later. a. The Agency must approve in writing any increase or decrease in the Health Plan s maximum enrollment level for each operational county to be served. The Health Plan shall submit requests for county enrollment level increases, decreases or expansions in writing to the Agency Bureau of Health Systems Development (HSD). b. Such approval shall be based upon the Health Plan s satisfactory performance of terms of the Contract and upon the Agency s approval of the Health Plan s administrative and service resources, as specified in this Contract, in support of each enrollment level. c. When the Statewide Medicaid Managed Care program for the Managed Medical Assistance component begins, these authorized counties of operation will be voided on a county-by-county basis to accommodate the transition. C. Service Level Required The Health Plan shall deliver Medicaid covered services at the service level(s) listed below in Table 4 with X. In addition, if the Health Plan is listed as approved to provide both comprehensive component only and comprehensive and catastrophic components, then the Health Plan is approved to provide services at the comprehensive component only service level only for the county populations listed below: TABLE 4 Effective Date: 09/01/12 08/31/15 Medicaid State Plan Comprehensive Component OnlyPlan AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 3 of 18

4 REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 4 of 18

5 D. Service(s) to be Provided 1. Covered Medicaid Services a. The Health Plan shall ensure the provision of the Medicaid services listed below in Table 5 with X and as specified in applicable exhibits to this attachment and as defined in Attachment II, Section I, Definitions; Section V, Covered Services; and Section VI, Behavioral Health Care, and as specified in applicable exhibits to Attachment I. b. For non- populations, Medicaid State Plan dental services and transportation services (notated in Table 5 with an asterisk and in bold-type font) are considered optional services, and the Health Plan may request that the Agency allow the Health Plan to provide these services under this Contract. The denotation of X in Table 5 below indicates the Agency has approved the Health Plan to cover these services. See Attachment II, Exhibit 5, for more information regarding the provision of these optional benefits. See Item 3., Other Service Requirements, of this subsection for more information regarding optional services. (1) For optional dental services for the non- population, the Health Plan is further limited as follows: (a) Dental services include the arrangement and provision of Medicaid State Plan dental services to the adult and child populations. The Health Plan shall comply with the limitations and exclusions in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (b) In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Dental Services Coverage and Limitations & Reimbursement Handbooks. (2) For optional transportation for the non- population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide transportation services to non- populations. The only county for which optional transportation services may be authorized is Miami Dade County. (b) Transportation services include the arrangement and provision of an appropriate mode of transportation, including emergency transportation services, for enrollees to receive medically necessary health care services. The Health Plan shall comply with the limitations and exclusions in the Medicaid Transportation Coverage and Limitations Handbook. In no instance may the limitations or exclusions imposed by the Health Plan be more stringent than those specified in the Medicaid Transportation Coverage and Limitations Handbook. (c) If an X is listed in the non- column, the Agency has authorized the Health Plan to provide such transportation services in Miami Dade County. AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 5 of 18

6 See Item 3., Other Service Requirements, of this subsection for more information regarding optional services. (3) For the optional frail/elderly program for the non- population, the Health Plan is further limited as follows: (a) Only certain HMOs are authorized to provide frail/elderly services to non- populations. The only county for which optional frail/elderly services may be authorized is Miami Dade County. When the statewide Medicaid managed care program for the Managed Long Term Care component begins, these designations will be voided on a county-by-county basis to accommodate the transition. (b) Frail/elderly services include the provision, coordination, and management of services to prevent or delay placement in a nursing home. A variety of mandatory and supportive services shall be available to enrollees who meet the eligibility requirements as set out in Attachment II, Exhibit III, HMO Frail/Elderly Program. (c) If an X is listed in the non- column, the Agency has authorized the Health Plan to provide such frail/elderly services in Miami Dade County. TABLE 5-B Effective Date: 09/01/12 08/31/15 Health Plan Covered Services Chart Covered Covered Advanced Registered Nurse Practitioner Services X X Ambulatory Surgical Center Services X X Birth Center Services X X Child Health Check-Up Services X X Chiropractic Services X X Community Behavioral Health Services X X County Health Department Services X X Dental Services* X Durable Medical Equipment and Medical Supplies X X Dialysis Services X X Emergency Room Services X X Family Planning Services X X Federally Qualified Health Center Services X X Frail/Elderly Program Services* Freestanding Dialysis Centers X X Hearing Services X X Home Health Care Services X X Hospital Services Inpatient X X AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 6 of 18

