Bid Event id number: evt0001028 KanCare Medicaid and chip capitated Managed Care Services Preface: High Priority Events and Items

Any and all data required to be provided at any time during the bid process or CONTRACT term shall be made available in a format as requested and/or approved by the State.

Submission of the bid will be considered presumptive evidence that the VENDOR is conversant with local facilities and difficulties, the requirements of the documents and of pertinent State and/or local codes, state of labor and material markets, and has made due allowances in the proposal for all contingencies. Later claims for labor, work, materials, equipment, and tax liability required for any difficulties encountered which could have been foreseen will not be recognized and all such difficulties shall be properly taken care of by CONTRACTOR at no additional cost to the State of Kansas.

VENDORs must include with their RFP response, a copy of any contracts, agreements, licenses, warranties, etc. that the VENDOR would propose to incorporate into the CONTRACT generated from this Bid Event. (State of Kansas form DA-146a remains a mandatory requirement in all contracts.)

In the event of CONTRACT termination or expiration, CONTRACTOR shall provide all reasonable and necessary assistance to State to allow for a functional transition to another vendor.

Award will be line item or group total, whichever is the best interest of the State of Kansas.

It is understood and agreed by the CONTRACTOR and the State of Kansas that all obligations of the State of Kansas including continuance of payments hereunder, are contingent upon the availability and continued appropriation of State and Federal funds, and in no event shall the State of Kansas be liable for any payments hereunder in excess of such available appropriated funds. In the event that the amount of any available or appropriated funds provided by the State or Federal sources for the purchase of services hereunder shall be reduced, terminated or shall not be continued at an aggregate level sufficient to allow for the purchase of the services specified hereunder for any reason whatsoever, the State of Kansas shall notify the CONTRACTOR of such reduction of funds available and shall be entitled to reduce the State's commitment hereunder or to terminate the CONTRACT as it deems necessary.

In the event of any termination, the CONTRACTOR shall:

4.1.1.57.1

Stop work under the CONTRACT on the date and the extent specified in the notice of termination.

4.1.1.57.2

Place no further orders or subcontractor services or facilities except as may be necessary for completion of such portion of the work under the CONTRACTs as is not terminated.

4.1.1.57.3

Terminate all orders and subcontracts to the extent that they relate to the performance of work terminated by the notice of termination.

4.1.1.57.4

Complete the performance of such part of the work as shall not have been terminated by the notice of termination.

Any payments advanced to the CONTRACTOR for coverage of Members for periods after the date of termination shall be promptly returned to the State of Kansas.

4.1.1.57.6

The CONTRACTOR shall promptly supply all information necessary for the reimbursement of any outstanding claims.

4.1.1.57.7

The CONTRACTOR shall comply with the terms and provisions of the turnover plan as submitted and approved. The final monthly payment will be withheld until all applicable data transition issues are resolved. If data transition is not completed within ninety (90) calendar days, penalties will be assessed at 20% of the final monthly payment with an additional 10% assessed for every 15 calendar days thereafter.

An amount representing 10 percent of the maximum total compensation payable under this CONTRACT during the last three months of operations shall be withheld by the State until 120 days after the final State approval of all services to be performed by the CONTRACTOR under this CONTRACT. Compensation is not deemed to have been earned until all conditions precedent to payment have been met.

Termination or expiration of this CONTRACT for any reason will not release either Party from any liabilities or obligations set forth in this CONTRACT that:

• 
  The Parties have expressly agreed shall survive any such termination or expiration; or
  
• 
  Arose prior to the effective date of termination and remain to be performed or by their nature would be intended to be applicable following any such termination or expiration
  
• 
  Any references to laws, rules, regulations, and manuals in this CONTRACT are deemed references to these documents as amended, modified, or supplemented from time to time during the term of this CONTRACT.
  

Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

• 
  KDHE-DHCF is authorized to enter into this CONTRACT under Kansas Statutes Annotated 75-7403 et al. and Executive Reorganization Order No. 38, hereinafter referred to as “ERO No. 38,” by Governor Sam Brownback on February 4, 2011. MCO is authorized to enter into this CONTRACT pursuant to the authorization of its governing board or controlling owner or officer.
  
• 
  The person or persons signing and executing this CONTRACT on behalf of the Parties, or representing themselves as signing and executing this CONTRACT on behalf of the Parties, warrant and guarantee that he, she, or they have been duly authorized to execute this CONTRACT and to validly and legally bind the Parties to all of its terms, performances, and provisions.
  

Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

4.1.1.61.1

Performance Review

4.1.1.61.1.1

A designated representative of the CONTRACTOR and a designated representative of the State shall meet as requested by either party, to review the performance of the CONTRACTOR under this CONTRACT. Written minutes of such meetings shall be the responsibility of the CONTRACTOR and shall be provided to the State no later than seven (7) calendar days after each meeting. In the event of any disagreement regarding the performance of services by the CONTRACTOR under this CONTRACT, the designated representatives shall discuss the problem and shall negotiate in good faith in an effort to resolve the disagreement.

