Termination of Contract Grounds for NYSDOH or CMS Termination With Cause

Transcription

1 Independence Care System has entered into a three way contract between ICS, The State of New York and The Center for Medicaid and Medicare Services (CMS) to provide a Fully Integrated Duals Advantage Plan. The Contract is subject to termination for a variety of reasons including ICS not performing adequately or the State deciding not to proceed with the Demonstration. In the event of a contract termination, ICS has clear obligations to our participants including: notification, and assistance in obtaining appropriate services in the community. Please see below for a complete list of reasons for contract termination and our obligations to our participants should that occur: Termination of Contract Grounds for NYSDOH or CMS Termination With Cause In addition to the grounds for termination under 42 C.F.R (a), NYSDOH and CMS shall have the right to terminate this Contract, in whole or in part if the FIDA Plan: Takes any action that threatens the health, safety, or welfare of its Participants; Based on creditable evidence, has committed or participated in false, fraudulent,or abusive activities affecting the Medicare, Medicaid, or other State or Federal health care programs including any unacceptable practice under 18 NYCRR, Part 515, that affects the fiscal integrity of the Medicaid program; No longer substantially meets the applicable conditions of 42 C.F.R. part 422 or 423 including if the FIDA Plan has its Certificate of Authority suspended, limited or revoked by NYSDOH; Is under sanction as described in 42 C.F.R and 42 C.F.R

2 Materially breaches the Contract or fails to comply with any term or condition of this Contract that is not cured within twenty (20) days, or to such longer period as the parties may agree, of NYSDOH s written request for compliance; Becomes insolvent; Brings a proceeding voluntarily, or has a proceeding brought against it involuntarily, under Title 11 of the U.S. Code (the Bankruptcy Code); or Knowingly has a director, officer, partner or person owning or controlling more than five percent (5%) of the FIDA Plan s equity, or has an employment, consulting, or other agreement with such a person for the provision of Covered Items and/or Services that are significant to the FIDA Plan s contractual obligation who has been debarred or suspended by the Federal, State, or local government, or otherwise excluded from participating in procurement activities The NYSDOH and CMS will notify the FIDA Plan of its intent to terminate this Contract for the FIDA Plan s failure to meet the requirements of this Contract and provide FIDA Plan with a hearing prior to the termination If NYSDOH suspends, limits, or revokes FIDA Plan s Certificate of Authority under PHL Article 44, and: If such action results in the FIDA Plan ceasing to have authority to serve the entire contracted Service Area, as defined by Appendix H of this Contract, this Contract shall terminate on the date the FIDA Plan ceases to have such authority; or If such action results in the FIDA Plan retaining authority to serve some portion of the contracted Service Area, the FIDA Plan shall continue to offer its Demonstration Plan under this Contract in any designated geographic area not affected by such action, and shall terminate its Demonstration Plan in the geographic areas where the FIDA Plan ceases to have authority to serve.

3 No hearing will be required if this Contract terminates due to NYSDOH suspension, limitation, or revocation of the FIDA Plan s Certificate of Authority Prior to the effective date of the termination, the NYSDOH shall notify Participants of the termination or delegate responsibility for such notification to the FIDA Plan, and such notice shall include a statement that Participants may disenroll immediately from the FIDA Plan s Demonstration Plan NYSDOH reserves the right to terminate this Contract in the event it is found that the certification filed by the FIDA Plan in accordance with New York State Finance Law 139-k was intentionally false or intentionally incomplete. Upon such finding, the State may exercise its termination right by providing written notification to the FIDA Plan is accordance with the written notification terms of this Contract FIDA Plan and NYSDOH/CMS Initiated Termination The FIDA Plan and the NYSDOH/CMS each shall have the right to terminate this Contract in the event that NYSDOH/CMS and the FIDA Plan fail to reach agreement on the monthly Capitation Rates. For CY 2014 rates related to Demonstration Year 1, the FIDA Plan shall have the right to terminate this Contract without penalty no later than ten (10) Business Days following the release of the final Medicaid Component of the Capitation Rates for Contract Year FIDA Plan Initiated Termination All FIDA Plan initiated terminations will be required to comply with the terms of 42 C.F.R (b) The FIDA Plan shall have the right to terminate this Contract in the event that NYSDOH or CMS materially breaches the Contract or fails to comply with any term or condition of this Contract that is not cured within twenty (20) days, or to such longer period as the Parties may agree, of the FIDA Plan s written request for compliance. The FIDA Plan shall give NYSDOH and CMS written notice specifying the reason for and the effective date of the termination, which shall not be less time than will permit an orderly Disenrollment of Participants from the FIDA Plan The FIDA Plan shall have the right to terminate this Contract in the event that its obligations are materially changed by modifications to this Contract and its Appendices by NYSDOH and CMS. In such event, FIDA Plan shall give NYSDOH and CMS written notice within ninety