7 TABLE 5-B Effective Date: 09/01/12 08/31/15 Health Plan Covered Services Chart Covered Covered Hospital Services Outpatient X X Immunizations X X Independent Laboratory Services X X Licensed Midwife Services X X Optometric Services X X Physician Services X X Physician Assistant Services X X Podiatry Services X X Portable X-ray Services X X Prescribed Drugs X X Prescribed Pediatric Extended Care Services Primary Care Case Management Services X X Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY) Rural Health Clinic Services X X Targeted Case Management X X Therapy Services: Occupational X X Therapy Services: Physical X X Therapy Services: Respiratory X X Therapy Services: Speech X X Transplant Services X X Transportation Services* X Vision Services X X 2. Approved Expanded Benefits a. The Health Plan shall provide the following expanded benefits to non- enrollees as specified below in accordance with Contract provisions including Attachment I, Section B., Population(s) to be Served, and Attachment II, Section V, Covered Services, of this Contract. TABLE 6 Effective Date: 09/01/12 08/31/15 Expanded Services List approved services here b. The Health Plan shall provide the expanded benefits listed in Section G, Benefit Grid/Customized Benefit Package Capitated Plans Only, below as part of AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 7 of 18

8 the Health Plan s customized benefit package to enrollees in accordance with Contract provisions including Attachment I, Section B., Population(s) to be Served, and Attachment II, Section V, Covered Services, of this Contract. AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 8 of 18

9 3. Other Service Requirements a. The Health Plan shall meet the minimum service requirements as outlined and defined in Attachments I and II of this Contract. b. Health plans serving populations agree to provide the services listed in Section G. of this attachment in accordance with Contract provisions. c. The Health Plan shall submit for approval any changes to the optional services listed in Table 5 and expanded services listed in Table 6 and, for health plans serving populations, those covered services listed in Section G. below, to the Agency s Bureau of Health Systems Development (HSD) by June 15 of each contract year. These services may be changed on a contract year basis and only if approved by the Agency in writing. d. The Health Plan shall use the following service provisions for prescribed drug services as allowed in Attachment II, Section V, Covered Services, and as listed by X below. TABLE 7 Effective Date: 09/01/12 08/31/15 Pharmacy Authorizations The Health Plan shall use a pharmacy benefits manager as specified in Attachment II, Section V. Authorized e. The Health Plan has agreed to and is authorized by the Agency to use the Medicaid redetermination date data provided in its enrollment files as specified in Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing only if listed by X below. TABLE 8 Effective Date: 09/01/12 08/31/15 Medicaid Rredetermination Ddate Ddata The Health Plan shall use Medicaid redetermination date data as specified in Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing. Authorized f. The Health Plan has agreed to and is authorized by the Agency to provide services through telemedicine and as specified in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, 21., Telemedicine; Exhibit 5, Covered Services; and Section VI, Behavioral Health Care, Item A., General Provisions, only if listed by X below. Telemedicine The Health Plan shall provide telemedicine as specified in Attachment II, Section V, Covered Services, Item H., Coverage Provisions, 21., TABLE 9 Effective Date: 09/01/12 08/31/15 Dental Authorized Behavioral Health Authorized AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 9 of 18

10 Telemedicine; Exhibit 5, Covered Services; and Section VI, Behavioral Health Care/Exhibit 6, Item A., General Provisions. E. Method of Payment 1. General This is a fixed price (unit cost) Contract. The Agency will manage this Contract for the delivery of services to enrollees (service units). The Health Plan will be paid through the Agency s Medicaid fiscal agent, in accordance with the terms of this Contract, a total dollar amount not to exceed $, subject to the availability of funds in accordance with Attachment II, Section XIII, Method of Payment. a. The Health Plan shall be paid capitation payments for each Agency service area, based upon the tables in Exhibit 2 of this attachment. b. All payments made to the Health Plan shall be in accordance with this section and Attachment II, Section XIII, Method of Payment. 2. Health Plan Capitation Rates and Kick Payments a. The Health Plan provider numbers associated with the capitation rates indicated in the Exhibit 2 NR and 2-R tables are provided in Exhibit 1, Maximum Enrollment Levels, of this attachment. b. For health plans serving non- populations, Attachment I, Exhibit 2-NR table(s) provides the capitation rates respective to the authorized areas of operation. The capitation rate payment shall be in accordance with Attachment II, Section XIII, Method of Payment. These rates are titled ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. c. For health plans serving populations, Exhibit 2-R tables of this attachment provide the capitation rates and kick payments respective to the authorized areas of operation. The capitation rate payment shall be in accordance with Attachment II, Section XIII, Method of Payment. These rates are titled ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 10 of 18