4.1.1.61.1.2

In the event that no such resolution is achieved within a reasonable time, the matter shall be referred to the State Contract Manager as provided under Section 3.44.2, the Disputes clause of this CONTRACT. If the State Contract Manager determines that the CONTRACTOR has failed to perform as measured against applicable CONTRACT provisions, the State Contract Manager may then assess financial penalties as set out below or terminate this CONTRACT in whole or in part, as provided under the Termination for Default clause.

4.1.1.61.1.3

Sanctions, Liquidated Damages, Temporary Management, and Termination Options:

4.1.1.61.1.3.1

The State may impose sanctions whenever the State has determined that the CONTRACTOR acts or fails to act as follows:

4.1.1.61.1.3.1.1

Fails substantially to provide medically necessary services that the CONTRACTOR is required to provide, under law or under its CONTRACT with the State, to a Member covered under the CONTRACT.

4.1.1.61.1.3.1.2

Imposes on Members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid and CHIP programs.

4.1.1.61.1.3.1.3

Acts to discriminate among Members on the basis of their health status or need for health care services.

4.1.1.61.1.3.1.4

Misrepresents or falsifies information that it furnishes to CMS or to the State.

4.1.1.61.1.3.1.5

Misrepresents or falsifies information that it furnishes to a Member, potential Member, or health care provider.

4.1.1.61.1.3.1.6

Fails to comply with the requirements for physician incentive plans, as set forth (for Medicare) in 42 CFR 422.208 and 422.210.

4.1.1.61.1.3.1.7

Has distributed directly, or indirectly through any agent or independent CONTRACTOR, marketing materials that have not been approved by the State or that contain false or materially misleading information.

4.1.1.61.1.3.1.8

Makes any statement that a Member must enroll to obtain or in order not to lose any benefits.

4.1.1.61.1.3.1.9

Makes any assertion or statement, written or oral, that the CONTRACTOR/MCO is endorsed by CMS, the Federal or State government or similar entity.

4.1.1.61.1.3.1.10

Has violated any of the other applicable requirements of sections 1903(m) or 1932 of the Act and any implementing regulations.

4.1.1.61.1.3.2

Only those sanctions specified in the subsection 4.1.1.61.1.3.2.1.2 may be imposed for this violation.

4.1.1.61.1.3.2.1

The State may choose, depending on the severity of the violation but at the State’s discretion, any of the following sanctions:

4.1.1.61.1.3.2.1.1

Withholding of capitation payments as specified in Section 4.1.1.62

4.1.1.61.1.3.2.1.1.1

Withholdings shall be graduated using the following percentages:

• 
  10%
  
• 
  25%
  
• 
  50%
  
• 
  75%
  
• 
  100%
  

Withholdings may accrue (i.e., withholdings increase by 10% each month a noncompliance action is not corrected (30% in month three)).

4.1.1.61.1.3.2.1.1.3

Monies withheld may be paid to the CONTRACTOR or may be paid less any liquidated damages incurred by the State or by civil monetary penalties imposed.

4.1.1.61.1.3.2.1.1.4

Withholding percentages are determined based on the seriousness of the noncompliant action.

4.1.1.61.1.3.2.1.1.5

In the event that civil monetary penalties are imposed they shall be in the following specified amounts:

4.1.1.61.1.3.2.1.1.5.1

A maximum of $25,000 for each determination of failure to provide services; misrepresentation or false statements to members, potential members or health care providers; failure to comply with physician incentive plan requirements; or marketing violations.

4.1.1.61.1.3.2.1.1.5.2

A maximum of $100,000 for each determination of discrimination; or misrepresentation or false statements to CMS or the State.

4.1.1.61.1.3.2.1.1.5.3

A maximum of $15,000 for each recipient the State determines was not enrolled because of a discriminatory practice (subject to the $100,000 overall limit above).

4.1.1.61.1.3.2.1.1.5.4

A maximum of $25,000 or double the amount of the excess charges, (whichever is greater) for charging premiums or charges in excess of the amounts permitted under the Medicaid program. The State must deduct from the penalty the amount of overcharge and return it to the affected member(s).

4.1.1.61.1.3.2.1.2

The following sanctions may be imposed for violations of subsection 4.1.1.61.1.3.1.10:

Suspension of all new enrollment, including default enrollment, after the effective date of the sanction.

4.1.1.61.1.3.2.1.3

Sanction by CMS: Denial of Payment. Payments provided for under this CONTRACT will be denied for new Members when, and for so long as, payment for those Members is denied by CMS in accordance with the requirements of 42 CFR 438.730.

4.1.1.61.1.3.3

Enrollment Suspensions: Suspension of new member enrollments as specified at Section 4.1.1.64.

4.1.1.61.1.3.4

Liquidated Damages: Liquidated damages as specified in Attachment G

4.1.1.61.1.3.5

Temporary Management:

4.1.1.61.1.3.5.1

Temporary management may only be imposed by the State if it finds that:

There is continued egregious behavior by the CONTRACTOR, including, but not limited to behavior that is described in 42 CFR 438.700, or that is contrary to any requirements of sections 1903(m) and 1932 of the Act; or

There is substantial risk to members’ health; or

The sanction is necessary to ensure the health of the CONTRACTOR’s members while improvements are made to remedy violations under 438.700 or until there is an orderly termination or reorganization of the CONTRACTOR.

