Medi-Cal Eligibility Data System (MEDS) and MEDS Monthly Extract File (MMEF) Access.
The Contractor shall enter into a Medi-Cal Privacy and Security Agreement (agreement) with the Department prior to obtaining access to MEDS and the MEDS monthly extract file (MMEF). The Contractor agrees to comply with the provisions as specified in the agreement. The County Mental Health Director or his or her authorized designee shall certify annually that Contractor is in compliance with the agreement. Failure to comply with the terms of the agreement will result in the termination of access to MEDS and MMEF.
Additional Requirements.
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The Contractor shall maintain written policies and procedures on advance directives in compliance with the requirements of Title 42, CFR, Sections 422.128 and 438.6(i)(1), (3) and (4). Any written materials prepared by the Contractor for beneficiaries shall be updated to reflect changes in state laws governing advance directives as soon as possible, but no later than 90 days after the effective date of the change. For purposes of this contract, advance directives means a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated as defined in Title 42, CFR, Section 489.100.
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Physician Incentive Plans. The Contractor shall obtain approval from the Department prior to implementing a Physician Incentive Plan. A Physician Incentive Plan is any compensation arrangement to pay a physician or physician group that may directly or indirectly have the effect of reducing or limiting the services provided to any beneficiary. For purposes of this definition, the words shall have the meanings set forth in Title 42, CFR, section 422.208(a). The Department shall approve the Contractor's request only if the proposed Physician Incentive Plan complies with all applicable federal and state regulations.
1)Pursuant to Title 42, CFR, Section 438.6(h), the Contractor shall comply with the requirements set forth in Title 42, CFR Section 422.208 and Title 42, CFR, Section 422.210.
2) The Contractor may operate a Physician Incentive Plan only if no specific payment can be made directly or indirectly under a Physician Incentive Plan to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual.
3) When seeking approval from the Department for its Physician Incentive Plan, the Contractor will disclose the following:
a Whether services not furnished by physician/group are covered by incentive plan. No further disclosure required if the Physician Incentive Plan does not cover services not furnished by physician/group;
b The type of incentive arrangement, e.g. withhold, bonus, capitation;
c The percentage of funds withheld or bonus provided (if applicable);
d The size of the panel, and, if patients are pooled, the approved method used for pooling; and,
e If the physician/group is at substantial financial risk, proof that the physician/group has adequate stop loss coverage, including amount and type of stop-loss.
4) If a physician or physician group is put at substantial financial risk for services not provided by the physician/group, the Contractor shall ensure adequate stop-loss protection to individual physicians and conduct annual beneficiary surveys.
5) Disclosure to Beneficiaries. The Contractor shall provide information on its Physician Incentive Plan to any Medicaid beneficiary upon request (this includes the right to adequate and timely information on a Physician Incentive Plan).
6) Disclosure to Department. If required to conduct beneficiary survey, survey results shall be disclosed to the Department and, upon request, to beneficiaries, per Social Security Administration (SSA) 1903(m)(2)(A)(x); 42 CFR, 422.208; 42 CFR 422.210; 42 CFR 438.6(h); and SSA 1876(i)(8)(A)(ii)(II).
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Sharing of Information with Beneficiaries. The Contractor shall not prohibit, or otherwise restrict, a licensed, waivered, or registered professional, as defined in Title 9, CCR, Sections 1810.223 and 1810.254, who is acting within the lawful scope of practice (pursuant to Title 42, CFR, Section 438.102(a)(1)), from advising or advocating on behalf of a beneficiary for whom the provider is providing mental health services for any of the following:
1. the beneficiary’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered;
2. information the beneficiary needs in order to decide among all relevant treatment options;
3. the risks, benefits, and consequences of providing or failing to provide treatment; and
4. the beneficiary’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.
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Limitation on Services for Moral or Religious Grounds. Pursuant to Title 42, CFR, Section 438.102(a)(2), the Contractor shall not be required to provide, reimburse for, or provide coverage of, a counseling or referral service if the Contractor objects to the service on moral or religious grounds.
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Pursuant to Title 42, CFR, Section 438.102(b)(1), 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:
1. To the Department
a) Prior to executing this contract;
b) Whenever it adopts the policy during the term of the contract; and,
2. Notice shall be consistent with the provisions of Title 42, CFR, Section 438.10; shall be provided to potential beneficiaries before and during enrollment; and provided to beneficiaries within 90 days after adopting the policy with respect to any particular service.
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Beneficiary Liability for Payment. Pursuant to Title 9, CCR, Section 1810.365, the Contractor or an affiliate, vendor, contractor, or sub-subcontractor of the Contractor shall not submit a claim to, or demand or otherwise collect reimbursement from, the beneficiary or persons acting on behalf of the beneficiary for any specialty mental health or related administrative services provided under this contract, except to collect other health insurance coverage, share of cost, and co-payments. Consistent with Title 42, CFR, Section 438.106, the Contractor or an affiliate, vendor, contractor, or sub-subcontractor of the Contractor shall not hold beneficiaries liable for debts in the event that the Contractor becomes insolvent, for costs of covered services for which the State does not pay the Contractor, for costs of covered services for which the State or the Contractor does not pay the Contractor's providers, for costs of covered services provided under a contract, referral or other arrangement rather than from the Contractor, or for payment of subsequent screening and treatment needed to diagnose the specific condition of or stabilize a beneficiary with an emergency psychiatric condition.
G. The Contractor shall comply with Title 42, CFR Section 438.236(b), which requires it to adopt practice guidelines.
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Such guideline shall meet the following requirements:
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They are based on valid and reliable clinical evidence or a consensus of health care professionals in the applicable field;
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They consider the needs of the beneficiaries;
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They are adopted in consultation with contracting health care professionals;
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They are reviewed and updated periodically as appropriate;
2) Contractor shall disseminate the guidelines to all affected providers and, upon request, to beneficiaries and potential beneficiaries.
3) Contractor shall take steps to assure that decisions for utilization management, beneficiary education, coverage of services, and other areas to which the guidelines apply shall be consistent with the guidelines.
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Health Information System. Pursuant to Title 42, CFR, Section 438.242 and consistent with Title 9, CCR, Section 1810.376, the Contractor shall maintain a health information system that collects, analyzes, integrates, and reports data. The system shall provide information on areas including, but not limited to, utilization, grievances, and appeals.
The Contractor’s health information system shall, at a minimum:
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Collect data on beneficiary and provider characteristics as specified by the Department, and on services furnished to beneficiaries as specified by the Department;
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Ensure that data received from providers is accurate and complete by:
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Verifying the accuracy and timeliness of reported data;
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Screening the data for completeness, logic, and consistency; and
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Collecting service information in standardized formats to the extent feasible and appropriate.
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Make all collected data available to the Department and, upon request, to CMS.
Consistent with Title 9, CCR, Section 1810.376(c), the Contractor’s health information system is not required to collect and analyze all elements in electronic formats.
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Persons with special health care needs for the purposes of this contract are adults who have a serious mental disorder and children with a serious emotional disturbance as defined in Welfare and Institutions Code Section 5600.3. The Contractor shall identify persons with special health care needs through the administration of surveys in accordance with the Department's Performance Outcome System.
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Cost Sharing. Pursuant to Title 42, CFR, Section 438.108, any cost sharing imposed on Medicaid beneficiaries shall be in accordance with Title 42, CFR, Sections 447.50 through 447.60.
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Service Authorization and Notices of Action. Pursuant to Title 42, CFR, Section 431.201, the Contractor shall define service authorization in a manner that at least includes a beneficiary’s request for the provision of a service.
Exhibit B
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