11 Attachment/ Exhibit* F. Applicable Exhibits[CR1] Any additions or variations from Contract requirements specified in Attachments I and II are provided in the exhibits to those attachments. Exhibits required are noted by X below depending on health plan type and population served. There are no additional requirements or changes to the Health Plan s Contract in those exhibits marked N/A. HMO HMO Table 9- B Revised Applicable Exhibits Effective Date: 09/01/12 08/31/15 Specialty Plans for Recipients Living with HIV/AIDS Fee- for- Service PSN Capitated PSN Fee- for- Service PSN Capitated PSN Specialty Plan for Children with Chronic Conditions HMO with Frail/ Elderly Program Att. I, Exh. 1 X X X N/A X N/A X N/A X X Att. I, Exh. 1- FFS Att. I, Exh. 2-NR HMOs that Specialize in HIV/AIDS N/A N/A N/A X N/A X N/A X N/A N/A N/A X N/A N/A X N/A N/A N/A X N/AX Att. I, Exh. 2-R X N/A X N/A N/A N/A X N/A N/A N/AX Att. I, Exh. 2-FFS-NR N/A N/A N/A X N/A N/A N/A N/A N/A N/A Att.I, Exh. 2-FFS-R N/A N/A N/A N/A N/A X N/A X N/A N/A Att. II, Exh. 1 N/A N/A X N/A N/A N/A N/A X N/A X Att. II, Exh. 2 X X X X X X X X X X Att. 2, Exh. 3 X N/A X X N/A X X X X X Att. II, Exh. 4 X N/A X N/A N/A X X X X X Att. II, Exh. 5 X X X X X X X X X X Att. II, Exh. 6 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 7 X N/A X X N/A X X X N/A X Att. II, Exh. 8 X X X X X X X X X X Att. II, Exh. 9 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 10 X X X X X X X X X X Att. II, Exh. 11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 13-CAP-R Att. II, Exh. 13-CAP-NR Att. II, Exh. 13-FFS X N/A X N/A N/A X X N/A N/A XN/A N/A X N/A N/A X N/A N/A N/A X N/AX N/A N/A N/A X N/A X N/A X N/A N/A Att. II, Exh. 14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Att. II, Exh. 15 X X X X X X X X X X Att. II, Exh. 16 X X X X X X X X X X * Plans offering certain optional coverage also will have additional language in the exhibits as follows: Exhibits 3, 4, 5, 8 and 13 Frail/Elderly Program; Exhibit 5 dental and transportation. Safety net hospital-based PSNs will have additional language in the exhibits as follows: Exhibit 13 Method of Payment. AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 11 of 18

12 G. Benefit Grid/Customized Benefit Package - Capitated Plans Only The benefit grids below describe the Health Plan s Customized Benefit Packages (CBP). The CBP comprises all covered services including expanded services as specified in Attachment I, Scope of Services, Attachment II, Section V, Covered Services, and Section VI, Behavioral Health Care. The CBP has been determined to meet actuarial equivalency and sufficiency standards for the population or populations covered by the CBP. The Health Plan shall provide these services to all enrollees in accordance with Contract provisions. REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 12 of 18

13 1. Area 10 Broward- Children and Families Sample Benefit Grid Hospital Inpatient COVERED SERVICE CATEGORY Visit/Script Limit Limit Period (Annual/Monthly) Dollar Limit Limit Period (Annual) Copay Amount Copay Application Behavioral Health $ admit Physical Health $ admit Transplant Services Outpatient Services Emergency Room Medical/Drug Therapies (Chemo, Dialysis) Ambulatory Surgery - ASC Hospital Outpatient Surgery $ visit Lab / X-ray $ day Hospital Outpatient Services NOS Annual $ visit Outpatient Therapy (PT/RT) Annual Outpatient Therapy (OT/ST) Maternity and Family Planning Services Inpatient Hospital Birthing Centers Physician Care Family Planning Pharmacy Physician and Phys Extender Services (non maternity) EPSDT Primary Care Physician $ - visit Specialty Physician $ visit ARNP / Physician Assistant $ - visit Clinic (FQHC, RHC) $ visit Clinic (CHD) Other Other Outpatient Professional Services Home Health Services Annual Annual $ visit Chiropractor Annual Annual $ visit Podiatrist Annual Annual $ visit Dental Services $ Annual - coinsurance Vision Services Annual $ - visit Hearing Services Annual Outpatient Mental Health $ visit Outpatient Pharmacy Monthly Annual Other Services Ambulance emergent Transportation $ trip Durable Medical Equipment Annual Expanded benefits AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 13 of 18