The State must impose temporary management if it finds that a CONTRACTOR has repeatedly failed to meet substantive requirements in section 1903(m) or section 1932 of the Act. The State must also grant Members the right to terminate enrollment without cause and must notify the affected Members of their right to terminate enrollment.
*Note: The State may not delay imposition of temporary management to provide a hearing before imposing this sanction. In addition, the State may not terminate temporary management until it determines that the CONTRACTOR can ensure that the sanctioned behavior will not recur.

4.1.1.61.1.3.6

Granting enrollees the right to terminate enrollment without cause and notifying the affected enrollees of their right to disenroll.

4.1.1.61.1.3.7

Suspension of payment for recipients enrolled after the effective date of the sanction and until CMS or the State is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur.

4.1.1.61.1.3.8

Termination: Termination of the CONTRACT as specified at Section 4.1.1.5, 4.1.1.6, 4.1.1.33 or 4.1.1.39.2.19. The State may terminate an MCO or PCCM contract and enroll that entity’s enrollees in other MCOs or PCCMs, or provide their Medicaid benefits through other options included in the State plan and for failure to carry out the substantive terms of this CONTRACT or to meet applicable requirements in section 1932, 1903(m) and 1905(t) of the Act.

4.1.1.61.1.4

Due Process: Notice of Sanction and Pre-Termination Hearing.

4.1.1.61.1.4.1

Notice: Before imposing any intermediate sanctions, the State shall give the CONTRACTOR timely written notice that explains:

• 
  The basis and nature of the sanction.
  
• 
  Any other due process protections that the State shall elect to provide.
  

4.1.1.61.1.4.2

Pre-Termination Hearing and Procedures: Before terminating this CONTRACT under 42 CFR 438.708, or the terms herein, the State must provide the entity a pre-termination hearing. The State shall:

• 
  Give CONTRACTOR written notice, at least 7 days in advance of the hearing, of its intent to terminate the CONTRACT, the reason for termination, and the time and place of hearing.
  
• 
  Give CONTRACTOR written notice, after the hearing, of the decision affirming or reversing the proposed termination of the CONTRACT, and for an affirming decision, the effective date of termination; and
  
• 
  For an affirming decision, give Members of the CONTRACTOR, notice of the termination and information, consistent with 42 CFR 438.10, on their options for receiving T-XIX – Medicaid or T-XXI – SCHIP services following the effective date of termination.
  

Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

The CONTRACT is not subject to arbitration. Any dispute concerning performance of this CONTRACT shall be decided by the State Contract Manager who shall put his/her decision in writing and serve a copy to the CONTRACTOR and the State. The State Contract Manager's decision shall be final unless the following appeal procedure is followed:

4.1.1.63.1

Any Kansas Medicaid and/or CHIP CONTRACTOR who has received an adverse decision from the agency shall have the right to request administrative review. Administrative review is an informal process that gives the CONTRACTOR the opportunity to have information and processes reconsidered by the State. The State will then determine if the action taken was appropriate and within the appropriate Medicaid or CHIP policies and guidelines.

4.1.1.63.2

The CONTRACTOR shall be notified in writing of the right to reconsideration and the process to make such a request. This right shall be effective through fifteen (15) calendar days after the date of the letter.

4.1.1.63.3

Fair Hearing

4.1.1.63.3.1

If reconsideration is not requested, the CONTRACTOR retains the right to further appeal within the time frames allowed by regulation.

4.1.1.63.3.2

If reconsideration is requested and allowed, the CONTRACTOR will be notified of the agency’s final determination in writing. When the reconsideration decision is adverse to the CONTRACTOR, the CONTRACTOR’s rights to an administrative fair hearing shall be contained in the final determination letter.

4.1.1.63.3.3

Pursuant to Kansas Administrative Regulation (K.A.R.) 30-7-68 (Attachment D), a written request for fair hearing must be received 30 days from the notice of adverse action. Written requests for fair hearings should be sent to:
Administrative Hearing Section

1020 South Kansas Ave.

Topeka, KS 66612
4.1.1.63.3.4

The administrative fair hearing officer shall issue a proposed decision to the CONTRACTOR and to the State. The CONTRACTOR and the State shall have 10 days after the mailing of the proposed decision to request a review. If such a request is made, the director shall, thereafter, issue a final decision. There shall be no ex-parte-communications with the administrative law judge during the appeal. The reasonable costs of an administrative appeal including costs of reporting and preparing a transcript will be paid by the party appealing. Such decision shall be final except to the extent that the CONTRACTOR, upon appeal to the District Court of Kansas, can demonstrate the decision was made either carelessly, negligently or in bad faith by the Health Services (CONTRACTOR). The appeal to the Director or the District Court shall not automatically stay any notice of termination that may be subject to appeal.

4.1.1.63.3.5

Pending final determination of any dispute, the CONTRACTOR shall proceed diligently with the performance of this CONTRACT and in accordance with the State Contract Manager's direction.