4 (90) days of notification of changes to the Contract or Appendices specifying the reason and the effective date of termination, which shall not be less time than will permit an orderly disenrollment of Participants from the FIDA Plan The FIDA Plan shall have the right to terminate this Contract in its entirety or in specified counties of the FIDA Plan s Service Area if the FIDA Plan is unable to provide the Combined Medicare Advantage and FIDA Plan Benefit Package pursuant to this Contract because of a natural disaster and/or an act of God to such a degree that Participants cannot obtain reasonable access to Combined Medicare Advantage and FIDA Services within the FIDA Plan s organization, and, after diligent efforts, the FIDA Plan cannot make other provisions for the delivery of such services. The FIDA Plan shall give NYSDOH written notice of any such termination that specifies: The reason for the termination, with appropriate documentation of the circumstances arising from a natural disaster and/or an act of God that preclude reasonable access to services; The FIDA Plan s attempts to make other provision for the delivery of FIDA Covered Items and Services; and The effective date of the termination, which shall be at least ninety (90) days after CMS and NYSDOH receive the FIDA Plan s notice of intent to terminate, and will in any event not be less time than will permit an orderly Disenrollment of Participants from the FIDA Plan Termination Due To Loss of Funding In the event that State and/or Federal funding used to pay for Covered Items and Services under this Contract is reduced so that payments cannot be made in full, this Contract shall automatically terminate, unless both parties agree to a modification of the obligations under this Contract. The effective date of such termination shall be ninety (90) days after the FIDA Plan receives written notice of the reduction in payment, unless available funds are insufficient to continue payments in full during the ninety (90) day period, in which case NYSDOH shall give the FIDA Plan written notice of the earlier date upon which the Contract shall terminate. A reduction in State and/or Federal funding cannot reduce monies due and owing to the FIDA Plan on or before the effective date of the termination of the Contract.

5 1.1.5 Termination without Prior Notice In the event the FIDA Plan materially fails to meet its obligations under this Contract or has otherwise violated the laws, regulations, or rules that govern the Medicare or New York State Medicaid programs, CMS or NYSDOH may take any or all action under this Contract, law, or equity, including but not limited to immediate termination of this Contract. CMS or NYSDOH may terminate the Contract in accordance with regulations that are current at the time of the termination Without limiting the above, if CMS and NYSDOH determine that participation of the FIDA Plan in the Medicare or New York State Medicaid program or in the Demonstration, may threaten or endanger the health, safety, or welfare of Participants or compromise the integrity of the Medicare or New York Medicaid program, CMS or the NYSDOH, without prior notice, may immediately terminate this Contract, suspend the FIDA Plan from participation, withhold any future payments to the FIDA Plan, or take any or all other actions under this Contract, law, or equity. Such action may precede enrollment of any Participant into any Demonstration Plan, and shall be taken upon a finding by CMS or the NYSDOH that the FIDA Plan has not achieved and demonstrated a state of readiness that will allow for the safe and efficient provision of Medicare-Medicaid services to Participants United States law will apply to resolve any claim of breach of this Contract Termination with Prior Notice CMS or NYSDOH may terminate this Contract without cause upon no less than ninety (90) days prior written notice to the other Party specifying the termination date, unless applicable law requires otherwise. Per Section 5.7, the FIDA Plan may choose to not renew prior to the end of each term pursuant to 42 C.F.R (a), and may terminate the contract by mutual consent of CMS and the NYSDOH at any time pursuant to 42 C.F.R In considering requests for termination under 42 C.F.R , CMS and NYSDOH will consider, among other factors, financial performance and stability in granting consent for termination. Any written communications or oral scripts developed to implement the requirements of 42 C.F.R (a) must be submitted to and approved by CMS and NYSDOH prior to their use.