14 2. Area 10 Broward- Aged and Disabled Benefit Grid FINAL DRAFT /01/11 Hospital Inpatient COVERED SERVICE CATEGORY Visit/Script Limit Limit Period (Annual/Monthly) Dollar Limit Limit Period (Annual) Copay Amount Copay Application Behavioral Health $ admit Physical Health $ admit Transplant Services Outpatient Services Emergency Room Medical/Drug Therapies (Chemo, Dialysis) Ambulatory Surgery - ASC Hospital Outpatient Surgery $ visit Lab / X-ray $ day Hospital Outpatient Services NOS Annual $ visit Outpatient Therapy (PT/RT) Annual Outpatient Therapy (OT/ST) Maternity and Family Planning Services Inpatient Hospital Birthing Centers Physician Care Family Planning Pharmacy Physician and Phys Extender Services (non maternity) EPSDT Primary Care Physician $ - visit Specialty Physician $ visit ARNP / Physician Assistant $ - visit Clinic (FQHC, RHC) $ visit Clinic (CHD) Other Other Outpatient Professional Services Home Health Services Annual Annual $ visit Chiropractor Annual Annual $ visit Podiatrist Annual Annual $ visit Dental Services $ Annual - coinsurance Vision Services Annual $ - visit Hearing Services Annual Outpatient Mental Health $ visit Outpatient Pharmacy Monthly Annual Other Services Ambulance emergent Transportation $ trip Durable Medical Equipment Annual Expanded benefits AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 14 of 18

15 SAMPLE EXHIBIT 1 MAXIMUM ENROLLMENT LEVELS EFFECTIVE DATE 09/01/12 08/31/15 Maximum enrollment levels and Health Plan provider numbers associated with the counties and populations served. Exhibits 2-NR and 2-R provide the capitation rate tables respective to the areas of operation listed below. A. See Exhibit 2-NR Table, General Capitation Rates, Mental Health Rates plus Dental Rates Area Counties: Effective Date: / / County Enrollment Level Provider Number To Be Assigned To Be Assigned See Exhibit 2-NR Table, General Capitation Rates, Mental Health Rates plus Dental Rates Area Counties: Effective Date: / / County Enrollment Level Provider Number To Be Assigned To Be Assigned B. TABLE 1 (Broward County) Agency Area 10 Effective Date: / / County Enrollment Level Provider Number To Be Assigned AHCA Contract No. _, Attachment I Capitated Health Plans, May , Page 15 of 18

16 SAMPLE EXHIBIT 2-NR ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS. EXHIBIT 2-NR November September 1, August 31, HMO RATES (MEDICAID HMO CAPITATION RATES) By Area, Age and Eligibility Category See attached Capitation Rate Spreadsheet REMAINDER OF PAGE INTENTIONALLY LEFT BLANK Effective September 1, August 31, AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-NR, May , Page 16 of 18

17 SAMPLE EXHIBIT 2-R EXHIBIT 2-R September 1, August 31, HMO RATES (MEDICAID HMO CAPITATION RATES) By Area, Age and Eligibility Category Revised on February 16, 2009??? TABLE 2 Area: 10 County: Broward Effective September 1, August 31, (ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS) Eligibility Category/ Population Total Rates for Comprehensive and Catastrophic Components Children and Families: Newborns aged 0-2 months $ $ Newborns aged 3-11 months $ $ Age 1 and Up - Base Rate for Risk adjustment $ $ Aged and Disabled: No Medicare Newborns aged 0-2 months $ $ Newborns aged 3-11 months $ $ Age 1 and Up - Base Rate for Risk Adjustment $ $ Medicare Parts A and B Under Age 65 $ N/A Age 65 and over $ N/A Medicare Part B Only All ages $ N/A HIV/AIDS Specialty Population No Medicare HIV $ N/A No Medicare AIDS $ N/A Medicare HIV $ N/A Medicare AIDS $ N/A Total Rate for Comprehensive Component Only AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-NR, May , Page 17 of 18

18 SAMPLE EXHIBIT 2-R Area: 10 County: Broward Effective September 1, August 31, Kick Payments Amounts for Covered Obstetrical Delivery Services: CPT Code Obstetrical Delivery CPT Code Description Vaginal delivery only Vaginal delivery including postpartum care Cesarean delivery including postpartum care Payment Amount $ Vaginal delivery only, after previous cesarean delivery Vaginal delivery only, after previous cesarean delivery including postpartum care Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care Area: 10 County: Broward Effective September 1, August 31, CPT Code Transplant CPT Code Description Children/Adolescents or Adult Payment Amount lung single, without bypass Children/Adolescents $ lung single, without bypass Adult $ lung single, with bypass Children/Adolescents $ lung single, with bypass Adult $ lung double, without bypass Children/Adolescents $ lung double, without bypass Adult $ lung double, with bypass Children/Adolescents $ lung double, with bypass Adult $ heart transplant with or without recipient All Age Groups $ cardiectomy liver, allotransplantation, orthotopic, partial or whole from cadaver or living donor All Age Groups $ liver, heterotopic, partial or whole from cadaver or living donor any age All Age Groups $ AHCA Contract No. _, Attachment I, DRAFT Exhibit 2-R, May , Page 18 of 18