4.1.1.63.3.6

The CONTRACTOR's failure to follow the procedure set out above shall be deemed a waiver of any claim which the CONTRACTOR might have had.

Whenever the State determines that the CONTRACTOR is out of compliance with this CONTRACT, the State may suspend enrollment of new Members under this CONTRACT. The State, when exercising this option, must notify the CONTRACTOR in writing of its intent to suspend new enrollment at the discretion of the State. The suspension period may be for any length of time specified by the State, or may be indefinite. The suspension period may extend up to the CONTRACT expiration date as provided under Section I. (The State may also notify existing Members of CONTRACTOR non-compliance and provide an opportunity to disenroll from the CONTRACTOR or to re-enroll with another CONTRACTOR).

4.1.1.65.1

The State may withhold portions of capitation payments from the CONTRACTOR whenever the State determines that the CONTRACTOR has failed to provide one or more of the medically necessary CONTRACT services required under Section V or if the CONTRACTOR does not follow specified procedures or signed contractual agreements, the State may withhold an estimated portion of the CONTRACTOR's capitation payment.

4.1.1.65.2

The CONTRACTOR may not elect to withhold any required services when it is determined that it will receive adjusted payment levels. The State may also adjust payment levels accordingly if the CONTRACTOR has failed to maintain or make available any records or reports required under this CONTRACT needed by the State to determine whether the CONTRACTOR is providing CONTRACT services as required under Section V.
Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

4.1.1.66 Liquidated Damages - Failure to Meet Performance Requirements

The purpose of liquidated damages is to ensure adherence to the performance requirements in the CONTRACT. No punitive intention is inherent. It is agreed by the State and the CONTRACTOR that, in the event of a failure to meet the performance requirements listed below, damage shall be sustained by the State, and that it is and shall be impractical and extremely difficult to ascertain and determine the actual damages which the State shall sustain in the event of, and by reason of, such failure; and it is therefore agreed that the CONTRACTOR shall pay the State for such failures at the sole discretion of the State according to the following subsections.
Damage assessments are linked to performance of system implementation or operational responsibilities. Where an assessment is defined as an "up to $,$$$" amount, the dollar value shall be set at the discretion of the State.
Written notification of each failure to meet a performance requirement shall be given to the CONTRACTOR prior to assessing liquidated damages. The CONTRACTOR shall have five (5) business days from the date of receipt of written notification of a failure to perform to specifications to cure the failure. However, additional days can be approved by the State Contract Administrator if deemed necessary. If the failure is not resolved within this warning/cure period, liquidated damages may be imposed retroactively to the date of failure to perform. The imposition of liquidated damages is not in lieu of any other remedy available to the State.
If the State elects to not exercise a damage clause in a particular instance, this decision shall not be construed as a waiver of the State's rights to pursue future assessment of that performance requirement and associated damages.

See Attachment G for further information.

4.1.1.67.1

Inspection and audit of financial records. Risk contracts must provide that the State agency and the Department may inspect and audit any financial records of the entity or its subcontractors. The Contract must state that there shall be no restrictions on the right of the State or Federal government to conduct what ever inspections and audits are necessary to assure quality, appropriateness or timeliness of services and reasonableness of their costs.

4.1.1.67.2

Report Transactions - Non-federally qualified MCOs must report a description of certain transactions with parties of interest. The SMM defines “transactions” and “parties of interest”.

4.1.1.67.3

Disclosure of Information on Business Transactions - State Plan Defined HMOs.--All HMOs which are not Federally qualified must disclose to you information on certain types of transactions they have with a "party in interest" as defined in the Public Health Service Act. (See §§1903(m)(2)(A)(viii) and 1903(m)(4) of the Act.) This requirement must be contained in your contract with the HMO or HIO as a precondition for approval by the RO for receiving FFP. Federally qualified HMOs already report this information to HCFA. The law exempts them from reporting it again to you.

4.1.1.67.3.1

Definition of A Party in Interest.--As defined in §1318(b) of the Public Health Service Act, a party in interest is:

4.1.1.67.3.1.1

Any director, officer, partner, or employee responsible for management or administration of an HMO and HIO; any person who is directly or indirectly the beneficial owner of more than 5% of the equity of the HMO; any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than 5% of the HMO; or, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation law;

4.1.1.67.3.1.2

Any organization in which a person described in subsection 4.1.1.67.3.1.1 is director, officer or partner; has directly or indirectly a beneficial interest of more than 5% of the equity of the HMO; or has a mortgage, deed of trust, note, or other interest valuing more than 5% of the assets of the HMO;

4.1.1.67.3.1.3

Any person directly or indirectly controlling, controlled by, or under common control with a HMO; or

4.1.1.67.3.1.4

Any spouse, child, or parent of an individual described in subsections 4.1.1.67.1, 4.1.1.67.2, or 4.1.1.67.3.

4.1.1.67.3.2

Types of Transactions Which Must Be Disclosed.-- Business transactions which must be disclosed include:

4.1.1.67.3.2.1

Any sale, exchange or lease of any property between the HMO and a party in interest;

4.1.1.67.3.2.2

Any lending of money or other extension of credit between the HMO and a party in interest; and
4.1.1.67.3.2.3

Any furnishing for consideration of goods, services (including management services) or facilities between the HMO and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment.