6 Pursuant to 42 C.F.R (a)(4) and (c), CMS considers FIDA Plan termination of this Contract with prior notice as described in paragraph 5.5.B.1 and non-renewal of this Contract as described in Section 5.7 to be circumstances warranting special consideration, and will not prohibit the FIDA Plan from applying for new Medicare Advantage contracts or Service Area expansions for a period of two years due to termination Termination pursuant to Social Security Act 1115A(b)(3)(B) Termination for Cause Any Party may terminate this Contract upon ninety (90) days notice due to a material breach of a provision of this Contract unless CMS or NYSDOH determines that a delay in termination would pose an imminent and serious risk to the health of the Participants enrolled with the FIDA Plan or the FIDA Plan experiences financial difficulties so severe that its ability make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its Participants, whereby CMS or NYSDOH may expedite the termination Pre-termination Procedures. Before terminating a Contract under 42 C.F.R and , the FIDA Plan may request a pretermination hearing or develop and implement a corrective action plan. CMS or NYSDOH must: Give the FIDA Plan written notice of its intent to terminate, the reason for termination, and a reasonable opportunity of at least 30 calendar days to develop and implement a corrective action plan to correct the deficiencies; and/or Notify the FIDA Plan of its appeal rights as provided in 42 C.F.R. 422(n) and Termination due to a Change in Law In addition, CMS or NYSDOH may terminate this Contract upon thirty (30) days notice due to a material change in law or appropriation, or with less or no notice if required by law Continued Obligations of the Parties In the event of termination, expiration, or non-renewal of this Contract, or if the FIDA Plan otherwise withdraws from the Medicare or New

7 York State Medicaid programs, the FIDA Plan shall continue to have the obligations imposed by this Contract or applicable law. These include, without limitation, the obligations to continue to provide Covered Items and Services to each Participant at the time of such termination or withdrawal until the Participant has been disenrolled from the FIDA Plan's Demonstration Plan; provided, however, that CMS and NYSDOH will exercise best efforts to complete all disenrollment activities within six months from the date of termination or withdrawal In the event that this Contract is terminated, expires, or is not renewed for any reason: If CMS or NYSDOH, or both, elect to terminate or not renew this Contract, CMS and NYSDOH will be responsible for notifying all Participants covered under this Contract of the date of termination and the process by which those Participants will continue to receive care. If the FIDA Plan elects to terminate or not renew the Contract, the FIDA Plan will be responsible for notifying all Participants and the general public, in accordance with Federal and State requirements; The FIDA Plan must promptly return to CMS and NYSDOH all payments advanced to the FIDA Plan for Participants after the effective date of their disenrollment; and The FIDA Plan must supply to CMS and NYSDOH all information necessary for the payment of any outstanding claims determined by CMS and NYSDOH to be due to the FIDA Plan, and any such claims will be paid in accordance with the terms of this Contract Participant Transition Plan Upon expiration and non-renewal, or termination of this Contract, and the establishment of a termination date, the FIDA Plan shall comply with the phase-out plan that the FIDA Plan has developed and that NYSDOH and CMS have approved The FIDA Plan shall contact other community resources to determine the availability of other programs to accept the Participants into their programs;

8 The FIDA Plan shall assist Participants by referring them, and by making their Comprehensive Health Record available as appropriate to health care Providers and/or programs; The FIDA Plan shall establish a list of Participants that is prioritized according to those Participants requiring the most skilled care; and Based upon the Participant s established priority and a determination of the availability of alternative resources, individual care plans shall be developed by the FIDA Plan for each Participant in collaboration with the Participant, the Participant s family and appropriate community resources In conjunction with such termination and Disenrollment, the FIDA Plan shall provide such other reasonable assistance as the NYSDOH or CMS may request affecting that transaction Upon completion of PCSPs and reinstatement of the Participant s Medicaid benefits through the fee-for-service system or Enrollment in another managed care plan, a Participant shall be disenrolled from the FIDA Plan s Demonstration Plan Contract Close-Out Procedures Upon termination or expiration of this Contract, in its entirety or in specific counties in the FIDA Plan s Service Area, and in the event that it is not scheduled for renewal, the FIDA Plan shall comply with closeout procedures that the FIDA Plan develops in conjunction with LDSS, and the NYSDOH, and CMS haves approved. The close-out procedures shall include the following: The FIDA Plan shall promptly account for and repay funds advanced by NYSDOH and CMS for coverage of Participants for periods subsequent to the effective date of termination; The FIDA Plan shall give NYSDOH and CMS, and other authorized Federal, state or local agencies access to all books, records, and other documents and upon request, portions of such books, records, or documents that may be required by such agencies pursuant to the terms of this Contract; The FIDA Plan shall submit to NYSDOH and CMS, and other authorized Federal, State or local agencies, within ninety (90) days of termination, a final financial

9 statement and audit report relating to this Contract, made by a certified public accountant, unless the FIDA Plan requests of NYSDOH and CMS and receives written approval from NYSDOH and CMS and all other governmental agencies from which approval is required, for an extension of time for this submission; and NYSDOH and CMS shall promptly pay all claims and amounts owed to the FIDA Plan.