4.1.1.67.3.3

The information which must be disclosed in the transactions listed in subsection 4.1.1.67.3.2 between an HMO and a party in interest includes:

4.1.1.67.3.3.1

The name of the party in interest for each transaction;

4.1.1.67.3.3.2

A description of each transaction and the quantity or units involved;

4.1.1.67.3.3.3

The accrued dollar value of each transaction during the fiscal year; and

4.1.1.67.3.3.4

Justification of the reasonableness of each transaction.

4.1.1.67.3.4

4.1.1.67.3.5

4.1.1.68.1

Right to Enter Into Other Contracts

4.1.1.68.1.1

The State and the CONTRACTOR agree that each may contract for the provision or purchase of services for and from third parties not related to this CONTRACT arrangement.

4.1.1.68.1.2

The State may undertake or award other contracts for services related to the services described in this CONTRACT or any portion herein. Such other contracts include, but are not limited to consultants retained by the State to perform functions related in whole or in part to CONTRACTOR services. The CONTRACTOR shall fully cooperate with such other contractors and the State in all such cases.

4.1.1.68.2

Subcontracts

4.1.1.68.2.1

The CONTRACTOR has the right to subcontract for services specified under this CONTRACT. Any subcontract into which the CONTRACTOR enters with respect to performance under the CONTRACT shall in no way relieve the CONTRACTOR of any responsibility for performance of its duties. All subcontracts must fulfill the requirements of 42 CFR 438 that are appropriate to the service or activity delegated under the subcontract. Each subcontract shall ensure the subcontractor’s ability to perform the services to be delegated. The State will consider the CONTRACTOR to be the sole point of contact with regard to contractual matters, including payment of any and all charges resulting from the CONTRACT. Nothing contained in the CONTRACT shall be construed as creating any contractual responsibility between the subcontractor(s) and the State.

4.1.1.68.2.2

The subcontractor(s) must be able to perform the same level of review and meet the same requirements as the CONTRACTOR. The CONTRACTOR must set forth a method by which to monitor the subcontractor and is ultimately responsible for the work performed.

4.1.1.68.2.3

Each contract must ensure that the entity monitor the subcontractor’s performance on an ongoing basis and subject it to formal review according to a periodic schedule established by the State, consistent with industry standards or State MCO laws and regulations. Each contract must ensure that deficiencies or areas for improvement are identified and that the CONTRACTOR or subcontractor takes corrective action when necessary.

4.1.1.68.2.4

CONTRACTOR shall require its physicians who provide services under this CONTRACT to have a unique identifier in accordance with the system established under section 1173(b) of the Balanced Budget Act, and to submit such identifier number to the State on the T-XXI Provider File (see the 837 Institutional Claim and Encounter Transactions, the 837 Professional Services Claim and Encounter Transactions companion guides and the NCPDP). These can be found under Publications, HIPAA Companion Guides, on our website at: https://www.kmap-state-ks.us/

4.1.1.68.3

Payment in Full:

4.1.1.68.3.1

CONTRACTOR is responsible for ensuring none of its assigned Members is charged for all, or any part (i.e., balance of bill), of services provided by network providers when CONTRACTOR Member obtains services (emergency or otherwise) that are covered by CONTRACTOR under this CONTRACT.

4.1.1.68.3.2

Failure of CONTRACTOR to ensure protection from inappropriate provider billing, as set forth above, shall result in CONTRACTOR reimbursing its Member(s) for any payments the Member made to a provider.

4.1.1.68.3.3

CONTRACTOR shall ensure that Members are protected against liability for payments to providers or entities when the State does not pay CONTRACTOR for any reason.

4.1.1.68.4

The CONTRACTOR must verify qualifications of subcontractors in accordance with all state licensing standards, all applicable accrediting standards, and any other standards or criteria established by the State to assure quality of services. These must be submitted with the Request For Consideration and on an annual basis on July 1 of each year.

4.1.1.68.5

The CONTRACTOR shall assure that all subcontracts shall be in writing, shall comply with the provisions of this CONTRACT, and shall include any general requirements of this CONTRACT that are appropriate to the service or activity identified. The subcontract shall specify the activities and report responsibilities delegated to the subcontractor; and provide for revoking said delegation or imposing other sanctions if the subcontractor’s performance is inadequate.

4.1.1.68.6

Copies of all subcontracts and subcontract revisions shall be submitted to the State no later than 30 days after the awarding of this CONTRACT or within 30 days of subcontract execution or revision if occurring after the awarding of this CONTRACT. When subcontractors within a given service category contain identical provisions and rates, a completed standard subcontract and list of service providers may be submitted in lieu of copies of all sub-contracts. Subcontracts shall not terminate legal liability of the CONTRACTOR under this CONTRACT. The CONTRACTOR may subcontract for any function covered by this CONTRACT, subject to the requirements of this CONTRACT.

4.1.1.68.7

The CONTRACTOR and its subcontractors must comply with all provisions and applicable conditions of title VI of the Civil Rights Act of 1964, as amended; title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975, as amended; the Equal Pay Act of 1963; the Rehabilitation Act of 1973, as amended; the Americans with Disabilities Act; and the Civil Rights Act of 1991. If applicable, the CONTRACTOR must also comply with all provisions of Executive Order #11246 including amendments, as well as rules, regulations and relevant orders of the Secretary of Labor (see also sections 3.50 and 5.5.6.b.ii. second bullet).

4.1.1.68.8

Physician Incentive Plans: The CONTRACTOR must obtain State approval of any Physician Incentive Plan prior to implementation. CONTRACTOR must certify to the State annually in the event that it does not have a Physician Incentive Plan. Under the terms of this CONTRACT, any PIP must meet the requirements at 42 CFR 417.479, 422.208, 422.210, 434.70, and 438.6.

4.1.1.68.8.1

The CONTRACTOR may operate a Physician Incentive Plan only if no specific payment can be made directly or indirectly under a Physician Incentive Plan as an inducement to reduce or limit medically necessary services furnished to an individual.

4.1.1.68.8.2

The CONTRACTOR shall disclose information specified in the Physician Incentive Plan regulations to the State at the initial CONTRACT, anniversary date of the CONTRACT and at CONTRACT renewal.

4.1.1.68.8.3

The CONTRACTOR shall report whether services not furnished by physician/group are covered by the incentive plan. No further disclosure is required if Physician Incentive Plan does not cover services not furnished by physician/group.

4.1.1.68.8.4

The State shall monitor the CONTRACTOR’s Physician Incentive Plan to ensure CONTRACT compliance. Upon request of the State, CONTRACTOR shall report: The type of incentive arrangement, e.g. withhold, bonus, capitation; the percent of withhold or bonus (if applicable); the panel size, and if patients are pooled, the approved method used; if the entity is at substantial financial risk, the entity must report proof the physician/group has adequate stop loss coverage, including amount and type of stop-loss.

4.1.1.68.8.5

The CONTRACTOR shall provide information on its Physician Incentive Plan to any member upon request (this includes the right to adequate and timely information on a Physician Incentive Plan). Member handbooks must annually disclose to Members their right to request such information.

4.1.1.68.8.6

If the physician/group is put at substantial financial risk for services not provided by physician/group, the CONTRACTOR must ensure adequate stop-loss protection to individual physicians and conduct annual Member surveys.

4.1.1.68.8.7

If the CONTRACTOR is required to conduct Member survey, survey results must be disclosed to the State and, upon request, disclosed to Members. Member handbooks must annually disclose to Members their right to request such information.

4.1.1.68.9

Ineligible Physicians/Groups:

4.1.1.68.9.1

Entities convicted of a criminal offense related to delivery of Title XVIII, T-XIX, or T-XXI services.

4.1.1.68.9.2

Entities convicted of payment abuse.

4.1.1.68.9.3

Entities convicted of fraud or other financial misconduct.

4.1.1.68.9.4

Entities convicted of obstructing an investigation.

4.1.1.68.9.5

Entities convicted of offenses relating to controlled substances.

4.1.1.68.9.6

Entities terminated from the T-XIX Program.

4.1.1.68.9.7

Entities terminated from the T-XXI Program.

4.1.1.68.9.8

Entities that meet the following criteria:

4.1.1.68.9.8.1

An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No.12549 or under guidelines implementing Executive Order No. 12549.

4.1.1.68.9.8.2

An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in paragraph (a)(1).

4.1.1.68.9.8.3

The relationship is described as follows:

4.1.1.68.9.8.3.1

A director, officer, or partner of the MCO, PCCM, PIHP, PAHP

4.1.1.68.9.8.3.2

A person with beneficial ownership of five percent or more of the MCO's, PCCM's, PIHP's or PAHP's equity.

4.1.1.68.9.8.3.3

A person with an employment, consulting or other arrangement with the MCO, PCCM, PIHP, or PAHP obligations under its contract with the State.
Please refer to the Federal Debarment List located at:
www.epls.arnet.gov ,
for a listing of federally debarred and suspended individuals.

4.1.1.68.10

Terminated Providers: The CONTRACTOR shall terminate contracts with any provider whose MCO Contract or Medicaid Provider Agreement has been terminated by the State. Such contract termination shall be effective 30 calendar days after receipt of notice of State termination of a MCO Contract or Medicaid provider agreement. The CONTRACTOR shall provide written notice of the provider termination to its members assigned to such provider at least 15 days prior to the effective contract termination date. Federal Financial Participation (FFP) is not available for amounts expended for providers excluded by Medicare, Medicaid, or CHIP, except for emergency services.

4.1.1.68.11

Provider Discrimination:

4.1.1.68.11.1

CONTRACTOR shall not discriminate against providers with respect to participation, reimbursement, or indemnification of any provider acting within the scope of that provider’s license or certification under applicable State law solely on the basis of the provider’s license or certification.

4.1.1.68.11.2

If CONTRACTOR declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reason for its decision.

4.1.1.68.11.3

In all subcontracts with health care professionals, CONTRACTOR must comply with the requirements specified in 42 CFR 438.214 that includes selection and retention of providers, credentialing and recredentialing requirements, and nondiscrimination.

4.1.1.68.11.4

This section may not be construed to:

4.1.1.68.11.4.1

Require the CONTRACTOR to contract with providers beyond the number necessary to meet the needs of its Members.

4.1.1.68.11.4.2

Preclude the CONTRACTOR from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or

4.1.1.68.11.4.3

Preclude the CONTRACTOR from establishing measures that are designed to maintain quality of services and control costs and is consistent with its responsibilities to Members.

4.1.1.68.12

Provider – Member Communication:

4.1.1.68.12.1

Alternative Treatment: CONTRACTOR shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a member who is his or her patient for the Member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered.

4.1.1.68.12.2

Treatment Options: CONTRACTOR shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a Member who is his or her patient, for any information the Member needs in order to decide among all relevant treatment options.

4.1.1.68.12.3

Treatment vs. Non-Treatment: CONTRACTOR shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a Member who is his or her patient, for the risks, benefits, and consequences of treatment or non-treatment.

4.1.1.68.12.4

Participate in Treatment Options: CONTRACTOR shall not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of a Member who is his or her patient, for the Member's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

4.1.1.68.12.5

Moral or Religious Objections: If the CONTRACTOR would otherwise be required to provide, reimburse for, or provide coverage of, a counseling or referral service is not required to do so if the CONTRACTOR objects to the service on moral or religious grounds.

4.1.1.68.12.6

Information Requirements: If the CONTRACTOR elects not to provide, reimburse for, or provide coverage of, a counseling or referral service because of an objection on moral or religious grounds, it must furnish information about the services it does not cover as follows:

4.1.1.68.12.6.1

To the State.

4.1.1.68.12.6.2

With its application for a Medicaid CONTRACT.

4.1.1.68.12.6.3

Whenever it adopts the policy during the term of the CONTRACT; and

4.1.1.68.12.6.4

It must be consistent with the provisions of 42 CFR 438.10.

4.1.1.68.12.6.5

It must be provided to potential Members before and during enrollment.

4.1.1.68.12.6.6

It must be provided to Members within 90 days after adopting the policy with respect to any particular service.
Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

4.1.1.69 Assignments and Mergers

This CONTRACT shall be binding on the parties and their successors and assignees, but neither party may assign this CONTRACT without the prior written consent of the other, which consent will not be unreasonably withheld; provided, however, that the CONTRACTOR may assign this CONTRACT to any corporation or firm which, upon such assignment, shall expressly assume this CONTRACT and which (i) shall acquire all or substantially all of the assets of the CONTRACTOR or any parent of the CONTRACTOR, as the case may be or (ii) shall be the surviving corporation into which the CONTRACTOR or any parent of the CONTRACTOR, as the case may be, shall have merged, provided in any such case that the State will be reasonably satisfied with the financial stability of the acquiring or surviving entity, whichever is applicable. Any successor or assignee must accept all outstanding claims of the State and contractual obligations of the CONTRACTOR.

CONTRACTOR must cover the duration of the CONTRACT period for which payment has been made to CONTRACTOR, as well as cover the continuation of services to Members confined in an inpatient facility on the date of insolvency until their discharge 42 CFR 434.59.

This CONTRACT may be terminated if CONTRACTOR fails to meet CONTRACT requirements or Balanced Budget Act requirements (BBA 4707). In the event the State chooses not to terminate this CONTRACT despite repeated CONTRACT or BBA violations, CONTRACTOR shall recognize the authority of temporary management appointed to oversee CONTRACTOR.

The following provisions shall apply:

4.1.1.72.1

EEO - CONTRACTOR shall comply with the Equal Employment Opportunity Provisions of Executive Order 11246, as amended by Executive Order 11375, and as supplemented by 41 CFR 60.

4.1.1.72.2

Rights to inventions – CONTRACTOR shall provide for the rights of the Federal Government and the State of Kansas in any resulting invention in accordance with 37 CFR 401 and any further implementing regulations issued by HHS.

4.1.1.72.3

Byrd Anti-Lobbying Amendment - CONTRACTOR shall file the required certification that each tier will not use Federal funds to pay a person or employee or organization for influencing or attempting to influence an officer or employee of any Federal agency, a member of Congress, officer or employee of Congress, or an employee of a Member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier shall also disclose any lobbying with nonfederal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the recipient (45 CFR 93). The disclosures shall contain a statement that Federal funds have not been used for lobbying.*

4.1.1.72.4

Debarment, Exclusion and Suspension - Certain contracts shall not be made to parties listed on the nonprocurements portion of the General Services Administration's "Lists of Parties Excluded for Federal Procurement or Nonprocurement Program." This list contains the names of parties debarred, suspended, or otherwise excluded by agencies, and CONTRACTORs declared ineligible under statutory authority. CONTRACTOR shall provide the required certification regarding their exclusion status and that of their principals prior to award.

CONTRACTOR agrees to comply with State and Federal anti-discrimination laws, including without limitation:

Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et seq.);

4.1.1.73.2

Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794);

4.1.1.73.3

Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.);

4.1.1.73.4

Age Discrimination Act of 1975 (42 U.S.C. §§6101-6107);

4.1.1.73.5

Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688);

4.1.1.73.6

Food Stamp Act of 1977 (7 U.S.C. §200 et seq.); and

4.1.1.73.7

The administrative regulations, for each State Agency identified in this RFP, as set forth in the KAR, to the extent applicable to this Agreement.

4.1.1.73.8

CONTRACTOR agrees to comply with Title VI of the Civil Rights Act of 1964, and its implementing regulations at 45 C.F.R. Part 80 or 7 C.F.R. Part 15, prohibiting a CONTRACTOR from adopting and implementing policies and procedures that exclude or have the effect of excluding or limiting the participation of clients in its programs, benefits, or activities on the basis of national origin. Applicable state and federal civil rights laws require CONTRACTORs to provide alternative methods for ensuring access to services for applicants and recipients who cannot express themselves fluently in English. CONTRACTOR agrees to ensure that its policies do not have the effect of excluding or limiting the participation of persons in its programs, benefits, and activities on the basis of national origin. CONTRACTOR also agrees to take reasonable steps to provide services and information, both orally and in writing, in appropriate languages other than English, in order to ensure that persons with limited English proficiency are effectively informed and can have meaningful access to programs, benefits, and activities.

4.1.1.73.9

CONTRACTOR agrees to comply with Executive Order 13279, and its implementing regulations at 45 C.F.R. Part 87 or 7 C.F.R. Part 16. These provide in part that any organization that participates in programs funded by direct financial assistance from the United States Department of Agriculture or the United States Department of Health and Human Services shall not, in providing services, discriminate against a program beneficiary or prospective program beneficiary on the basis of religion or religious belief.

4.1.1.73.10

Upon request, CONTRACTOR will provide Kansas Human Rights Commission with copies of all of the CONTRACTOR’s civil rights policies and procedures.

4.1.1.73.11

CONTRACTOR must notify Kansas Human Rights Commission of any civil rights complaints received relating to its performance under this Agreement. This notice must be delivered no more than ten (10) calendar days after receipt of a complaint. Notice provided pursuant to this section must be directed to:
Kansas Human Rights Commission

900 SW Jackson, Suite 568-South

Landon State Office Building

Topeka, KS 66612-2818

Telephone: 785-296-3206

fax: 785-296-0589

TTY: 785-296-0245

Web Address:

Business hours are from 8:00 am - 5:00 pm, Monday thru Friday

CONTRACTOR shall comply with the applicable provisions of federal environmental protection laws as described in this Section:

4.1.1.74.1

Pro-Children Act of 1994.

CONTRACTOR shall comply with the Pro-Children Act of 1994 (20 U.S.C. §6081 et seq.), as applicable, regarding the provision of a smoke-free workplace and promoting the non-use of all tobacco products.

4.1.1.74.2

National Environmental Policy Act of 1969.

CONTRACTOR shall comply with any applicable provisions relating to the institution of environmental quality control measures contained in the National Environmental Policy Act of 1969 (42 U.S.C. §4321 et seq.) and Executive Order 11514 (“Protection and Enhancement of Environmental Quality”).

4.1.1.74.3

Clean Air Act and Water Pollution Control Act regulations.

CONTRACTOR shall comply with any applicable provisions relating to required notification of facilities violating the requirements of Executive Order 11738 (“Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect to Federal Contracts, Grants, or Loans”).

4.1.1.74.4

State Clean Air Implementation Plan.

CONTRACTOR shall comply with any applicable provisions requiring conformity of federal actions to State (Clean Air) Implementation Plans under §176(c) of the Clean Air Act of 1955, as amended (42 U.S.C. §740 et seq.).

4.1.1.74.5

Safe Drinking Water Act of 1974.

CONTRACTOR shall comply with applicable provisions relating to the protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as amended (21 U.S.C. § 349; 42 U.S.C. §§ 300f to 300j-9).

4.1.1.74.6

The CONTRACTOR shall abide by all Federal, State and local laws, and rules and regulations regarding the protection of the environment. The CONTRACTOR shall report any violations to the applicable governmental agency. A violation of applicable laws or rule or regulations may result in termination of this CONTRACT for cause.
Acceptance: ____ Yes (Initial) ____ No (Initial and Provide a Detailed Explanation of Exception)

4.1.1.76 Compliance with Applicable Law

The CONTRACTOR shall observe and comply at all times with all Federal and State laws and regulations in effect during the term of the CONTRACT including title VI of the Civil Rights Act of 1964; title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the Americans with Disabilities Act. The CONTRACTOR must comply with all provisions of State policies, procedures, regulations, guidelines and rules for CONTRACTOR services, as well as pertinent Federal regulations. The CONTRACTOR must remain in compliance with the Balanced Budget Act(s). The CONTRACTOR must comply with all applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA) (see also sections 3.45.2.i and 5.5.6.b.ii. second bullet).

CONTRACTOR attests that CONTRACTOR has not and shall not use Federal funds derived under this CONTRACT for lobbying and will comply with all applicable provisions of 45 CFR 93.

____________________________ ______________________

Signature Date

____________________________

Printed Name:

____________________________

Title: